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Byron J Good A Reader in Medical Anthropology Theoretical Trajectories Emergent Realities 1 PDF
Byron J Good A Reader in Medical Anthropology Theoretical Trajectories Emergent Realities 1 PDF
Byron J Good A Reader in Medical Anthropology Theoretical Trajectories Emergent Realities 1 PDF
Edited by
Byron J. Good, Michael M. J. Fischer,
Sarah S. Willen, and Mary-Jo
DelVecchio Good
~VVILEY-BL~C~LL
A John Wiley & Sons, Ltd., Publication
This edition first published 2010
© 2010 Blackwell Publishing Ltd except for editorial material and organization
0 Byron J. Good, Michael M. ]. Fischer, Sarah S. Willen, and Mary-Jo DelVecchio Good
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4 2014
Contents
Acknowledgments ix
About the Editors xiii
Introduction 1
Part I Antecedents 7
Introduction 9
1 Massage in Melanesia 15
W. H. R. Rivers
2 The Notion of Witchcraft Explains Unfortunate Events 18
E. E. Evans-Pritchard
3 Muchona the Hornet, Interpreter of Religion 26
Victor Turner
4 The Ojibwa Self and Its Behavioral Environment 38
Irving A. Hallowell
5 The Charity Physician 47
Rudolf Virchow
6 The Role of Beliefs and Customs in Sanitation Programs 50
Benjamin Paul
7 Introduction to Asian Medical Systems 55
Charles Leslie
8 Medical Anthropology and the Problem of Belief 64
Byron]. Good
vi CONTENTS
Index 540
Acknowledgments
The editors and publisher also gratefully acknowledge the permission granted to
reproduce the copyright material in this book:
1 W. H. R. Rivers, "Massage in Melanesia," pp. 57-61 in Psychology and
Ethnology. New York: Harcourt, Brace and Co., 1926.
2 E. E. Evans-Pritchard, "The Notion of Witchcraft Explains Unfortunate
Events," pp. 18-32 in Witchcraft, Oracles, and Magic among the Azande. Oxford:
Clarendon Press, 1976. ©Oxford University Press. By permission of Oxford Univer-
sity Press.
3 Victor Turner, "Muchona the Hornet, Interpreter of Religion" pp. 131-50 in
The Forest of Symbols. Ithaca, NY: Cornell University Press, 1970.
4 Irving A. Hallowell, "The Ojibwa Self and its Behavioral Environment," pp.
172-82 in Culture and Experience. New York: Schocken Books, 1955.
5 Rudolf Virchow, "The Charity Physician," pp. 33-6 in L. J. Rather, ed.,
Collected Essays on Public Health and Epidemiology. Canton, MA: Science History
Publications, 1985 [1879]. Used by kind permission of the publisher: Science History
Publications/USA, division of Watson Publishing International LLC, Sagamore
Beach, MA.
6 Benjamin Paul, "The Role of Beliefs and Customs in Sanitation Programs,"
American Journal of Public Health 48 (1958): 1502-6.
7 Charles Leslie, "Introduction," pp. 1-12 [modified] in C. Leslie, ed., Asian
Medical Systems. Berkeley: University of California Press, 1976. © 1976 University
of California Press Books. Reproduced with permission of University of California
Press Books in the format textbook via Copyright Clearance Center.
8 Byron J. Good, "Medical Anthropology and the Problem of Belief," pp. 1-24
[modified] in Medicine, Rationality and Experience. Cambridge: Cambridge Univer-
sity Press, 1994. Reprinted by permission of Cambridge University Press.
X ACKNOWLEDGMENTS
University of California Press- Books in the format Textbook via Copyright Clear-
ance Center.
35 Didier Passin, "Humanitarianism as a Politics of Life," Public Culture 1913
(2007): 499-520.
36 Byron J. Good and Mary-Jo DelVecchio Good: written especially for this
volume.
37 Erica James, "The Political Economy of 'Trauma' in Haiti in the Democratic
Era of Insecurity," Culture, Medicine and Psychiatry 28 (2004): 127-49. With kind
permission from Springer Science & Business Media: Culture, Medicine and Psych-
iatry 28 (2004), pp. 127-49.
38 Mariella Pandolfi, "Contract of Mutual (ln)Difference: Governance and the
Humanitarian Apparatus in Contemporary Albania and Kosovo," Indiana Journal
of Global and Legal Studies 10 (2003 ):3 69-80.
39 Sarah S. Willen, "Darfur through a Shoah Lens: Sudanese Asylum Seekers,
Unruly Biopolitical Dramas, and the Politics of Humanitarian Compassion in Israel."
Substantially modified version of a piece that appeared in French in Cultures &
Conflits n72, autumn 2008, as "L'hyperpolitique du 'Plus jamais ~a!': demandeurs
d'asile soudanais, turbulence gouvernementale et politiques de controle des refugies
en Israel."
40 Angela Garcia, "The Elegiac Addict: History, Chronicity, and the Melan-
cholic Subject," Cultural Anthropology 23/4 (2009): 718-746. Reproduced by per-
mission of the American Anthropological Association from Cultural Anthropology
23/4 (2009), pp. 718-46.
Every society grapples with large questions of the meaning of illness, suffering, and
death, and every culture has developed specialized bodies of knowledge, with
practitioners or healers and distinctive therapeutic modalities aimed at managing
the human body, treating illness, and providing care for those who suffer. Anthro-
pologists have had a long-standing interest in how illness is understood and experi-
enced, theorized and treated, in the diverse cultures and civilizations within which
they work. Medical anthropologists have collaborated with physicians and public
health specialists to improve the distribution and effectiveness of medical care,
demonstrating the relevance of detailed understanding of local forms of medical
knowledge and social organization. At the same time, anthropologists are often
deeply influenced by the societies in which they work, by how individuals and
societies cope with the most intimate moments of birth, sickness, and death, by
therapeutic forms that provide important alternatives to biomedical conceptualiza-
tions of health and healing, and by the religious and spiritual traditions drawn on by
individuals and communities throughout the life cycle and in times of crisis. Medical
anthropology thus deals with many of the most vital issues that define what it means
to be human.
At the same time, anthropologists increasingly live and carry out research in
societies that are extraordinarily culturally diverse, with globalized media and com-
peting cultural and religious claims, where the very categories "culture" and "com-
munity" are called into question. Some find themselves working amidst violence or in
communities in various stages of post-conflict recovery, responding to health care
needs in settings in which trauma is an everyday reality and humanitarian organiza-
tions, local NGOs and advocacy groups, and governmental facilities and military
forces, interact in complex ways. Nearly all anthropologists work in societies with
increasing access to high technology medical regimes, though often in partial and
incomplete ways, and the "medical imaginary" (M. Good 2001; ch. 21, this volume)-
a profound fascination with biotechnologies and therapeutics - is increasingly ubi-
quitous. Diseases and biotechnologies follow new structures of inequalities, no
longer neatly tied to "developed" versus "developing" or high and low income
nations, producing unthinkable existential dilemmas and new contradictions. Deeply
2 INTRODUCTION
indebted Indian women have to decide whether to sell a kidney to maintain their
families. Individuals and families worldwide are forced to make decisions about
mortgaging the future to pay for treatments for cancer or other diseases, which
may or may not be effective. The language of human rights has increasingly entered
this domain, with varied effects. Access to anti-retroviral drugs is increasingly
seen as a human right for persons with AIDS, which has spurred a global movement
to increase HIV treatment. At the same time, efforts to make psychotropic medica-
tions, often highly effective, available to treat mental illnesses may be seen as the
imposition of Western categories fostered by drug companies. It is in this complex
new world, unimaginable to the anthropologists of a previous era, that medical
anthropologists now take on diverse roles as researchers, activists, health care
providers, teachers, participants in international organizations, and collaborators
with local institutions and organizations.
Any sourcebook or collection of essays in a field as diverse as this is necessarily a
partial representation of a discipline, a personal reading of the field and a statement
about where the authors feel the field has come from, where it is going, and which
writing exemplifies the most interesting work in the field. David Landy's 1977
reader, Culture, Disease, and Healing, was organized around 14 substantive topics
in the field, from "Paleopathology" and "Ecology and Epidemiology of Disease" to
sections on "Obstetrics and Population Control," on the roles of patients and healers,
and on medical systems in settings of social change. Thomas Johnson and Carolyn
Sargent's 1990 reader was intended as a "handbook of theory and method," a set of
essays aimed at summarizing particular topics and research methods current in the
field at that time. And Peter Brown's 1998 reader, Understanding and Applying
Medical Anthropology, is divided between essays distinguishing "biocultural" and
"cultural" approaches to the field, and a set of chapters representing applications of
medical anthropology to issues such as stigma and chronic illness, gender and
women's health, and culture and nutrition.
Medical Anthropology: Theoretical Trajectories, Emergent Realities is intended as
a source book of theoretically engaged writing in medical anthropology. Rather than
representing the field in bimodal terms as biosocial versus cultural, or setting out
sections on theory, methods, and substantive topics, this reader is organized around
what we consider the most important theoretical frames that have shaped and
continue to shape medical anthropology, along with the "emergent realities" - new
biotechnologies, new epidemics, new forms of "postcolonial disorders," new forms
of subjectivity- that medical anthropologists have struggled to make sense of using
these analytic frames. In our view, medical anthropology has gone from being a
largely a-theoretical practice-oriented discipline to one of the most deeply engaged
theoretical subfields within anthropology. Our goal is to provide a guide to the field
from this perspective. We bring together in each section of this book authors and
essays that represent distinctive ways of thinking about and writing in medical
anthropology, point out the theoretical lines of inquiry that link authors working
within particular traditions, and illustrate the distinguishing elements of writings and
theoretical perspectives across traditions.
In this book, we view the history of medical anthropology as a set of competing
and complementary theoretical perspectives that have their own "trajectories,"
which might be sketched out in the broadest terms as follows. Medical anthropology
INTRODUCTION 3
Part rv, "The Biotechnical Embrace," brings together essays that explore both
classic and unexpected sites of the emergence of the medical imaginary and the
powerful force of the biosciences and biotechnical therapeutics in managing funda-
mental issues of life, birth, and death in late modernity. While this work grows out of
earlier studies of the culture of biomedicine and the sociology of medical experimen-
tation, these studies of the "biotechnical embrace" represent medical anthropology's
encounter with "emergent realities" - the global trade in human organs, the deploy-
ment of reproductive technologies in a poor Islamic nation, the growing faith in
biotechnical responses to the worldwide AIDS epidemic - all in the context of
globalized therapeutic procedures. C. P. Snow's classic divide between the worlds
of science and humanities (1959) is here refigured as the conjoining of technology
and desire, as clinical narratives and the political economy of hope, technologies
deeply invested with affect and loosed in the popular imaginary.
This focus carries over to Part V, "Biosciences, Biotechnologies," which more
explicitly links writing from the history, philosophy, sociology, and anthropology
of science to medical anthropology. In the 1990s, anthropology came to have an
increasing presence in a field dedicated to exploring social and historical contingen-
cies of scientific practice and knowledge. Sociologists of science often preferred to
focus on the "hard" cases, on physics or bench research, rather than medicine to
explore such contingencies. But a flourishing anthropology of science quickly spilled
out of the laboratory, following the "social life" of emergent scientific objects- stem
cell lines, medical images, molecules labeled as pharmaceuticals- into their diverse
social worlds. This section represents the conjunction of medical anthropology and
studies of science, technology and society, suggesting possible futures for work in this
field.
Part VI, "Global Health, Global Medicine," juxtaposes a long trajectory of
medical anthropology working in international public health with the emergence
of a new global health movement at the opening of the twenty first century. On close
observation, anthropologists working in international public health, whether earlier
figures such as George Foster or the most prominent contemporary practitioners,
share an interest in issues that are newly labeled "implementation sciences." It is little
wonder, however, that leading anthropologist-physicians, Paul Farmer, Jim Kim,
Didier Passin, for example, prefer to see this new global health movement as linked
genealogically to the social medicine tradition of Rudolf Virchow, with his clarion
call for physicians to be the "natural attorneys for the poor, and his advocacy for
medicine to serve as an applied domain of human rights and social justice. This
section provides a small representation of what was in the past, and has yet again
become, one of the most vital domains of medical anthropology.
Finally, "Postcolonial Disorders" represents another potential future for medical
anthropology. The term "postcolonial disorders" bears twofold significance, refer-
ring both to a theoretical orientation and to a constellation of phenomena in which
medical anthropologists are increasingly engaged - communal violence and post-
conflict interventions, humanitarianism and new sites of global governance, dis-
placed populations and cultures, and the continued social pathologies associated
with colonial violence, displacement, and remembered trauma. Defined as social
pathologies, these phenomena provoke new forms of therapeutic interventions,
reproducing in some ways interventions of the colonial era. Bringing together a
6 INTRODUCTION
REFERENCES
Brown, Peter
1998 Understanding and Applying Medical Anthropology. Mountain View, CA: Mayfield
Publishing Co.
Good, Mary-Jo DelVecchio
2001 Biotechnical Embrace. Culture, .Medicine and Psychiatry 25:395-410.
Johnson, Thomas M. and Carolyn F. Sargent
1990 Medical Anthropology: A Handbook of Theory and Method. New York: Green-
wood Press.
Kleinman, Arthur
1973 Toward a Comparative Study of Medical Systems. Science, Medicine and Man
1:55-65.
Landy, David
1977 Culture, Disease, and Healing: Studies in Medical Anthropology. New York: Mac-
millan Publishing Co.
Snow, C. P.
1959 The Two Cultures and the Scientific Revolution. New York: Cambridge University
Press.
Part I
Antecedents
Introduction
Setting the Stage: Historical
Antecedents to Contemporary
Medical Anthropology
anthropological writings. Rivers was among the first of the physicians who have
become ethnologists, and is sometimes claimed as a founder of medical anthropol-
ogy. Rivers was recruited to be a member of the Torre~ Straits Expedition to the
Pacific in 1898, where he conducted basic psychological experiments with local
populations. He went on to travel widely on colonial scientific expeditions and
became a specialist of Polynesian and Melanesian societies (Rivers 1914). His Fitz-
Patrick Lectures to The Royal College of Physicians of London in 1915 and 1916,
published as Medicine, Magic, and Religion (1924), are far more widely cited by
medical anthropologists than actually read. The writing is archaic, embedded in
discussions of the stages of evolution of societies toward "civilization," and largely
non-ethnographic in the contemporary sense of the word. His arguments, however,
are powerful. Writing on the "Rationality of Leechcraft," a term used to denote a
domain of empirical medical knowledge, he argued, "The practices of these peoples
in relation to disease are not a medley of disconnected and meaningless customs, but
are inspired by definite ideas concerning the causation of disease" (1924: 51). The
book is devoted largely to identifying and describing those ideas and the practices
they inspired.
The 1926 essay included here, "Massage in Melanesia," demonstrates how appar-
ently empirical practices such as massage "are inspired by definite ideas," which turn
out not to be "empirical" as expected. Rivers uses the example to show that a clear
distinction between the rational and the superstitious cannot be maintained, and that
the evolutionary view that medicine evolved by "sloughing off" the superstitious is
untenable. Ultimately, Rivers' clinical work on shell shock among World War I soldiers
and his ethical reflections on curing soldiers in order to send them back to the front to
die is far more gripping and contemporary than his ethnology. However, his discussion
of how native medical systems provide causal frames for explaining illness and
misfortune and his efforts to classify these explanatory systems were an early example
of what came to be known as the rationality tradition within British anthropology.
E. E. Evans-Pritchard (1902-73), Professor of Social Anthropology at Oxford
from 1946 through 1970, was a master ethnographer rather than expeditionary
ethnologist. Working for extended time in several African societies, particularly the
Azande, he provided the classic formulation of how witchcraft, along with oracles
and sorcery, served as devices to explain the unknown. It is what is explained that is
critical, he argued (1937). The Azande are aware that termites cause granaries to fall.
What is to be explained is why a granary falls at a particular moment on a particular
person, causing injury or death. Witchcraft, and by extension all systems of medical
knowledge, serve to explain both how and why someone becomes ill. They serve as
theodicy, Evans-Pritchard argued, ways of explaining why terrible misfortune and
suffering occur in this world and why good persons suffer no less than the bad.
Within British anthropology, the claim that witchcraft and local healing beliefs
were to be understood as particular modes of explanatory rationality, not so distant
from a natural science, provoked a later set of vigorous debates about the nature of
science and rationality (see Good 1994: 10-14, for a review). However, while
beginning with a similar recognition that illness and misfortune call forth a search
for underlying causes and efforts at healing, Victor Turner (1920-83) carried his
work on Ndembu "medicine" and healing rituals, what he called "rites of affliction,"
in quite a different direction. "Disease among the Ndembu must be viewed not only
INTRODUCTION 11
social concerns and that medical anthropology should be rooted in the struggle
for social justice (see Part VI in this volume).
The final essay in this section, "Medical Anthropology and the Problem of Belief,"
drawn from Byron Good's 1994 Medicine, Rationality and Experience, demon-
strates the relevance of the divide between rationalist, "belief" -oriented theories
and the phenomenological tradition. This essay demonstrates how the logic of these
positions has given rise to very different types of medical anthropology, criticizes the
use of "belief" as a category of analysis in medical anthropology and public health,
and argues for a medical anthropology grounded in a meaning-centered or phenom-
enological tradition.
REFERENCES
Barker, Pat
1991 Regeneration. New York: Plume.
Barker, Pat
1993 The Eye in the Door. New York: Dutton Books.
Barker, Pat
1995 The Ghost Road. New York: Plume.
Bates, Don
1995 Knowledge and the Scholarly Medical Traditions. Cambridge: Cambridge University
Press.
Eisenberg, Leon
1984 Rudolf Ludwig Karl Virchow, Where Are You Now That We Need You? The
American Journal of Medicine 77:524-32.
Evans-Pritchard, E. E.
1937 Witchcraft, Oracles and Magic among the Azande. Oxford: The Clarendon Press.
Good, Byron 1.
1994 Medicine, Rationality and Experience: An Anthropological Perspective. Cambridge:
Cambridge University Press.
Hallowell, A. Irving
1955 Culture and Experience. New York: Schocken Books.
Hallowell, A. Irving
1976 {1963] Ojibwa World View and disease. In Contributions to Anthropology:
Selected Papers of A. Irving Hallowell, pp. 391-448. Chicago: University of Chicago Press.
Kleinman, Arthur
1973 Toward a Comparative Study of Medical Systems. Science, Medicine and Man
1:55-65.
Kleinman, Arthur
1980 Patients and Healers in the Context of Culture. Berkeley: University of California
Press.
Kleinman, Arthur, Leon Eisenberg, and Byron Good
1978 Culture, lllness and Care: Clinical Lessons from Anthropologic and Cross-Cultural
Research. Annals of Internal Medicine 88:251-58.
Kleinman, Arthur, Peter Kunstadter, E. Alexander, and james Gale, eds.
1976 Medicine in Chinese Cultures. Washington, DC: Fogarty International Center.
Leslie, Charles, ed.
1976 Asian Medical Systems. Berkeley: University of California Press.
Leslie, Charles, and Allan Young
1992 Paths to Asian Medical Knowledge. Berkeley: University of California Press.
14 ANTECEDENTS
Paul, Benjamin
1955 Health, Culture, & Community: Case Studies of Public Reactions to Health Pro-
grams. New York: Russell Sage Foundation.
Redfield, Robert
1956 Peasant Society and Culture. Chicago: University of Chicago Press.
Rivers, W. H. R.
1914 The History of Melanesian Society, voJ. 2: Percy Sladen Trust Expedition to Mela-
nesia, Publication No. 1. Cambridge: Cambridge University Press.
Rivers, W. H. R.
1924 Medicine, Magic, and Religion. The FitzPatrick Lectures delivered before The Royal
College of Physicians of London in 1915 and 1916. London: Kegan Paul, Trench, Trubner &
Co. Ltd.
Rivers, W. H. R.
1926 Massage in Melanesia. In Psychology and Ethnology. New York: Harcourt, Brace &
Co., Inc.
Turner, Victor
1967 The Forest of Symbols: Aspects of Ndembu Ritual. Ithaca, NY: Cornell University
Press.
Virchow, Rudolf
1985 [1879] Collected Essays on Public Health and Epidemiology, vols. 1 and 2, ed. L. J.
Rather. Canton, MA: Science History Publications.
Waitzkin, Howard
2006 One and a Half Centuries of Forgetting and Rediscovering: Virchow's Lasting
Contributions to Social Medicine. Social Medicine 1:5-10.
1
Massage in Melanesia
W. H. R. Rivers
When I was working in the Solomon Islands result, however, was not ascribed so much to
with Mr A. M. Hocart, 1 it was our custom, the mechanical action of the manipulation as
whenever possible, to accompany the native to the fonnulre and other features of the treat-
medicos on their visits to their patients. On ment which accompanied the massage.
one of these occasions the treatment consisted On another occasion I observed the
chiefly of abdominal massage carried on, so treatment of a case of supra-orbital neuralgia.
far as I could tell, just as it would have been The brow was kneaded carefully for a time and
by a European expert. On questioning the then a fold of the skin was caught and a motion
woman who was the subject of the treatment, made as though something were being drawn
I learned that she was suffering from chronic through the skin. The invisible object called
constipation, and if the matter had not been tagosoro was thus extracted and blown away.
gone into more fully, it might have been I asked the leech2 to carry out the treatment for
supposed that the Solomon Islanders treated tagosoro on my own forearm, and kneading
this disease according to the most modern and manipulations, exactly like those of our own
scientific therapeutics. Further inquiries, how- massage, were carried out till, by a sudden
ever, brought out the fact that the treatment we movement he showed me how he would have
had observed was for the purpose of destroying caught the tagosoro if it had been there, and
an octopus which, according to the native would have blown it away. Here again a super-
pathology, was the cause of the woman's ficial inquiry would have seemed to show the
troubles. She was said to be suffering from a existence of a massage indistinguishable from
disease called nggasin, caused by the presence our own, and applied to conditions to which,
of an octopus in her body, and an inquiry into according to our ideas, it is well adapted. It was
the diagnosis revealed the belief that the ten- only through systematic inquiry that it was
tacles of the octopus would pass upwards, and discovered that the ideas underlying the treat-
when they reached the head of the patient, ment were wholly different from our own, and
would kill her. The object of the treatment that the whole process rested upon a magico-
was to kill the octopus, and the treatment had religious basis. My object in describing this
already been carried out for several days, feature of Melanesian therapeutics is as an
so that the octopus, which had at first been example of a difficulty which confronts that
very large, had now become small, and was department of the history of Medicine which
expected soon to disappear altogether. This attempts to deal with origins. A few years ago
W. H. R. Rivers, "Massage in Melanesia," pp. 57-61 in Psychology and Ethnology. New York: Harcourt,
Brace and Co., 1926.
16 W. H. R. RIVERS
I should have had no hesitation in regarding have been the result of a blend between an
this Melanesian practice as an example of the introduced therapeutical measure and an indi-
growth of a rational therapeutical measure out genous belief. According to this, disease is due
of a magical or religious rite. I should have to animals or other agents which have found
supposed that the practices of the Solomon their way into the human body.
Islanders were originally designed to extract I cannot attempt here to deal fully with
the octopus or the tagosoro from the body, the evidence which would enable us to weigh
and that it would only be necessary to slough the two hypotheses against one another, for the
off what we regard as the superstitious aspect subject can only be treated adequately in con-
of the practice to have a true therapeutical junction with the study of many other features
measure. I should have regarded the Melanesw of culture. I can now point only to two consid-
ian practice as one which has preserved for us a erations. One is that true massage, such as is
stage in the process of evolution whereby practised by ourselves, apparently exists in
medicine evolved out of magic and, as a matter Polynesia. It is, of course, possible that deeper
of fact, I believe that the vast majority of my inquiry would show that, underlying Polynes-
anthropological colleagues, at any rate in ian massage, there are ideas which give it a
this country, would still be fully satisfied with special character, just as we found to be the
this view. case with the massage of the Solomon Islands.
Many students of anthropology, howw But the way in which the Polynesians use mas-
ever, are coming to see that human institutions sage as a restorative suggests that the massage
have not had so simple a history as this view of this people is a true therapeutical measure
implies, and that many of the cases, formerly thoroughly comparable with our own practice.
supposed to show stages in a process of a simple True massage thus seems to exist in the same
and direct evolution, are rather the outcome of part of the globe as the Solomon Islands. On
the blending of peoples and their cultures. The the hypothesis of transmission, it may have
example I have described wiJl show the possi- been introduced into those islands by Polynes-
bility that Melanesian massage, as we now find ian castaways, who often found their way to
it, may have had a very different history. It is the Solomon Islands, or more probably may
possible that massage, much in the form in have been brought to these islands by the same
which it is found among ourselves and so many people who were responsible for its introduc-
other peoples of the earth, was introduced into tion into Polynesia.
Melanesia by an immigrant people, and that the A second consideration, to which it is
beliefs in the octopus or the tagosoro are merely very difficult to know how much weight to
the outcome of attempts to account for the attach, is the extraordinary similarity of the
success of the new treatment on lines suggested massage of the Solomon Islanders to the true
by the pathological ideas of the indigenous therapeutical practice. When I observed the
people. The process would be like that among massage applied to others and experienced its
ourselves when any new treatment, if suffi- application to my own arm, the manipulations
ciently successful to attract attention, is ex- seemed to me to be like those of true massage
plained according to the current pathology rather than the result of an attempt to catch an
and therapeutics of the day. A case analogous animal or some less material agent. When we
to that of my Melanesian example would be consider the intense conservatism of people of
the orthodox explanation of the success of rude culture, their tendency for generation
Christian Science based on the pathological after generation to carry out operations in the
distinction between organic and functional disM traditional way, I cannot help feeling that the
eases and the therapeutical ideas summed up in resemblance of their manipulations to those of
the term "suggestion." Before we accept Mela- true massage may be the perpetuation of the
nesian massage as an example showing us a practice as it was originally taught to them,
stage in the evolution of a medical remedy out although the ideas underlying the practice have
of a magico-religious rite, it is necessary to come to be very different from those of their
suggest the alternative hypothesis that it may teachers.
MASSAGE IN MELANESIA 17
My object in this place, however, is not independently, and how far they are the out-
merely to introduce a curiosity nor to lay come of transmission from people to people.
down any dogmatic view of its origin, but The fundamental importance of this problem
rather to point out a basic difficulty which is at last adequately recognized by the student
confronts those who attempt to trace out the of human culture, and I have ventured to use
origins of medical beliefs and practices. Medi- Melanesian massage as a means of calling
cine is a social institution. It comprises a set attention to a problem which must be faced
of beliefs and practices which only become by all who attempt to study the origins and
possible when held and carried out by mem- early history of medicine.
bers of an organized society, among whom a
high degree of the division of labour and spe-
cialization of the social function has come into NOTES
being. Any principles and methods found to 1 As members of the Percy Sladen Trust Exped-
be of value in the study of social institutions in ition.
general cannot be ignored by the historian of 2 Mr Hocart has suggested that this old word
medicine. Here, as in other departments of should be used as a technical term for the
human culture, the outstanding problem of practitioners of the rude art, which can be
to-day is to determine how far similar prac- called neither medicine nor magic, but lies
tices in different pans of the world have arisen somewhere between the two.
2
The Notion of Witchcraft
Explains Unfortunate Events
E. E. Evans-Pritchard
E. E. Evans-Pritchard, "The Notion of Witchcraft Explains Unfortunate Events," pp. 18-32 in \VIitchcra(t.
Oracles, and Magic among the Azande. Oxford: Clarendon Press, 1976. © Oxford Universit)' Press. By
permission of Oxford University Press.
THE NOTION OF WITCHCRAFT EXPLAINS UNFORTUNATE EVENTS 19
any time of the day or night. He would be just that he had knocked his foot against the stump
as surprised if he were not brought into daily of wood because he had been careless, and that
contact with it as we would be if confronted by witchcraft had not placed it in the path, for it
its appearance. To him there is nothing miracu- had grown there naturally. He agreed that
lous about it. It is expected that a man's witchcraft had nothing to do with the stump
hunting will be injured by witches, and he of wood being in his path but added that he
has at his disposal means of dealing with them. had kept his eyes open for stumps, as indeed
When misfortunes occur he does not become every Zande does most carefully, and that if he
awestruck at the play of supernatural forces. had not been bewitched he would have seen the
He is not terrified at the presence of an occult stump. As a conclusive argument for his view
enemy. He is, on the other hand, extremely he remarked that all cuts do not take days
annoyed. Someone, out of spite, has ruined to heal but, on the contrary, close quickly, for
his ground-nuts or spoilt his hunting or given that is the nature of cuts. Why, then, had his
his wife a chill, and surely this is cause for sore festered and remained open if there were
anger! He has done no one harm, so what right no witchcraft behind it? This, as I discovered
has anyone to interfere in his affairs? It is an before long, was to be regarded as the Zande
impertinence, an insult, a dirty, offensive trick! explanation of sickness.
It is the aggressiveness and not the eerieness of Shortly after my arrival in Zandeland we
these actions which Azande emphasize when were passing through a government settlement
speaking of them, and it is anger and not awe and noticed that a hut had been burnt to the
which we observe in their response to them. ground on the previous night. Its owner was
Witchcraft is not less anticipated than adul- overcome with grief as it had contained the
tery. It is so intertwined with everyday happen- beer he was preparing for a mortuary feast.
ings that it is part of a Zande's ordinary world. He told us that he had gone the previous night
There is nothing remarkable about a witch - to examine his beer. He had lit a handful of
you rna y be one yourself, and certainly many of straw and raised it above his head so that light
your closest neighbours are witches. Nor is would be cast on the pots, and in so doing
there anything awe-inspiring about witchcraft. he had ignited the thatch. He, and my compan-
We do not become psychologically trans- ions also, were convinced that the disaster was
formed when we hear that someone is ill - we caused by witchcraft.
expect people to be ill - and it is the same with One of my chief informants, Kisanga, was a
Zande. They expect people to be ill, i.e. to be skilled woodcarver, one of the finest carvers in
bewitched, and it is not a matter for surprise or the whole kingdom of Gbudwe. Occasionally
wonderment. the bowls and stools which he carved split
I found it strange at first to live among during the work, as one may well imagine in
Azande and listen to naive explanations of mis- such a climate. Though the hardest woods be
fortunes which, to our minds, have apparent selected they sometimes split in process of carv-
causes, but after a while I learnt the idiom ing or on completion of the utensil even if the
of their thought and applied notions of witch- craftsman is careful and well acquainted with
craft as spontaneously as themselves in sit- the technical rules of his craft. When this
uations where the concept was relevant. A happened to the bowls and stools of this par-
boy knocked his foot against a small stump of ticular craftsman he attributed the misfortune
wood in the centre of a bush path, a frequent to witchcraft and used to harangue me about
happening in Africa, and suffered pain and the spite and jealousy of his neighbours. When
inconvenience in consequence. Owing to its I used to reply that I thought he was mistaken
position on his toe it was impossible to keep and that people were well disposed towards
the cut free from dirt and it began to fester. He him he used to hold the split bowl or stool
declared that witchcraft had made him knock towards me as concrete evidence of his asser-
his foot against the stump. I always argued tions. If people were not bewitching his work,
with Azande and criticized their statements, how would I account for that? Likewise a
and I did so on this occasion. I told the boy potter will attribute the cracking of his pots
20 E. E. EVANS-PRITCHARD
during firing to witchcraft. An experienced thatch of his hut? Again, my friend the wood-
potter need have no fear that his pots will crack carver had made scores of bowls and stools
as a result of error. He selects the proper clay, without mishap and he knew all there was to
kneads it thoroughly till he has extracted all know about the selection of wood, use of tools,
grit and pebbles, and builds it up slowly and and conditions of carving. His bowls and stools
carefully. On the night before digging out his did not split like the products of craftsmen
clay he abstains from sexual intercourse. So he who were unskilled in their work, so why on
should have nothing to fear. Yet pots some- rare occasions should his bowls and stools split
times break, even when they are the handiwork when they did not split usually and when he had
of expert potters, and this can only be ac- exercised all his usual knowledge and care?
counted for by witchcraft. 'It is broken - there He knew the answer well enough and so, in
is witchcraft,' says the potter simply. Many his opinion, did his envious, back-biting neigh-
similar situations in which witchcraft is cited bours. In the same way, a potter wants to know
as an agent are instanced throughout this and why his pots should break on an occasion when
following chapters. he uses the same material and technique as on
other occasions; or rather he already knows, for
the reason is known in advance, as it were. If the
II pots break it is due to witchcraft.
We shall give a false account of Zande phil-
In speaking to Azande about witchcraft and in osophy if we say that they believe witchcraft
observing their reactions to situations of mis- to be the sole cause of phenomena. This prop-
fortune it was obvious that they did not attempt osition is not contained in Zande patterns
to account for the existence of phenomena, or of thought, which only assert that witchcraft
even the action of phenomena, by mystical brings a man into relation with events in such a
causation alone. What they explained by witch- way that he sustains injury.
craft were the particular conditions in a chain In Zandeland sometimes an old granary
of causation which related an individual to nat- collapses. There is nothing remarkable in this.
ural happenings in such a way that he sustained Every Zande knows that termites eat the sup-
injury. The boy who knocked his foot against a ports in course of time and that even the
stump of wood did not account for the stump hardest woods decay after years of service.
by reference to witchcraft, nor did he suggest Now a granary is the summerhouse of a Zande
that whenever anybody knocks his foot against homestead and people sit beneath it in the
a stump it is necessarily due to witchcraft, nor heat of the day and chat or play the African
yet again did he account for the cut by saying hole-game or work at some craft. Consequent-
that it was caused by witchcraft, for he knew ly it may happen that there are people sitting
quite well that it was caused by the stump of beneath the granary when it collapses and they
wood. What he attributed to witchcraft was are injured, for it is a heavy structure made
that on this particular occasion, when exercis- of beams and clay and may be stored with
ing his usual care, he struck his foot against eleusine as well. Now why should these par-
a stump of wood, whereas on a hundred other ticular people have been sitting under this par-
occasions he did not do so, and that on this ticular granary at the particular moment when
particular occasion the cut, which he expected it collapsed? That it should collapse is easily
to result from the knock, festered whereas intelligible, but why should it have collapsed at
he had had dozens of cuts which had not fes- the particular moment when these particular
tered. Surely these peculiar conditions demand people were sitting beneath it? Through years
an explanation. Again, every year hundreds of it might have collapsed, so why should it fall
Azande go and inspect their beer by night and just when certain people sought its kindly shel-
they always take with them a handful of straw ter? We say that the granary collapsed because
in order to illuminate the hut in which it is its supports were eaten away by termites; that
fermenting. Why then should this particular is the cause that explains the collapse of the
man on this single occasion have ignited the granary. We also say that people were sitting
THE NOTION OF WITCHCRAFT EXPLAINS UNFORTUNATE EVENTS 21
under it at the time because it was in the heat of to do so', and so on. Herein he is stating empir-
the day and they thought that it would be a ically ascertained facts. But he also says 'a buf-
comfortable place to talk and work. This is the falo charged and wounded so-and-so', 'a tree
cause of people being under the granary at fell on so-and-so and killed him', 'my termites
the time it collapsed. To our minds the only refuse to make their flight in numbers worth
relationship between these two independently collecting but other people are collecting theirs
caused facts is their coincidence in time and all right', and so on. He tells you that these
space. We have no explanation of why the things are due to witchcraft, saying in each
two chains of causation intersected at a certain instance, 'So-and-so has been bewitched.' The
time and in a certain place, for there is no facts do not explain themselves or only partly
interdependence between them. explain themselves. They can only be explained
Zande philosophy can supply the missing fully if one takes witchcraft into consideration.
link. The Zande knows that the supports were One can only obtain the full range of a
undermined by termites and that people were Zande's ideas about causation by allowing
sitting beneath the granary in order to escape him to fill in the gaps himself, otherwise one
the eat and glare of the sun. But he knows will be led astray by linguistic conventions. He
besides why these two events occurred at a tells you 'So-and-so was bewitched and killed
precisely similar moment in time and space. It himself' or even simply that 'So-and-so was
was due to the action of witchcraft. If there had killed by witchcraft'. But he is telling you the
been witchcraft people would have been sitting ultimate cause of his death and not the second-
under the granary and it would not have fallen ary causes. You can ask him 'How did he kill
on them, or it would have collapsed but the himself?' and he will tell you that he committed
people would not have been sheltering under suicide by hanging himself from the branch of a
it at the time. Witchcraft explains the coinci- tree. You can also ask 'Why did he kill him-
dence of these two happenings. self?' and he will tell you that it was because he
was angry with his brothers. The cause of his
death was hanging from a tree, and the cause
Ill of his hanging from a tree was his anger with
his brothers. If you then ask a Zande why he
I hope I am not expected to point out that the should say that the man was bewitched if he
Zande cannot analyse his doctrines as I have committed suicide on account of his anger with
done for him. It is no use saying to a Zande his brothers, he will tell you that only crazy
'Now tell me what you Azande think about people commit suicide, and that if everyone
witchcraft' because the subject is too general who was angry with his brothers committed
and indeterminate, both too vague and too suicide there would soon be no people left in
immense, to be described concisely. But it is the world, and that if this man had not been
possible to extract the principles of their bewitched he would not have done what he did
thought from dozens of situations in which do. If you persevere and ask why witchcraft
witchcraft is called upon to explain happenings caused the man co kill himself the Zande will
and from dozens of other situations in which reply that he supposes someone hated him, and
failure is attributed to some other cause. Their if you ask him why someone hated him your
philosophy is explicit, but is not formally informant will tell you that such is the nature
stated as a doctrine. A Zande would not say of men.
'I believe in natural causation but I do not For if Azande cannot enunciate a theory
think that that fully explains coincidences, of causation in terms acceptable to us they
and it seems to me that the theory of witchcraft describe happenings in an idiom that is ex-
offers a satisfactory explanation of them', but planatory. They are aware that it is particular
he expresses his thought in terms of actual circumstances of events in their relation to
and particular situations. He says 'a buffalo man, their harmfulness to a particular person,
charges', 'a tree falls', 'termites are not making that constitutes evidence of witchcraft. Witch-
their seasonal flight when they are expected craft explains why events are harmful to man
22 E. E. EVANS-PRITCHARD
and not how they happen. A Zande perceives relations. Azande always say of witchcraft that
how they happen just as we do. He does not see it is the umbaga or second spear. When Azande
a witch charge a man, but an elephant. He does kill game there is a division of meat between
not see a witch push over a granary, but ter- the man who first speared the animal and the
mites gnawing away its supports. He does not man who plunged a second spear into it. These
see a psychical flame igniting thatch, but an two are considered to have killed the beast and
ordinary lighted bundle of straw. His percep- the owner of the second spear is called the
tion of how events occur is as clear as our own. umbaga. Hence if a man is killed by an ele-
phant Azande say that the elephant is the first
spear and that witchcraft is the second spear
IV and that together they killed the man. If a man
spears another in war the slayer is the first
Zande belief in witchcraft in no way contra- spear and witchcraft is the second spear and
dicts empirical knowledge of cause and effect. together they killed him.
The world known to the senses is just as real Since Azande recognize plurality of causes,
to them as it is to us. We must not be deceived and it is the social situation that indicates
by their way of expressing causation and the relevant one, we can understand why the
imagine that because they say a man was doctrine of witchcraft is not used to explain
killed by witchcraft they entirely neglect the every failure and misfortune. It sometimes
secondary causes that, as we judge them, were happens that the social situation demands a
the true causes of his death. They are fore- common-sense, and not a mystical, judgement
shortening the chain of events, and in a par- of cause. Thus, if you tell a lie, or commit
ticular social situation are selecting the cause adultery, or steal, or deceive your prince, and
that is socially relevant and neglecting the are found our, you cannot elude punishment by
rest. If a man is killed by a spear in war, or saying that you were bewitched. Zande doc-
by a wild beast in hunting, or by the bite of trine declares emphatically 'Witchcraft does
a snake, or from sickness, witchcraft is the not make a person tell lies'; 'Witchcraft does
socially relevant cause, since it is the only not make a person commit adultery'; 'Witch-
one which allows intervention and determines craft does not put adultery into a man. "Witch-
social behaviour. craft" is in yourself (you alone are responsible),
Belief in death from natural causes and that is, your penis becomes erect. It sees the
belief in death from witchcraft are not mu- hair of a man's wife and it rises and becomes
tually exclusive. On the contrary, they supple- erect because the only "witchcraft" is, itself'
ment one another, the one accounting for ('witchcraft' is here used metaphorically};
what the other does not account for. Besides, 'Witchcraft does not make a person steal';
death is not only a natural fact but also a social 'Witchcraft does not make a person disloyal.'
fact. It is not simply that the heart ceases to Only on one occasion have I heard a Zande
beat and the lungs to pump air in an organism, plead that he was bewitched when he had com-
but it is also the destruction of a member of a mitted an offence and this was when he lied to
family and kin, of a community and tribe. me, and even on this occasion everybody pre-
Death leads to consultation of oracles, magic sent laughed at him and told him that witch-
rites, and revenge. Among the causes of death craft does not make people tell lies.
witchcraft is the only one that has any signifi- If a man murders another tribesman with
cance for social behaviour. The attribution of knife or spear he is put to death. It is not
misfortune to witchcraft does not exclude what necessary in such a case to seek a witch, for
we call its real causes but is superimposed on an objective towards which vengeance may be
them and gives to social events their moral directed is already present. If, on the other
value. hand, it is a member of another tribe who has
Zande thought expresses the notion of speared a man his relatives, or his prince, will
natural and mystical causation quite clearly take steps to discover the witch responsible for
by using a hunting metaphor to define their the event.
THE NOTION OF WITCHCRAFT EXPLAINS UNFORTUNATE EVENTS 23
It would be treason to say that a man put to is a history of incest in his case then incest is
death on the orders of his king for an offence the cause of leprosy and not witchcraft. In
against authority was killed by witchcraft. If a these cases, however, a curious situation arises
man were to consult the oracles to discover the because when the child or the leper dies it is
witch responsible for the death of a relative necessary to avenge their deaths and the Zande
who had been put to death at the orders of his sees no difficulty in explaining what appears to
king he would run the risk of being put to death us to be most illogical behaviour. He does so
himself. For here the social situation excludes on the same principles as when a man has been
the notion of witchcraft as on other occasions killed by a wild beast, and he invokes the same
it pays no attention to natural agents and em· metaphor of 'second spear'. In the cases men·
phasizes only witchcraft. Also, if a man were tioned above there are really three causes of a
killed in vengeance because the oracles said person's death. There is the illness from which
that he was a witch and had murdered another he dies, leprosy in the case of the man, perhaps
man with his witchcraft then his relatives could some fever in the case of the child. These sick-
not say that he had been killed by witchcraft. nesses are not in themselves products of witch-
Zande doctrine lays it down that he died at the craft, for they exist in their own right just as a
hand of avengers because he was a homicide. If buffalo or a granary exist in their own right.
a man were to have expressed the view that his Then there is the breach of a taboo, in the one
kinsman had been killed by witchcraft and to case of weaning, in the other case of incest.
have acted upon his opinion by consulting the The child, and the man, developed fever, and
poison oracle, he might have been punished for leprosy, because a taboo was broken. The
ridiculing the king's poison oracle, for it was breach of a taboo was the cause of their sick·
the poison oracle of the king that had given ness, but the sickness would not have killed
official confirmation of the man's guilt, and it them it witchcraft had not also been operative.
was the king himself who had permitted ven· If witchcraft had not been present as 'second
geance to take its course. spear' they would have developed fever and
In these situations witchcraft is irrelevant leprosy just the same, but they would not have
and, if not totally excluded, is not indicated died from them. In these instances there are
as the principal factor in causation. As in our two socially significant causes, breach of taboo
own society a scientific theory of causation, and witchcraft, both of which are relative to
if not excluded, is deemed irrelevant in ques· different social processes, and each is empha-
tions of moral and legal responsibility, so in sized by different people.
Zande society the doctrine of witchcraft, if But where there has been a breach of taboo
not excluded, is deemed irrelevant in the same and death is not involved witchcraft will not
situations. We accept scientific explanations of be evoked as a cause of failure. If a man eats a
the causes of disease, and even of the causes forbidden food after he has made powerful
of insanity, but we deny them in crime and sin punitive magic he may die, and in this case
because here they militate against law and the cause of his death is known beforehand,
morals which are axiomatic. The Zande since it is contained in the conditions of the
accepts a mystical explanation of the causes situation in which he died even if witchcraft
of misfortune, sickness, and death, but he does was also operative. But it does not follow
not allow this explanation if it conflicts with that he will die. What does inevitably follow
social exigencies expressed in law and morals. is that the medicine he has made will cease
For witchcraft is not indicated as a cause to operate against the person for whom it is
for failure when a taboo has been broken. If a intended and will have to be destroyed lest it
child becomes sick, and it is known that its turn against the magician who sent it forth.
father and mother have had sexual relations The failure of the medicine to achieve its pur-
before it was weaned, the cause of death pose is due to breach of a taboo and not to
is already indicated by breach of a ritual pro- witchcraft. If a man has had sexual relations
hibition and the question of witchcraft does with his wife and on the next day approaches
not arise. If a man develops leprosy and there the poison oracle it will not reveal the truth and
24 E. E. EVANS-PRITCHARD
its oracular efficacy will be permanently under- given for failure. Incompetence, laziness, and
mined. If he had not broken a taboo it would ignorance may be selected as causes. When a
have been said that witchcraft had caused the girl smashes her water-pot or a boy forgets to
oracle to He, but the condition of the person close the door of the hen-house at night they
who had attended the seance provides a reason will be admonished severely by their parents
for its failure to speak the truth without having for stupidity. The mistakes of children are
to bring in the notion of witchcraft as an due to carelessness or ignorance and they are
agent. No one will admit that he has broken a taught to avoid them while they are still young.
taboo before consulting the poison oracle, but People do not say that they are effects of witch-
when an oracle lies everyone is prepared to craft, or if they are prepared to concede the
admit that a taboo may have been broken by possibility of witchcraft they consider stupidity
someone. the main cause. Moreover, the Zande is not so
Similarly, when a potter's creations break nai've that he holds witchcraft responsible for
in firing witchcraft is not the only possible the cracking of a pot during firing if subsequent
cause of the calamity. Inexperience and bad examination shows that a pebble was left in the
workmanship may also be reasons for failure, clay, or for an animal escaping his net if some-
or the potter may himself have had sexual rela- one frightened it away by a move or a sound.
tions on the preceding night. The potter him- People do not blame witchcraft if a woman
self will attribute his failure to witchcraft, but burns her porridge nor if she presents it under-
others may not be of the same opinion. cooked to her husband. And when an inexperi-
Not even all deaths are invariably and enced craftsman makes a stool which lacks
unanimously attributed to witchcraft or to the polish or which splits, this is put down to his
breach of some taboo. The deaths of babies inexperience.
from certain diseases are attributed vaguely to In all these cases the man who suffers the
the supreme Being. Also, if a man falls sud- misfortune is likely to say that it is due to witch-
denly and violently sick and dies, his relatives craft, but others will not say so. We must bear
may be sure that a sorcerer has made magic in mind nevertheless that a serious misfortune
against him and that it is not a witch who especially if it results in death, is normally at-
has killed him. A breach of the obligations of tributed by everyone to the action of witchcraft,
blood-brotherhood may sweep away whole especially by the sufferer and his kin, however
groups of kin, and when one after another of much it may have been due to a man's incompe-
brothers and cousins die it is the blood and tence or absence of self-control. If a man falls
not witchcraft to which their deaths are attrib- into a fire and is seriously burnt, or falls into
uted by outsiders, though the relatives of the a game-pit and breaks his neck or his leg, it
dead will seek to avenge them on witches. would undoubtedly be attributed to witchcraft.
When a very old man dies unrelated people Thus when six or seven of the sons of Prince
say that he has died of old age, but they do Rikita were entrapped in a ring of fire and
not say this in the presence of kinsmen, who burnt to death when hunting cane-rats their
declare that witchcraft is responsible for his death was undoubtedly due to witchcraft.
death. Hence we see that witchcraft has its own
It is also thought that adultery may cause logic, its own rules of thought, and that these
misfortune, though it is only one participating do not exclude natural causation. Belief in
factor, and witchcraft is also believed to be witchcraft is quite consistent with human
present. Thus is it said that a man may be killed responsibility and a rational appreciation of
in warfare or in a hunting accident as a result of nature. First of all a man must carry out an
his wife's infidelities. Therefore, before going activity according to traditional rules of tech-
to war or on a large-scale hunting expedition a nique, which consist of knowledge checked by
man might ask his wife to divulge the names of trial and error in each generation. It is only if
her lovers. he fails in spite of adherence to these rules
Even where breaches of law and morals do that people will impute his lack of success to
not occur witchcraft is not the only reason witchcraft.
THE NOTION OF WITCHCRAFT EXPLAINS UNFORTUNATE EVENTS 25
I first became aware of Muchona on a dusty padding perkily beside us. He was evidently
motor road of packed red clay towards the keenly observant, for he joined in our sport
end of a Northern Rhodesian dry season. In and soon took the lead. Kasonda told me he
one direction the road ran to harsh, colorful was a chimbuki, a "doctor,'' in several kinds of
Angola, in the other to the distant Copperbelt curative ritual, and "knew many medicines." I
town of Chingola. Along it passed an occa- pricked up my ears, for ritual symbolism was
sional truck, mail van, or missionary's car, and my major interest. Each plant used in ritual
many tough black feet, most of them going stood for some aspect of Ndembu social life
east to European mines and towns. On this or belief. In my opinion a full interpretation
day the road was almost empty in the hot late of these symbols would lead me to the heart
afternoon. Kasonda, my African assistant, and of Ndembu wisdom. Consequently, I seized the
I had walked a few miles from our home village opportunity of asking the little man, whose
to a cluster of villages where we had collected name was Muchona, the meaning of some of
census material. Now we were returning, gay the medicines I had seen doctors handle.
with the millet beer and gossip that usually Muchona replied readily and at length, with
rounded off our more serious sessions. To make the bright glance of the true enthusiast. He
the miles go faster we played a game popular had a high-pitched voice, authoritative as a
among Ndembu children: each of us tried to be school-teacher's when conveying information,
the first to spot the budding kapembi shrubs expressive as a comedian's when telling a tale.
with their frail red presentiment of the rains. Kasonda found his manner and mannerisms
Even Ndembu find it hard to distinguish this both funny and irritating, as he tried to show
species from three others. Kasonda, of course, me by giggling conspiratorially behind his hand
soon had a higher total than myself, for like all whenever Muchona had his back to us. I did
Ndembu he prided himself on his knowledge of not respond, for I liked the doctor's warmth,
the mystical and practical properties of the and thus began Kasonda's bitter jealousy of
herbs and trees that flourish in this area. Muchona. Kasonda was worldly, and a shade
We were so absorbed in our rivalry that we spiteful, au fait with the seamier side of
failed to notice a swart elderly gnome who was Ndembu (and indeed human) nature. He took
Victor Turner, "Muchona the Hornet, Interpreter of Religion" pp. 131-50 in The Forest of Symbols. Ithaca,
NY: Cornell University Press, 1970.
MUCHONA THE HORNET, INTERPRETER OF RELIGION 27
a rancorous zest in the struggles for headman- Now I had heard many other Ndembu
ship, prestige, and money that were the bane of interpret plant symbols before, but never so
village life. Muchona, for all his battling against clearly and cogently as this. I was to become
witchcraft and the moody, punitive dead, had a familiar with this mode of exposition, the
curious innocence of character and objectivity swift-running commentary on unsolicited
of outlook. I was to find that in the balance details, the parenthetical explanations, the
mankind came off well for Muchona. Between vivid mimicry of ritual speech, and above all,
these men lay the gap that has at all times di- the depth of psychological insight: "What hurts
vided the true philosopher from the politician. you, when discovered and propitiated, helps
Muchona showed me his quality that first you."
day when he pointed to a parasitic growth on a Kasonda was whispering to me, "He is just
mukula tree (a red hardwood). "That plant is lying." I could not heed him, for Muchona had
called mutuntamu," he said. "Do you know already pointed out another tree and had
why it has that name?" Before I could confess begun to explain its ritual use and significance
my ignorance he rattled on: in a way that also compelled belief. I felt that a
Well, it is from ku-tuntama, "to sit on some- new dimension of study was opening up to me.
body or something.'' Now, hunters have a Sympathy was quickly growing between us and
drum [a ritual] called Ntambu, an old word when we parted we arranged to meet again in a
for "lion." In Ntambu, a hunter who has been few days.
unlucky and has failed to kill animals for many Muchona did not come. Perhaps he hesi-
days, goes into the bush and finds a big mukula tated to visit me, for my camp was in Kasonda's
tree like this one. The mukula tree has red village, and it is probable that Kasonda had
gum, which we call "mukuJa•s blood." It is a already hinted that he would be unwelcome
very important tree for hunters, and also for there. Perhaps he had been performing curative
women. For hunters it means "the blood of rituals in distant villages. He was a restless
animals." They want to see this blood when man, seldom at home anywhere for long, like
they go hunting. Now this unlucky hunter puts many another Ndembu doctor. Soon after-
his bow over his right shoulder and his axe into wards I also had to go away - to Lusaka, for
his right hand- for the right side is for men and a conference of anthropologists. For one
the left side for women, who carry their ba hies reason or another I did not see him again for
on their left arm- and he climbs up the mukula two months.
bearing bow and ax. When he is high up, he Meanwhile, I learned many details of Mu-
stands with one foot on one branch and one chona's life which were common knowledge in
foot on another. Then he shoots an arrow at his neighborhood. He did not live in the trad-
a mutuntamu plant. His arrow goes in strongly. itional circular village, but with his two wives
Then he cries, "I have shot at an animal." Then occupied a couple of low huts near the motor
he says, "I have shot you, Ntambu spirit. Please road. He had seven children, the eldest of
bring me quickly to animals." After that he whom was a clerk at the government township,
roars like a lion. Then he puts his strung bow a well-educated youth by Ndembu standards.
over the mutuntamu branches and breaks Kasonda insinuated that this tall son of a
them with the strength of the bowstring. He meager father was the by-blow of a youthful
throws the broken twigs on the ground. They affair of Muchona's senior wife. The remark
will later be mixed with other medicines for was pure malice. The alert intellect of the
washing his body and his hunting gear. Just as father was unmistakably reproduced in his
the mutuntamu "sits on" the tree of blood, so son; and the son's achievement was reflected
must the spirit come and sit on the animal and in his father's pride in him.
blind it, in order that the hunter may kill it Muchona came from Nyamwana chiefdom,
easily. He shoots Ntambu to show the spirit just across the Congo border. His mother had
that he has found him out. He now wants been a slave, taken by the Ndembu before Brit-
Ntambu to help him, and not to trouble him ish rule was firmly established. His maternal
any longer. kin were widely scattered over Mwinilunga
28 VICTOR TURNER
District and adjacent areas in Angola and "I know the very man to talk about these
the Belgian Congo. The nuclear group of a hidden matters with you,, he said after my
Ndembu village is a small matrilineage; and return, "Kapaku. He has very many brains.,
no such nucleus had been formed by Muchona 's Next day he brought Kapaku- none other than
kin. Later he was to complain to me that his Muchona! Muchona, as fluid and evasive in his
two sisters in distant villages had ten children movements as wood smoke, had many names
between them and that if they had come to live and Kapaku was one of them. It turned out
with him he could have founded a real village. that Muchona and Windson were neighbors,
He ignored the fact that Ndembu women the one inhabiting a big house of sun-dried
customarily reside with their husbands after "Kimberley" brick, the other his pole-and-daub
marriage and that, indeed, his own wives had hut. Thus began an association that was to last
left their brothers' villages to live with him. eight months. Eight months of exhilarating,
Poor Muchona had been doomed to rootless quick-fire talk among the three of us, mainly
wandering from early boyhood. First of all he about Ndembu ritual. Sporadically, our collo-
had lived in the village of his mother's captors. quy would be interrupted by Muchona 's
That village had split, and Muchona and his doctoring trips, but most evenings after school
mother went with the dissident group. His Windson would stroll over to my grass hut
mother was then transferred as a debt slave to and Muchona would rustle on its still green
yet another group where she was married to one door for admittance. Then we would spend an
of her owners. It seems that when he was a hour or so running through the gamut of
young man, Muchona bought his freedom and Ndembu rituals and ceremonies. Many I had
lived in the villages of several successive wives. seen performed, others I had heard about,
However, he was never able to achieve a high and still others were now no more than old
secular status or an established position in a men's memories. Sometimes, under Windson's
single village. These vicissitudes were both prompting, we would turn to the Old Testa-
his curse and the source of his great ability to ment and compare Hebrew and Ndembu obser-
compare and generalize. Living as he had done vances. Muchona was especially fascinated by
on the margins of many structured groups and the fact that the symbolism of blood was a
not being a member of any particular group, major theme in both systems. My method was
his loyalties could not be narrowly partisan, to take a Ndembu ritual that I had observed and
and his sympathies were broader than those of go through it, detail by detail, asking Muchona
the majority of his fellow tribesmen. His experi- for his comments. He would take a symbol, say
ence had been richer and more varied than that the mudyi tree which is the pivotal symbol of
of most Ndembu, though all Ndembu, being the girl's puberty ritual, and give me a whole
hunters and seminomadic cassava cultivators, spectrum of meanings for it.
travel considerable distances during their lives. Mudyi has white gum [latex]. We say that
When I returned from Lusaka, I decided this is mother's milk. So mudyi is the tree of
to pursue my inquiries into ritual esoterica very motherhood. Its leaves represent children. So
much further than before. In this quest I was when the women seize mudyi leaves and thrust
assisted by the senior teacher at the local them into the hut where the novice's bride-
Mission Out-School, Windson Kashinakaji groom is sleeping, this means that she should
by name, Ndembu by tribe. Windson was a bear many live and lovely children in the mar-
man of independent mind, obsequious to no riage. But the mudyi is also the matrilineage.
European, arrogant to no villager. He was a For our ancestress lay under the mudyi tree
keen but by no means uncritical student of the during her puberty ritual; and women danced
Bible. We often discussed religion together, round her daughter, our grandmother, when
and he became as eager as myself to learn the she lay in that place of death or suffering.
hidden meanings of Ndembu beliefs and prac- And our mother who bore us lay there. And
tices. Most of his boyhood had been spent at a the mudyi also means learning. It is like going
Mission Station behind a sort of spiritual to school today, for it stands for the instruction
cordon sanitaire against "paganism." the girl receives in her seclusion hut.
MUCHONA THE HORNET, INTERPRETER OF RELIGION 29
Later, Muchona would relate the whiteness doctor's technical jargon and salty village argot
of the mudyi to the white beads that are draped into a prose I could better grasp. When taking a
on a miniature bow and placed in the apex of text I made him repeat slowly word by word
the novice's seclusion hut. "These beads stand Muchona's staccato speech so as not to water
for her capacity to reproduce, her lusemu - down its vividness. After a while, the three of
from ku-sema, 'to bear children or beget.' us settled down into a sort of daily seminar on
When the girl comes out of seclusion and religion. I had the impression that Muchona
dances publicly her instructress hides these had found a home of some kind at last.
beads in a pack of red clay on her head. No I also came to know a few of Muchona's
man but her husband may see these beads. She peccadilloes. For example, his knock would
reveals them to him on her nuptial bed." Then now and then be ragged; he would totter into
he would discuss the meaning of the quality the hut, his greeting an octave higher than
of whiteness which many symbols possess. "It usual, and slump down on a stool. He would
means good luck, health, strength, purity, then boast that his real name was "Chief
friendship towards other people, respect for Hornet" (Mwanta lyanvu). This was his weak
the elders and for the ancestors; it means pun on the title of the mighty Lunda potentate
revealing what is hidden." in the Belgian Congo from whose realm the
At other times, I would ask Muchona to Ndembu had come some centuries previously.
describe a ritual from the beginning, whether This title, Mwantiyanvwa, was the most im-
I had seen it or not. Sometimes I would men- portant name the Ndembu knew. Iyanvu was
tion to him what other Ndembu specialists Muchona's "beer-drinking name" (ijina dakun-
had said about its symbols. His accounts and wa walwa), and when he used it he had come
glosses were always fuller and internally more from drinking warm honey beer, a heady brew
consistent than theirs. He had evidently bobbing with bees. "Like a hornet or a bee," he
pondered long on the mysteries of his profes- would say, "I stay near the beer calabashes,
sion, critically comparing the explanations talking loudly, and stinging those who annoy
given him by those who had instructed him in me." Hereupon Windson would fix him with a
the various cults in which he was an adept. stern look, relieved by a twinkle of amusement,
Windson's comments were usually to the and tell him to go away and stay away until he
point. His father had been a famous councilor had become "Mwanta Muchona" again. So the
in the court of a former subchief and from him mighty "Chief Hornet," bedraggled with beer,
as well as from the Mission School, Windson would creep out of the hut.
has acquired a flair for elucidating knotty ques- This was the Muchona at whom men might
tions. Although he was a product of modern scoff - at whom some did scoff, although
change, he had never lost his deep respect others who had been treated by him for illness
for the now passing traditional order and its took a different view. Along with other motives
"reverend signors. n At the time I knew him, he less altruistic perhaps, Muchona had a genuine
was, like other converts to Christianity, begin- desire to cure the ailing and help the unlucky
ning to look askance at the privileged lives of by his magical therapy. For instance, he would
certain of the white missionaries and to wonder often say when describing how he first came
whether the religion of his loved father was to learn some curative technique, "I dearly
really such a farrago of deviltries as he had wanted to cure well by means of Kaneng'a
been led to believe. His major value for me [or Kayong'u or some other ritual]." Kaneng'a
lay in his ability to slow down Muchona's doctors are often feared, as well as invoked,
word-spates into digestible sentences and intel- for they are the authentic "witch-doctors"
ligible texts. For, as I have indicated, Muchona who fight off the attacks of those given to the
was an enthusiast, not only in talk, but, as I use of black art against their kin and neighbors.
have seen him, in professional action as well - There is an implicit threat in the very know-
brisk, agile, full of prescience and elan. Wind- ledge the Kaneng'a doctors possess about
son spanned the cultural distance between Mu- the ways of witches and sorcerers. Muchona
chona and myself, transforming the little himself practiced a modified form of Kaneng'a,
30 VICTOR TURNER
exempt from most of its terrifying elements. the villages, were our kin.'' Other Ndembu
Thus, while most Kaneng'a practitioners col- brought out the propitiatory character of this
lected medicines from the interior of graves, rite in their interpretations; Muchona had
and some would even brandish human thigh- mercy on the disreputable dead. Could it have
bones while they danced, Muchona merely been because he himself had to wander around
took grass from the surface of graves and the margins of respectable society that he felt
leaves and barkscrapings from trees growing fellowship with the despised and the rejected?
in a circle around them. It is difficult to deduce In our "seminars," Muchona seldom betrayed
attitudes from the behavior of members of an- the emotional bases of his calling. A new and
other culture, but I once attended a Kaneng'a exhilarating intellectual dimension had opened
of Muchona's in company with a South African up to him as well as to myself in our discus-
artist from Natal who had seen Zulu doctors at sions of symbolism. At such times he had the
work. Muchona was treating an unfortunate bright hard eye of some raptor, hawk or kite,
woman who was suffering from delusions as as he poised over a definitive explanation.
the result of puerperal fever. My friend was Watching him, I sometimes used to fancy that
impressed by what he considered the "compas- he would have been truly at home scoring
sionateness" of Muchona's demeanor. Gone debating points on a dan's dais, gowned or
was the rather uneasy pertness and comicality perhaps in a habit. He delighted in making
of his usual manner; in its stead was an almost explicit what he had known subliminally
maternal air - kind, capable hands washing about his own religion. A curious quirk of fate
with medicine, a face full of grave concern. had brought him an audience and fellow
My friend commented on the "heroism" with enthusiasts of a kind he could never have en-
which Muchona, at one phase of the ritual, countered in the villages. In this situation, he
ventured out alone into the ghostridden grave- was respected for his knowledge in its own
yard, far from the firelight, to exorcise the right. What has become of him since? Can he
agencies of evil that were making the poor ever be again the man he was before he experi-
victim writhe and babble nonsense. He sub- enced the quenchless thirst for objective
dued his fear to his curative vocation. knowledge?
The compassionate side of Muchona's For Muchona, the homeless, was peculiarly
nature also emerged in the form of comments susceptible to nostalgia. He had a recurrent
he made from time to time during our sessions dream which I translate literally to keep the
on the luckless spirits whom Ndembu call smack of his speech. "I dream of the country
ayikodjikodji, "mischief-makers." These are of Nyamwana where I was born and used to
the spirits of persons inimical to society for live. I am where my mother died. I dream of the
one reason or other: through their greed and village which is surrounded by a palisade, for
selfishness, because they were sterile, because bad people raided for slaves. Streams which
they loved to stir up trouble, and so on. At were there I see once more. It is as though
many rituals gifts of food and beer are offered I were walking there now. I talk, I chat, I dance.
to the ancestors and always a small portion is Does my shadow [mwevu/u- the personal life-
set aside for the ayikodjikodji, usually at the principle] go there in sleep?" Here the rational
margin of the sacred site and far from the side of Muchona came uppermost, for he went
person being treated. Instead of emphasizing on: "I find that place the same as it was long
the outcast position of these entities, Muchona ago. But if I had really visited it, the trees
invariably called attention to the fact that des- would have grown big, grass perhaps would
pite their delinquencies in life these spirits were have covered it. Would there have been a stock-
still entitled to be fed. "For were they not ade? No, it is just a memory." He shook his
human beings once, men and women like our- head lugubriously and said, lingering on each
selves? Wickedness is in the heart [literally syllable, "Aka" (meaning "alas," with a flavor
"liver"] and few can change the hearts they of "Eheu fugaces!").
are born with. We do not want the ayikodji- Muchona appears to have had an excep-
kodii to harm the living, but once they lived in tionally close relationship with his mother,
MUCHONA THE HORNET, INTERPRETER OF RELIGION 31
even for an Ndembu. This emerges in three menstrual disorders, but also to remove frigid-
ways from the history of his inductions into ity and barrenness. Its dominant medicine is
many kinds of ritual. First, it is apparent in the red mukula tree, which Muchona had men-
the fact that Muchona was initiated into the tioned to me at our first encounter. Here the
preliminary grades of certain cults along with tree symbolizes the blood of birth or mother-
his mother, who held the position of senior hood, and the aim of the ritual is to placate an
novice or patient - in Ndembu ritual one must ancestress who is causing the patient's maternal
suffer before one is entitled to learn how to blood to drain away and not to coagulate
cure. Secondly, one finds that after Muchona's around the "seed of life" implanted by her
mother died she became for him an agent of husband. At the esoteric phase of Nkula, a
supernatural affliction in at least one ritual mukula tree is ceremonially cut down and then
context. The spirits of one's kin in Ndembu carved into figurines of infants which are medi-
society punish one for a number of reasons, cated with red substances and put into small
but through punishment, bane may become round calabashes, representing wombs. These
blessing, for the conduct of a ritual to mollify amulets are then given to the patients to carry
the spirit gives the patient the right of entry on strings adorned with red feathers until they
into a tribal cult. Affliction may thus well be bear "live and lovely children."
a blessing in disguise. Thirdly, Muchona 's Muchona was inducted into the Nkula cult
attachment to his mother appears obliquely in when he was about seven years old. His mother
that dead male relatives on her side plagued was principal patient. At her request he was
him into the acquirement of expertise in a given the role of Chaka Chanku/a, usually
number of rituals from which women are taken by the patient's husband or uterine
debarred, such as hunting cults. brother, although sometimes a classificatory
My relationship with Muchona was at a "brother" or "son" may be chosen. The idea
professional rather than a personal level; we behind these choices is that a male who occu-
maintained towards one another a certain pies a social position in which he might be
reserve about our intimate affairs. I did not called upon to support the patient jurally and
ask him direct questions about his past, espe- economically should enact a role symbolizing
cially where the delicate question of his slave the protective and responsible aspects of the
origin was concerned, but I learned much male-female relationship. In practice, however,
about it indirectly from his long spoken rev- it is indeed very seldom that a patienfs own son
eries on rituals in which he had taken part. becomes Chaka.
Now and then, to be sure, he would suddenly A Chaka's main task is to squat behind the
take Windson and myself into his confidence patient, after she has been washed with medi-
about some matter that was currently troubling cines by the doctor, and then to lead her back-
him. In the main, however, the pattern of his wards, while she rolls her head round and
personality, like that of a poet in his poems, round under the doctor's flat collecting basket,
expressed itself in his accounts and interpret- to a small hut built for the afflicting spirit
ations of ritual, and in the nuances of gesture, behind her own marital hut. Then the Chaka
expression, and phrase with which he embel- pulls her into the hut, both of them with their
lished them. In a sense, therefore, Muchona's backs to the entrance. Later they emerge in the
ritual history is his inner biography, for in same fashion and return to the ritual fire.
ritual he found his deepest satisfactions. tvluchona displayed his interest in "etymo-
Muchona's mother had been an adept in logical" interpretations - an interest, inciden-
many kinds of ritual, for among the Ndembu tally, very common among Ndembu- when he
slavery does not debar a person from ritual told me that Chaka was derived from kwaka,
eminence. She also encouraged her children "to deliver a child," or, more accurately, "to
to acquire ritual skills. Muchona had been catch it as it drops."
initiated into three women's cults concerned Only a circumcised male can perform the
with curing reproductive disorders. One of role of Chaka since uncircumcised persons are
these, Nkula, is performed principally to cure reckoned ritually impure. An uncircumcised
32 VICTOR TURNER
boy, like a menstruating woman, is wunabula- called him in to perform the Kayong'u ritual
kutooka, "one who lacks whiteness," and for her, a ritual I shall shortly describe, for
hence purity, good luck, and other qualities Muchona 's first induction into it was a critical
possessed by "whiteness.'' Again, an uncircum- point in his development. Muchona might be
cised boy represents social immaturity, and a described as a Tiresias figure, in that he had
barren woman is also regarded as in some sense considerable insight into feminine as well as
immature. As Muchona explained, "Mukula masculine psychology, especially in the fields
and Nkula both come from ku-kula, 'to grow of sex and reproduction. It seems certain that
up or become mature.' When a girl has her first he identified himself closely with his mother,
menstruation she has grown up a little. When even to the extent of speaking in an alto voice.
she has her first child she has grown up still A young man I knew in Kasonda 's village used
more. Both of these occasions have to do with to speak in a similar way, copying his mother,
blood. After a boy is circumcised he sits, with until he went away to work in a European
others who have been cut, on a long log of township. When he came back he possessed a
mukula, the tree of blood. He has also grown rich baritone, but had acquired a stutter in the
up a little." process of masculinization. Muchona never
Another curious feature of Nkula should be lost his shrill pitch.
noted here, for it may well have influenced He resembled Tiresias in another important
Muchona's development as a doctor. In the respect, for he was a diviner as well as a doctor.
role of Chaka a man is regarded as a midwife, Here again the secret influence of his mother
in Muchona's case his own mother's, in con- can be seen at work. During her lifetime she
tradiction to the strict Ndembu norm that had caused Muchona to be initiated into no
only a woman may deliver another woman less than four kinds of ritual. After her death
in childbirth. Since many Yaka (plural of Muchona believed that she came as a spirit to
Chaka) become Nkula specialists, and since afflict him "in the mode of Kayong'u," and
such specialists are thought to cure reproduct- thus to make a diviner of him. Kayong'u is
ive disorders, the implication is that they are the name of a specific set of symptoms, of the
spiritual midwives. In addition, the Nkula spirit that inflicts them, and also of the ritual to
patient is thought of as being ritually reborn cure the victim. It has two variant forms, one to
into fruitful maturity, reborn that she too may cure the illness and the other to prepare the
bear. Muchona's desire to help the unfortunate patient to be a diviner as well as to cure him.
by the only means known to Ndembu, leech- Women may suffer from Kayong'u and may be
craft and ritual, may have found its first chan- treated by the curative ritual, but they cannot
nel in this early indoctrination in his mother's become diviners. They may, however, carry out
Nkula. minor ritual tasks during subsequent perform-
Without being markedly effeminate in his ances of Kayong'u, if they have been cured.
deportment, Muchona always seemed more at Muchona 's mother had been, in this sense, a
ease among women than men. In my mind's eye Kayong'u doctor.
I can still see him pleasantly gossiping with Muchona's initiation into Kayong'u, and
Kasonda's sister, both of them clucking their the events leading up to it, stood out in his
tongues at the misdeeds of their little world. memory with harsh clarity. He was in his early
This gay, full-blown woman had scant time for thirties at the time and was living with his
her scheming brother, whom she often scolded recently acquired wife, Masonde, among his
for his meanness to her. Muchona, to his credit, stepfather's kin on the Angolan border. Appar-
or perhaps through timidity, never to my ently it was just about this time that he eman-
knowledge said a word out of place about cipated himself from slavery. One pictures him
Kasonda, who himself had no hesitation in then as a minuscule fellow with a needle-sharp
slandering Muchona behind his back. I fancy and pin-bright mind. He must have already
that Kasonda's sister more than once, in her developed a streak of buffoonery to curry the
imperious way, defended the tiny doctor favor of the bigger and better-born. He must
against Kasonda's insinuations. Certainly, she already have been something of an intellectual
MUCHONA THE HORNET, INTERPRETER OF RELIGION 33
prodigy for his society, half derided and half sudden spasm, leaps on the cock and bites
grudgingly admired - and entirely unable to through its neck, severing the head. Blood
belong. spouts out and Muchona "beats the bloody
He told me that for a long time he had head on his heart to quieten his mind." Then
intermittent attacks of "being caught by a very the big doctor orders a goat to be beheaded. Its
heavy sickness in my body; I found it hard to blood pours on the ground and Muchona laps
breathe, it was like being pricked by needles in it up where it puddles. The cock's head is
my chest, and sometimes my chest felt as placed on a pole called muneng'a, newly cut
though it has been blown up by a bicycle from the same species of tree from which an-
pump." A diviner was consulted, and he diag- cestor shrines of quickset saplings are made,
nosed that Muchona was suffering from the symbolizing ritual death and contact with
sickness of Kayong'u. Furthermore, not one spirits. The sun now rises and the doctor takes
but three spirits had come out of the grave to a hoe, a cupful of goat's blood, the hearts of the
catch him, two full brothers of his mother, and cock and goat, various "sharp" objects, and
his father. He himself had dreamed of one of leads a procession of the doctors from the vil-
his uncles and of his father while he was ill. lage into the bush. They go to a fork in the path
Both these spirits, he said, were urging him to and keep straight on instead of following either
become a diviner, for they had practiced that path. They find the principal medicine tree of
profession. He had also dreamed of his mother, the ritual, a kapwipu tree, which stands in
significantly enough. "She came too,, he told this context for initial misfortune followed by
me, "but she was so weak that the diviner did success- a meaning it also possesses in hunting
not recognize her." It is typical of Muchona cults. They pray to the afflicting spirits and
that he felt compelled to stress the novelty of then heap up a mound of earth at the foot of
his personal lot in religious matters. A whole the tree roughly in the shape of a crocodile,
battery of spirits, not merely a single ancestor, with legs and a tail. Next they conceal the
had singled him out for this arduous and various small objects, such as a knife, a razor,
dangerous profession. needles, a bracelet, and a string of beads under
The values and attitudes expressed and in- the mound, at the head, tail, and sides. Before
culcated in Ndembu ritual leave their stamp on concealing the razor and needle, the big doctor
its subjects. Personality is shaped at the forge pricks the cock's and goat's hearts with them.
of ritual, especially where the ritual deals with Then they bring the drums and beat out the
life-crisis, serious illness or, as I believe in Kayong~u rhythm.
Muchona's case, with a severe psychosomatic Now Muchona is led out of the village to
disorder. Thus, an account of one phase of the crocodile image and seated on its "neck"
Muchona 's Kayong'u and his interpretations facing forward. The doctors question him on
of it may reveal something of the man. why he has come to Kayong'u and he gives the
Let us go back thirty years or so to the stereotyped responses regarded as appropriate.
flaring ritual fire of green wood outside Next he has to divine where each of the objects
Muchona's hut in the dull dawn. All night he has been concealed. He told me jubilantly
has been washed with medicine, shuddering that he was completely successful in this, that
convulsively to the Kayong'u drum rhythm, a he seemed to know just where everything
plaything of the savage spirits within him. At was hidden. Each time he answered correctly,
the first faint light, the senior officiant, a he said, the women who had accompanied
hunter-diviner, who was Muchona's father's him to the sacred site trilled their praises
brother-in-law, brings a red cock to the sacred aloud, "making me very happy." Suddenly,
site and holds it up before the patient by its two doctors dart off to the village to hide
beak and legs. Kayong'u like Nkula and the something there. Muchona is led home where
hunting cults is a "red" ritual, full of red sym- he begins searching and snuffling about to find
bolism standing for killing, punishment, witch- what has been concealed. At length he says,
craft, and in general, for violent breach in the "You have kept something here for the name
natural and social orders. Muchona, in a of a dead man." He approaches the muneng'a
34 VICTOR TURNER
pole, he claws up the earth near it. He shouts lightning, as if he were being beaten by a hoe-
aloud, "The name of the dead man is Nkayi handle, as if his ears were completely closed, as
["duiker"], for you have hidden a duiker horn if he could not breathe. He is stopped up. But
here.', Someone called Nkayi, he said, had re- he is opened when he kills the cock. From the
cently died in the village. Then he explains to killed animals he gets wakefulness, alertness,
the doctors, showing off a little, one suspects, for he must be wide awake to become a diviner
"A duiker-antelope is an animal of the bush. and seek out hidden things." The orifices of
An animal lives in the bush, but a man lives in various senses - ears, nostrils, eyes - are
the village.» He explained this to me by saying stopped up during his ritual seizure; then the
that while hunters seek out hidden animals in novice experiences a release, an access of
the bush diviners hunt out the secret affairs of heightened sensitivity. Again the curious paral-
men in villages. At any rate, according to lel with Tiresias springs to mind for the Greek
Muchona, the big doctor is highly impressed soothsayer was smitten with blindness before
and calls out, "This man will make a true div- he attained insight.
iner." All gather round Muchona and praise Muchona said of the fork in the path:
him, but he had to pay the doctors many yards
of cloth, he added rather ruefully. Nevertheless, When people come to a fork, they must then
he had been cured of his malady. It had gone choose exactly where they want to go. It is the
place of choice. UsuaJly they have foreknow~
immediately. The spirits that had afflicted him
ledge of the way to go. Everyone has such
henceforth helped him to divine and protected
knowledge. But the diviner goes between the
him from evil. Shortly after the performance,
paths to a secret place. He knows more than
he apprenticed himself to a famous diviner and other people. He has secret knowledge.
learned the difficult manipulative and inter- When the doctor pricks the hearts with
pretative techniques of that profession, many needle and razor, he is representing the pa~
of which he went on to describe in a series of tient's pain. The patient must not feel it again
sessions. because it has already been done in the hearts
Muchona's interpretation of the symbolism of the cock and goat. But if he becomes a
of Kayong'u was compounded of both trad- diviner, he will again feel that pricking inside
itional beliefs and his own deeper insights: him - while he is divining. It is the thing which
"The cock represents the awakening of people tells him to look at the tuponya [the symbolic
from sleep; at dawn the cock begins to crow objects shaken up in a basket whose combin-
and rouses them. The goat too stands for ations tell the diviner the cause of his clienes
waking up, for at dawn it begins to bleat when illness or bad luck or how someone's death
it runs after she-goats and it disturbs people was brought about by a witch or sorcerer].
with its sound. The Kayong'u spirit too The diviner must be sharp like the needle,
awakens people it has caught. It makes them cutting like the knife. His teeth must be sharp
emit a hoarse breathing, like a cock or a goat." to bite off the cock's head with one bite. He
I have myself heard Muchona and other div- goes straight to the point in hidden matters.
iners make a deep asthmatic wheezing noise in The crocodile in Kayong'u stands for divin-
the course of ordinary conversation. This is ation because it has many sharp teeth, like
needles.
supposed to be the voice of the Kayong'u spirit
A diviner can catch witches by Kayong'u,
inside them. The Kayong'u then endows its
by its sharpness, and also by his divining
possessor with special alertness, with the
basket. These help one another. A person
power of the first light that follows the secret- who has Kayong'u is safe from witchcraft.
ive night, full of witches and mysteries. Thus if someone tries to bewitch me, my three
Muchona continued: "It is the power of the Tuyong'u [plural of Kayong'u] would kill that
Kayong'u spirit that makes a man kill the cock witch. For they are terrible spirits.
with his teeth. It makes a person a little mad.
When he is shuddering he feels as though he I have tried to sketch some of the factors
were drunk or epileptic. He feels as though he that may have been responsible for making
were struck suddenly in his liver, as if by Muchona a "marginal man'' in Ndembu
MUCHONA THE HORNET, INTERPRETER OF RELIGION 35
society. His slave origin, his unimpressive ap- speculate that beneath his jester's mask, and
pearance, his frail health, the fact that as a child under his apparent timidity, he may have cher-
he trailed after his mother through several vil- ished hatred against those more securely placed
lages, even his mental brilliance, combined to in the ordered groupings of society. Such
make him in some measure abnormal. His hatred may itself have given him a certain clair-
special abilities could not overcome the handi- voyance into tense relationships in the kinship
caps of his social marginality and psychical and political systems. Forever outside the
maladjustment. But he found some kind of in- village circle, he could see the villagers' weak
tegration through initiation into curative ritual spots and foibles more clearly than most.
and especially into divinatory status. For these, His very objectivity could further his general
his outsider characteristics were positive quali- revenge. Nevertheless, he may himself have felt
fications. In a ritual context he could set himself unconscious fear that those he disliked plotted
apart from the battles for prestige and power counter-retribution against him. This fear
that bedevil kinship and village relationships in made him at once meek and comical in his
Ndembu society. Ndembu ritual, like ritual daily doings. By playing the timorous fool he
everywhere, tends to assert the higher unifying belittled his own powers and thus defended
values of the widest effective congregation. The himself. Moreover, his fear may have had
doctor-diviner heals or judges by reference to something to do with the fact that he invariably
commonly held beliefs and values which tran- rationalized his ritual tasks as being for the
scend the laws and customs of everyday secular good of society. The flower of altruism some-
society. Thus Muchona 's very weakness and times has twisted roots.
vulnerability in village life were transmuted It was an undoubted fact that Muchona,
into virtues where the maintenance of the total popular with most elderly women, was disliked
society was concerned. by many men. For example, when his junior
The rich symbolism of oral aggression in wife's baby died, a child who he admitted to
Kayong'u points up a very different aspect of everyone was not his, men from a number of
the diviner's role, and since Muchona set so villages took pleasure in telling me that they
much store by his occupancy of such a role it suspected he had bewitched it to death. To
must have modeled many of his attitudes. In discredit these damaging views, communicated
the past, a diviner had to ply a dangerous trade. to Muchona by innuendo, he took the trouble
I have been told of diviners who were shot or to make a wearisome journey of several score
speared by the relatives of those they had de- miles to his parents-in-law to report the details
clared to be witches or sorcerers. Moreover, of the baby's illness and the remedial measures
they had to overcome by aggressive means he had taken. He told me wryly on his return
much fear and guilt in themselves to reach that they had taken fifteen shillings - a consid-
decisions that might result in the death by erable sum for a village - from him as compen-
burning of their fellow men. At its mildest, sation for the child's loss to their lineage.
their profession entailed the probability of de- Muchona, as the husband, was held respon-
daring in public that someone was a witch. No sible for the child's welfare. He said that they
one but a diviner would do this, for as in all had taken no account of the money he had
societies, the polite fiction prevails among already paid a diviner to ascertain the cause
Ndembu that social intercourse is governed of death, nor of the cost of treatment by a
by amity and mutual consideration. Only the herbalist, also borne by Muchona himself.
diviner, fortified by ritual and protected by The diviner had declared him innocent of the
ferocious spirits that torment him while they child's death in the presence of his wife's kin,
endow him with insight, can publicly expose had indeed nominated as the sorcerer an
the hates that simmer beneath the outward important headman belonging to her lineage.
semblance of social peace. If Muchona had been a tougher personality
One feels, therefore, that there is an aspect in secular affairs, he might have refused to
of unconscious revenge against the social order pay compensation for an illicit child and
in divination. In Muchona's case, one may have gotten away with it. As it was, he felt
36 VICTOR TURNER
constrained to ingratiate established authority polite or too diplomatic to say so, for everyone
whenever he met it - or else to run away and knew that Kasonda and I had been friends of
build his hut in a different area. long standing.
There is another instance of Muchona 's When Windson heard this sorry tale, his
tendency to capitulate without a struggle to expression grew bleak and precipitous, as I
public pressure. One day, after he had been suspect it must often have done when he dealt
working with me for about three months, he with refractory schoolchildren. "I must have a
strutted in wearing a suit of white ducks, paid word with some of these people," he said.
for out of my cash gifts. He had informed "Most of them have children at my school."
everyone with some pride, I was told later, He turned to Muchona, "Don't take any notice
that his son Fanuel Muchona had given him of these troublemakers. They won't say an-
the suit. Indeed, poor Muchona often tried other word." Nor did they. For Windson was
to give the impression that Fanuel was more not only deeply respected as a man of integrity,
solicitously filial than he really was. It was but he also had effective sanctions at his
soon discovered that Fanuel had only put his command. As village schoolmaster, he could
father in touch with the vendor, not given him recommend or fail to recommend children for
the money for the suit. After our session, Middle School education at the distant Mission
schoolmaster Windson said to me sadly, "That Station. Village Africans in Zambia are well
fine suit will make everyone jealous, for aware that a good education is a vital means
people will realize that you have been paying to such upward social mobility as is available
him well, and we Ndembu are a very jealous to black people. If the schoolmaster were to
people." become unduly aware of acts of naughtiness
Sure enough, a few days later Muchona on the part of certain borderline cases for
came to us in his usual khaki rags, looking promotion, he might well send in an adverse
utterly woebegone. "What on earth's the report. I don't think Windson would have
matter?" I asked. He replied, "This is the last done this, for he was a gentle, earnest, and
time we can speak about customs together. not unkindly man, but a hint in the proper
Can't you hear the people talking angrily in quarters that Muchona was not to be bothered
the village shelter? When I passed it on my again had a wonderfully sobering effect.
way here, they were saying loudly, so that I Windson had become uncommonly fond
could hear, that I was giving away our [tribal] of Muchona in the course of our discussions.
secrets, and that I was teaching you witchcraft At first, he had tended to display a certain
matters.'' I was distressed and a little hurt to coolness, bordering on disparagement, to-
hear this, for my relations with the villagers wards Muchona's "paganism," but in a very
had always seemed extremely friendly. I said short time he grew to admire the little man's
as much to Muchona, who went on, "No, it is intellect and his appreciation of the complexity
not the people of this village, at least only a few of existence. Later still, Windson came to take
of them, who are talking like this, but others positive pride in the richness and sonority of
who come to hear a case discussed in the village the symbolic system Muchona expounded to
shelter. But the people of this village, especially us. He would chuckle affectionately at Mucho-
one man - I name no names - say that I am na 's occasional flashes of dry wit.
telling you only lies. Before I came, they say, One of those flashes came after we had
you heard only true things about our cere~ spent a long session on a painful subject, the
monies, but now you just hear nonsense. But ihamba. In its material expression, an upper
one thing I found wonderful. The village front incisor tooth of a dead hunter imbeds
people call me a liar, the strangers say I am itself in the body of a person who has incurred
betraying secrets. Their reasons [for disliking the hunter's displeasure. The tooth is removed
meJ don't agree, but they agree with each by means of a ritual procedure which includes
other!" I knew that it was Kasonda who called confession by the patient and by his village
Muchona a liar, for he had hinted as much to relatives of their mutual grudges, and the
my wife often enough, but Muchona was too expression of penitence by the living for having
MUCHONA THE HORNET, INTERPRETER OF RELIGION 37
forgotten the hunter-ancestor in their hearts. bear an unconscious grudge against his
Only after "the grudge has been found" will mother - displaced on to her unknown brother
the tooth cease "to bite" its victim and allow -for saddling her son with slavery? Did he not
itself to be caught in one or another of a have the fantasy that even a slave could become
number of cupping horns affixed to the pa- great, as his uncle was reputed to have done?
tient's back by the doctor's principal assistant. At any rate, in Muchona's phrasing of ihamba
After about a couple of hours, Muchona beliefs, he seemed to feel that he was in the grip
became very restive on his hardwood stool. of some irremediable affliction, that indeed
Full of the zest of inquiry, I had become his sickness was himself. Although suffering
thoughtless and had forgotten to give him made him a doctor in many curative cults,
his usual cushion. Eventual1y he burst out, he never became an ihamba specialist. One
"You have been asking me where an ihamba fancies that this one incurable trouble repre-
goes. Well, just now I have an ihamba in the sented for him the deathless gnawing of his
buttocks." I silently passed him his cushion. chagrin at being of slave origin and at not
However, this was not all. We used to punctu- really "belonging" in any snug little village
ate our deliberations pleasantly enough with community.
an occasional cigarette. Today I had forgotten No man can do justice to another's human
even to pass around the yellow pack of "Bel- total. I have suggested that in Muchona there
gas." So Muchona said, "I have another iham- was a deep well of unconscious bitterness and a
ba." "What's that one?" "The angriest ihamba desire for revenge against a society that had no
of all, the ihamba of drinking [i.e., smoking] secular place for him compatible with his abil-
tobacco." Like a true professional, Muchona ities. Yet the small man had a big mind. He was
could make innocuous quips about his craft. only too sensitively aware of the undertone of
Muchona normally took ihamba beliefs derision and resentment with which many men
very seriously. He had been treated no less than regarded him. Although he was paramountly
eight times, he said, to gain relief from an intellectual rather than warm-hearted, he tried
ihamba that made his joints sore. Either on the whole to speak and act civilly and char-
because the doctors were charlatans- one tried itably; and he treated his patients with compas-
to deceive him with a monkey's tooth- or more sion. In our long collaboration he achieved an
often because "the grudge was unknown," amazing degree of objectivity about the sacred
the ihamba remained to vex him. Several values of his own society. Whether his outlook
divinations had established to his satisfaction was radically altered by our threefold discus-
that the ihamba came from a mother's brother sions I was not to know. All I do know is that
who had been taken while still a boy by Luba shortly before I left his land, probably forever,
slave raiders many years ago. Later, his mother he came to see me, and we had an outwardly
had learned that her brother had become a cheerful drink together. Presently, he grew
famous hunter and a wealthy man in Lubaland, quiet, then said, "When your motor car sets
having purchased his freedom there, but she out in the early morning do not expect to see
never saw him again. Muchona believed that me nearby. When someone dies we Ndembu do
he held an undying grudge against his maternal not rejoice, we have a mourning ceremony."
kin, perhaps because he had not been captured Knowing Muchona as I did, I could not help
but had been sold into slavery by them - who feeling that he was not simply feeling sorry at
could teH so long afterwards? Muchona the loss of a friend. What grieved him was that
was being afflicted on account of this grudge. he couJd no longer communicate his ideas to
Since no one could now find out what it was, anyone who would understand them. The phil-
he felt he could never be cured of the biting, osophy don would have to return to a world
creeping ihamba. May we not see in this a that could only make a "witchdoctor" of him.
projection of Muchona's own state? Did he Had not some kind of death occurred?
4
The Ojibwa Self and
Its Behavioral Environment
Irving A. Hallowell
Although there is no single term in Ojibwa my Indian speaker knowledge and experience
speech that can be satisfactorily rendered into derived from the statements of a number of
English as "self," nevertheless, by means of different informants. Furthermore, the state-
personal and possessive pronouns, the use of ments of my Indian speaker, which all appear
kinship terms, and so on, the Ojibwa Indian between quotation marks, may be taken as a
constantly identifies himself as a person. Every free translation of a possible Ojibwa text, since
individual knows who he is, where he is, and I have not used any English words that do not
what kind of being he is; he entertains definite have a fairly good equivalent in Ojibwa. Beside
beliefs and concepts that relate to his own this, Ojibwa terms for key concepts are cited.
nature. Besides this, his language enables him In brackets I have added my comments on
to express such concepts as self-defense, self- particular points in order to highlight signifi-
glorification, self-deceit, self-command. Large cant concepts and have sometimes gone into
areas of his most characteristic thinking, his further elaboration. 1
affective experience, his needs, motivations, "When I was born I had a body, miy6, and
and goals are not thoroughly intelligible unless I had a soul, otcatcakwin. My body came out
we take the content of his self-image into of my mother's womb and when I was an old
account. man it was buried in the earth [the body has a
I believe that the essential features of the definitive existence in time]. I was not one of
self-image of the Ojibwa, in their full psycho- those people who knew what was happening
logical reality, can best be communicated by before he was born. But my father did.
indicating how they function as an integral part "I have heard some other old people say
of the experience of an individual. To present that they had heard babies crying constantly
the material in this form I have let an Indian, until someone recognized the name they were
long deceased, speak in the first person, rather trying to say. When they were given this name
than attempt an abstract exposition. In order they stopped crying. This shows that someone
to cover as many aspects of the topic as pos- who had once lived on the earth came back to
sible and yet remain as close as possible to Jive again. [Reincarnation is possible, even if
data collected in the field, I have attributed to occasional. There are special cues in such cases:
Irving A. Hallowell, "The Ojibwa Self and its Behavioral Environment," pp. 172-82 in Culture and Experi~
ence. New York: Schocken Books, 1955.
THE OJIBWA SELF AND ITS BEHAVIORAL ENVIRONMENT 39
the recall of prenatal memories; crying and the self assumes great importance. The further
babbling that only stops when the name of a implication is that an attack on the body des-
deceased person is mentioned,2 which indicates troys the balance that should exist between soul
the importance of the personal name in self- and body in order to realize the Good Life, that
identification. Another cue is the presence of a is, life in terms of longevity, health, and absence
few gray hairs on the infant's head. In cases like of misfortune. Since self-awareness is given
this no personal identification may be made. content in terms of a self-image defined by this
Certain inferences are clear: the soul is inde- dichotomy, anxiety may be aroused if either
pendent of a particular body; it transcends the soul or body is endangered. In a positive sense
body in time; an implicit concept of the self is this is why pimddaziwin expresses a very cen-
intimately connected with the idea of the soul. tral goal for the self - a level of aspiration
Self-objectification is clearly implied since self- towards which the self is motivated. 3 ]
awareness is even attributed to the foetus. The "When I died and my body was buried that
informant says that his father knew when he was not the end of me. I still exist4 in djtbaicxk-
was going to be born. To the Ojibwa to know ing, Ghost land or the Land of the Dead.
what is going to happen ahead of time is one of [Existence of self is not coordinate with bodily
the signs of a "great" man, i.e., a man with existence in the ordinary human sense.J When
unusual powers.} I was dead people called me a djibai, ghost.
"When I was living on the earth I had to be Some Indians have seen djtbaiak (plural) or
careful that nobody got hold of any part of heard them whistle. [In other words, a dead
my body. When my hair was cut I always burnt person has a form, a ghostly appearance that
the part that was cut off. I was afraid that can be seen by the living and, without being
someone with power [magic] might get hold visually perceived, may occasionally be heard
of it. If he wanted co, such a person could make by the living. Death involves metamorphosis
me sick or even kill me. I didn't want to die because the body formerly associated with the
before I had to. I wanted life, pimddazi'win. soul has become detached from it and lies in
But someone did manage to kill me by sending the ground. On the other hand "P' know when
something towards me that penetrated my "!" am a djibai; self-awareness, personal iden-
body. That's when you need a nibakiwin-inr tity, personal memories persist; there is a con-
[an Indian doctor who tries to remove the tinuity of the self maintained.]
object by sucking as part of his ritual]. Some- "It is a long hard journey to the Land of the
times he will suck out a shell, a piece of metal, Dead. To reach it you travel south. 5 [There are
or a dog's tooth and show it to you. Then you cases known in the past in which pagan Indians
can live. But he couldn't cure me. He didn't begged their Christianized relatives not to bury
have enough power. The person who killed them in a coffin. They believed that they would
me had more. [The body is intimately con- have to carry it with them on the iourney to the
nected with the self, so intimately that physical Land of the Dead, and they did not wish to be
possession of even a part of it is considered as burdened with it. This journey is not conceived
endangering the self. The self can also be in "spiritual" terms at all; the "living" self can
attacked by magically potent material sub- become emotionally disturbed by the anticipa-
stances projected into the body. In general, it tion of difficulties to be encountered by the
may be said that bodily illness of any kind "dead" self. It is plain that, psychologically,
arouses great anxiety. The Ojibwa tend to be the behavioral environment of the self is all of
hypochondriacal. There are two points of inter- one piece.]
pretation that are relevant in this connection: "When I got there I found it to be a very fine
Since serious illness, in many instances, is place. The Indians who had died before me
thought to be due to sorcery, it becomes a direct were glad to see me. Some of them had moss
personal attack upon the self by an enemy. At growing on their foreheads [like old rocks],
the same time since illness, viewed from the they had died so long ago. I sang and danced
standpoint of experience, involves the dysfunc- with them. A few Indians have reached the
tioning of bodily processes, the bodily aspect of Land of the Dead and then gone back to tell
40 IRVING A. HALLOWELL
those who were alive what they saw there. [The done when I was living. This helped my son
dead in appearance are thought of anthropo- to get well. 8 [Under these circumstances the
morphically, not as disembodied spirits. They ghost has no usually perceptible form; only
live in wigwams. But there are differences. In the soul is there. But functionally, a self con-
one account a youth visiting the land of of dead tinuous with a "living" existence is implied
was offered food by his grandmother. It was because personal memories of an earlier period
decayed (i.e., phosphorescent) wood. When he in life are recalled.]
refused, she said: "Naturally you are not truly "When a person is sleeping anyone can see
dead. . . .'' An essential point for emphasis is where his body is, but you can't tell whether his
the continuation of a fundamental duality of soul is there or not. Some conjurer may have
essence. Djtbaiak like linicindbek have souls, enough power to draw your soul into his
and some kind of form. As will become more shaking tent while you are asleep. If he has
apparent later, this duality holds for all orders the power you can't resist. Perhaps he only
of animate beings.] wants to have you talk to the people in his
"If an Indian dies and a good medicine man camp and teH them the latest news. But he
starts after him quickly enough he may be may want to kill you. If your soul doesn't get
brought back [i.e., his soul may be captured back to your body then you'll be a djibai by the
and returned to his body]. Then he can go on next morning and have to start off to the Land
living as before. Once I saw Owl do this. 6 of the Dead. I had a lucky escape once. I was
T cetcebu was very ill. By the time Owl arrived only sixteen years old. A conjurer drew my soul
where her father was encamped, she died. Owl into his conjuring lodge and I knew at once that
tied a piece of red yarn around the girl's wrist at he wanted to kill me, because I had made fun of
once [to enable him to identify her quickly in a his son who was a 'humpy' [hunchback]. I said
crowd] and lay down beside her body. He lay in 'I'm going out.' But the old man said, 'No! You
this position a long, long time. He was still; he can't go.' Then I saw my own head rolling
did not move at all. Then I saw him move ever about and the people in the lodge were trying
so little. The girl began to move a little also. to catch it. [The "people" were the guardian
Owl moved more. So did the girl. Owl raised spirits, pawaganak, of the conjurer - super-
himself up into a sitting posture. At the same human entities.] I thought to myself that if only
moment the girl did the same. He had followed I could catch my head everything would be all
her to the Land of the Dead and caught her soul right. So I tried to grab it when it rolled near me
just in time. Everything has to have a soul in and finally I caught it. 9 As soon as I got hold of
order to exist (as an animate being). I'm in the it I could see my way out and I left. Then I
Land of the Dead now but I have a soul just as I woke up but I could not move my legs or arms.
had one before I came here. [Death involves the Only my fingers I could move. But finally I
departure of the soul from the body; the soul managed to speak. I called out to my mother.
takes up its residence in a new locale. There is I told her I was sick. I was sick for a couple of
metamorphosis. The body becomes inanimate days. No one saw my sould go to and fro but I
and "selfless." The persistence of the self in knew where I had been. I told my father about
conjunction with the soul in its new form is it and he agreed with me.
implied in the self-awareness attributed to [It is quite clear from all this that the soul is
ghosts.] detachable from the body and may occupy
"If a conjurer, diisakiwinini, has power a different position in space. This is true both
enough he can bring a soul back from the Land with respect to a dead person and a person
of the Dead into his 'shaking tent.' I was called asleep. It is also possible to infer with reasonable
by a conjurer once because my son was ill and certainty that the soul cannot be conceptually
this man was trying to cure him. My grand- dissociated from the self. Where a functioning
child went with me. When her mother, who self exists, there must be a soul. Where a soul
was sitting with the other Indians outside the exists there must be a self. In terms of an as-
conjuring tent, heard her speak, she cried. 7 sumed dependent relationship the self-soul rela-
I had to tell about something wrong I had tion in Ojibwa thought logically parallels the
THE OJIBWA SELF AND ITS BEHAVIORAL ENVIRONMENT 41
self-body relation in our sophisticated thinking. threw off the blanket and fell over towards
We emphasize a certain kind of physical body or the fire. Blood was running from his mouth;
form as a necessary substratum for a function- he was dead. My friend found out what killed
ing self. We are skeptics so far as any other kind him. At the very same time that the sorcerer
of a structural substratum is concerned. On the was lying under his blanket so quietly, in
other hand, the Ojibwa take it for granted that another part of the camp Pindlmdakwan was
the soul is the only necessary substratum. Any waiting with a gun in the dark beside the body
particular form or appearance is incidental. of his son who had been killed by sorcery. A
Thus, various kinds of metamorphosis can be kind of 'fire' had appeared around the camp
accepted so long as it is assumed that a soul several times before the boy died. This night
continues to exist. What is particularly inter- Pindandakwan saw the 'fire' coming again. It 12
esting to note, it seems to me, is that once we made a circle around the corpse, which was
accept this assumption, it becomes more and covered by birch bark. He heard a voice saying,
more apparent that functionally the same gen- 'This is finished.' Then he saw a bear trying to
eric attributes of the self as we understand it- lift the bark near the head of his son; he was
and that we assume can only be manifested going to take what he wanted. 13 Pindandak-
where a human bodily structure is present - wan shot the bear and he heard a man's voice
are constant functions of the soul as thought crying out. Both the sorcerer and the boy were
of by the Ojibwa. The soul of the living or the buried the next day. Everyone thought the old
dead knows who it is, what it is, where it is in man was a bad one. No one blamed
space and time; it is conscious of past experi- Pindandakwan.
ences, it has a capacity for volition, etc., irre- [This anecdote requires some lengthy com-
spective of the form or appearance it may ment, since it will enable us to penetrate further
present to others at the moment. This interpret- into Ojibwa thought and the basic premises
ation is further illustrated by what follows.] involved. (a) It is obvious that there is not
"There was a djibai here who paid a visit to metamorphosis of the body of the sorcerer.
her grandfather. He was so very sad after she The miy6 remains in the wigwam in its usual
died. She visited him one day when he had form. (b) Unlike the previous case where the
put a mast up in his canoe and with a blanket soul was drawn from the body by the power of
for a sail was crossing a lake. She appeared to another person, here the soul leaves the body
him as a little bird that alighted on the top of behind through a volitional act of the conjurer
the mast. She didn't say anything but he knew himself. In fact the Ojibwa would say that he
who it was because he was a wise old man. 10 left his body and point out that this was not the
[The deceased - one of the very old people, first time, since his reputation for wickedness
keteiinicindbek - may be seen by a living implies this kind of behavior. And the "fire"
person, not as a ghost but in the form of a bird. had been seen at Pindandakwan's camp before.
Metamorphosis is possible for a djtbai; in this (c) It is likewise obvious that, in this case, the
case from ghost to bird.] conjurer was not understood to be prowling
"The soul of a living person, roo, after it around dressed up in a bear skin. This was
leaves the body can look like an animal. A John Tanner's interpretation, over a century
powerful medicine man can do a lot of harm ago, of similar stories. He writes: " ... by some
because he can go about secretly at night. But composition of gunpowder, or other means
you can see his body lying there in his wigwam [they] contrive to give the appearance of fire
all the time. A long time ago a friend of mine to the mouth and eyes of the bear skin, in
told me what he had seen. 11 He and his wife which they go about the village late at night,
were living with an old man suspected of being bent on deeds of mischief, oftentimes of
a sorcerer. One night he thought the sorcerer blood." 14 This is simply Tanner's effort at an
was up to something. The latter lit his pipe and explanation intelligible to him. (d) I believe
covered himself up completely with his blan- that all we need to say is that the self of
ket. My friend kept watch. After a long, long the sorcerer was in Pindfmdakwan's camp. To
time had gone by, all of a sudden the sorcerer say that he was there is the meaningful core of
42 IRVING A. HALLOWELL
the whole situation; it was Pindandakwan's time to resume living (which was, no doubt,
assumption that he would be there and he part of the magic employed by Pindanadak-
acted on this premise. In these terms the situ- wan), the sorcerer's soul was compelled to
ation is as humanly intelligible to us as it is to assume the form of a ghost. In a brief account
the Objbwa. What is always difficult for them of his puberty fast, to which our Indian speaker
is to explain what we would call the mechan- now refers, the reader will note another in
ism of events, exactly how they occur. To them, which the temporary separation of the soul
this line of thought seems "pedantic.'' Explan- from the body occurs. To the Ojibwa there is
ation is never pursued in much detail at this nothing particularly unusual in such a personal
level (which is actually the level of science). But experience. We lack autobiographical anec-
to say that he (the sorcerer) had visited Pindan- dotes, however, because there is a traditional
dakwan's camp on several occasions, that he taboo upon references to personal experiences
had killed Pindandakwan's son, that he was during the puberty fast.]
caught there on a particular night and killed "Long ago, when every boy used to go out
by Pindandakwan in revenge is thoroughly alone into the woods to obtain his helpers his
meaningful to them. All they take for granted body remained in the wazisan (nest) his father
(as an implicit metaphysical principle) is that built for him. 1 ·'i If you had been there you could
multiform appearance is an inherent potential have seen his body for yourself. But his soul
of all animate beings. What is uniform, con- might have been elsewhere. One of his helpers
stant, visually imperceptible and vital is the might have taken him somewhere. That is what
soul. A sorcerer being a person of unusual happened to me."
power is able to leave his human body in one
When I was a boy I went out to an island to
place and appear in another perceptible mani-
fast. My father paddled me there. For several
festation elsewhere. (e) There is an additional nights I dreamed of an 6gimii (chief, superior
point to be noted. Inquiry revealed that Pin- person). Finally he said to me, "Grandson, I
dandakwan was known to have considerable think you are now ready to go with me., Then
power himself. Since he assumed it was a sor- 6gima began dancing around me as I sat there
cerer prowling around and not an ordinary on a rock and when I happened to glance
bear, he did not load his gun with an ordinary down at my body I noticed that I had grown
bullet. He mixed "medicine," m&ckiki (having feathers. Soon I felt just like a bird, a golden
magical potency), with his gunpowder. Just as eagle (kinlu). Ogimii had turned into an eagle
it is thought possible to attack a person's ordin- also and off he flew towards the south.
ary body with intent to kill by projecting a I spread my wings and flew after him in the
material object with magical properties into same direction. After a while we arrived at a
it, in the same way the sorcerer, in the bodily place where there were lots of tents and lots of
appearance of a bear, could be directly "people." It was the home of the Summer
attacked through his body, although something Birds. . . . [After returning north again the
more than an ordinary bullet was required. boy was left at their starting point after his
(Under the circumstances there was no way of guardian spirit had promised help whenever
focusing the attack on his soul). In both in- he wanted it. The boy's father came for him
stances the body is assumed to be a vulnerable and took him home again]. 16
point of attack. Since it is fairly clear that what From this account it can be inferred that in
death implies for the Ojibwa is the separation addition to living Indians and deceased
of the soul from its humanly-formed body, I Indians, there are other classes of animate
believe they would agree that the soul of the beings in the behavioral environment of the
sorcerer did not succeed in getting back to his Ojibwa self with whom the individual comes
human body. This explains why his body was into direct contact under certain circum-
seen to collapse. It could not resume its normal stances. For it is apparent that the dreams
functioning without a soul. This is why Owl of the puberty fast are interpreted as experi-
was in such a hurry to capture the soul of ences of the self. The being that first appears
T cetcebu. Not being able to reach his body in as a human being and then is transformed into
THE OJIBWA SELF AND ITS BEHAVIORAL ENVIRONMENT 43
a bird is representative of a large class of appearance alone. Myths illustrate this, too,
other-than-human entities that maintain an and unless we are aware of the point I have just
existence independently of iinicinabek and are made it is utterly impossible to apprehend their
more powerful than man. The eagle-man is not verdical nature from the Ojibwa point of view.
the bird one ordinarily perceives but belongs to Myths are sacred stories because they rehearse
the class of "owners, or "bosses." All animal actual events in which the superhuman pawa-
species, such as the golden eagle, are thought to ganak are the main characters. These pawaga-
have a kadabenimikuwat. These "owners" are nak are specially adept at metamorphosis. This
only perceived, however, in dreams or visions. is part of the dramatic interest of the myths.
If we assume that dream experiences are The Ojibwa are quite prepared to have the
interpreted by the Ojibwa as experiences of pawdganak manifest the same characteristic
the self we then arrive at a very important attribute in dreams. It is one of their essential
deduction. The pawaganak are experienced as attributes because metamorphosis, especially
appearing in a specific form, that is, as having a when volitionally induced, has the implication
bodily aspect, whether human or animal. Years of "power." It is thought that the human being
ago I wrote in my notebook that Chief Berens, who is capable of metamorphosis has derived
my most intelligent informant, said flatly that his power through the help of pawdganak. This
the pawaganak had "bodies" and "souls," but is the only source of it. When he possesses it he,
no "ghosts." Since my natural bias was to think therefore, becomes superior to his fellow-men
of these pawaganak as "spiritual beings," I did in this regard. They have to respect him even
not at first see the implications of the statement though they fear him. The only metamor-
he had made. In our present discussion its full phosis of all iinicindbek is brought about by
import is clarifying. The soul is the essential death. The dead, however, have more power
and persisting attribute of all classes of animate than the living; consequently they are more like
beings, human or nonhuman. But the soul is pawaganak, including the power of metamor-
never a direct object of visual perception under phosis. But the pawaganak, who are eternal, do
any conditions. What can be perceived visually not die; they never become djtbaiak.
is only the aspect of being that has some form The only sensory mode under which it is
or structure. Consequently, it is not surprising possible for human beings to directly perceive
to find that when the pawdganak appear in the presence of souls of any category, and then
dreams they are identifiable in a tangible visual under certain conditions only, is the auditory
form. This experiential fact taken at its face one. The chief context of this kind of experi-
value indicates, of course, that they, too, have ence is the conjuring tent where, as I have
a body as well as a soul. Structurally, they are already pointed out, the souls of djibaiak
the counterpart of man. On the other hand, it may be present and speak. 17 It is only infre-
is not assumed that they have a uniform or quently that ghosts may be heard to whistle,
stable appearance. Metamorphosis is always perhaps in the neighborhood of a grave, where
possible, as in the dream reported. It may be it is sometimes said they have been seen. It is
inferred, therefore, that there are inherent at- from the conjuring tent, too, that the voices of
tributes which remain constant for different pawaganak may be heard to issue. They cannot
classes of beings. In the dream referred to the be seen. Thus from the standpoint of our cen-
being that appeared was a pawagan of a certain tral problem it is difficult not to draw the
kind and not a human being, even though conclusion that, while according to Ojibwa
he first appeared in a human form. This is just dogma it is a soul that is present, even to them
the reverse of the bad old sorcerer who was it is always an identifiable self- pawdganak or
essentially human even though he appeared as ghost - that speaks. For them otcatc.dk
a bear on certain occasions. This means, of defines the conceptual substratum of beings
course, that in the behavioral world of the with self-awareness and other related attri-
Ojibwa, no sharp line can be drawn between butes (speech, memory, volition, etc.) that we
animals, pawaganak, men, or the spirits of the associate only with a stabilized anthropomor-
dead on the basis of outward bodily aspect or phic structure. When Ojibwa speak of their
44 IRVING A. HALLOWELL
animals do not ordinarily come so close to scribed by the Ojibwa by saying that the
any human habitation]. "I saw the flame pawaganak took "pity" upon the kigusinno,
when he breathed. I said to my wife very the faster. It was through dreams or visions,
quietly: 'Hand me the axe.' She could not while the body lay inert, that direct experi-
find it. The bear started to go. I tried to ence of these entities occurred.
follow but I could not walk fast enough. I 16 This account was repeated to me by a man
spoke to the bear. I said, 'I know who you are who said he had heard the dreamer narrate it
and I want you to quit. I'm good natured but when he was an old man. The conjuring tent
if you come here again I won't spare you. • He consists of a barrel-like structure, covered
never came back and after that I gradually with bark or canvas, that conceals the con-
got better." It is said that a sorcerer who kills jurer who kneels within. Those who witness
a person in this way is bound to visit the the performance are outside this structure.
grave. He cuts off the fingertips of the Since the pawaganak reputedly are inside
corpse, the tip of the tongue, and gouges they, like the conjurer himself, are invisible
out the eyes, and stores them in a little box to the audience without.
for magical use. This is why Pindfmdakwan 17 On the other hand, it is said that the pawa-
made a pseudo-grave for his son outside the ganak do have a visible aspect from inside
wigwam. It was a deliberate "trap" for the the tent. They look like tiny stars or minute
sorcerer. Pindfmdakwan was an actual sparks. It is only under very exceptional cir-
person who appears in my genealogies. cumstances, however, that any person except
14 John Tanner, Narrative of the Captivity and the conjurer ever has an opportunity to even
Adventures of john Tanner, etc., E. James peep inside the structure during the perform-
(ed.), 1830, p. 343. Tanner was a white ance. Consequently, the sensory manifest-
man captured by Indians as a boy. He lived ation of the spirits is typically auditory, not
with Ojibwa and Ottawa, learned their lan- visuaL
guage and published his reminiscences in 18 See HalJowell, 1942, pp. 50-51.
later life. For further information on bear
walking and the attitude of contemporary
Indians toward it, see R. M. Dorson, Blood- REFERENCES
stoppers and Beartvalkers. Folk Traditions
of the Upper Peninsula (Cambridge, 1952), Barnouw, Victor
pp. 26-29 and Notes, p. 278. 1949 "The Phantasy World of a Chippewa
15 The Ojibwa boy, at puberty or before, Woman," Psychiatry XII: 67-76.
sought tutelaries or guardian spirits: with- Dorson, Richard Mercer
out their help no man could be expected to 1952 Bloodstoppers and Bearwalkers. Folk
get much out of life or amount to anything. Traditions of the Upper Peninsula. Cambridge,
The "nest" referred to was a sort of stage MA: Harvard University Press.
constructed by laying poles across the Hallowell, A. Irving
branches of a tree about fifteen feet from 1939 "Sin, Sex and Sickness in Saulteaux
the ground. The boy was expected to remain Belief," British journal of Medical Psychology
on this stage several days and nights without XVIII: 191-7.
food or drink. He was only allowed to des- Hallowell, A. Irving
cend to the ground to urinate and defecate. 1942 The Role of Conjuring in Saulteaux
This fast was the most crucial event in a Society. Philadelphia and London: University
man's life and to undertake it he has to be of Pennsylvania Press.
pekize, pure (without sexual experience). Hallowell, A. Irving
Failure to observe all preliminary conditions 1955 Culture and Experience. Philadelphia:
and the fasting regulations destroyed his University of Pennsylvania Press.
chances of blessings from other-than-human Tanner, John
entities - the pawaganak (literally, "dream 1830 Narrative of the Captivity and Adven-
visitors") - who were more powerful than tures of john Tanner, ed. Edwin James. New
human beings. The situation is often de- York: G. & C. & H. Carvill.
5
The Charity Physician
Rudolf Virchow
Health care for the indigent or, in other words, and human dignity began to stir in them and
the medical treatment of poor patients, as prac- were exploited for purposes of generalized agi-
ticed up to now has involved two great wrongs: tation on an ever increasing scale, an agitation
one against the patients, and the other against allegedly endangering European civilization.
the physician. But who can be surprised that democracy and
The indigent were compelled to accept socialism nowhere found more adherents than
treatment by certain physicians assigned from among the physicians or that, on the extreme
above, as they had no choice other than to left, it is physicians who frequently head the
either remain untreated or to consult the phys- movement? Medicine is a social science, and
ician approved by the authorities. The phys- politics is nothing more than medicine on a
icians, due to unlimited competition, were large scale.
obliged to accept a position which withheld Not enough that politically and socially
from them payment commensurate to their both the poor and the physicians were driven
efforts. into the opposition, very often their mutual
And with it all the patients who had at their relations also became most deplorable. Poor
disposal such an assigned physician, and the patients made demands on the physician who
physicians who had managed to obtain such had been officially foisted on them that the
an ungrateful position had to be thankful, rich would not have dared to make without
as there were large parts of the land where promising very high rewards, and they faced
patients searched in vain for a physician, and him distrustfully, rudely and brutally in the
numerous physicians worn out by years of vain bargain. While they not infrequently neglected
struggle against nepotism of all sorts in their and disregarded the physician's instructions
futile endeavor to obtain even such a beggarly and prescriptions, they nevertheless demanded
post. from him utter dedication by day and by
These conditions were bound to embitter night, complete devotion of body and spirit.
the poor as well as the physicians; both were The physician on his part, burdened with
bound to be gradually imbued by the con- the demands of his profession and no doubt
viction that they were the victims of false social with worries for his own living, lacking ad-
principles. Society thus created its own equate means for the proper care of the
enemies. The proletariat grew more restive patients, almost without any prospects of per-
day by day; confused ideas of human welfare sonal appreciation for the pains he was taking,
Rudolf Virchow, "The Charity Physician," pp. 33-6 in L. J. Rather, ed., Collected Essays on Public Health and
Epidemiology. Canton, MA: Science History Publications, 1985 [1879]. Used by kind permission of the
publisher: Science History Publications/USA, division of Watson Publishing International LLC, Sagamore
Beach, MA
48 RUDOLF VIRCHOW
exhausted and ill-humored, only too easily a certain degree of physical and moral power.
tended to neglect his charges, to counter their That mortality, too, should be a measure of the
exaggerated demands with cold phlegm, and security of public institutions in the civilized
to search in a more profitable and grateful states seems at first sight a bit far-fetched.
practice compensation for his privations. What However, regardless of the fact that increase
would be simpler and more natural? in mortality denotes abnormal conditions in
And what were the consequences of such national public life, which fact sooner or later
a situation for the state? The number of the ill must be implanted in the public consciousness
increased, as did the number of poor in general; of a people, there is a yet more direct danger
the lower classes increasingly fell victim to in the rapid change of generations. The experi-
diseases and epidemics. Their children either ence of various different countries, in particu-
died prematurely, or developed in a stunted lar the investigation of the Irish immigration
and crippled manner. Even though great indi- in England, has shown that under such condi-
vidual wealth may have accumulated in the tions births increase with shortness of life span.
hands of some, national prosperity as a whole Generation rapidly follows on generation. All
stood on an increasingly unstable foundation conservative elements disappear in the progres-
and an ever increasing army of inimical dispos- sive break-up of the family in such ephemeral
sessed grew up within society. The proletarian populations, who become indifferent to their
knows that he owns nothing, and if the finan- short life. Thus, society nurtures in its bosom
ciers and statisticians prove to him even more the proliferating seed of its destruction.
brightly than did Mr. Thiers that the prices of Perhaps we have dwelt on this point longer
the necessities have been falling in the past 50 than was quite necessary in this context. But
years, of what use is this to those who com- we shall have to return to it later, and we
pletely lack the means of purchasing all these therefore wished to clearly illuminate dangers
cheap and beautiful things? Had Mr. Thiers, which threaten the community from a faulty
the well-to-do bourgeois, whose father-in-law, organization of the care for the poor from the
if we are not mistaken, for so long a time was medical point of view.
General Tax-Receiver in Lille, only looked If we now return to the physician for the
around in that city, he would have soon found poor, who should be one of the most essential
out who profited by the low prices. Statistical members in the care for, and the welfare of the
evidence furnished by two members of the Lille poor, and to his position with respect to the
Board of Health, Mr. Gosselet and Mr. Loiset, impoverished patient, we soon note a great
would have shown him that from 25 children difference in the requirements of different
of the poor, only one reached the fifth year of localities. In the cities, especially in the big
life; that, when recruiting in 1841, 95 percent cities, there is an over-accumulation of phys-
of the young men were rejected because of icians, many of whom have nothing to do. In
small size; and that, so as to find 300 able- the flat country, especially in the eastern prov-
bodied men, these had to be selected from inces, there is a great shortage in physicians.
537 conscripts. Such figures demonstrate more The iniquity is evident.
than would thick volumes on property. They Mr. S. Neumann ("Die offentliche Gesund-
sufficiently prove that a state which tolerates heitspflege und das Eigenthum/' p. 82) has
such conditions is facing the greatest of already drawn attention to the favorable effect
dangers. Mortality, as well as physical and of the number of physicians on mortality rates,
moral debilitation of the population, rise in and to the error of believing that physicians
direct proportion with impoverishment. It goes increase mortality. In the eastern provinces of
without saying that no state can long endure on Prussia almost as many people die from acute
such a basis. Working power is the source of internal diseases as from chronic ones, while
national prosperity and the wish to work the the proportion in the western and central prov-
expression of the moral state of the population. inces is 1: 2. From these figures public opinion
Therefore, peace and legality can be assured immediately demanded that the number of
only in a state formed by individuals possessing physicians be increased in these areas and that
THE CHARITY PHYSICIAN 49
they be assured of a sufficient income at public utterly deprived. All their efforts to save them-
expense, since the poverty and ignorance of the selves from sinking into total destitution were
inhabitants precluded any prospects of their futile. First a man had to become a pauper and
making a living from their practice. That is only then was he given, in a bureaucratic way,
how the idea of appointed district physicians documents of legitimation which insured his
arose, and it now only remained to be decided poverty for ever. The derelicts must not only
whether these physicians should be paid by the taste their misery to the last drop, they must
state or by the community. This is tantamount also carry it in their pockets in black and white.
to proposing for the countryside and the small Only then were they taken care of, and a
cities a repetition of the very conditions already special physician for paupers was procured
existing in the large cities and in certain rural for them in advance.
areas: certain physicians were to be forced on The practical disadvantage hence arises
the patients. from mistaken principles, and it would seem
The demands of some physicians, in the here too, as always, that the reasonable also is
pursuit of their special interests, went still fur- the appropriate, or at least that the unreason-
ther; consequently they claimed that all phys- able is always inappropriate. If one truly wants
icians should be engaged by appointment. to create a public health service as would
Without going into further detail on these follow from the legally acknowledged principle
questions which we will discuss in a later art- of equal rights for all, as we have shown
icle, we here only want to refute those who, before, one must also liberate the dispossessed
while they defend free practice and the free from his extraordinary position, and as far as
right of establishing such a practice anywhere, possible rescue him from the dependence in
nevertheless demand definitely remunerated which he has fallen on account of his need. It
posts by the appointment of physicians for the is realized that this cannot be achieved through
indigent (as community or district physicians) a public health service alone, but only if educa-
everywhere. tion and a measure of prosperity are attainable
We have already exposed above the prac- to the poor to a wider extent than up to now.
tical disadvantages inherent in the system of But public health care must at least contribute
appointed physicians for the poor as practiced to maintain that individual independence as far
up to now, on account of the element of coer- as possible. For this reason we do not wish to
cion associated with it. But the erroneous see any special physicians for the poor, when-
principle of the system is at least as harmful. ever that is possible. In the great cities and in
For if the health services for the poor so far the well-to-do regions we certainly do not need
have rather appeared to be an outflow of any. In poor districts with a low population one
public beneficence, while the natural right to can perhaps not do without appointed district
such health and welfare services transpired physicians even though difficulties will arise
only incidentally, and while their political and there for them which will render their efficient
economical character was totally denied, the functioning difficult.
health services for the poor were looked upon We shall take up this subject at a later date.
as an exceptional institution exclusively des-
tined for a certain part of the population and
established out of mercy or mere necessity.
REFERENCE
This was accepted because one's heart strings
were touched, or because nothing else could be Neumann, S.
done in safeguarding one,s own security, but 194 7 Die Offentliche Gest.tndheitsflege und
one always waited until the poor had become das Eigenth~tm, Berlin: Riess.
6
The Role of Beliefs and
Customs in Sanitation
Programs
Benjamin D. Paul
Man is a biological and social animal; he is also assume their way is the way or the "natural''
a cultural animal. He is cultural in that he runs way. Interacting with others in their own
his life and regulates his society not by blind society who share their cultural assumptions,
instincts or detached reason alone, but rather they can ignore culture as a determinant of
by a set of ideas and skills transmitted socially behavior; as a common denominator, it seems
from one generation to the next and held in to cancel out. An engineer can construct health
common by the members of his particular facilities in his home area without worrying
social group. Culture is a blueprint for social too much about the cultural characteristics of
living. Man resides in a double environment- the people who will use the facilities. Sharing
an outer layer of climate, terrain and resources, their habits and beliefs, he has in effect taken
and an inner layer of culture that mediates them into account. But in another country
between man and the world around him. By with another culture, his assumptions and
applying knowledge which comes to him as those of the residents may not match so well.
part of his cultural heritage, man transforms In parts of Latin America maternity patients
his physical environment to enhance his of moderate means expect a private hospital
comfort and improve his health. He also inter- room with an adjoining alcove to accommo-
prets his environment, assigning significance date a servant or kinswoman who comes along
and value to its various features in accordance to attend the patient around the clock. In parts
with the dictates of his particular culture. of rural India the hospital should be built
Among other things, culture acts as a selective with a series of separate cooking stalls where
device for perceiving and understanding the the patient's family can prepare the meals, in
outer world. Since cultures vary from group view of cultural prohibitions against the hand-
to group, interpretations of the physical ling of food by members of other castes. And
environment vary correspondingly. of course the effect of cultural differences
Ordinarily people are unaware that cul- looms even larger where sanitation has to be
ture influences their thoughts and acts. They built directly into the habit systems of people,
Benjamin Paul, "The Role of Beliefs and Customs in Sanitation Programs," American journal of Public Health
48 (1958): 1502-6.
THE ROLE OF BELIEFS AND CUSTOMS IN SANITATION PROGRAMS 51
rather than into structures and plants that serve times, that because some areas of the world
the people. are technically underdeveloped their people or
Anyone familiar with the operation of tech- their cultures are in general underdeveloped.
nical assistance programs knows about the A third and particularly common shortcom-
kind of behavioral differences I have men- ing in our understanding of cultural differences
tioned. Unfortunately, however, it is easy to is a tendency to view customs and beliefs as
misconstrue these observed differences. Three isolated elements rather than as parts of a
kinds of misinterpretation are common. The system or pattern. The linkages between the
first is to suppose that "thei' have more odd parts of culture may be loose or tight and the
beliefs and habits, while we have less of them. connections are not always apparent upon first
We tend to see them as captives of blind custom inspection, but it frequently turns out that
and ourselves as relatively free from cultural people cling to a particular practice or belief
peculiarities. The fact is that all men are crea- not merely because it is familiar and traditional
tures of their culture with its inevitable ad- but because it is linked to other elements of the
mixture of rational and nonrational elements. culture. Conversely, a change effected in one
Cultures differ and rates of cultural change area of the culture may bring with it unex-
differ, but peoples do not differ appreciably in pected changes in other areas or may result in
the degree to which their actions are influenced awkward dislocations, as the following illus-
by their respective cultures. We are quick to tration will indicate.
apply the term "superstition" or the epithet On the island of Palau in the western Pacific
"uncouth custom" to the other fellow's manner the pattern of living calls for frequent and large
of thinking or behaving. We may be repelled by gatherings of people to celebrate or solemnize
the custom of eating domesticated dogs and certain social events. In the old days, Palauan
yet impatient with people who would rather houses were large enough to hold many people.
go hungry than eat their cattle. Americans take There were no partitions, and it was possible
offense at the odor of night soil in the settle- for each man attending a feast to receive his
ments of Korea and other parts of eastern Asia; food in the order of rank and to sit in such a
a Korean gentleman on his first visit to New way as not to cause offense by turning his back
York was asked by a friend how he liked the on anyone. Since the last war, most Palauans
great city, whereupon he replied: "Oh, very live in small two- or three-room houses built in
well, but the smells are so bad!" 1 Measured the Japanese or American style. They try to
by the standards of one culture the manifest- maintain the old customs but they have their
ations of another are bound to appear more or troubles. Visitors overcrowd the small house
less arbitrary or bizarre. We need to realize that and sit packed together on the floor. They must
we have culture, too, and that our ways can suffer the insult of having to look at a neigh-
seem as peculiar to others as theirs do to us. bor's back and must take their food in any
Even allowing that our behavior as well as order they can. The Palauans are incessant
their bears the stamp of cultural conditioning, a betel chewers - and spitters. The old houses
second facile assumption is that our ways and had several doors and numerous floor cracks
ideas are more advanced than theirs, that to accommodate this habit. The new buildings,
they have yet to catch up with us. The trouble especially the Quonset huts now being created
with this assumption is that it represents a for chiefs' dwellings and council chambers,
partial truth: Some aspects of culture, notably have caused a minor crisis. The two Quonset
scientific knowledge and technical skills, are doors are premium locations; knotholes in the
indeed subject to measurement and relative plywood floors are too scarce to provide relief
ranking. But knowledge is not wisdom, and for the majority of chewers. Tin cans are
many aspects of culture, including language, coming in as spittoons, but these are in scarce
esthetics, moral codes, and religious values, lie supply. 2
beyond objective rating for want of a culture- Housing customs and hospitality customs,
free standard of measurement. It is a mistake once closely linked in Palau, are now in
and an insult to imply, as we inadvertently do at strained relationship. It should be stated
52 BENJAMIN PAUL
social sciences is rapidly being introduced into tal Sanitation, Government of India Ministry
schools of public health. of Health.
4 WeiJin, Edward
''Water Boiling in a Peruvian Town." In Health,
NOTES Culture and Community: Public Reactions
to Health Programs (Benjamin D. Paul, Ed.).
Moose, J. Robert New York: RusseH Sage Foundation, 1955.
Village Life in Korea, 1911. 5 Foster, George M.
2 Barnett, H. G. Use of Anthropological Methods and Data in
Innovation: The Basis of Cultural Change. Planning and Operation. Pub. Health Rep.,
New York: McGraw-Hill, 1953, p. 91. 68:848, 1953.
3 Mimeographed material distributed by the 6 Ackerknecht, Erwin H.
Research-cum-Action Project in Environmen- Personal communication.
7
Introduction to
Asian Medical Systems
Charles Leslie
The health concepts and practices of most with similar institutions for cosmopolitan medi-
people in the world today continue traditions cine. Together with folk practitioners, physi-
that evolved during antiquity. Ideas about the cians who utilize these institutions provide a
ways that body processes are thrown off bal- major source of medical consultation for all
ance by the improper consumption of "hot" or classes of people. Asian medical systems thus
"cold" foods, or the ways that envy, fear, and provide fascinating opportUnities both to ob-
other strong emotions generate poisonous sub- serve directly practices that continue ancient sci-
stances by disturbing the body's equilibrium, entific modes of thought and to analyze the
are based upon humoral theories that were first historical processes that mediate their relation-
elaborated in the classic texts of medical science ship to modern science and technology.
several thousand years ago. These ideas, and Three primary traditions of medical science
others related to them, are held by the majority were formulated in what Alfred Louis Kroeber
of Asians and by large segments of European called the Oikoumene of Old World society.
and African society. Imported to the New The Greeks used the word Oikoumene, the
World in colonial times, they still play an inhabited, to refer to the entire range of man-
important role in Latin American communities. kind, but Kroeber redefined the term to desig-
Folk curers throughout the world practice nate the civilizations of Asia, Africa, and
humoral medicine, but in Asia alone educated Europe that from ancient times to the present
physicians continue its learned traditions. day have formed "a great web of cultural
Most notably in China and India, but also growth, areally extensive and rich in content"
in Japan, Sri Lanka (formerly Ceylon), and (Kroeber 1952:392). Ideas and products have
other countries, the institutional forms of pro- been transmitted from one end of this network
fessional education and practice have been to the other for thousands of years, and yet
adapted to indigenous medical traditions. stylistically distinctive traditions have con-
Research institutes, colleges, hospitals, profes- tinued to exist. The stylistic continuities that
sional associations, and pharmaceutical com- distinguish the civilizations of the Oikoumene
panies for Chinese, Ayurvedic, and Yunani can be identified in their medical traditions.
medicine coexist to a greater or lesser extent For example, in Asian Medical Systems (Leslie
Charles Leslie, "Introduction," pp. 1-12 {modified} in C. Leslie, ed., Asian Medical Systems. Berkeley:
University of California Press, 1976. © 1976 University of California Press Books. Reproduced with permis·
sion of University of California Press Books in the format textbook via Copyright Clearance Center.
56 CHARLES LESLIE
1976), Manfred Porkert and W. T. jones con- century. It continued in this form through the
trast fundamental styles of thought in Chinese Middle Ages in Christian and Islamic societies,
and Western medicine, though they approach and was carried by the spread of Islam to Cen-
the subject from different methodological per- tral Asia, India, and Southeast Asia. The
spectives. Also, Gananath Obeyesekere and system was called Yuniini Tibbia in Arabic,
Alan Beals describe long-enduring South Asian meaning Greek medicine, and it is still prac-
forms of thought, in Obeyesekere's case by ana- ticed under that name in Pakistan, India, Sri
lyzing the popular culture of Ayurvedic phys- Lanka, and other South Asian countries.
icians and their patients in urban Sri Lanka, J. Christoph Biirgel (1976) emphasizes the
and in Beals' essay by describing the habits Galenic character of Arabic medicine: it was
of mind of peasant villagers in Mysore State, not significantly influenced by South Asian
India, as they decide to use different kinds of theories, although Ali al-Tabari was familiar
therapy. with Indian medical texts as early as the
I will call the three main streams of learned ninth century. Nor, according to Sir Joseph
medical practice and theory that originated in Needham (1970: 14-29), did knowledge of
the Chinese, South Asian, and Mediterranean Chinese medicine notably effect the Galenic
civilizations "great-tradition'' medicine - a tradition, though a thirteenth-century Persian
term derived from Robert Redfield's work on physician, Rashid at-din al-Hamadani, dir-
the comparative study of civilizations. Observ- ected the preparation of an encyclopedia of
ing that the development of civilizations was Chinese medicine.
characterized by the differentiation of great Knowledge of the South Asian and Chinese
from little traditions, Redfield described this medical traditions was carried through the
process as "the separation of culture into hier- Oikoumene from the nuclear areas of their
archic and lay traditions, the appearance of an development, just as the Mediterranean trad-
elite with secular and sacred power and includ- ition was carried to distant societies. The South
ing specialized cultivators of the intellectual Asian system was called Ayurveda, meaning
life, and the conversion of tribal peoples into knowledge of life, or longevity. It was known
peasantry" (Redfield 1956:76}. Illustrating the in the Mediterranean region long before the
interdependency of great and little traditions, translation of Greek texts into Arabic. Several
Redfield speculated that "the teaching of Galen Hippocratic authors recommended medica-
about the four humors may have been sug- tions that they attributed to India, and Plato's
gested by ideas current in little communities theory of vision - that a fiery element in the
of simple people becoming but not yet civil- eye joined with the corresponding element
ized; after development by reflective minds in things - resembled that of Ayurveda, as did
they may have been received by peasantry and some details of his conceptions of illness and
reinterpreted in local terms" (ibid: 71). of anatomy (Filliozat 1964: 229-237). The
The first point that I want to make about diffusion of Buddhism from India to China
the great medical traditions is that they main- was certainly accompanied by exchanges of
tained their individual characters although Ayurvedic and Chinese medical knowledge,
they were in contact with each other. The yet Chinese medicine had no discernible effect
integrity of the separate traditions needs to be on the development of Ayurveda, and Joseph
emphasized to avoid the assumption that all Needham maintains that the overall influence
significant early medical science originated in of Indian on Chinese medicine was minor.
Greece (or India or China, for that matter). My Evaluating the relation of Chinese medicine
second point will be that the three traditions to Greek and Arabic tradition, Needham
nevertheless share general features of social writes: "It is really hard to find in it any West-
organization and theory that allow us to describe ern influences" (1970: 18-19). On the other
a generic great-tradition medicine which can be hand, Chinese medicine strongly affected med-
contrasted with cosmopolitan medicine. ical institutions in Korea, Japan, and parts of
The Mediterranean tradition was compre- Southeast Asia, and Ayurveda had a marked
hensively formulated by Galen in the second influence in Tibet, Burma, and Southeast Asia.
INTRODUCTION TO ASIAN MEDICAL SYSTEMS 57
Although the three great medical traditions medical aid was a philanthropic enterprise
were relatively independent, they evolved in appropriate to religious institutions and to
similar ways. They aU became professional wealthy individuals. Needham's discussion of
branches of scientific learning in the millen- Chinese priorities is directed toward correcting
nium between the fifth century ac and the the biases that have caused Western writers on
fifth century AD. Professional standards for the history and philosophy of science to focus
education and practice were achieved by on why the Scientific Revolution occurred in
appeals to the authority of Galen, Caraka, the seventeenth-century Europe. The framework
Nei Ching, and other highly respected texts. in which this question is asked sometimes
Since rational theories and therapeutic formu- resembles that of a believer in witchcraft who
las were elaborated in the texts far beyond the confronts the death of an old man with the
knowledge of laymen and folk curers, the abil- question, "Why did it happen on Tuesday?"
ity to show acquaintance with them validated The fact that the Scientific Revolution first
claims to a superior social position. Claims occurred in Europe is taken by Europeans as
to high status were symbolically expressed in a priori evidence that the Western tradition
special modes of dress and deportment recom- possessed a genius for scientific progress
mended by the texts, and they were rational- lacking in the Chinese and Indian traditions.
ized by ethical codes that defined a physician's Thus it is possible to question the orientation-
responsibilities. shared by Needham as much as by those he
Women were not educated in medicine, criticizes- that makes temporal priority a pre-
and the perspective of the classic texts was dominant issue.
masculine. Practitioners ranged from phys- Besides resembling each other in the organ-
icians who had undergone long periods of ization of practice, the great traditions of
training to individuals with little education medicine were formulated from generic physio-
who practiced a simplified version of the great logical and cosmological concepts. All of them
tradition. Other healers coexisted with these were humoral theories: four humors in the
practitioners, their arts falling into special cat- Mediterranean tradition (yellow bile, black
egories: bone-setters, surgeons, midwives, bile, phlegm, and blood); three humors in the
snake-bite curers, shamans, and so on. But South Asian tradition (kapha, pitta, and vayu,
the complex and redundant system of learned usually translated as phlegm, bile, and wind};
and humble practitioners, of full-time and and six humors in Chinese medicine (the chii,
part-time practitioners, of generalists and spe- or pneuma, which were held in the sway of
cialists, of naturalist and supernaturalist yang and yin). The humors were alignments
curers, was ideologically simplified by the dis- of opposing qualities: hot-cold, wet-dry, heavy-
tinction elaborated in the texts between light, male-female, dark-bright, strong-weak,
quacks and legitimate practitioners. The con- active-sluggish, and so on. The equilibrium of
cern the texts show for this distinction indi- these qualities maintained health, and their dis-
cates that society assigned learned physicians equilibrium caused illness, whatever the number
a lower social status than the one that they of humors. Equilibrium was regulated by an
aspired to, and that their power to dominate individual's age, sex, and temperament in
the overall system of medical practice was dynamic relationship to climate, season, food
limited. consumption, and other activities. Diagnoses re-
The Chinese may have led in rationalizing quired skill in observing and correlating physical
medical services, for they developed an exten- symptoms and environment. Therapy utilized
sive bureaucratic system to instruct and exam- physical manipulations, modification of the pa-
ine physicians, along with what, according to tient's diet and surroundings, and numerous
Joseph Needham and Lu Gwei-djen, "can only medications. Some medications required elabor-
be described as a national medical service" ate preparation; others, valuable and esoteric
(1969:268}. But in all of these societies, armies substances such as herbs gathered from distant
required organized medical services, rulers mountainsides, saffron, gold, precious stones, or
acted as patrons to medical scholarship, and parts of rare animals.
58 CHARLES LESLIE
associations, various routines of hospital admi- continue to refer to Western medicine. But for
nistration, or the etiquette of doctor-patient comparative purposes another term is needed,
relationships. A second and equally stultifying and the model that I have outlined in the pre-
assumption is that all medicine other than ceding pages is best referred to as "cosmopol-
cosmopolitan medicine is unscientific. By com- itan medicine."
monly recognized criteria, Chinese, Ayurvedic, The picture I have drawn of the great med-
and Arabic medicine are scientific in substan- ical traditions formed in the Oikoumene of Old
tial degrees. They involve the rational use of World civilizations, and of the recent full emer-
naturalistic theories to organize and interpret gence of cosmopolitan medicine, brings the
systematic empirical observations. They have subject of Asian Medical Systems in view. Let
explicit, orderly ways of recording and teach- me restate it briefly. In countries like the United
ing this knowledge, and they have some effica- States or Japan, cosmopolitan medicine is pre-
cious methods for promoting health and for eminent: its representatives dominate medical
curing illness. Of course, by other criteria, such work and exercise unprecedented legal and
as the degree of instrumentation and standard- cultural authority to define situations and
ization of techniques, or the refinement of make decisions during birth, illness, and death,
experimental methods, these systems are less as well as to shape norms for sexual conduct,
scientific. In objective comparative research, child rearing, or questions of sanity. Although
judgments about the scientific character of cosmopolitan medical institutions exist in
medical theories and practices vary because every country, most people alive today con-
multiple criteria exist for calling them scien- tinue to depend on humoral theories and prac-
tific, and because most criteria specify elements tices. In large parts of Asia, educated
that may be more or less well developed. Rec- practitioners still draw upon these traditions
ognition of the need to evolve conceptual and, with folk practitioners, provide a major
models and to record data for the complex source of medical care. Thus, great and little
analyses that this subject requires is discour- medical traditions coexist to various degrees
aged by preemptively labeling one set of insti- and in various ways with cosmopolitan medi-
tutions "scientific medicine." cine in China, India, Japan, and other coun-
Finally, the term "Western medicine" is mis- tries. Analyses of these variations are avenues
leading for obvious reasons. The scientific to understanding the role of scientific know-
aspects of Western medicine are transcultural. ledge and professional organization in trans-
Ethnic interpretations of modern science are formations of the human condition.
the aberrations of nationalistic and totalitarian I have defined the subject of our essays in
ideologies or, in this case, a reflex of colonial language suited to their scholarly spirit, but my
and neo-colonial thought. Furthermore, the tone has been too cool to indicate the nature of
social organization of cosmopolitan medicine our enterprise. Asian Medical Systems began in
as I have described it is as Japanese as it is a castle on a mountain in Austria. Ours was the
Western. Because modern science and profes- fifty-third Burg Wartenstein Symposium spon-
sionalization processes are intrinsically cosmo- sored by the Wenner-Gren Foundation for
politan, Fred Dunn's phrase "cosmopolitan Anthropological Research. Our aim was to
medicine" is appropriate. Still, Croizier Ralph develop new lines of research in medical an-
(1976) te1ls us that the Chinese referred to thropology, some of which the Foundation had
their own tradition simply as medicine, and initiated in previous symposia (Galdston 1963
began self-consciously to call it "Chinese" only and Poynter 1969). Preliminary drafts of our
in modern times as they adopted the contrast- essays were circulated prior to our discussions,
ing term "Western medicine." Since ethno- which lasted from july 19 to 27, 1971. Lira
graphic and historical descriptions benefit by Osmundsen, Director of Research for the
using categories of the cultures they describe, it Foundation, lifted the spirit of the Symposium
makes sense to use these terms in writing about by participating in it, and by orchestrating
modern China. For similar reasons, descriptive arrangements for it to proceed in elegant in-
accounts of other Asian medical systems may formality through meals and intermissions and
INTRODUCTION TO ASIAN MEDICAL SYSTEMS 61
entertainments. We were honored, too, by altogether outside of it. To some members of
Raymond and Rosemary Firth, who visited the Symposium, the model of a uniform cosmo-
the castle briefly during the Symposium. politan medical system with a monopoly of
Had we been members of a single discipline legitimate practice seemed more scientific and
or nationality, our discussions might have gen- efficient and therefore truer and more desirable
erated more disputes than they did. Most of us than a pluralistic model, which from their per-
arrived at Burg Wartenstein knowing nothing spective appeared to legitimize quack medi-
or very little about most other members of the cine, or at least to tolerate and romanticize
Symposium. We had a great deal to learn from medical ignorance.
and about each other, and we spent no time at In fact, medical systems are pluralistic struc-
all drawing intellectual boundaries. Initially tures of different kinds of practitioners and
our focus was substantive rather than meth- institutional norms. Even in the United States,
odological. This will sound dull to methodolo- the medical system is composed of physicians,
gists, and downright anemic to polemicists for dentists, druggists, clinical psychologists,
whom the good guys wear white hats and the chiropractors, social workers, health food
bad guys wear black. In fact, as the Symposium experts, masseurs, yoga teachers, spirit curers,
progressed we returned continuously to con- Chinese herbalists, and so on. The health con-
ceptual differences that caused some of us to cepts of a Puerto Rican worker in New York
think that others of us were naive or dogmatic city, the curers he consults, and the therapies he
or fuzzy-minded. Our guide in clarifying these receives, differ from those of a Chinese laun-
disagreements was the philosopher W. T.Jones, dryman or a Jewish clerk. Their concepts and
whose message was that we did not have to the practitioners they consult differ in turn
agree on most theoretical issues so long as from those of middle-class believers in Chris-
we understood how we differed. It worked tian Science or in logical positivism. Yet the
because he showed us our commonalities and institutions of cosmopolitan medicine are so
analyzed our differences with authority and extensive, well organized, and powerful, that
good humor. the concept of a single, standardized, hieratic
I will describe some of the differences that medical system administered by university-
emerged in our thinking about the systemic trained physicians appears to be normative in
properties of "the medical system." We had American popular culture, as well as in law.
not been asked to develop a particular model Since this is not true in Asian countries, where
for this purpose, though the titles of the Sym- the structures of learned and folk, of humoral
posium and of its various sessions and their and cosmopolitan medicine are coexisting nor-
constituent papers provided guidelines for our mative institutions, members of the symposium
discussions. Mark Field and Edward Mont- who reasoned from a pluralistic model felt that
gomery addressed the issue directly, but all of they were more objective- because less chau-
the papers reasoned from general concepts of vinistic- than those who assumed the norms of
the system that they were reporting. Since they a cosmopolitan medical model.
have been revised for publication and speak for Another disagreement that emerged at our
themselves in the following pages, I will de- conference is related to different conceptions of
scribe our conceptual differences in a sche- cultural organization. Some participants con-
matic manner. ceived the systemic qualities of "the medical
In human affairs, concepts never simply systemu by using concepts of standardization
name and describe things without implying or and consistency derived from the ideal of mass
recommending evaluations of them. The pre- culture. When Asian respondents differed
eminence of cosmopolitan medicine in a coun- among themselves in classifying items of food
try like the United States causes laymen and as belonging to "hot, or "cold" categories, or
specialists alike to identify its professional simultaneously used medicines associated with
institutions with the medical system. All other different ways of defining a malady, their ideas
practices are then considered to be irregular, and behavior were interpreted as having a low
and thus to be aberrations of the system or degree of systematization. Other members of
62 CHARLES LESLIE
the Symposium saw variations of this kind as conception locates the system in the role rela-
an essential dimension of the systems under tionships between people who have reputa-
consideration rather than evidence that they tions as authorities in matters of health and
were disorganized. They interpreted categories illness, and between these specialists and
of food and illness, or of the causes of illness laymen.
and kinds of therapy, as a rhetoric for defining Though our differential preferences for one
situations, deciding what to do, and justifying or another of these approaches did not logic-
one or another course of action. If the categor- ally entail disagreements, they did cause us to
ies were fixed and inflexible they could not be have different feelings abouc what was inter-
used for these purposes. esting or important in our discussions. But
A third source of disagreement concerned even those who shared a preference for one
ways of drawing the boundaries of a medical approach would differ on other grounds.
system. Indeed, the format of the Symposium For example, those who used the cultural
encouraged the use of conceptual models approach would locate the systemic nature
derived from three approaches to this problem, of a medical tradition in the coherence of its
which for convenience can be labeled bio- theories, and reason that it was the integrity
logical, cultural, and social. of the theory that held practices together in a
From the point of view of the biological medical system. One might argue that Chinese
approach, all ideas and behavior that the medicine was an integrated system in the past,
trained observer finds relevant to interpreting whereas contemporary physicians who were
patterns of health and illness are considered to supposedly working in the tradition did not
be part of the medical system. Thus behavioral understand the theories as they were previ-
epidemiology, which would analyze such ously understood, or believe in them in the
things as the relationships between customary way that they were once believed in. Thus
diet or working habits and disease vectors, contemporary practices appeared to be an
would be important for developing compara- opportunistic or non-systematic set of behav-
tive studies of medical systems. This inclusive iors. But another student of Chinese tradition
conception of the systems under study has the would disagree with this conception of history
advantage of emphasizing research goals that and of the relationship between medical
will be useful to health planners trained in theory and practice; while a third might agree
cosmopolitan medicine. By using the best with the general concept but disagree about
current knowledge in ecology, nutrition, path- how to evaluate evidence that the theories of
ology, and other subjects, it provides standards Chinese medicine are now misunderstood or
for comparing the health conditions and the disbelieved.
utility of health practices in different societies. In general, it is fair to report that those
In contrast, the cultural approach conceives the members of the Symposium who focused on
medical system to be composed of deliberate the historical continuities in Asian medical
actions, by members of a society, to maintain systems, and on the systemic qualities of con-
or enhance health and to cure illness. This way temporary great and little traditions, appeared
of thinking about the system emphasizes cat- "romantic" and "theoretical" to those who
egories of thought and traditions within the emphasized historical discontinuities and who
culture. It excludes many ideas, items of behav- argued that the pluralistic, structurally differ-
ior, and ecological relationships that the first entiated Asian medical systems show a low
approach includes. It emphasizes such things as degree of systematization. Of course, the
a mother's self-conscious efforts to promote participants who thought that others were
her child's health by regulating its diet. The "romantic" felt that their own perspective was
social approach to conceiving the medical "realistic,' and "pragmatic.''
system would exclude the mother's behavior Although I have only briefly described the
and conceptions of health and illness until she methodological issues that emerged during
decided to consult another individual recog- our conference, enough has been said to indi-
nized in her community as a specialist. This cate their nature. Our collection of essays as a
INTRODUCTION TO ASIAN MEDICAL SYSTEMS 63
whole has been designed to show how the FiiJiozat, Jean
comparative study of Asian medical systems 1964 The Classical Doctrine of Indian Medi-
opens a new field of scholarship. Such a book cine. Delhi: Munshi Manoharlal.
required the skills of authors with diverse Freidson, Eliot
kinds of training. Those who have contribu- 1970 The Profession of Medicine: A Study of
ted to it are trained in history, sociology, the Sociology of Applied Knowledge. New
anthropology, public health, pharmacology, York: Dodd, Mead.
epidemiology, cosmopolitan medicine, and Galdston, lago
philosophy. One is a practitioner of Chinese 1969 Man's Image in Medicine and Anthro-
medicine, and two are the sons of Ayurvedic pology. New York: International Universities
Press.
physicians. My task has been to define the
Kroeber, Alfred Louis
subject and to indicate concepts that join our
1952 The Nature of Culture. Chicago: Uni-
individual essays in a unified dialogue. Our
versity of Chicago Press.
work will have been well done if others find Leslie, Charles
in it both something to correct and something 1973 "The Professionalizing Ideology of
to build upon. Medical Revivalism," in Milton Singer, ed.,
Entrepreneurship and Modernization of Occu-
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Brass, Paul Leslie, Charles
1972 "The Politics of Ayurvedic Education: A 1976 Asian Medical Systems. Berkeley: Uni-
Case Study of Revivalism and modernization in versity of California Press.
India," in Lloyd and Susanne Rudolph, eds., Needham, Joseph
Politics and Education in India. Cambridge: 1970 Clerks and Craftsmen in China and the
Harvard University Press. West. Cambridge: Cambridge University Press.
Biirgel, J. Christoph Needham, Joseph, and Lu Gwei-djen
1976 "Secular and Religious Features of 1969 "Chinese Medicine/' in F.N.L. Poynter,
Medieval Arabic Medicine," in Charles Leslie, ed., Medicine and Culture. London: Wellcome
ed. Asian Medical Systems. Pp. 44-62. Berke- Institute of the History of Medicine.
ley: University of California Press. Nef,John U.
Croizier, Ralph C. 1967 The Conquest of the Material World.
1976 "The Ideology of Medical Revivalism in Cleveland: World.
Modern China," in Charles Leslie, ed. Asian Poynter, F. N. L.
Medical Systems. Pp. 341-55. Berkeley: Uni- 1969 Medicine and Culture. London: Well-
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Dunn, Fred L. Redfield, Robert
1976 "Traditional Asian Medicine and 1956 Peasant Society and Culture. Chicago:
Cosmopolitan Medicine as Adaptive Systems," University of Chicago Press.
in Charles Leslie, ed. Asian Medical Systems. Sherrington, Charles
Pp. 133-58. Berkeley: University of California 1955 Man on His Nature. Garden City: Dou-
Press. bleday (Anchor).
8
Medical Anthropology
and the Problem of Belief
Byron ]. Good
banner of Neo-Tylorianism in an important set supports [of the granaries] in course of time
of debates about the nature of rationality and that even the hardest woods decay after
during the 1970s. 1 Even a cursory examination years of service," Evans-Pritchard reports. But
will indicate how the rationalist position flows "why should these particular people have been
out of the "Enlightenment" tradition of anthro- sitting under this particular granary at the par-
pology, demonstrate the critical role of "belief" ticular moment when it collapsed?" Thus, al-
in this paradigm, and suggest why it has had though practical reasons explain the immediate
such power within medical anthropology. causes of illness and misfortune, the Azande
A central issue in the rationality debate has turn to witchcraft to answer the "why me?"
been discussion of the problem of "apparently question, to find an underlying cause in the
irrational beliefs'' (for example Sperber 1985: moral universe and a response that is socially
ch. 2). How do we make sense of cultural views embedded and morally satisfying.
of the world that are not in accord with con- The Azande text has been the key for the
temporary natural sciences, it is often asked. rationality debate for another reason. Evans-
Do we argue that members of traditional cul- Pritchard in this text was explicitly empiricist,
tures live in wholly different worlds, and their and his work provided examples that serve as
statements are true in their worlds, not ours, or paradigmatic challenges to relativism. Take,
even that they cannot be translated intelligibly for example, his analysis of the Zande autopsy
into our language? Advocates of a typical ra- to investigate witchcraft, which appears as a
tionalist position hold that such relativism is substance in the intestine of a witch. Since
essentially incoherent, and have often argued witchcraft is inherited by kin, an autopsy may
either that seemingly irrational statements be performed on a deceased kinsman to deter-
must be understood symbolically rather than mine whether others bear the unwanted sub-
literally or that they represent a kind of "proto- stance. Evans-Pritchard (1937: 42) describes
science,'' an effort to explain events in the the scene:
world in an orderly fashion that is a functional
equivalent of modern science. The crucial in- Two lateral gashes are made in the belly and
terpretive problem, for this tradition, is how to one end of the intestines is placed in a cleft
answer a question stated explicitly by Lukes branch and they are wound round it. After the
other end has been severed from the body
(1970: 194): "When I come across a set of
another man takes it and unwinds the intes-
beliefs which appear prima facie irrational,
tines as he walks away from the man holding
what should be my attitude toward them?''
the cleft branch. The old men walk alongside
Given our claims that other forms of thought the entrails as they are stretched in the air and
are rational, how do we make sense of beliefs examine them for witchcraft-substance. The
that are obviously false? intestines are usually replaced in the belly
For much of this debate, Evans-Pritchard's when the examination is finished and the
Witchcraft, Oracles and Magic among the corpse is buried. I have been told that if no
Azande (1937) serves as the primary source. witchcraft-substance were discovered in a
This book was the first and is arguably still man's belly his kinsmen might strike his ac-
the most important modernist text in medical cusers in the face with his intestines or might
anthropology. It has had enduring influence dry them in the sun and afterwards take them
because of the wealth of the ethnography and to court and there boast of their victory.
the richness of its interpretation of witchcraft
as an explanation for illness and misfortune. Evans-Pritchard's (1937: 63) interpretation of
Which anthropologist can think of cultural re- this dramatic scene is telling.
sponses to misfortune without conjuring the It is an inevitable conclusion from Zande de-
image of Evans-Pritchard's young lad stubbing scriptions of witchcraft that it is not an object-
his toe and blaming witchcraft for its failure to ive reality. The physiological condition which
heal, or of the granary collapsing? To these is said to be the seat of witchcraft, and which I
misfortunes, the Zande explanation was clear. believe to be nothing more than food passing
"Every Zande knows that termites eat the through the small intestine, is an objective
MEDICAL ANTHROPOLOGY AND THE PROBLEM OF BELIEF 67
condition, but the qualities they attribute to it do we (as Evans-Pritchard responded to
and the rest of their beliefs about it are mys- Levy-Bruhl)? Are some societies simply organ-
tical. Witches, as Azande conceive them, ized around views that are reasonable but
cannot exist. wrong?
Not altogether obvious in Evans-Pritchard's
He goes on immediately to argue that al- text is the juxtaposition of "belief" and "know-
though mistaken, the Zande views serve as a ledge." The book is devoted largely to Zande
natural philosophy and embrace a system of mystical notions- witchcraft and sorcery- and
values which regulate human conduct. They ritual behaviors, such as resort to the poison
are, however, mystical. "Mystical notions," he oracle. One chapter, however, entitled "Leech-
argues in the book's introduction (p. 12), are craft," is devoted to their common-sense
those that attribute to phenomena "supra- notions of sickness. The language of "belief"
sensible qualities," "which are not derived and "knowledge" mirror this distinction. The
from observation" and "which they do not book begins: "Azande believe that some people
possess." "Common-sense notions" attribute are witches and can injure them in virtue of an
to phenomena only what can be observed in inherent quality ... They believe also that sor-
them or logically inferred from observation. cerers may do them ill by performing magic
Though they may be mistaken, they do not rites with bad medicines . . . Against both they
assert forces that cannot be observed. Both employ diviners, oracles, and medicines. The
are distinct from "scientific notions." "Our relations between these beliefs and rites are the
body of scientific knowledge and Logic," he subject of this book" (p. 21; my emphasis). On
says (p. 12), "are the sole arbiters of what the other hand, the Leechcraft chapter argues:
are mystical, common-sense, and scientific "Azande know diseases by their major symp-
notions." toms" (p. 482). "The very fact of naming dis-
Evans-Pritchard assumes in this account eases and differentiating them from one
that the meaning of Zande "medical dis- another by their symptoms shows observation
course" - whether of witchcraft, oracles, or and common-sense inferences" (pp. 494-5).
"leechcraft" - is constituted by its referential Thus, the book is organized around a distinc~
relationship to the natural order as reflected in tion between those ideas that accord with ob-
empirical experience. Analysis in the rational- jective reality [ ... ] and those that do not; the
ity literature follows from this assumption; it language of knowledge is used to describe the
frames Zande beliefs as propositions, then former, the language of belief the latter. Evans-
questions the verifiability and the deductive Pritchard's text transcends its empiricist for-
validity of their inferences. Since we know mulation, in particular because of the subtlety
that witches cannot exist empirically, it is of its analysis of Zande reasoning and the loca-
argued, the rationality of Zande thought is tion of witchcraft in Zande social relations, but
called into doubt. It follows that the anthro- it makes explicit many of the assumptions
pologist must therefore organize analysis in found more generally in the rationality trad~
response to the following kinds of questions. ition and shared by much of the medical social
How can a set of beliefs and institutions which sciences.
are so obviously false (propositionally) be If Evans-Pritchard's work on the Azande is
maintained for such long periods of time by the classic modernist text on witchcraft and
persons who in much of their lives are so illness, Jeanne Favret-Saada's Deadly Words:
reasonable? How could they possibly believe Witchcraft in the Bocage (1980), first pub-
that, and why haven't their beliefs progressed, lished in French in 1977, is surely the classic
that is come to represent the natural world post-modernist ethnography on the topic.
more correctly? Do such beliefs imply that Favret-Saada's ethnography is a first-person
the Zande have a different "mentality" or dif- account of her effort to investigate witchcraft
ferent psychological or logical processes than in rural France. In the early months of her
we? Do they simply divide up the common- work, villagers referred her to a few well
sense and religious domains differently than known healers who were often interviewed by
68 BYRON J. GOOD
the press, but the peasants themselves refused misfortune," backed by powerful social agen-
to discuss the matter with her. Witchcraft? cies: the School, the Church, the Medical Asso-
Only fools believe in that! ciation. Language is not a set of neutral
propositions about the world, which the eth-
"Take an ethnographer," she begins (1980: 4). nographer judges to be more or less empirically
"She has spent more than thirty months in the valid, but the medium through which vicious
Bocage in Mayenne, studying witchcraft ... and life-threatening power struggles are en-
'Tell us about the witches', she is asked again gaged. The world of illness and witchcraft only
and again when she gets back to the city. Just opens to the ethnographer as she enters the
as one might say: tell us tales about ogres or discourse. And much of the text turns on ironic
wolves, about Little Red Riding Hood. reflections on "belief" - the peasants' claims
Frighten us, but make it clear that it's only a
not to believe in witchcraft, even as they seek
story; or that they are just peasants: credulous,
the help of the unwitcher; the mocking view of
backward and marginal ...
the authorities about those who do believe; and
"No wonder that country people in the
West are not in any hurry to step forward Favret-Saada's juxtaposition of the meaning of
and be taken for idiots in the way that public belief in her text and in that of Evans-Pritchard.
opinion would have them be ... " For many ethnographers, as for the French
press, the question is whether the peasants
The book is an account of how she eventually really believe in witchcraft, and if so, how they
found her way into the discourse of witchcraft. can hold such beliefs in today's world. But for
She was taken ill, beset with accidents, and those attacked by a sorcerer, for those peasants
sought the aid of a healer in the region, an - and Favret-Saada herself- whose very lives
unwitcher. She began to interview a man and were at stake, belief in witchcraft is not the
his family, whom she had met when the man question. How to protect oneself, how to ward
was a patient in a mental hospital. As they told off the evil attacks producing illness and mis-
her the details of his illness and who they sus- fortune, is the only significant issue to be
pected might be responsible, she realized that addressed.
they saw her as a healer and now expected her Much has changed in the world of anthro-
to act on their behalf. Why else would she ask pology between that of 1935 colonialist Africa
about such matters so explicitly? Only the and contemporary post-colonialist ethnog-
powerful would dare to ask such questions. raphy. Evans-Pritchard's confident positioning
Simply by asking about their difficulties, she of himself as observer and arbiter of the ration-
was seen to be entering into their struggle with ality of the native discourse is largely unavail-
an enemy wishing them harm, a life and death able to us today. And throughout the history
struggle in which she was now an advocate for and sociology of science, the confident
their interests. Witchcraft, she came to see, was recording of science's progress in discovering
a battle of powerful wills, a fight to the death, a the facts of nature has also given way. I will
fight through the medium of spoken words. return to these issues as the discussion
One could only talk about witchcraft from an proceeds, but the juxtaposition of Evans-
engaged position - as one bewitched, as a sus- Pritchard's and Favret-Saada's texts brings into
pected witch, or as one willing to serve as un- focus the role of "belief" as an analytic
witcher. To engage in talk was to enter the category in the history of anthropology and in
struggle. the study of such phenomena as witchcraft,
In Favret-Saada 's account, the language provoking several questions. Why has the dis-
of belief, the position of the ethnographer, cussion of others' beliefs come to be invoked
and assumptions about the relation of culture increasingly with irony? What is the role of
and reality are radically different than in Evans- belief in the empiricist paradigm, and why has
Pritchard's text. Science for Favret-Saada is that position begun to give way? Where does
not the arbiter between the empirically real the disjunction between "belief" and "know-
and the mystical, as for Evans-Pritchard, ledge," which I noted in Witchcraft, Oracles,
but one of several "official theories of and Magic and which serves as the basis for
MEDICAL ANTHROPOLOGY AND THE PROBLEM OF BELIEF 69
Favret-Saada's irony, come from? Why world which does not exist in ours and which
"belief," and what is at stake here? we are comfortable asserting is not part of
empirical reality. How is it that "belief" has
come to be the language through which we
The Problem of Belief discuss such matters - the Zande witches, or
in Anthropology the three humors wind, bile, and phlegm in
Ayurvedic medicine, or the four humors of
Rodney Needham's Belief, Language and Ex- seventeenth-century European and American
perience, published in 1972, is the classic medicine? Moreover, why have we in Western
examination of the philosophy of belief by an civilization given such importance to beliefs,
anthropologist. Needham explores in great such importance that wars in Christendom
detail assumptions about belief as mental state, are fought over beliefs, that church schisms
asking whether philosophers have formulated and persecutions and martyrdom revolve
this with adequate clarity to allow us to use the around correct belief? How is it that belief
term in cross-cultural research, and asking came to be so central to anthropological analy-
whether members of other societies indeed ex- sis, and what is implied by the juxtaposition of
perience what we call "belief.'' After an extra- belief and knowledge?
ordinary review, he concludes both that By far the richest discussion of the history
philosophers have failed to clarify "the sup- of the concept belief is to be found in the
posed capacity for belief" and are unlikely to writing of Wilfred Cantwell Smith, the histor-
do so, and that evidence suggests the term rna y ian of religion, whose lectures when I was a
well not have counterparts in the ethnopsycho- graduate student set me to thinking about
logicallanguage of many societies. Needham's these matters. In two books completed during
analysis suggests that Evans-Pritchard's claim the late 1970s, Smith explores the relation
that the Azande believe some people are between "belief" and "faith" historically and
witches may be a less straightforward descrip- across religious traditions. He sets out not
tion of the mental states of Zande individuals to compare beliefs among religions, but to
than we usually presume. For the moment, examine the place of belief itself in Buddhist,
however, I want to focus on another dimension Hindu, Islamic, and Christian history.
of belief as anthropologists have used the term Through careful historical and linguistic an-
in cultural analysis. alysis, he comes to the startling conclusion
Mary Steedly, an anthropologist who that "the idea that believing is religiously im-
worked with the Karobatak people in Sumatra, portant turns out to be a modern idea," and
tells how when she was beginning fieldwork that the meaning of the English words "to
she was often asked a question, which she believe" and "belief" have changed so dramat-
understood to mean "do you believe in ically in the past three centuries that they
spirits?" (1993: ch. 1). It was one of those em- wreak profound havoc in our ability to under-
barrassing questions anthropologists struggle stand our own historical tradition and the
to answer, since she didn't, personally, but religious faith of others.
respected and wanted to learn about the under- The word "belief" has a long history in the
standings of persons in the village in which she English language; over the course it has so
worked. After stumbling to answer the question changed that its earlier meanings are only
for some months, she discovered her question- dimly felt today (Smith 1977: 41-46; 1979:
ers were asking "Do you trust spirits? Do 105-27). In Old English, the words which
you believe what they say? Do you maintain a evolved into modern "believe" (geleofan, gele-
relationship with them?" Any sensible person fan, geliefan) meant "to belove," "to hold
believes in their existence; that isn't even a dear," "to cherish," "to regard as lief." They
meaningful question. The real question is how were the equivalent of what the German word
one chooses to relate to them. belieben means today (mein Iieber Freund is
Anthropologists often talk with members of "my dear or cherished friend"), and show the
other societies about some aspect of their same root as the Latin tibet, "it pleases," or
70 BYRON J. GOOD
libido, "pleasure." This meaning survives in the as beliefs have come to mean "presuppos-
Modern English archaism "lief" and the past itions," as in "belief systems."
participle "beloved." In medieval texts, "leve/' A second shift has occurred in the subject of
"love," and "beleue" are virtual equivalents. In the verb "to believe,'' from an almost exclusive
Chaucer's Canterbury Tales, the words use of the first person - "I believe" - to the
"accepted my bileve" mean simply "accept my predominant use of the third person, "he be-
loyalty; receive me as one who submits himself lieves" or "they believe." In anthropology, the
to you." Thus Smith argues that "belief in impersonal "it is believed that" parallels the
God" originally means "a loyal pledging of discussion of culture as belief system or system
oneself to God, a decision and commitment to of thought. This change in subject subtly shifts
live one's life in His service" (1977: 42). Its the nature of the speech act involved - from
counterpart in the medieval language of the existential to descriptive - and alters the au-
Church was "I renounce the Devil," belief and thorization of the speaker.
renunciation being parallel and contrasting Third, Smith observes that an important
actions, rather than states of mind. and often unrecognized change has occurred
Smith (1977: 44) sums up his argument in the relation of belief to truth and knowledge,
about the change of the religious meaning of as these are historically conceived. Bacon
"belief" in our history as follows: wrote in 1625 of "the belief of truth,'' which
he defined as the "enjoyment of it," in contrast
The affirmation "I believe in God" used to to the inquiry or wooing of truth and the
mean: "Given the reality of God as a fact of knowledge or presence of truth. Belief main-
the universe, I hereby pledge to Him my heart tains its sense here of holding dear, of appro-
and soul. I committedly opt to live in loyalty priating to oneself that which is recognized as
to Him. I offer my life to be judged by Him
true. By the nineteenth century, however, "to
trusting His mercy." Today the statement may
believe" had come to connote doubt, and today
be taken by some as meaning: "Given the
uncertainty as to whether there be a God it suggests outright error or falsehood. Know-
or not, as a fact of modern life, I announce ledge requires both certitude and correctness;
that my opinion is 'yes'. I judge God to be belief implies uncertainty, error, or both. [ ... J
existent." Smith's favorite illustration of the juxtapos-
ition of belief and knowledge is an entry in
Smith argues that this change in the lan- the Random House dictionary which defined
guage of belief can be traced in the grammar "belief'' as "an opinion or conviction," and at
and semantics of English literature and phil- once illustrates this with "the belief that the
osophy, as well as popular usage. Three earth is flat" I Indeed, it is virtually unaccept-
changes - in the object of the verb, the subject able usage to say that members of some society
of the verb, and the relation of belief and "believe" the earth is round; if this is part of
knowledge- serve as indicators of the changing their world view, then it is knowledge, not
semantics of the verb "to believe.'' First, Smith belief!
finds that grammatically, the object of the verb Smith goes on to argue that our failure to
"to believe'' shifted from a person (whom one recognize this shift in meaning has led to mis-
trusted or had faith in), to a person and his translation of texts in the Christian tradition
word (his virtue accruing to the trustworthi- and ultimately to "the heresy of believing," the
ness of his word), to a proposition. This latter deeply mistaken view that belief in this modern
shift began to occur by the end of the seven- sense is the essence of the religious life rather
teenth century, with Locke, for example, who than faith. Credo, in the Latin, is literally "I set
characterized "belief" along with "assent" and my heart" (from Latin cordis or heart [as in
"opinion" as "the admitting or receiving any cordial] and *-do or *-dere, to put). Credo in
proposition for true, upon arguments or proofs unum Deum was correctly translated in the
that are found to persuade us . . . without cer- sixteenth century as "I believe in one God,"
tain knowledge ... " (Smith 1977: 48). In the when it meant "I formally pledge my allegiance
twentieth century we have seen a further shift to God," Whom we of course all acknowledge
MEDICAL ANTHROPOLOGY AND THE PROBLEM OF BELIEF 71
to be present in the world. Today, it is a mis- believe, for how else could it happen that in
translation, suggesting that the Credo consists the morning and evening the sun burns less hot
of propositions the veracity of which we assert. than in the day? It must be because the sun has
This is historically inaccurate and profoundly been cooled when it emerges from the water
misrepresents the traditional ritual acclam- and toward setting it again approaches the
ation. Equally importantly, for the comparati- water. And furthermore, how can it be pos-
vist, the misplaced focus on beliefs as the sible that the sun remains still when we are yet
primary dimension of religious life has led to able to observe that in the course of the year it
mistranslations and misunderstandings of changes its position in relation to the stars?
[emphasis added] (Goodenough 1981: 69).
other religious traditions, and in Smith's view,
to the great failure to explore the faith of others Quite reasonable, even if mistaken: that is how
in their historical and communal contexts, the beliefs of others seem to be.
even to make faith a central category in com- The juxtaposition of belief and knowledge
parative research. is most evident in the intellectualist writing of
Smith's argument about the importance of turn-of-the-century British social anthropol-
placing the study of faith rather than beliefs at ogy. An example from a classic text in medical
the center of comparative and historical studies anthropology will be particularly instructive.
of religion has important implications for the W. H. R. Rivers' Medicine, Magic and Religion
study of illness experience. My interest at this was published in 1924, the first major com-
time, however, is the place of "belief" in the parative study of medical systems by an an-
history of anthropology, and what the use of thropologist-physician.2 The book is designed
the term tells us about the anthropological pro- to show how concepts of disease vary cross-
ject. In what way does Smith's analysis of belief culturally, but focuses largely on beliefs about
relate to the use of the term in anthropological causation of disease. Rivers uses "believe"
writing? What is the history of believing in largely in the third person or impersonally;
anthropology? How is the use of "belief" re- the object of belief is almost exclusively prop-
lated to the epistemological assumptions of ositions; and these propositions are, from
anthropologists? Rivers' point of view, counter-factual. For
From my initial explorations, it would example, he writes (1924: 29):
appear that the term "belief" as it is employed
Thus, in Murray Island, in Torres Straits, dis-
in anthropology does indeed connote error or
ease is believed to occur by the action of cer-
falsehood, although it is seldom explicitly tain men who, through their possession of
asserted. A quick scan of the typical volumes objects called zogo and their knowledge of
on an anthropologisfs shelf will provide many the appropriate rites, have the power of inflict-
examples. My own favorite, paralleling Smith's ing disease. Thus, one zogo is believed to make
discovery in the Random House Dictionary, people lean and hungry and at the same time
comes from Ward Goodenough's little book, to produce dysentery; another will produce
Culture, Language and Society (1981). In a constipation, and a third insanity.
discussion of "propositions" and the nature of
reasoning cross-culturally, he provides the His attitude is made clear several pages later,
following example from the German ethnolo- when he discusses the rationality of such
gist Girschner, to illustrate the "reasonable- beliefs. "From our modern standpoint we are
ness" of members of other cultures. able to see that these ideas are wrong. But the
important point is that, however wrong may be
Consider, for example, the following comment the beliefs of the Papuan and Melanesian con-
by a Micronesian navigator, defending his cerning the causation of disease, their practices
belief that the sun goes around the earth are the logical consequence of those beliefs."
(Girschner, 1913 ... ) This view is conveyed more subtly, however,
I am weiJ aware of the foreigner's claim and with far more profound implications at the
that the earth moves and the sun stands still, end of the book. The conclusion is devoted to
as someone once told us; but this we cannot illuminating the role of belief in me practice of
72 BYRON J. GOOD
Western medicine. Whereas in earlier chapters not senile, Sperber was left to puzzle how such
of the book, the word "believe," along with a person could actually believe in dragons and
"ascribe," "regard," and "attribute,'' appears about how to reconcile his respect for Filate
on nearly every page of discussion of the med- with "the knowledge that such a belief is
ical concepts of others, the word "believe" does absurd."
not appear in the final fourteen pages of the Sperber's analysis of this problem leads
book. Here the word "knowledge," and cog- him directly to the usual arguments about
nates "recognize," "realize," "acknowledge," the nature of rationality. How are we as an-
and "awareness,'' are used to describe Western thropologists to interpret cultural beliefs - be
medicine. Rivers could not have more clearly they about dragons or the role of witchcraft in
stated his judgment. causing illness - that are "apparently ir-
This juxtaposition of what others believe to rational," that is, not in accord with how we
what we know is not only true of intellectualist know the empirical world to be? Are such
writers such as Tylor, Frazer, and Rivers. Close beliefs to be taken as literal or "symbolic"?
reading of the Evans-Pritchard text shows that If they represent literal claims about the
he uses "belief" and its cognates to far greater nature of the empirical world, why have such
analytic advantage than his predecessors, fo- systems not given way in the face of empirical
cusing on the coherence of a set of ideas. "All experience? In Evans-Pritchard's words, why
their beliefs hang together," he writes (1937: do the Azande practitioners not "perceive
194 ), "and were a Zande to give up faith in the futility of their magic" (1937: 475)? And
witch-doctorhood he would have to surrender what is the alternative? A strong relativist
equally his belief in witchcraft and oracles." claim that the Azande world and ours are
The study of folk "logics" is an important part incommensurable, that so different are they
of the repertoire of cultural analysis, and that we cannot translate between our world
Evans-Pritchard was a master of this genre. and theirs? Sperber follows through these
Nonetheless, his analysis framed culture as arguments; he ridicules the view that the
beliefs, and these were juxtaposed to know- mind "actively creat[es} its universe" (Douglas
ledge -grossly in the introduction of the book, 1975: xviii), as deriving from a "hermeneuti-
then in a subtle and nuanced way throughout co-psychedelic subculture" (Sperber 1985:
this classic text. 38), and develops a detailed analysis of differ-
The subtle or explicit representation of ent types of propositional beliefs. In the end,
belief and knowledge as disjunct continues he concludes that old Filate's belief was only
to be found in anthropological writing up "semipropositional" and was "not factual,"
to the present time. It is most explicit in that is, that it was not a kind of belief
rationalist writing and subsequent discussions intended to really represent the way the world
of relativism. A final example from Dan is and not clear enough to be stated in prop-
Sperber's book On Anthropological Know- ositional terms that could be falsifiable. Thus
ledge (1985), which proposes to "outline an his solution is that the old man really didn't
epistemology of anthropology" (p. 7), will il- believe in the dragon after all, that it was only
lustrate. The central chapter in the book is a kind of fantasy to entertain himself and
entitled "Apparently Irrational Beliefs." It ultimately the anthropologist.
begins with an extract from Sperber's field My intent is not to join the rationality
diary during his research in Ethiopia, when an debate and the technical issues it raises here,
old man, Filate, comes in a state of great ex- although these questions serve as the stimulus
citement to tell Sperber that he has learned of a for many of the concerns of this book, nor to
dragon - "Its heart is made of gold, it has one speculate on old Filate's motives. Here my in-
horn on the nape of its neck. It is golden all tention is to raise meta-level questions about
over. It does not live far, two days' walk at the role of "belief" in anthropology. How does
most ... " - and asks him if he will kill it. Since it happen that the "apparently irrational
Sperber had respect and affection for old Filate, beliefs" provide the paradigmatic problem for
and since Filate was too poor to drink and was a central tradition in anthropology? Any
MEDICAl ANTHROPOLOGY AND THE PROBLEM OF BELIEF 73
human science, historical or anthropological, than in British social anthropology, in particu-
must deal with problems of translation, of lar in the rationality literature.
differing world views and understandings of Fourth, the representation of others' culture
reality, of course. But how does it happen that as "beliefs" authorizes the position and know-
"irrational beliefs" becomes the central, para- ledge of the anthropological observer. Though
digmatic issue? differing in content, anthropological character-
Surprisingly, there seems to be little analysis izations of others' beliefs played a similar role
of the history of the concept "belief" in anthro- in validating the position of the anthropologist
pology. It is constantly employed, a kind of as the description of native religious beliefs did
Wittgensteinian "odd job word," but often for missionaries. However, the rising concern
used with little self-consciousness. The word about the position of the anthropologist vis-a-
almost never appears in indexes, even when it vis members of the societies he or she studies
is employed throughout a text, and thus its use has produced a "crisis" in ethnographic writing
is not easy to trace. It is beyond the scope of (Marcus and Fischer 1986: 8) and a generalized
this discussion to attempt such a history, but a epistemological hypochondria, and this change
brief review of anthropological texts suggests in the relationship of anthropologist to
several hypotheses. the "Other" can be traced in the increasingly
First, the juxtaposition of "belief" and self-conscious and ironic uses of the term
"knowledge" and the use of "belief" to "belief."
denote (or at least connote) counter-facmal Fifth, despite such post-modern hypochon-
assertions has a long history in both anthro- dria in some regions of the contemporary social
pology and philosophy. This is contrary to sciences, the term "belief" and its counterparts
what might be expected for both disciplines- continue to be important odd job words not
for anthropology, because our primary goal only in the cognitive sciences, where culture is
has been to make understandable other soci- closely linked with states of the mind, but in
eties in a non-judgmental way; for philosophy, fields such as the medical social sciences, where
because much of modern epistemology is the conflict between historicist interpretations
designed to investigate the grounds for true and the claims of the natural sciences is most
belief. intense. Examination of the concept thus has
Second, belief as an analytic category in special relevance for medical anthropology.
anthropology appears to be most closely asso- These are rather crude hypotheses. How-
ciated with religion and with discussions of the ever, they reflect my conviction that it was
so-called folk sciences. "Belief" is most closely fateful for anthropology when belief emerged
associated, that is, with cultural accounts as a central category for the analysis of culture.
either of the unknowable or of mistaken under- This formation of anthropological discourse
standings of the "natural world," where science was linked to the philosophical dimate within
can distinguish knowledge from belief. In med- which anthropology emerged, a climate in
ical anthropology, analysis of "beliefs" is most which empiricist theories and sharp conflicts
prominent in cultural accounts of those condi- between the natural sciences and religion were
tions (such as infectious diseases) for which bio- prominent. It was also rooted in anthropolo-
logical theories have greatest authority, and least gists' traditional relations to those they studied,
prominent for those forms of illness (for framed by the superiority of European and
example psychopathology) for which biological American science and industrial development
explanations are most open to challenge. and by the colonialist context of research.
Third, the term belief, though present Given the semantics of the term, that is the
throughout anthropological writing, appears meaning "belief" had taken on by the late nine-
with quite varied frequency and analytic mean- teenth century and continues to have in the
ing in different theoretical paradigms. For twentieth century, the analysis of culture as
example, it seems far less central in American belief thus both reflected and helped reproduce
anthropology, with its background in nine- an underlying epistemology and a prevailing
teenth-century German historicist theorizing, structure of power relations.
74 BYRON J. GOOD
In 1973, Arthur Kleinman published a brief but remarkably prescient essay entitled
"Medicine's Symbolic Reality." (The paper is all the more remarkable for being
Kleinman's first publication.) Kleinman (1973a: 208) used Wittgenstein's metaphor
of natural language as being like "a maze of little streets and squares, of old and new
houses," in contrast with the "straight regular streets and uniform houses" of
scientific language, to argue that a new interest in "the relation of medicine and
science to culture" was beginning to "radically remake our understanding of medi-
cine." He called for a cross-cultural, "comparative study of medical systems" that
would recognize the powerful role of language as mediating between the scientific
and the human dimensions of medicine, a study of medicine as a "social and cultural
enterprise" {208) and a "form of symbolic reality" (212), a "system" of "ordered,
coherent ... ideas, values, and practices embedded in a given cultural context from
which it derives its signification" (208).
Throughout the 1970s and continuing to the present, anthropologists have taken
up Kleinman's challenge to study the "maze of little streets and squares" that make up
medical cultures and practices in diverse settings, in the process elaborating a broad
theoretical program of "interpretive medical anthropology," drawing on closely
related philosophical and analytic traditions committed to understanding culture in
terms of symbolic meanings and embodied experience. First, working within the
broad tradition of American anthropology and semiotic and symbolic analyses of the
1960s and 1970s, medical anthropologists began to systematically investigate local
medical systems as "symbolic realities" in Kleinman's terms {1973a, 1973b, 1980), to
explore the cultural "meaning of symptoms" (B. Good and M. Good 1980), the
"semantics of medical discourse" (B. Good and M. Good 1981), and "semantic
networks" (B. Good 1977; Bibeau 1981). Referencing Geertz's classic phrase "the
interpretation of culture" (Geertz 1973) and the philosophic tradition of hermeneut-
ics (see Ricoeur 1981; Taylor 1985), this new generation of medical anthropologists
80 ILLNESS AND NARRATIVE, BODY AND EXPERIENCE
saw medicine as consisting of a set of "interpretive practices" (B. Good 1994) that
constitute illness as a particular form of reality and as the site of potential interpretive
conflict (B. Good, Herrera, M. Good and Cooper 1985). Kleinman (1973a, 1980)
drew special attention to the "cognitive management" of illness, to the role of
classificatory schemes and "explanatory models" available in all medical systems,
and cognitive anthropologists, particularly Linda Garro (1986a, 1986b, 1988,
2003), used formal techniques to investigate the structure and distribution of medical
"knowledge" and the relation of cultural models to care-seeking.
Second, medical anthropologists drew on cultural phenomenology to explore
how illness is constituted as social, intersubjective, and experiential "realities" and
how it becomes the object of therapeutic attention, with "the body" serving as
"existential ground of culture and self" (Csordas 1994a). Whether as the "clinical
construction of reality" of biomedicine (Kleinman, Eisenberg and Good 1977) or
the discursive production of sorcery or witchcraft as sources of illness in con-
temporary France (Favret-Saada 1980), culture and symbolic practices were under-
stood to play a critical role in producing distinctive modes of experience associated
with disease, even "creating the form disease takes" (Kleinman 1973a: 209). Par-
ticular attention was given to "the body" as the often invisible agent and object of
experience that emerges into awareness with disability (Frank 1986) or pain (Scarry
1985; M. Good, Brodwin, B. Good and Kleinman 1992). Illness, Pandolfi (1990,
1991) wrote, is history "written on the body," and "embodiment" emerged as a key
paradigm in medical anthropology (Csordas 1990, 1994a, 1994b) and in humanis-
tic writing (Benner 1994; Charon 2006). A classic essay by Scheper-Hughes
and Lock (1987) demonstrated how an analytic of the body could be extended
to a critical analysis of links between oppressive social forces and embodied
experience.
Third, medical anthropologists in this tradition increasingly explored the
fundamental role of narrative in medicine, illness, and healing. Influenced by a
broad "narrative turn" in the social sciences, medicine, and psychiatry (e.g., Schafer
1981; Bruner 1986; Sarbin 1986; Brody 1987; Kleinman 1988; Hunter 1991;
Kaufman 1993), medical anthropologists began exploring how stories make sense
of and shape illness experience (Early 1982, 1985; Price 1987; Garro 1994; B.
Good 1994). This notion was extended to the joint construction by physicians,
patients and families of "clinical narratives" that organize therapeutic action and
the experience of care (B. Good and M. Good 1994; M. Good et al. 1994;
Mattingly 1998; M. Good and B. Good 2000; Mattingly and Garro 2000). Draw-
ing in particular from writings on the phenomenology of reading and reader
response theory (Iser 1978; Ricoeur 1981 ), medical anthropologists explored how
illness experience is "emplotted" (Mattingly this volume; Garro 1994; B. Good
1994; M. Good 1995), how therapeutic narratives are structured to shape and
manage desire, and how technologies are drawn into the "economy of hope"
(M. Good 2001, 2008).
This tradition of interpretive medical anthropology, linking phenomenology, nar-
rative studies, and semiotics, and more recently psychoanalysis and post-structuralist
studies, continues as a lively tradition until today. In Part II, "Illness and Narrative,
Body and Experience," we include seven examples representing a range of this work.
The section begins with Kleinman's classic essay, "Medicine's Symbolic Reality,"
INTRODUcriON 81
referred to above. In the second essay, Thomas Csordas elaborates one line of
argument in Kleinman's essay (1973a: 208)- that "meaning and efficacy ... have
always been inseparable from medical healing"- and develops a general theory of
healing rooted in cultural phenomenology that links efficacy to rhetorical practices
and the powerful relationship of language and the body (cf. Csordas 2004 for a
monograph-length development of this argument). The third essay, by Ellen Carin,
extends phenomenological methods in another direction. Drawing on the classic
tradition of European phenomenological psychiatry, combined with intensive ethno-
graphic research, Carin explores the lives of persons suffering with schizophrenia in
Montreal. Her research, aimed at determining why some persons are frequently
rehospitalized while others are able to live continuously in the community, comes
to the startling conclusion that rehospitalization is closely linked with efforts to be
reintegrated into the community, while those who develop a style of "positive
withdrawal" are, paradoxically, able to remain in the community. From this she
raises more general questions about how some societies make available religious and
therapeutic spaces for withdrawal, and about the role North American values play in
producing relapse for persons suffering severe mental illness (Corin 1990, 2007).
The essay by Cheryl Mattingly takes on in brief form the issues raised in her
1998 monograph, Healing Dramas and Clinical Plots. Mattingly's rich ethno~
graphic writing links a very difficult and mundane aspect of medical practice -
occupational therapists' work with persons suffering severe physical and neuro~
logical losses - with a broad and deeply philosophical theorization of narrative
practices. She demonstrates that "therapeutic emplotment" is critical to this mun-
dane work, providing sense at the site of the breakdown of meaning, placing
therapeutic work within larger time horizons, and, when successful, establishing
the desire and motivational structures necessary for patients to carry on in the face
of nearly unbearable losses.
The last three essays in this section illustrate new directions for interpretive
medical anthropology. First we excerpt a small section from Minima Ethnographica
by Michael jackson, a leading theorist and fine ethnographic writer in the phenom-
enological tradition, in which he explores the place of memories of colonial trauma
in the collective suffering of an Aboriginal community in Australia. Jackson's writing
has served as an important resource and guide for medical anthropologists working
in the phenomenological tradition. Second, we include an analysis by Janis Jenkins
that links traumatic emotions and embodied experience of Salvadoran refugees to the
United States to the state construction of a political ethos of terror that organized
those embodied emotions. We conclude this section with a fascinating essay by
Robert Desjarlais, based on research with homeless men and women in a Boston
shelter, in which he deconstructs the category "experience," arguing that the mode of
being~in-the-world of many persons who are homeless lacks the qualities we usually
associate with experience - reflexive interiority, hermeneutical depth, and narrative
flow. He thus unsettles the very category "experience" used broadly within the
interpretive tradition, including in his own earlier writing, suggesting this term is
far from neutral and that it describes a very particular mode of subjectivity rather
than serving as a natural category for investigating cross~cultural difference. These
three essays in particular point ahead to the final part of this book on "postcolonial
disorders."
82 ILLNESS AND NARRATIVE, BODY AND EXPERIENCE
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9
Medicine's Symbolic Reality
On a Central Problem in the
Philosophy of Medicine
Arthur M. Kleinman
'Our language can be seen as an ancient city: a maze of little streets and squares, of
old and new houses, and of houses with additions from various periods; and this
surrounded by a multitude of new boroughs with straight regular streets and
uniform houses'. (Ludwig Wittgenstein, Philosophical Investigations, trans.
by G. E. M. Anscombe (Blackwell, Oxford 1968), p. 8.)
Wittgenstein's winsome metaphor for scientific system, as a practice and a human reality. Obvi-
language ('straight regular streets and uniform ously, it is this archaic root of medicine which
houses') against ordinary language ('maze of strikes us as most like the twisting, narrow, un-
litde streets ... of old and new houses') applies mapped streets and clutter of old and new
quite aptly to a traditional distinction in medical houses of the ancient inner city, Wittgenstein's
theory: medicine deals with two kinds of reality, analogy for the messy and poorly understood,
'scientific' and 'ordinary'; or put differently, it is yet crucial, social and individual aspects of lan-
both a biophysical and a human science. guage. Likewise these sides of medicine, which
Modem medical theory has concerned itself are now appreciated for their enormous import-
almost entirely with the wide, well-designed ance, though not at all clearly understood, pre-
and clearly mapped suburban avenues of the sent a challenge to the modern theoretical
former, particularly in the study of disease, its structure of medical science, a structure based
biological substratum, and its determinants, largely upon knowledge limited to medicine's
effects, and control. Often the biophysical root biophysical reality.
of modem medicine has been used as the basis Recently, the pendulum has swung away
for a general critique of the whole of medicine; from the theoretical disinterest and even scorn
an example of which is the great amount of shown by entrenched medical empiricism for
consideration given to the precise definition of medicine as a human science to a kind of theor-
such abstractions as illness and health, a largely etical chaos, as various social and behavioral
unprofitable endeavor which has characterized science theories are stretched and forced to fit
much of what could be called the philosophy of an elusive medical subject. Even though no
medicine. Only recently has there been more sound theoretical integration or systematic cri-
than superficial and somewhat embarrassed at- tique of this enterprise has yet been forthcoming,
tention given to medicine as a socio-cultural there is general agreement that the socio-cultural
Arthur M. Kleinman, "Medicine's Symbolic Reality: On a Central Problem in the Philosophy of Medicine,"
Inquiry 16 (1973): 206-13. Reprinted by permission of the publisher (Taylor & Francis Group; www.
inform a world. com)
86 ARTHUR M. KLEINMAN
approach is beginning to radicaJJy remake our culcural context from which it derives its signi-
understanding of medicine and, accordingly, we fication. It is an important part of the cultural
find the traditional dichotomy in scientific medi- world and as such it is structed, like any other
cine undergoing marked change. Here again, the segment of social reality, by the regnant body
quotation from Wittgenstein, who apropos of of symbolic meanings. The medical system
our subject did speak of the similarity between forms an indissoluble and hierarchical whole
philosophical investigations and medical in which healing acts are closely linked with
healing, is most relevant, since he was writing ideas about disease causation and models for
about language as a mediating reality, and, as we classifying disease. The whole is oriented
shall attempt to adumbrate below, the realm of toward the problem of effectively dealing with
symbolic reality would appear to mediate be- illness. From this view point, healing is not the
tween medicine's dual roots so as to form a outcome of diagnostic acts, but the healing
bridging or unifying reality, which itself becomes function is active from the outset in the way
a central problem for medical theory. illness is perceived and the experience of illness
All of this is the result of several new per- organized.
spectives on medicine, and for that matter sci- Medical systems function along the lines of
ence generally, which have focused their the cultural dialectic, relating and treating both
attention upon the relation of medicine and individual and social realities. In fact, the pa-
science to culture. 1 Moreover, these historical, tient for most medical systems has traditionally
anthropological, sociological, psychiatric, and been both the individual and his nexus of social
medical field studies have begun to unify their relations. The acts of ordering, naming, inter-
interests around a common theme, the com- preting, and offering therapy for illness are
parative study of medical systems: that is, aspects of symbolic reality common to both
appreciation for the structure and significance the sick individual, the healer, and their society.
of medicine as a health care system in differ- Medical systems employ different explanatory
ent cultural settings and historical contexts. 2 models and idioms to make sense of disease
Recent developments in the sociology of and give meaning to the individual and social
knowledge, linguistic theory, and structural experience of illness. 4 Meaning and efficacy,
and symbolic analyses have made important until the very recent advent of biomedical tech-
contributions to the reconstruction of given nologies which actually control biochemical,
medical systems, which in turn have been com- physiological, and psychological processes,
pared, either in part or as total structures, his- have always been inseparable in medical
torically and cross-culturally. 3 This approach healing. Medical systems may be crudely char-
has produced a remarkable body of research acterized as expressions of the cultural loci of
findings and offers a phenomenology of med- power which they utilize to explain and control
ical practice. It is my intention to bring certain illness. 5
of these findings to bear upon the question A given medical system in its socio-cultural
of medical reality. In briefly doing so, I hope context does considerably more than name,
to demonstrate that the study of medicine as classify, and respond to illness, however. In a
a social and cultural enterprise represents not real sense, it structures the experience of illness
only a fundamental breakthrough in our under- and, in part, creates the form disease takes.
standing of medicine, but also openly invites Disease occurs as a natural process. It works
broad philosophical enquiry into medicine, upon biophysical reality and/or psychological
something that has been strangely and seri- processes, as the case may be. But the experi-
ously lacking in the past. ence of illness is a cultural or symbolic reality.
No matter what the perspective - dia- The experience of illness involves feelings,
chronic or synchronic - medicine is always ideas, values, language and non-verbal com-
found to constitute a system. The medical munication, symbolic behaviour, and the like.
system is an ordered, coherent body of ideas, What is perceived as illness in one culture may
values, and practices embedded in a given not be so perceived in another. We know a
MEDICINE's SYMBOLIC REALITY 87
great deal today about typing and labeling of deviance and those studying the sociology of
diseases, less so about symptom choice and medical knowledge, for example, are wont to
culturally specified disease forms, and just point out. 8
enough about how illness behaviour is learned The ring of medicine's symbolic reality is
and socialized to know that socio-cultural made complete in the question of healing.
factors are of enormous importance. More Healing is an elemental social function and
than that, we know that symbolic communi- experience. It is equally as primary as the gift
cation forms a pathway of sorts between social or exchange relationship, and comprises one of
and cultural events and psychophysiological the fundamental forms of symbolic action,
reactions. 6 Psychosomatic pathology has been native to all societies. Even a surface examin-
well described, but we are iust learning about ation of healing makes us aware that medicine
sociosomatic pathology. The line begins to blur begins as a radical form of humanism. 9 Trad-
between ordering the experience of illness and itionally, medical systems have not made a dis-
shaping illness per se. I do not mean merely tinction between healing efficacy and provision
that psychiatric disorders or psychosomatic of meaning for the personal and social experi-
diseases are in this sense symbolic phenomena, ence of sickness. Efficacy, itself, is a cultural
but any disease - smallpox, leprosy, syphilis, construct. The healing dialectic has been con-
hypertension, cardiovascular disorders, cancer, sidered effective when the bonds between the
etc. - is in part a cultural construct. Disease sick individual and the group, weakened by
derives much of its form, the way it is ex- disease, are strengthened, social values re-
pressed, the value it is given, the meaning it affirmed, and the notion of social order no
possesses, and the therapy appropriate to it in longer threatened by illness and death; or when
large measure from the governing system of the individual experience of illness has been
symbolic meanings. made meaningful, personal suffering shared,
Medical knowledge is intended to be effect- and the individual leaves the marginal situation
ive. This can be seen in the way diseases and of sickness and has been reincorporated in
their therapies are taxonomized. Medical clas- health or even death back into the social body.
sificatory schemes are most often not objective Healing is the end-point of the medical system,
descriptions of empirical reality. Rather they the successful reordering and organizing of the
reflect healing concerns and the theoretical disease experience and, where possible, its con-
biases of given cultural and medical ideologies. trol. Though it is clear that morbidity and mor-
Classification of disease is, in fact, the first tality statistics, as well as empirical measures of
therapeutic act. Classificatory schemes are therapeutic effectivity, do not measure healing
intended to domesticate and make known a efficacy, little is known about what personal
'wild' and unknown phenomenon, which and social standards of healing efficacy are in
threatens the very idea of social order and per- modern society, yet these should be crucial
sonal stability, and transform it into something concerns for modern medicine.
known, named, and thus manageable. In this Within the form of symbolic reality struc-
sense, ideas of witchcraft as a random and tured by the system of medical care, healing
highly malignant explanatory model are not has a position situated at the strategic inter-
at all badly matched with diseases such as face between the cultural systems, the system
endemic malaria and the pneumonia-diarrheal of social relations, and the individual. Healing
complex of disorders of infants, which are occurs along a symbolic pathway of words,
random and highly malignant. Some diagnostic feelings, values, expectations, beliefs, and the
systems are entirely symbolic, relating specific like which connect cultural events and forms
illnesses to specific therapies. 7 Though much of with affective and physiological processes.
what we are describing for medical cognitive Psychosomatic and sociosomatic correlates
systems pertain for the most part to traditional are implicit in all medical healing relation-
forms of medicine, there are certainly a number ships. Feelings and physiological responses
of modern equivalents as students of social are in some way linked to socio-cultural
88 ARTHUR M. KLEINMAN
reality via early socialization and learning. principles responsible for the structuring of
Language and other symbolic forms are the given medical systems. To do so requires an
most obvious bridge. In this way, medicine's understanding not only of medicine as a
biological and cultural roots are connected; system, but particularly of a given medical
the formal barriers between these realities system's cultural and historical contexts.
begin to dissolve if we penetrate medicine's Our general medical model confronts the
thoroughgoing symbolic reality. We reiterate tremendous distortion and abridgement of
that this symbolic structure is present not only traditional purposes in contemporary techno-
in therapy, where it plays a patent role of logical medicine: increasing technical control
mediation, but also in the social construction has been accompanied by the separation of ef-
and cognitive mapping of illness; in other ficacy from meaning, progressive dehumaniza-
words it is to be found at all levels of the tion of the healing function, so much so that we
medical system. are seeing traditional healing activities surface
In studying medicine as a human science in the wider social structure just as they are
this symbolic realm of ideas and actions be- disappearing from clinical practices, and sys-
comes a fundamental problem with consider- tematic attempts to restrict medicine's symbolic
able practical and theoretical importance. The reality to a single discipline, psychiatry, periph-
specific issues questioned are remarkably dif- eral to the central core of medical research
ferent from those emerging out of a concern interests and practices. Ironically, medicine,
with medicine's biophysical aspects, without one of the first human sciences and in some
disparaging the clear importance of the latter. ways a paradigmatic one, is in the tragic process
Indeed, these issues come much closer to giving of emancipating itself, via technicalization of
us a long-awaited general theoretical critique all of its problems, from this vital source.
of medicine. What are real health needs of The study of medicine as a cultural system
individuals, communities, or populations? returns our attention to the artificial and unfor-
What are the purposes of clinical care? What tunate separation of medicine into two distinct
is the nature of clinical interpretation and areas, only the first of which has heretofore
knowledge? What is medical healing? How qualified for scientific investigation. We have
are medical ideologies constructed and how briefly tried to show that we must reconsider
do they relate to political ideologies and social the 'maze of little streets, of the ancient city,
phenomena? How are social sources of power medicine taken as a human reality, if we are to
tapped for explanation and therapy? These arrive at any general understanding of medicine,
questions are of particular significance for de- or have some success with the tangle of impor-
veloping countries, where health structures are tunate problems besetting modern medicine.
being remade. But certainly, they bring our Since Plato, there has been a persistent and more
study of modern medicine to a deeper level; or less unspecified ideal in the West of an an-
they expose the infra-structure of medical thropological medicine, a kind of medical sci-
knowledge and practice; and they call into ence and practice that would be concerned
question the interests and values which stand unashamedly with such problems as human
behind medicine. 10 If we consider medicine on nature and other critical aspects of philosoph-
the plane of symbolic reality, we rapidly come ical anthropology, a medical science conceived
to think of the medical system as structured of in radically human terms, just as medical
somewhat like a language; we may even think systems have traditionally been structured, and
of 'medemes' (similar to phonemes and mor- taking its place as an essential part of the human
phemes) in the comparative study of medicine, sciences. Though such an enterprise has
essential units of medical meaning which form nowhere been realized, we now seem to have
the elements of medical systems and whose before us a 'royal road' for systematically
relational arrangements result in the unique exploring medicine in these terms; comparative
configuration of different kinds of medicine. studies in medicine offer enormous support
This analogy suggests that we might be able for the appreciation of medicine as a form of
to describe in a general way basic relational symbolic reality, a new direction which has
MEDICINE'S SYMBOLIC REALITY 89
already begun to challenge modern medical 3 On the sociology of knowledge, see Peter Ber-
theory and which could well become a central ger and Thomas Luckmann, The Social Con-
problem for a philosophical reconsideration of stmction of Reality (Doubleday, New York
medicine. 1967); and Burkart Holzner, Reality Con-
struction in Society (Schenkman, Cambridge,
Mass. 1968), both of which are made relevant
NOTES for medicine in Freidson (1970}. On the rela-
tion of modern linguistic developments to the
1 A leading example of the comparative social study of medical systems, see Claude Levi-
study of science is Everett Mendelsohn and Strauss, 'The Effectiveness of Symbols', Struc-
Arnold Thackray (Eds.), Science and Human tural Anthropology (Doubleday, New York
Values (Humanities Press, New York, 1972). 1967), pp. 181-202; and S. J. Tambiah, 'The
No single volume is yet available that satisfac- Magical Power of Words', Man, Vol. 3 (1968),
torily reviews the comparative social study of No. 2, p. 175. Examples of symbolic and
medicine, rather one must tum to a number of structural analyses applied to medicine are
outstanding articles in different areas. found in: Clifford Geertz, 'Ethos, World-View
2 The reader is referred to the following para- and the Analyses of Sacred Symbols', in Alan
digmatic studies of different systems of medi- Dundes (Ed.), Every Man His Way (Prentice-
cine: for traditional Chinese medicine, Pierre Hall, Englewood Cliffs, New Jersey 1968);
Huard and Ming Wong, Chinese Medicine Victor W. Turner, 'The Syntax of Symbolism',
(World University Library, New York 1968); Philosophical Transactions of the Royal Soci-
for primitive medicine, Victor W. Turner, The ety of London, Series B (1966), 251, p. 295;
Forest of Symbols (Cornell University Press, and Nur Yalman, 'The Structure of Sinhalese
New York 1967); for folk medicine, John M. Healing Rituals', Journal of Asian Studies,
Ingham, 'On Mexican Folk Medicine', Ameri- Vol. 23 (1964), p. 115. For modern ethno-
can Anthropologist, Vol. 72, (1970), No. 1, graphic approaches to medical systems, see:
p. 76; for ancient Greek medicine, Pedro Lain CharJes 0. Frake, 'The Diagnosis of Disease
Entralgo, The Therapy of the Word in Clas- among the Subanum of Mindanao', American
sical Antiquity, ed. and trans. by L. J. Rather Anthropologist, Vol. 63 (1961 ), No.1, p. 113;
(Yale University Press, New Haven 1970); for and L. B. Glick, 'Medicine as an Ethnographic
modern medical systems, Eliot Freidson, Pro- Category', Ethnology, Vol. 6 (1967), p. 31.
fession of Medicine (Dodd, Mead & Co., New Historical and cross-cultural comparisons of
York 1970}; for culture contact and trans- elements of medical systems are exemplified
formations between traditional and modern by Michel Foucault, Madness and Civilization
systems of medicine, R. C. Croizier, Trad- (Mentor Books, New York 1965); and Mary
itional Medicine in Modern China (Harvard Douglas, Purity and Danger (Pelican Books,
University Press, Cambridge, Mass. 1968 }, Baltimore 1970). Alland (1970) attempts to
Charles Leslie, 'Modern India's Ancient Medi- compare whole medical systems in his evolu-
cine'~ Transaction, Vol. 6 (1969), No.8, p. 46, tionary framework. General comparisons of
and Alexander Alland, Adaptation in Cultural Asian, African and Western medical systems
Evolution (Columbia University Press, New are found in: Robbin Horton, 'African Trad-
York 1970). Recently, the Wenner-Gren Foun- itional Thought and Western Science. I',
dation has conducted an interdisciplinary con- Africa, Vol. 37 (1967), No. 1, p. 50; Pierre
ference on the comparative study of Asian Huard, 'Western Medicine and Afro-Asian
systems of medicine, which is soon to be pub- Ethnic Medicine', in F. N. L. Poynter (Ed.),
lished. In October 1973 the first of several Medicine and Culture (Wellcome Institute
international conferences on the comparative Publications, London 1969); and T. A. Lam-
study of medical systems will be held at the bo, 'Traditional African Cultures and Western
University of Washington and will deal with Medicine', in Poynter, Medicine and Culture.
Chinese medicine and scientific medicine in 4 See Horton (1967).
China, as well as theoretical issues in com- 5 Glick (1967}, p. 34.
parative medicine; it is to be followed by a 6 Cf. Heinz Werner and Bernhard Kaplan,
conference on African medical systems. Symbol Formation (Wiley, New York 1967),
90 ARTHUR M. KLEINMAN
pp. 15-54; K. I. Platnov, The Word as a Museum Occasional Papers, Vol. 15 (1964),
Physiological and Therapeutic Factor (For- pp. 4-5.
eign Language Pub. House, Moscow 1959), 8 Freidson (1970), pp. 205-23.
pp. 16-38; and Marcel Mauss, 'Les Tech- 9 See Pedro Lain Entralgo, Doctor and Patient
niques Du Corps', Socio/ogie et Anthropolo- (World University Library, New York 1969).
gie (Presses Universitaires de France, Paris 10 Cf. Jiirgen Habermas, 'Knowledge and
1950). Human Interests: a General Perspective'.
7 Victor W. Turner, 'Lunda Medicine and the Appendix to his Knowledge and Httman
Treatment of Disease', Rhodes-Livingstone Interests (Beacon Press, Boston 1971).
10
Elements of Charismatic
Persuasion and Healing
Thomas ]. Csordas
...
[ ] the sacred, episodes of insight, or changes
The problem of efficacy appears repeatedly in thought, emotion, attitude, meaning, behav-
at the center of debate about religious healing ior. Third is outcome, or the final disposition
practices. Although other reviewers have of participants both with respect to their
chosen to treat the diverse and voluminous expressed level of satisfaction with healing,
literature on this problem (cf. Bourguignon and to change (positive or negative) in symp-
1976; Dow 1986; Moerman 1979), my pur- toms, pathology, or functioning.
pose here is to develop an approach that is Of these three elements, therapeutic proced-
sensitive to incremental and inconclusive ure has been treated exhaustively in many em-
effects that define the lowest threshold of effi- pirical studies and comparative works (Frank
cacy. It is by now commonplace to observe that 1973 [1961]; Prince 1980). Therapeutic out-
efficacy is contingent on the nature of the prob- come has only recently begun to be treated
lems addressed by different forms of healing, systematically by anthropologists (Finkler
how those problems are defined in cultural 1985; Kleinman and Sung 1979; Kleinman
practice, and what counts in cultural terms as and Gale 1982). However, therapeutic process
their successful resolution. Given these obser- as defined here has been virtually neglected,
vations, however, we are left with a lack of and relegated to the status of a "black box."
analytic specificity to the concept. This neglect may originate in a failure to dis-
A first step is to be aware of which of three tinguish between prototypical cases for ritual
aspects, implicit in most discussions of healing analysis, such as rites of passage (Turner 1969)
practice, is the focus of analysis. The first is and ritual healing. What is typically called pro-
procedure, or who does what to whom with cess in anthropological studies of such rites
respect to medicines administered, prayers re- conforms more to what we are calling proced-
cited, objects manipulated, altered states of ure. Following this convention, studies of reli-
consciousness induced or evoked. The second gious healing have been based on descriptions
aspect of healing practice is what we may call of healing rituals and interviews with ritual
process, referring to the nature of participants' specialists, and have included little explicit at-
experience with respect to encounters with tention to the phenomenology of the
Thomas J. Csordas, "Elements of Charismatic Persuasion and Healing," Medical Anthropology Quarterly 212
(1988): 121-42. Reproduced by permission of the American Anthropological Association from Medical
Anthropology Quarterly 2/2 (1988), pp. 121-42. Not for sale or further reproduction.
92 THOMAS J. CSORDAS
transformative process as lived by participants. participants. The analysis I shall present at-
Moreover, while most studies acknowledge tempts to balance interpretive and clinical
that ritual healing is religious, participants' interests, while staying as close as possible to
experience of the sacred is seldom explicitly experiential data.
documented, with the result that it is often
difficult to determine the contribution of
the religious dimension of religious healing Catholic Pentecostalism and
(Csordas 1987a). Charismatic Healing
Moreover, whereas the condition for effi-
cacy in rites of passage is social consensus The healing system examined here is that of
about a biological inevitability (puberty, death) the Catholic Charismatic Renewal, a move-
or a social fait accompli (marriage), efficacy ment within the Roman Catholic Church.
in a situation of affliction is not so straight- The movement is characterized by its integra-
forward a matter. Rites of passage fail only tion of Pentecostal elements into Catholicism.
under extraordinary circumstances, while Among these are Baptism in the Spirit (an
the results of ritual healing are immensely vari- experience of being infused with the power
able in any circumstance. Yet ritual healing and blessing of God through His Holy Spirit),
is often described in such a way that its speaking in tongues or glossalalia (a kind of
results must be seen as inevitable and defini- pseudolanguage lacking a semantic component
tive: it is either invariably successful (Kleinman and used primarily as a form of prayer which
and Sung 1979) or fails to do what it claims expresses praise to God), and the healing min-
(Pattison, Lapins, and Doerr 1973). Given istry (prayer accompanied by the laying on of
this situation, analysis has nor been able to hands for the relief of physical, emotional, or
define satisfactory empirical conditions of effi- demonic illness). Since its beginning in 1967,
cacy that can also account for much healing this movement has spread into the general
that may be partial, incremental, and inconclu- Catholic population and includes members
sive. I suggest that these conditions may be from working, middle, and professional classes
found in the experiential dimension of ritual (Csordas 1980; McGuire 1982).
healing. Catholic Pentecostals are organized either
A fruitful analysis of therapeutic process in "prayer groups" affiliated with particular
can begin with the common ethnographic ob- parishes or in more highly structured inten-
servation that a primary effect of religious tional organizations known as "covenant
healing is to alter the meaning of an illness for communities., The principal ritual event is
the sufferer (Bourguignon 1976). Frank (1973 the prayer meeting, characterized by the coord-
[1961]) pointed the direction toward under- inated use of several genres of ritual lan-
standing this change by defining healing as a guage (Csordas 1987b). Initiation seminars
form of persuasion that alters a person's "as- introduce new members to the "life in the
sumptive world." Compatible with Frank's in- Spirit" and integrate them into prayer group
sight is the work in interpretive anthropology activities.
that analyzes ritual as performance (Csordas Catholic Pentecostals participate in the late
1983; Kapferer 1979, 1983; Schieffelin 1985; 20th-century shift among Christians from em-
Tambiah 1977, 1985). This work raises issues phasis on suffering and self-mortification as an
of subjective experience among ritual partici- imitation of Christ, to emphasis on the possi-
pants, impacts of utterance and action carried bility and benefit of divine healing as practiced
out within specific ritual genres, and performa- by Jesus in the gospels (Favazza 1982). The
tive transformation of context as well as of processes of healing and spiritual growth are
meaning. However, while interpretive scholar- linked, because illness is typically regarded as
ship has been able to highlight changes in as- an obstacle to spiritual growth. Healing is
sumptive worlds, it is generally more attuned therefore considered necessary for all persons
to issues of language and rhetoric than to either in the process of spiritual growth, and spiritual
clinical issues or to the concrete experience of growth is in turn conducive to good health.
ELEMENTS OF CHARISMATIC PERSUASION AND HEALING 93
The healing system is holistic in that it aims in for self and others may also occur in a segment
principle to integrate all aspects of the person, of smaller weekly prayer meetings. Following
conceived as a tripartite composite of body, these prayer meetings, prayer for individual
mind, and spirit. supplicants may be conducted in a separate
The tripartite concept of the person is the "healing room" by a specially chosen team of
basis for three distinct but interrelated types of healing ministers from within the group. More
healing: physical healing of bodily illness, inner intensive group healing also occurs in smaller
healing of emotional illness and distress, and day-long or weekend retreats and "days of re-
deliverance from the adverse effects of demons newal." Private sessions may be arranged with
or evil spirits (Csordas 1983 ). Physical healing an experienced healing minister or healing
is the simplest in form, in which laying on of team. Some of those who practice in the private
hands and, in some instances, anointing with setting also have professional training in coun-
blessed oil accompany prayer. Healing minis- seling or psychotherapy and integrate these
ters pray for relief from illness, success of practices with ritual healing. In addition, pri-
medical treatment, lessening of side effects vate healing prayer sometimes occurs over the
from medication, or release from suffering telephone. Finally, healing prayer for oneself or
through death. Inner healing may be aimed at others may be practiced in the solitude of pri-
removing the effects of a particular life trauma, vate devotion.
or it may be a review and reinterpretation of an
individual's entire life history in light of the
"healing presence of jesus." Supplicants are Methods
frequently exhorted to forgive others for past
wrongs. Vivid imagery often accompanies The discussion presented here is based on a
inner healing, either as a revelation of some larger study of therapeutic process in Catholic
repressed experience or as a confirmation that Pentecostal ritual healing. Of the 75 healing
healing is taking place. In deliverance, a suppli- ministers interviewed in the first phase of the
cant is relieved of oppression by evil spirits. research, six were recruited to participate in an
Demons in this instance typically do not have intensive phase, in which their private healing
complete control over a person in such a way as sessions were observed and recorded. Healer
to require the formal Church rite of exorcism, recruitment was based on willingness to par-
but are nevertheless regarded as having a detri- ticipate, a reputation within the movement as
mental effect on the person's life and spiritual experienced and reliable, and an adequate case
growth. Evil spirits identified or "discerned" by load. Healing ministers participated in recruit-
either the healing minister or the supplicant are ment of subjects, making initial contacts to
dispatched by a "prayer of command" in the determine their willingness to participate. Both
name of Jesus Christ. While healing ministers to protect individuals who may have been par-
tend to specialize, most recognize the necessity ticularly vulnerable and to enhance healer-re-
at times of using all three forms in varying searcher rapport, healing ministers were given
combinations. discretion in determining which individuals to
Charismatic ritual healing occurs in a var- exclude.
iety of settings. Large group-healing services For each person recruited, up to five healing
originated at the periodic conferences in which sessions were recorded on cassette tape with the
movement participants assemble on a national researcher present. During a subsequent inter-
or regional basis both to show their strength view, each participant was asked to identify
and unity and to worship and teach. In the the most important or meaningful event within
decade from the late 1970s to the late 1980s the session. These events were played back, and
these conference sessions evolved into the commentaries were elicited for each person,
public healing service, in which healing minis- using an adapted form of the Interpersonal
ters of some reputation attract Catholics who Process Recall (IPR) method developed by psy-
may not otherwise participate in the Charis- chotherapy process researchers (Elliott 1984,
matic Renewal. Healing prayers or petitions 1986). An additional background interview
94 THOMAS J, CSORDAS
covered basic life history and medical/psychi- can't get in touch with it." Discernment- div-
atric history, nature and level of involvement in inely heightened intuition- is understood as a
the Charismatic Renewal, and attitudes and divinely inspired ability to understand people,
expectations of religious healing. In order to problems, and situations. Father Felix recounts
confirm presence or absence of psychiatric dis- two incidents in which he felt the granting
order, this interview included an adapted and of this charism was confirmed. In the first,
shortened form of the Schedule of Affective while praying with a parish priest, he spoke
Disorders and Schizophrenia (SADS). about problems that were so uniquely relevant
Both individuals whose cases are presented to the priest's situation that the latter thought
here were followed from beginning to end of his parishioners had already spoken to Father
their involvement with one of the participating Felix about them beforehand. In the second,
healing ministers. They represent precisely the he discerned that he should ask someone else
kind of incremental and inconclusive process in the healing group to lead a vocal prayer
that I suggested above as characterizing the while he prayed silently with his hand on a
lowest limits of therapeutic efficacy in ritual priest's back. During the prayer his hand
healing, and it is for that reason they were became extremely hot. This heat was also per-
chosen as the focus of this analysis. Before ceived by the supplicant, who later mentioned
discussing them, however, I shall introduce that he had cancer in his back at the spot where
the healer with whom I followed these cases. Father Felix had "discerned" that he should
place his hand. For Father Felix, the fortuitous
placement of his hand was a manifestation
A Minister of Charismatic Healing of discernment, while the heat was a sign that
healing was taking place. Since then, Father
Father Felix, an experienced Charismatic Felix has relied strong! y on this gift in his
healing minister, is a 60-year-old Catholic priest, healing practice.
ordained as a member of a religious order in Father Felix holds private healing encoun-
1952. He holds a Doctorate of Ministries with ters in one of the counseling rooms at the mon-
concentrations in psychology and counseling astery where he resides. The session begins
and has been an assistant supervisor of a pro- with a period of light talk or counseling, during
gram for priests in Clinical Pastoral Education which the priest typically inquires about
(CPE). In 1975, as part of an assignment as changes that may have occurred since the pre-
director of pastoral care at a Catholic medical vious session. He then places a straight-backed
center, he was asked by the executive adminis- chair in the center of the small room, asks the
trator to coordinate a Charismatic healing min- supplicant to be seated there, and anoints the
istry within the hospital. Although he had been person's forehead with holy oil. He stands
aware of Charismatic prayer groups, he had behind the person with one hand on her head
previously taken no interest; thus his involve- and another on her shoulder, praying silently
ment in Catholic Pentecostalism began with his for approximately five minutes. During this
consent to become active in Charismatic healing. period he often receives "discernment" about
Since then he has remained active in the healing the person and the problem. Afterwards he
ministry, leading public healing services and asks the person about any experiences she
workshops and conducting private healing might have had during the prayer. After this
sessions. second brief period of conversation and coun-
Catholic Pentecostals believe that the power seling, the session ends, seldom having lasted
to heal stems from "spiritual gifts" ("charisms" more than a half hour.
in theological terms) granted by God. As Father Father Felix strongly believes in the neces-
Felix continued to work as both a counselor sity of "getting to the source" of a problem in
and healing minister, he asked God for "the gift order to heal it. From his experience, two im-
of discernment to be able to know what to pray portant sources of people's problems are evil
for. Because a lot of people are coming in. spirits and previous generations. To eliminate
There's a lot of stuff that's unconscious; they the influence of evil spirits he uses deliverance
ELEMENTS OF CHARISMATIC PERSUASION AND HEALING 95
prayer, and to eliminate that of previous gener- he sometimes tells the supplicant that he has
ations he uses the mass for healing of ancestry. discerned things that may hurt if told. In this
Each of these will be briefly described. way he establishes a role both of wise protector
In the Catholic Pentecostal healing system, and empowered healer who is in direct contact
evil spirits typically are named after emotions with the sacred.
or behavioral patterns; Anxiety, Depression, In addition to private healing sessions,
Lust, and Rebellion are all common spirit Father Felix often says a "healing-of-ancestry
names. Father Felix agrees with most other mass" in the home of the supplicant. Before-
Catholic Pentecostal healers interviewed that hand, he asks the person to prepare a family
spirits attack individuals at their most vulner- tree going back as many generations as pos-
able points, whether these be the propensity for sible, noting any important events or health
committing a particular type of sin or the problems, such as suicide, alcoholism, mental
lasting effects of traumatic experience. No illness, or abortion. He then "prays over" the
one can be completely possessed by Satan genealogy for discernment about the individ-
unless he makes a conscious decision or pact; uals represented. The principle enacted in this
all other spiritual afflictions are in the form of ritual is that illnesses or adverse effects of trau~
oppression or harassment in a particular matic experiences can be passed "through the
domain of life experience. Father Felix also blood line" to successive generations. Part of a
allows for human sources of negative emotions person's healing can include the healing
in the absence of demonic influence, however, through prayer of individual forebears who
and it is a matter for discernment whether a died without having been healed. In some re-
person plagued by depression or lust is in fact spects this practice is akin to praying for the
under attack by the spirit of Depression or souls of the dead, but it goes a step farther in
Lust. Among the most common spirits in his actually trying to heal the dead. When this is
experience is Fear-of-Being-Found-Out, which accomplished, the chain of negative influence is
causes such thoughts as "if only people knew "severed," and the person is freed of the
the things I did or I think, I'd have no friends." affliction.
Another very common spirit is Devaluation, This is a brief description of the Charismatic
akin to Self-Hatred, which causes "low self- healing ministry as practiced by a single
image and self-esteem." person. While it is well within the bounds of
Father Felix's typical mode of deliverance is Catholic Pentecostal healing practice as de-
to pray silently as follows: "By the power of the limited by the research described above, several
Word of God,] esus Christ, and by the power of contextualizing remarks are in order. First,
the Sword of the Spirit I sever forever all nega- while it is quite common for priests and
tive spiritual, emotional, psychic, or physical members of religious orders to practice ritual
negative influences that are bothering my sister healing, many Charismatic healing ministers
[or brother]." Following this general prayer he are laypersons. Second, while some healing
specifically addresses whatever evil spirits may ministers have had professional training in
be present: "You, dark binding forces, I com- counseling or psychology, most have had
mand you in the name of jesus Christ to be none. With respect to procedure, Father Felix
separate one from the other, to be without makes less use of guided imagery than do many
communication and to be rendered powerless. Charismatic healing ministers, although he
You have no more power over this person. He encourages spontaneous mental imagery. On
[or she] belongs to Jesus Christ." He then si- the other hand, he makes great use of deliver-
lently commands individual demons by name, ance, which many healing ministers avoid be-
as their presence is revealed to him through cause of the perceived danger of dealing with
discernment. He does not necessarily inform powerful evil spirits. Finally, performing the
supplicants that there are evil spirits involved, mass for healing of ancestry in supplicants'
but instead waits for a sign in their speech or homes appears to be a practice unique to
behavior that confirms his discernment. Yet in Father Felix, and provides him with an oppor~
withholding this divinely inspired knowledge, tunity to observe family dynamics in a way that
96 THOMAS J, CSORDAS
is typically reported only of healers in small- distress appears to be the accidental death of
scale traditional societies. a brother some years earlier. Given this constel-
lation of patterns and events, a major area of
intense anxiety for her is relationships with
Two Cases of Charismatic Ritual men. Through psychotherapy she has come to
associate this anxiety with a lack of opportun-
Healing ity to develop a sense of trust for others.
Margo is a practicing Catholic, and was
Case 1 involved in Charismatic prayer groups for a
Margo is a 2 7-year-old woman, third youngest period of months several years prior to her
of nine children, who lives with her parents, illness, but for no clear reason she ceased
three of her sisters, and one sister's three-year- attending. Since the onset of her illness, how-
old daughter. She is concurrently under treat- ever, Margo has frequently attended public
ment with a psychiatrist (psychopharmacolo- healing services and is on the mailing lists of
gist) and in therapy with a psychologist, but two influential Charismatic healing ministers.
she has been frustrated by the failure of both At these services she often experiences "resting
medication and therapy. The diagnostic por- in the spirit," a form of motor dissociation in
tion of her interview confirmed panic disorder which a person, at the touch of the healing
and major depression as her principal prob- minister, falls in a peaceful, relaxing, and reju-
lems. She and her mother both report that venating swoon as the "power of the Holy
one of her sisters, who lives at home, suffers Spirit" overcomes her. Yet Margo had been
from schizophrenic illness. disturbed in one of these services when the
Margo's illness began in 1985, two years healer declared that she was being healed. On
before recourse to the healing minister. She inquiry, the healer explained that her "gift of
had dropped out of nursing school after doing discernment" revealed that the healing process
less well than she had hoped, and had returned had already started. Margo reported being con-
to full-time work as a hospital administrative fused and baffled, since "if the healing has
assistant. She felt overworked and preoccupied already started, personally I don't feel any
by this stressful job. At the same time she felt different.,,
that she was "losing" most of her previous Margo called Father Felix to ask for help,
friends as they got married, so that her social and he advised that she attend his public
life had become "flat." After six months she healing service. At that event she requested
"burned out" and took a transfer to a lower- prayer for severe depression, and the priest
status, less stressful job. Her first panic attack instructed his assistants to pray for expulsion
occurred two months after the transfer. of a "spirit of Darkness." He then suggested
Difficulties of family life appear to have that she come to him for private healing ses-
contributed to the problem. She regards her sions. At the initial session he recounted previ-
parents' marriage as very poor, characterized ous situations of successful healing, and stated
by frequent loud arguments. She describes her that he felt she could be healed quickly. He
father as critical, cruel, and authoritarian, to "corrected" her idea that prayer would be more
the point of physically abusive discipline when successful if she made her mind blank while he
his children were young. She is very close to her prayed, explaining that she should expect
mother and older sister, but feels a need to spontaneous mental imagery to emerge from
distance herself from emotional overinvolve- her unconscious during the course of prayer
ment and establish an independent life. She and that God did not need her assistance for
reports developing, one year prior to the onset the prayer to be successful. He also "corrected"
of her illness, overt hostility and hatred for a her view that she should cease weekly psycho-
previously close sister who had "ruined her therapy while undergoing ritual healing.
own life" and moved back into the family During the second session, Margo told
home after having had a baby with a man she Father Felix of a disturbing experience she
did not marry. An additional factor in her had had repeatedly for several months prior
ELEMENTS OF CHARISMATIC PERSUASION AND HEALING 97
to the onset of her illness. As she was drifting M: I had thoughts like, you know, I'm slowly
off to sleep, she "could feel another presence in going to wither away. Almost like having
my room. I could feel someone actually sit some form of cancer. It doesn't leave me.
down on the end of my bed.'' She had never It haunts me. It never leaves me. It won't
mentioned this to her psychiatrist or psycholo- go away. I can't get rid of it. I don't know
gist, for fear that they would think her crazy. how to get rid of it. It's driving me crazy.
Father Felix agreed that she was right not to It's driven me crazy. It's overtaken my
have told them, but that he himself was quite whole life. And I ...
familiar with such experiences: it was an evil FF: What did I tell you last time? I guess you
spirit. This confirmed what she had suspected, forgot. About taking authority over
these things within yourself. You take
and reassured her that it was a phenomenon
authority in the name of Jesus Christ,
with which Father Felix could deal.
and you command them to just get the
During the period of silent prayer, perhaps heck out. They have to obey.
in response to Father Felix's advice to allow M: I have said that to myself at different
thoughts to come to her mind, Margo experi- times. Like this whole past week while I
enced a series of ideas "coming from all direc- was at mass. I had the tremors and the
tions." Three issues emerged: the difficulties shakes real bad. You know, the fears
she experienced in her past administrative job, around other people being there, what-
whether or not to change doctors (she had been ever. And I kept saying that to myself
told that everything had been tried yet nothing over and over again.
seemed to help), and a disappointing relation- FF: What did you say?
ship with an older man. The latter situation M: I kept saying, you know, "In the name of
was one in which the man, who lived in a Christ, leave me, leave me." Trying to
different city, had courted her for a period of force the way that I thought into another
time until she discovered that he was married. direction, more positive. And ...
She cared for him, but was very angry, and felt FF: Let me clue you in to something. If you
say, for instance, "In the name of jesus,"
conflict about her desire to be with him in spite
right? There's an evil spirit that calls
of a conviction that it would be morally wrong
itself "Jesus" ... but it's a false Jesus.
to do so. None of these issues was subsequently You've got to remember that. Some
discussed with the healer. Father Felix simply people get caught up - it's like conjuring
told Margo to make note of what came into her up a spirit, and they're confronting the
mind during prayer because "it would be im- evil spirit [that] calls himself "Jesus." So
portant" for her. I always use the name "Jesus Christ" or
A final event that unfolded over two ses- "Jesus of Nazareth," you know? That
sions had to do with the priest's advice that Jesus. Oh, yeah, hundreds of [Spanish-
one can verbally address negative emotions speaking] people call themselves jesus.
and command them to leave in the name of
Jesus Christ. This event was explicitly identi- In this interaction (identified as significant
fied as most significant by Margo in a subse- by Margo herself), the directive to specify the
quent interview. She interpreted the advice to name jesus Christ was more than a move by the
mean that the problem is "all in the way that healer to cover the technique's lack of success.
you're thinking." Invoking God indicates that For the failure to command one's emotions
He does not want her to feel as she does, and if indicates in the logic of the healing system
she has the strength and faith to say "leave" in that more than one's emotions are involved. A
His name, the negative emotions of anxiety powerful force must be standing in the way,
and depression should go. blocking the path to healing. In a follow-up
During the following session, Father Felix interview, Margo acknowledged surprise at
discovered that this technique had not been learning both the subtlety of the religious tech-
successful in achieving the goal of changing nique and the demonic cause of her problem.
her attitude. The following key exchange took She recalled Father Felix's original invocation
place: of the "spirit of Darkness" during her first
98 THOMAS J. CSORDAS
public healing service. She intimated that she Another major source of distress is his brother,
had always "thought [about her problem] who in the past has also been under psychiatric
along those lines" and that the idea of evil care. He cannot tolerate his brother, who is
forces being involved "struck home." With re- highly abusive to their parents, so the two have
spect to how this interaction helped her, she taken turns living with their grandfather in a
responded that it was "to give me courage nearby town. Ralph appears to have a close
and more strength, and more faith. Faith-wise, relationship with his father, but he feels that
to know that this is not of God. And how his mother is critical and habitually makes
prayer can build your faith. It can build your him feel guilty even in small daily events.
strength." His primary pleasure comes from listening to
In addition to having a home mass for recorded music and from writing poetry in a
healing of ancestry. Margo attended a total of style that he considers similar to that of Ker-
three private sessions with Father Felix. Instead ouac and Ginsberg, though he finds it ex-
of going to her fourth session, she kept an tremely difficult to write creatively under the
appointment with her psychopharmacologist, influence of his antipsychotic medication.
who decided that since no other treatment had Ralph's religious background includes ex-
worked, she should be admitted for electrocon- posure to the Charismatic Renewal when he
vulsive therapy (ECT). She indicated that she was 16, when he attended a prayer group for
would have resumed the sessions after dis- about a month with his mother. During this
charge, but this was precluded by Father Felix's time he had the experience of "Baptism in the
departure for a long sabbatical. Holy Spirit" and became familar with speaking
in tongues and other Charismatic practices. He
currently claims not to believe in God, but even
Case2 so, admits that religious themes consistently
Ralph is a 25-year-old man who has finished emerge in his poetry. The encounter with
high school and spent a short period in college. Father Felix was initiated by Ralph,s mother,
He now lives with his parents and brother, a who thought that, as a psychologist, he could
year his junior, and is under medical and psy- best advise the family about a psychiatrist's
chiatric treatment for a variety of problems. recommendation that Ralph submit to electro-
The diagnostic portion of our interview con- convulsive therapy (ECT). Father Felix res-
firmed a complex situation revolving around a ponded that if Ralph saw him on a regular
primary diagnosis of paranoid schizophrenia basis he would not need ECT. Ralph entered
originating from serious drug abuse; obses- the situation expecting counseling for his main
sive-compulsive disorder with onset at age 14; problem of social nervousness, and only when
probable dysthymic disorder (a mild form of the sessions began did he realize they consisted
clinical depression); symptoms of agoraphobia, primarily of healing prayer.
panic disorder, and simple phobia (fear of Hopes were raised after the first session,
heights}; epilepsy related to a probable brain during which Ralph experienced warmth em-
lesion; and asthma. anating from the priest's hands and the sensa-
In 1983, approximately four years before tion of purple rings expanding concentrically
Charismatic healing, Ralph had had a major in his visual field while his eyes were closed.
psychiatric hospitalization following a drug Father Felix interpreted the vision in terms of
overdose. His inpatient experience was trau- Catholic liturgical symbolism, in which purple
matic and appears to have been the occasion represents death. He concluded that something
on which his principal complaint began: ex- negative within Ralph was dying. More im-
treme "nervousness" in social situations for portant for Ralph, the sense of a benign pres-
fear people are thinking negatively about him, ence accompanied him for two days after this
in particular that they are thinking he might be initial session. This experience encouraged him
homosexual. Since the advent of these fears, he to attend mass with his grandfather, where he
has been unable to hold a job and finds it felt his eyes rotating upward in their sockets
nearly intolerable to be in a group of people. (nystagmus). One of Ralph's greatest fears is
ELEMENTS OF CHARISMATIC PERSUASION AND HEALING 99
that this occasional phenomenon will occur in Ralph's nervousness would prevent him from
public, and its occurrence during the mass attending a party, Father Felix stated that he
prompted him to feel betrayed by God. In sub- thought mingling with people would be just the
sequent sessions he again experienced heat and thing Ralph needed. In response to Ralph's
color, but the sensations progressively declined statement that he was too nervous, the healer
in intensity. In addition, although he had said that if you think nervous, you'll be ner-
prayed silently along with Father Felix during vous. Ralph objected, "No, rm not thinking
the first few sessions, he ceased this participa- nervous, I am nervous!" In the follow-up inter-
tion in the final ones. view, he stated specifically that he felt misun-
Ralph's post-session interviews reveal his derstood, and that with paranoia one cannot
perception of the therapeutic process as unsat- simply tell oneself to do something. In another
isfactory. Two types of comments indicate that segment Ralph mentioned that his father en-
the healer at times either overinterpreted or couraged him to "be like him" and not care
misunderstood Ralph's experience in ways that what others think. Father Felix interpreted this
weakened the rhetorical impact of the healing. as an expression of the father's insecurity, indi-
One of Father Felix's overinterpretations cating that he did not feel in control of his life
occurred when he was trying to convince Ralph and really did care about others' opinions. In
that by dweJling on his nervousness he would the follow-up interview, Ralph took exception
perpetuate it, just as someone who repeats to to this, arguing that his father had made this
himself "don't think about the color green" is statement only once or twice, in the context
in fact thinking about green. During the period of encouraging Ralph, and wasn't guilty of
of prayer with laying on of hands which "denial." He felt that Father Felix's basic point
followed this conversation, Ralph saw the about people in general was correct, but that
color green in addition to his usual purple. he was inaccurate in attributing such denial to
Father Felix attributed significance to this, his father. Finally, in a session when Ralph
pointing out that green is the color of hope in stated that no changes had occurred since the
liturgical symbolism. Ralph rejected the inter- previous session, Father Felix turned to the
pretation, attributing his vision of green to the researcher and asked if in fact I could' not ob-
suggestion planted by the previous advice, serve any changes. Ralph interpreted this at-
rather than to divine inspiration. In another tempt to solicit impressions of observable
example, Father Felix asked if he could invite behavioral change as an outright contradiction
two women from the local Charismatic prayer of his report of no internal experience of
group to help him in the healing prayer in order change. He stated that this made him angry,
to expose Ralph to female influence, which he although it "didn't have anything to do with
felt was inadequate in his client's life, and ap- the praying" as a form of treatment.
parently also in response to Ralph's fear of In spite of this apparent willingness to sep-
being thought a homosexual. Ralph's response arate the religious effects of the prayer from
to this therapeutic move was to list a variety of the perceived missteps of the healing minister,
women he knew, rejecting the idea that his successive overinterpretations and misunder-
exposure to female presence was deficient. standings appear to have undermined the
Finally, Father Felix attempted to portray as therapeutic process. Ralph terminated his in-
positive Ralph's uncharacteristic attendance at volvement after five sessions and a healing-of-
mass and visit to a restaurant with his grand- ancestry mass. Subsequently, Father Felix met
father. Ralph's response was that he had in several sessions with the father, praying
attended mass only once, and that going to a ostensibly for the second son with the father
restaurant never made him as nervous as did as "proxy." In private, however, he admitted
being in a group of people. he was simultaneously praying for the father
In addition to these overinterpretations, himself, who he felt had an overly critical and
Father Felix appears to have misunderstood negative manner. The priest felt that the man's
Ralph on a number of occasions. In a segment manner was somewhat ameliorated through
during which the two discussed whether healing, and the family also reported that
100 THOMAS J. CSORDAS
their second son had become less wrathful mood or tendency and of the act of dispos-
and abusive. However, the father soon termin- ing or arranging in an orderly way. In other
ated his sessions with Father Felix as well. words, under this heading we are looking
In an interview two months following his not only at psychological states, such as
termination, Ralph described interactions with expectancy or "faith to be healed," but at
a new psychiatrist, who was skeptical of the the disposition of persons within the healing
diagnosis of paranoid schizophrenia and who process vis-a-vis social networks and sym-
had successfully hypnotized Ralph into not bolic resources.
feeling nervous on a recent date with a woman. While neither client was very active in the
He tended to discount the apparent similarity Charismatic movement, Margo was more fa-
between the peaceful feeling of being prayed miliar with religious healing through attend-
over with eyes closed and being placed in light ance at prayer meetings and public healing
trance and was hopeful about his new course of services and had no questions about basic reli-
treatment. gious belief. In addition, her mother was
oriented toward Charismatic spirituality and
subscribed to the leading Catholic Pentecostal
Incremental Change, magazine. In spite of strong disappointment at
Inconclusive Success a healing service in which she was told that her
healing had already begun, Margo's positive
Much of the literature on religious healing im- disposition within the process was expressed
plies that ritual necessarily and definitively ac- in her gratitude for having been singled out
complishes, at least in its own terms, what it for one-on-one healing sessions with Father
sets out to do. Far from being definitive, the Felix and in her openness to his instructions.
effects of healing in the two cases presented She accepted his injunctions both to be open to
here are incremental and inconclusive. Both spontaneous images from her unconscious
are close to what we could call limiting cases, during prayer and to conceive of her anxiety
beyond which the relevance of any idea of and depression as "diminishing" from day to
efficacy becomes questionable. Even so, the day. Her positive disposition was enhanced by
case descriptions indicate that the healing ex- the reassurance that an apparition at her bed-
perience was more satisfying for Margo than side, about which she had never told her secu-
for Ralph, since he rejected the process and she lar therapist, was not a sign of mental illness
wished to continue it. This contrast in behavior but a frequent and fully understandable mani-
suggests the need for an interpretive approach festation of an evil force. Finally, in one session
sensitive to subtle but important modulations she took the initiative of asking the priest if
of meaning and experience in the therapeutic he had spiritually "picked up" or "discerned"
process. In an earlier analysis based on retro- anything particular about her problem while
spective accounts of Charismatic healing, I he prayed over her. This anticipation of divine
proposed that therapeutic process in ritual empowerment in fact caught Father Felix
healing be analyzed in terms of participants' by surprise, but he was able to summarize sev-
predispositions, their experience of empower- eral "fears" about which he had been "led" to
ment, and their experience of transformation pray, thus reinforcing Margo's already strong
(Csordas 1983). Following cases prospectively disposition.
has allowed a reformulation of these elements Ralph, in contrast, entered the process with
in more precise terms. Thus, we will examine ambivalence: he expressed agnosticism but
the two cases in light of these elements of acknowledged a preoccupation with religion
therapeutic process. that emerged both in his poetry and even occa-
sionally in praying by repeating the name
"jesus.'' Like Margo, he had been exposed to
Disposition of participants the practices of the Charismatic Renewal, al-
The term "disposition" is fortuitious in that though he had not been involved for at least
it has the dual meaning of a prevailing eight years and then only briefly. In addition,
ELEMENTS OF CHARISMATIC PERSUASION AND HEALING 101
he had entered healing under the assumption undermined the evocation of the sacred, since
that his sessions with Father Felix would con- Ralph himself attributed the experience to the
sist not of prayer but of counseling. Neverthe- power of suggestion rather than to divine
less, his disposition during the process was power.
favorable enough that he prayed along with The most striking difference between the
the priest during the first several sessions. Yet two cases is that Margo's experiences had
this level of participation diminished, with the more sacred content that pertained immedi-
final result that he discounted the healing pro- ately to her situation, as opposed to Ralph's
cess as cultlike. vague sense of divine presence, heat, and
color that received only minimal interpret-
ation by the healing minister. The observer
Experience of the sacred
might surmise that the healer could have
The human capacity to attend to the world worked with this experience either by inter-
as sacred, other, and powerful has been docu- preting it as a mystical companion who could
mented repeatedly by phenomenologists of protect the young man from pathological ner-
religion (Eliade 1958, 1959; van der Leeuw vousness in social situations or by using it as
1938). Each healing system attends to the an experiential wedge into Ralph's agnosti-
human condition differently, elaborating a rep- cism, thereby facilitating greater disposition
ertoire of ritual elements that constitute legit- toward healing. Father Felix might also have
imate manifestations of divine power. Within a taken the occasion to induce behavioral and
particular healing system, we are concerned attitudinal transformation through his stated
with individual variation in experience of the priority of getting to the "root" of Ralph's
sacred that may influence the course of thera- problems. Instead, any potential content of
peutic process. Ralph's experience remained unelaborated as
Margo's experiences of concrete empower- insight, interpretation, or direction. It is un-
ment included periodic "resting in the Spirit" clear whether this did not occur because the
at other healing services before entering the healer was unaware of Ralph's experience of
series of sessions with Father Felix. With the "presence" or because such a strategy would
priest, instruction to be open to unconscious be unacceptable.
material resulted in the spontaneous experi- Margo's experiences of empowerment were
ence of three significant aspects of her prob- substantially different, rich in biographical
lem, "rushing at her from all directions." Both meaning (sudden emergence of thoughts
the motor dissociation of resting in the Spirit about her job, doctor, and former boyfriend).
and the spontaneous imagery are examples of For her, the experience was a moment not
concrete, embodied experience of the sacred. of abstract but of concrete transcendence. As
Ralph's experience of progressively diminish- pointed out by Kapferer, "A ritual fixed in
ing empowerment began with a distinct experi- a transcendent moment is empowered to act
ence of abandonment by the transcendent on contexts external to the performance and
presence that had initially been evoked in the to transform them in accordance with the
healing prayer. The significance of this event rearrangement or reordering which the tran-
never came to Father Felix's attention during scendent moment of the rite expresses" (1979:
the sessions; hence, he did not have the oppor- 17). Unless the concrete rhetoric within such
tunity of dealing with it in the context of Cath- moments is identified, the phrase "in accord-
olic Pentecostal belief and practice. In short, ance with'' posits no more than an abstract
this experience of the sacred was not incorpor- homology between elements of ritual and
ated into the therapeutic process for Ralph, elements of a distressed life. The concrete ex-
and the intensity of his experience of power as perience of the sacred is not an experience of
presence, heat, and color progressively dimin- "the supernatural" but a transformed way
ished. It is also possible that the priesfs attempt of attending to the human world. For Margo
to attribute symbolic meaning to the emer- but not for Ralph, the link between transcend-
gence of green in Ralph's visual field further ence and the reordering of life was forged in
102 THOMAS J. CSORDAS
relationship. Similarly, the parents' report of may readily discern factors that contribute to
change in his brother had minimal effect, since the fragmentary and inconclusive nature of the
strained relations between brothers persisted to healing process which do not pertain in the
the point where they were unable co live in the traditional societies from which the bulk of
same house. ethnographic knowledge comes.
In sum, the therapeutic process for Margo First, consider Father Felix's attempt to
was characterized by an initially positive dis- draw the families of Margo and Ralph into
position; experiences of divine power with dis- the healing process through the healing-of-an-
crete, intelligible content; the elaboration of cestry mass. If there is anything unique about
viable possibilities; and significant, if incre- Father Felix's healing practice in comparison to
mental, changes. Ralph exhibited ambivalent that of other Catholic Pentecostal healing min-
disposition, diminishing empowerment, non- isters, it is his practice of entering the home and
recognition of possibilities, and rejection of mobilizing family support through participa-
change, with a strong perception of being mis- tion in this event. Most Charismatic healing is
understood by the healing minister. In these based on the model of the individual encounter,
terms, healing was more successful for Margo and it is not unknown for a woman to be in the
than for Ralph, and the analysis thus sheds healing process to the displeasure of her hus-
light on the different modes in which the two band. Even when the healer takes the initiative
terminated their sessions. Ralph left the reli- in mobilizing social support, his authority is
gious healing process to find apparently greater not such that he can intervene in the way some-
satisfaction from a psychiatrist/hypnotist, with times described for traditional healers. Margo's
no sense of continuity from his Charismatic father was pointedly absent from her ancestry
healing encounter. Margo, who was initially mass, as was Ralph's brother from his. Ralph's
demoralized about psychiatry and psychother- father participated enthusiastically in several
apy, left the healing process to try an additional private sessions of his own with the priest, but
inpatient psychiatric treatment and probably he discontinued them without resolution,
would have continued religious healing if the simply failing co make another appointment.
priest had not left the area for an extended Thus social support, often cited as one of the
period. hallmarks of ritual healing, is by no means
automatic. Support from the family and sup-
port from the community of religious believers
Discussion are not identical or necessarily even compat-
ible. Support from either may be less emphatic
While moving in the right direction, this analy- than might be expected from the cases com-
sis still does not establish the significance of monly reported in the ethnographic literature.
these transformations in comparison to what Consider, in addition, the ease with which
clinical thinking would call a cure. What is people may enter and leave the healing process
striking in the examples presented is their in- in these examples. In cross-cultural perspec-
cremental character, with no guarantee that tive, this kind of mobility among healing
they will be permanently integrated into the resources seems to be a function of both the
person's life. The incremental and open-ended number of resources available and the exclu-
process of religious healing may prove to be an sivity of each healing form. Finkler (1985)
essential characteristic that requires some reli- observed a distinction among Mexican Spiritu-
gious cures to be "symbiotic" (Crapanzano alists between those who were devotees and
1973 ): perhaps there is no therapeutic out- those who made casual or periodic use of
come, only therapeutic process. Catholic Spiritualist healing; Crapanzano (1973) noted
Pentecostal healing can include the symbiotic a similar distinction between Hamadsha de-
goal, encouraging supplicants to incorporate votees who experienced a symbiotic cure and
religious meaning and inhabit a religiously de- others who received a "one-shot" exorcistic
fined community. Yet in the sociocultural set- cure. As Catholic Pentecostalism has developed
ting of late 20th-century North America, we over the past two decades, its healing forms
104 THOMAS J. CSORDAS
have become more accessible to those with previous hospitalization and interaction with
only a marginal exposure to the movement. mental health professionals affect the encoun·
Like Ralph and Margo, they are less likely to ter with Father Felix, and how did the experi·
become involved in a total "symbiotic cure" ence with Father Felix influence Ralph's
and will more likely experience the kinds of subsequent encounter with the psychiatrist
incremental transformations documented here. using hypnotherapy? Margo was seeing both
Thus, little understanding will result if research a psychiatrist and a psychologist before meet-
is directed toward definitive therapeutic out· ing Father Felix, who suggested that she switch
come, rather than toward the ambiguities and to a Christian psychotherapist while she con·
partial successes (and failures) embedded in tinued with healing prayer. In the end she
therapeutic process. appeared committed to both psychiatric treat·
Furthermore, if their diagnoses are correct, ment and religious healing. But were these in-
Ralph suffers from a serious schizophrenic ill· dependent commitments or did, for example,
ness characteristically associated with psycho· religious healing influence Margo's willingness
therapeutic failure, while Margo's problems of to submit to ECT?
depression and panic typically respond well to The clinician should find this kind of in·
a variety of psychotherapeutic interventions. formation valuable, but it is not likely to be
Research in traditional societies is often com· volunteered by the patient. Like Ralph and
plicated by the fact that the anthropologist Margo, both of whom refused to permit me
does not have comparable diagnostic informa· to contact their physicians, many of those
tion; on the other hand, research in contempor· who have recourse m religious healing un-
ary society can be complicated by the fact that doubtedly believe they are better off not
the informant does have this information. informing their physicians unless or until
Ralph's rejection of Father Felix's comment, some dramatic change occurs for which they
"If you think nervous, you'll be nervous," was want medical documentation of a miraculous
based on his conception that clinical paranoia healing. Medical prejudice- real or perceived-
cannot simply be banished by a change of atti· against religious conviction may create a crit·
tude. In contrast, Margo's willingness to tell ical blind spot in the clinical picture of the large
about her experience of an apparition only to number of people who find religious healing
the priest and not to her psychotherapist was congenial.
based on her concern that she might receive a In concluding, we should allow a final word
diagnosis that to her was worse than depres· to Father Felix, who was himself disappointed
sian and panic disorder. that more noticeable and quicker results had
One might say that the religious healing not been achieved in either case. He attributed
encounters of both supplicants were condi • the difficulty with Ralph both to the suppli·
tioned by previous encounters with mental cant's resistance and to his own failure to
health professionals, in terms both of know- include more of a counseling component along·
ledge about their conditions and, especialJy side healing prayer. He also saw Margo's main
for Margo, of insights gained from previous problem as a negative family environment and
psychotherapy. This interpretation would rep- her inability to achieve independence from it.
resent ethnographic myopia, however. More
accurate for both Margo and Ralph, religious
healing was an interlude in a history of encoun· Conclusion: Therapeutic Process
ters with the mental health establishment. and the Theory of Healing
Herein lies both the clinical and anthropo·
logical significance of these cases: anthropo· The method adopted in this study of examin·
logically, in terms of how the interaction of ing disposition, religious experience, possibil-
both religious and clinical meanings shape ity, and incremental change as elements of
the illness experience; and clinically, in terms therapeutic process contrasts with studies that
of how the religious encounter may influence emphasize the global role of psychological
the trajectory of the illness. How did Ralph's mechanisms such as suggestion, catharsis,
ELEMENTS OF CHARISMATIC PERSUASION AND HEALING 105
placebo effect, or regression in service of the While Dow states that the healer "per-
ego (Calestro 1972; Sargant 1973; Scheff suades'' the patient that the mythic symbols
1979; Torrey 1972). These studies tend to are relevant to his or her condition, he does
discourage detailed analysis of therapeutic not explain how such persuasion occurs and
process in the experience of individual per- creates a disposition to be healed. Elements of
sons, since if healing can be accounted for religious experience are judged by Dow to be
by a nonspecific mechanism, all that need be "therapeutic preludes," the purpose of which
specified is how that mechanism is triggered. is to establish a therapeutic relationship based
Even when more specificity is given, as in on paradox; transcendence (Kapferer 1979)
Scheff's (1979) proposal that a mechanism of and experience of the sacred (Csordas 1987a)
distancing is essential to the mechanism of play no part. Finally, the relationship among
catharsis, analysis tends to discount the nature social, self, and somatic levels is characterized
of distress and the differential effects of as analogous to that of a "thermostat," such
healing across individuals. We cannot defini- that "it is possible to affect processes in the self
tively say, for example, that the technique of and unconscious-somatic systems through the
commanding her emotions constituted distan- manipulation of symbolic parameters at the
cing for Margo, and even if we can, the effect social level" (Dow 1986:63). The thermostat
may have been more cognitive than cathartic. analogy is entirely too mechanistic. What is
A similar point applies to invocation of needed at this stage in the development of a
"altered states of consciousness" in explaining theory of healing is specification of how thera-
the effects of healing. These states cannot be peutic process effects transformation in exist-
treated like mechanisms such as catharsis or ential states.
suggestion. Their nature must be defined in An approach grounded in participants' own
cultural as well as psychophysiological terms, experience and perceptions of change may
and their place within healing systems must be arrive at a more pragmatic conceptualization
specified. of healing as a cultural process. This should be
In staying close to the experiential data, this a goal not only on a conceptual, theoretical
method also contrasts with other more globally level but also on the level of interaction be-
stated conceptions of the healing process. For tween medical and sacred aspects of complex
example, Dow (1986) describes the healing health care systems, as illustrated by the two
process as one in which symbols from the cases analyzed here. Having chosen a type of
mythic realm are "particularized'' in meaning religious healing that is formally and experien-
for an individual supplicant. The symbols are tially different from psychotherapy, yet suffi-
then "manipulated" by a healer to mediate or ciently similar for systematic comparison, I
"transact" between the hierarchical levels of suggest the possibility of a theory of the
society and self. In addition, emotions are "at- healing process that will not only include
tached" to the symbols to transact between other, more seemingly exotic forms but also
levels of self and soma. In the case of Margo permit a rethinking of healing in cosmopolitan
it is certainly possible to label the spirit of biomedicine.
Darkness as a transactional symbol to which
the healer attaches the emotion of depression;
it could just as easily be described as a quality
predicated by the healer on an inchoate pro- REFERENCES
noun (Fernandez 1974), or as a management of Bourguignon, Erika
meaning by the healer, who is acting as a spir- 1976 The Effectiveness of Religious Healing
itual broker defining the conditions of the sup- Movements: A Review of the Literature. Trans-
plicanfs participation in the religious group cultural Psychiatric Research Review 13:5-21.
(Kapferer 1976). In short, a model is needed Calestro, Kenneth
that can specify conditions for change, criteria 1972 Psychotherapy, Faith Healing, and Sug-
for a job well done by the healer, and cultural gestion. International Journal of Psychiatry
repertoires of significant patient experience. 10:83-113.
106 THOMAS J. CSORDAS
The construction of knowledge builds on the schizophrenia and have argued for the need to
dialectical tension between researchers' cat- reintroduce subjectivity and experience into psy-
egories and the reality they aim to describe. chiatric research and practice (Ciompi 1984,
Although categories are progressively refined 1989; Strauss 1985). Other studies have tried
and honed, they remain bound by an initial to grasp the "thick" dimension of the experience
intellectual frame of reference that predeter- and its dynamics through alternative research
mines what deserves attention within a given methods, including life histories (Carpenter
reality, for which our categories never suffice. 1987; Estroff 1989; Fabrega 1989; Hatfield
In relation to psychiatry, Jaspers (1963) 1989; Strauss 1989). These studies have resulted
reminded us decades ago that reality, especially in significant breakthroughs, reminding us
human reality, always transcends our know- above all that patients undergo tremendous
ledge of it and that knowledge always depends suffering and are often actively engaged in trying
on, and is bound by, the methods used to access to cope with this debilitating experience. How-
it. This process is inherent to knowledge, but ever, authors tend to consider experience a
researchers often forget that their knowledge is "transparent reality," where meaning is directly
only part of the whole picture. Like the blind accessible. It is still uncommon for researchers in
men in the fable who build a whole, imaginary psychiatry to consider other philosophical and
picture of the elephant based on what they social sciences' perspectives for the renewal
touch (trunk, tusk, tail, leg), researchers tend or deepening of our common understanding of
to make generalizations from results obtained experience and subjectivity.
with their research instruments. Recent anthropology has been dominated
In recent years, challenges associated with by a rise in critical trends that question the
the heterogeneity of outcome in schizophrenia possibility of access to other people's lived
and the limitations of current knowledge to worlds. Authors are now aware that know-
explain this phenomenon have led to the explor- ledge of other cultures is always colored by
ation of new approaches and avenues of think- the observer's own cultural belonging and in-
ing. Some researchers have explored the tellectual orientations and by academic debates
hypothesis that personal and interpersonal strat- (Crapanzano 1992; Clifford and Marcus
egies for dealing with symptoms could signifi- 1986). In his reflections for justifying and
cantly alter the course and outcome of grounding an anthropology of experience,
Ellen Corin, "The Thickness of Being: Intentional Worlds, Strategies of Identity, and Experience among
Schizophrenics," Psychiatry 61 (1998): 133-46.
THE THICKNESS OF BEING 109
Bruner (1986) emphasized that experience is way of situating oneself within the world.
by definition self-referential and therefore, Within this context, "experience" is a basic,
only accessible to the individual. Access to "intentional" position toward the world.
the expression of experience is possible, "Being there" in the world is by necessity "being
but the relationship of experience to its expres- in'' space and time, and "being with" in a shared
sion is always partial and dialectical: experi- world. Building on these perspectives in their
ence is not just "being there," unrelated to its approach to psychiatric disorders, European
expression and context. Other authors have psychiatric phenomenologists understood psy-
defended the idea that parts of experience chiatric disorders as expressing a basic alter-
always remain obscure to the actors themselves ation of the subject's intentional position
and require various levels of interpretation toward the world. They attempt to describe
(Bibeau and Corin 1995). For example, indi- the kind of presence in the world manifest
viduals are constrained by the limitations through psychiatric symptoms and to describe
of language and by their own alienation alterations which characterize the main cat-
from subjective experience; experience can be egories of psychiatric disorders (Binswanger
revealed through silences, contradictions or 1970; Blankenburg 1991; Tellenbach 1979).
inconsistencies which permeate lived experi- This contradicts what mainstream North
ence as well as by the explicit content of dis- American psychiatry used to call phenom-
course. Experience cannot be reduced to its enological. Although they both intended to
conscious dimension or to what is expressed eliminate biases introduced by theories and ex-
in discourse. planations, North American psychiatry relies
on an empirical, objectivist notion of phenom-
ena which must be observed from the outside,
Experience and Its Horizon whereas European phenomenological psych-
iatrists prefer "diagnosis by penetration" which
Half a century ago, European phenomeno- transcends the empirical surface of phenomena
logical psychiatrists perceived psychiatric dis- to reach understanding of the deep structure of
orders to be problems affecting the basic the "being-in-the-world" expressed through
coordinates of the being-in-the-world experi- phenomena. Empirical everyday discourses
ence. However, they relied on a non-empirical and behaviors provide access to "experience,"
notion of experience developed by philoso- but this experience cannot be reduced to it, be-
phers such as Husserl, Heidegger, and others. cause it is beyond facticity and empiricism.
In reaction to the formalism of neo-Kantian Diagnosis by penetration requires a dialectical
thinkers, Husserl argued for a return to "phe- to and fro between attention to the empirical
nomena" per se, regardless of categories and reality of existence, and the constituents
learning. This implies bracketing the stock of and foundations of experience. Blankenburg
knowledge and theories constitutive of science (1991) writes that a phenomenological attitude
and of a commonsense understanding of the "eliminates nothing"; it studies everyday exist-
world, suspending a sense of co-belonging to ence, from "chatting" to "humble, even despised
the world where meaning is taken for granted. states of things."
This "phenomenological reduction" approach However, it is difficult to apply this per-
intends to give access to the essence of things, spective to research, mainly because of the
beyond their empirical manifestations which nonempirical nature of the referred experi-
always depend on a network of interpretations ence. European phenomenological psychiatry
and purposeful actions. What is then revealed is a clinical discipline aimed above all at ani-
is not what is sensually perceptible but rather mating and orienting the clinical encounter.
the basic structures through which the percep- It can only be used in research in an ana-
tible becomes understandable. logical, transposed way. Research strategies
Husserl was particularly interested in dis- and methods must be designed to help analyze
covering the essence of human consciousness the basic structure of the patient's being-in-
and of human experience understood as a the-world experience.
110 ELLEN CORIN
Analytical perspectives developed by Ricoeur to clarifying the pitfalls and the limitations
(1986) in hermeneutics present interesting par- of deinstitutionalizing psychiatric patients
allels with the phenomenological approach to and, more particularly, to understand what
experience and provide inspiration for research contributes to community tenure for people
strategies. Ricoeur denounced the limitations of who have been diagnosed with schizophrenia.
"empathy" which assumes a direct and unmedi- Our main hypothesis was that deinstitut-
ated communication from experience to experi- ionalization from psychiatric institutions is
ence. For Ricoeur, empathy is an illusion and a paralleled by a process of "social deinstitutio-
seductive trap; it is inescapably contaminated by nalization" through which patients are not
personal expectations and desires, which we allowed to resume normative social roles and
tend to project on the other's world, and by are therefore pushed back toward the psychi-
ideology. A specialist in text analysis, Ricoeur atric institution and at risk for readmission.
presents hermeneutics as an analytical method The hypothesis therefore focused on the impact
which combines detachment and communi- of sociological processes of stigmatization
cation, with both a critical stance assuming the and marginalization of the experiences and
distancing associated with science, and the rees- lives of schizophrenic patients.
tablishment of a relationship of co-belonging More generally, we were also interested in
between researcher and his object of study, in- understanding how subjectivity and experience
escapable in human sciences. The basic structure are transformed in schizophrenia and how
of the text must be interpreted through analyz- individuals affected by schizophrenia attempt
ing recurrences and contradictions, sets of to rearticulate their relationship with them-
opposites and combinations which hold the selves and the world. We wanted to examine
text together. There must be a dialectical rela- to what extent certain types of transformation
tionship between "understanding," or "integrat- of the experience may be associated with better
ing within oneself the structuring work of the outcome.
text," and the discovery of codes underlying the
structure of the text.
From that perspective, listening to the pa-
Methodological markers
tient's experience in his or her own words and The purpose and methods of the Montreal
developing an empathetic relationship with study have been presented more extensively
him or her remains a minimum but inadequate elsewhere (Corin 1990; Corin and Lauzon
requirement. On the one hand, empathy is best 1992). I focus here on elements of methods
perceived as a project or an aim rather than as a which are particularly relevant to the approach
real possibility. On the other hand, the empath- of experience as mentioned previously.
etic understanding of the patient's experience The study involved 45 male patients diag-
in his or her own words (Ratey, Sands, and nosed as schizophrenic more than 5 and less
O'Driscoll 1986} must be complemented by than 15 years ago. Selection criteria included a
an attempt to gain access to the underlying principal diagnosis of schizophrenia and a rela-
premises and coordinates of his or her life- tive stability of diagnosis. All were between
world. Analysis must involve both careful at- 25 and 50 years old and lived in the catchment
tention to the details of the person's daily life area of the Douglas Hospital, a lower middle
and an attempt to understand the basic struc- and working-class residential area. We divided
ture of their experience. them into three groups according to their
rehospitalization history over the previous
4 years: patients without rehospitalization
The Life-World of (15), those rehospitalized once or twice (17},
Nonrehospitalized Schizophrenics those rehospitalized three or more times (13}.
in Montreal Statistical tests allowed us to verify the compar-
ability of the three groups according to socio-
The general objective of a research study demographic variables, age of first contact with
carried out in Montreal was to contribute psychiatry, stability of diagnosis, and initial
THE THICKNESS OF BEING 111
In order to identify the general structure of even if they remain ambivalent towards their
the being-in-the-world experience underlying desires and expectations regarding their per-
the empirical data, we qualified the significant sonal involvement in these roles. In general,
variables as a function of the orientation the frequently hospitalized patients therefore
they indicated with regard to the social field: appear to be characterized by a discrepancy
toward (+),outward (-),or neutral (0). This between an intentional stance, which remains
revealed that social integration in the two oriented positively toward the relational and
groups is mainly differentiated by features social field, adhering to some extent to a nor-
describing the patient's basic personal stance mative ideal of social integration, and a sense of
towards the world, which cuts across the areas being marginalized or excluded from this field.
of social life under consideration. With regard to the nonrehospitalized pa-
This first level of analysis, aimed at compar- tients, a globally similar "objective" situation
ing the two groups of patients, was comple- seems to be perceived as proceeding from a
mented by analyses at an individual level. personal movement and as being part of a
Here, we began to examine the specific pattern global style of relating to the world. They
of variables coded in a single narrative. A mention having less contact during their
qualitative analysis of the content of these nar- reconstructed days even if their accessible
ratives provided important information for the social network appears to be of similar size.
further understanding of the meaning of struc- They perceive themselves as receiving and
tural orientation abstracted through quantita- giving less support to other people. As for
tive techniques and for examining how they the categories of people they mention, non-
translate on a daily life level. It shed light on hospitalized patients attach great importance
the imaginary and symbolic aspects of the rela- to friends as significant individuals, as support
tionship schizophrenic patients develop with people, and meet them more often in their
themselves and the world. daily life; it could be hypothesized that friends
are less intrusive than family and kin, and
The basic coordinates of pose less of a threat to the relatively with-
drawn position they take toward the world.
an intentional world The frequently hospitalized patients also men-
Group comparisons indicated that both groups tion positive relationships with friends, but
revealed a relative paucity of interpersonal re- in their case, friends are not mentioned as
lationships with family members and their significant others and do not appear to com-
social network, as well as global marginality pensate for a general feeling of experienced
regarding normative social roles. However, exclusion and marginality. In the area of
data on perceptions and expectations reveal social roles, the nonrehospitalized patients
that this shared feature has two different tend to express a global detachment toward
frames of meaning. the importance of interpersonal and instru-
The frequently hospitalized patients express mental social roles as well as an apparent lack
a feeling of being "kept out of things" at the of desire or expectation of being involved in
interpersonal level while at the same time these roles. This analysis of quantified data
demanding more attention from others; they pertaining to various areas of life therefore
also perceive themselves as being excluded reveals recurrences that indicate contrasting
from family life: from contact with kin, friends, structural stances toward the world.
and neighbors, from family activities and from An examination of the individual patterns
everyday family life. In the area of social sup- of data collected with each of the nonrehospi-
port, they see themselves in an asymmetrical talized patients reveals that a dominant with-
subordinated position, receiving more support drawn position is always slightly compensated
than they give; they also perceive their parents by "relating" elements in spheres which vary
as having no positive expectations of them. from person to person and which permit them
At the level of social roles, they tend to be to perceive themselves as continuing to be
convinced of the value of interpersonal roles, articulated to the world in spite of, or through,
THE THICKNESS OF BEING 113
their withdrawal. We have therefore qualified left with oneself, one is able to move at one's
their position toward the world as "positive own rhythm, one takes the time to master
withdrawal." things, to advance slowly, to think.
The qualitative aspect of the patients' A second trend emanating from the narra-
narratives and the data concerning their daily tives is the important role played by religious
routine allow a better qualification of this signifiers for a considerable portion of nonre-
"positive withdrawal" by providing access to hospitalized patients. Reference to a broadly
the "subjective thickness'' of the patients' defined religious frame allows them in some
world. Nonrehospitalized patients' narratives way to "inhabit" their private world, to protect
emphasize the positive value attached to with- and reinforce their withdrawal by giving it a
drawal and its role in the significant reframing positive value. Religious signifiers tend to be
of a lonely position. borrowed from marginal religious groups or to
For example, a nonrehospitalized patient remain expressed in global terms without refer-
describes himself as quite uncommunicative: ence to particular religions. Individuals also
"I do not go out a lot. I rather stay at home. tend to privilege some of the religious group's
I wait for time to go by. When I want peace, signifiers, to reinterpret them in accordance to
I go to my room, on my bed. I meditate, I their own life and to mix them with other kinds
listen to music, I listen to the vibrations of the of signifiers (like those pertaining to astrology
home's silence. I want calmness, to be with or to extraterrestrial beings). This gives the im-
myself, then to evolve internally." Another pression that their belief system is a kind of
person, for whom the psychiatric hospital rep- personal collage of a variety of beliefs rather
resented protection, a shelter from other than resulting from strict adhesion to an
people, and who is now member of a charis- existing system. Religious signifiers appear to
matic group, says: "It is slow, I go quietly, I play a number of functions involving the re-
want to master things"; (to a question asking shaping of the inner experience of oneself, the
if he likes to be alone): "Yes, it is better to elaboration of a sense of self-worth, providing
think, to pray." A patient who describes his the feeling of being part of a meaningful world,
past life as overly busy and hectic, comments: of being embedded within an interpersonal
"When I left the hospital, I settled things frame.
with myself, I almost tried to withdraw into The analysis of the patients' daily routine
myself, I needed to retire, to be alone occasion- reveals the central importance attached by
ally." A few individuals describe their with- most nonrehospitalized patients to frequenting
drawal as an intentional strategy aimed at public spaces like small restaurants, corner
counteracting a tendency to fuse too much with shops or shopping centres. For some of them,
the others. For example, a very active person this gives a structure and a rhythm to their
who has created his own religious group, who spatial and temporal world. It also enables
has a number of followers and is involved in them to relate to other people while not dir-
many activities, says: "I never did put my trust ectly interacting with them and keeping dis-
in others. One needs to keep a secret side. One tance. Some patients inhabit these spaces in a
cannot, one does not have to say everything"; more intense affective way, through the devel-
(to a question asking if he likes to be alone): opment of privileged and often imaginary rela-
"Yes, because then I rest, I clear out my body tionships with waitresses who sometimes
entirely." The first person quoted below explains appeared to them to be especially sensitive
that he also tends to be overly talkative with and attentive toward them.
neighbors, especially about religious matters, It can therefore be said that nonrehospita-
and comments: "I am not centered enough on lized schizophrenic patients appear to be par-
the inside to be at peace with myself. I would like ticularly skillful at developing a position on
to find an inner peace." the margin of our common world, simultan-
Generally speaking, withdrawal is described eously elaborating and protecting a space for
as enabling the person to find inner peace, withdrawal that allows them to reconnect
to settle things with oneself; in solitude, one is with themselves and to construct an intimate
114 ELLEN CORIN
and private space, to maintain or to draw resisting the pressure of his family environ-
symbolic or imaginary links with the outside ment which he experiences as hypernormative
world. Individuals are simultaneously in and and rejecting. He opposes the value his
out of the social field, detached rather than parents attach to work and the success that
excluded, inhabiting an inner space of with- comes through work and justifies the value
drawal rather than being trapped in it. of being on welfare on the basis of his reli-
gious values: "For my family, welfare is sin. I
could not live being rich; living wealthy is
Living at the margins
sin." At the same time, he is aware of being
Patients' narratives reveal how distancing and "humiliated" by his mother and grandmother
relating elements are interwoven in their lives, because he is on welfare. He expresses a simi-
how a stance of positive withdrawal is negoti- lar personal distancing regarding interper-
ated and can be the main organizer of the sonal roles; marriage is only important for
existence. men unable to manage at home alone, not
Mr. H. lives with his mother, has no for him. His intentional and ethically
friends, and displays general disinterest in grounded opposition toward his parents'
interpersonal roles, such as those of husband values can be understood as a positive reshap-
or father. He describes himself as having ing of his perceived marginality toward his
acquired a spirit of freedom yet at the same family environment which he presents as
time, his time frame is carefully scheduled and highly cohesive: "My father had my mother.
one of his main endeavors is to impose discip- I had my sisters; my father didn't want me to
line on himself. Each day, his morning is be in contact with my mother. I was always
taken up looking for work and preparing him- alone .... My six sisters were doing every-
self for possible work: reading newspapers for thing alike." At the same time, when discuss-
job offers, going to the employment office, ing his own values, he continues to share his
practicing with a typewriter. He insists, parents' wishes; "to succeed," as for his
"I have a schedule, a timetable." The second mother, and "to be happy," as for his father.
half of the day, he strolls through the innercity It is interesting to note that the religious idiom
streets and in shopping centers "to see he has chosen to resist them is in some way
people." He has a girlfriend whom he met their own, as they went successively through
in a shopping center "for helping psycho- various conversions; from Catholicism to the
logical development." Listening to him, one United Church, to Evangelism and to Pente-
gets the impression that this very schedule in costalism. Pentecostalism is his own current
itself gives a frame and meaning to his life. religion.
It is interesting to notice that the area where In a third example, Mr. I. is divorced and his
he concentrates much of his energy is related wife refuses to allow him to go out with their
to the source to which he actually attributes child. He describes himself as having lost all
his problems: an excess of tension due to hope for the future; he feels indifferent, with no
his former work. He seems to be able to con- interests. However, in his fantasy life, he is the
front and control his original anxiety by intro- best, admired by everyone while at the same
ducing it at the core of his life and in time not taking himself seriously. He has no
neutralizing it through rigid organization that friends apart from a brother-in-law he sees
resonates with the general detachment he every 3 months. His social life is organized
expresses throughout the interview. around regular visits to two restaurants where
Another nonrehospitalized patient, Mr. E., he has been going for the last 4 years and where
has no girlfriend nor any other friends; he he knows the waitresses. He came alone to
only has some contact with patients he met Montreal at the age of 19 from a remote rural
in the psychiatric hospital or in prison, about area of Quebec where his father was a lum-
whom he says, "We have things in common." berer. His symbolic way of resituating himself
He goes several times a day to a corner shop, within a significant frame of belonging is
always the same one. He spends his energy to read an etymological dictionary with
THE THICKNESS OF BEING 115
regularity, as his father did. "Without the dic- to this picture relapsed the year following the
tionary," he says, "I would feel lonely." He also research.
mentions the role God plays in his life, even
though he does not practice nor pray nor ask The construction of a narrative
God for things. He says that he often thinks of
God and believes in him, due to a special ex-
identity
perience he had years ago when "light took on One section of the open-ended interview
a different quality." aimed at grasping how patients perceive and
In a last case, intense involvement in a bib- describe themselves. Classical methods for
lical school and charismatic groups provide studying self-perceptions propose a list of
Mr. C. with an important interpersonal and qualifiers from which respondents have to
supportive environment and with a significant choose the one that best describes them. This
source of social feedback which helps him to method assumes that self-perceptions can be
adjust his speech and behaviors according to subsumed under a few discrete attributes and
what is socially acceptable. This sense of that they possess a well-defined, constant
belonging contrasts with a double alienation meaning that is the same for respondents
from his family milieu - because they live in and researchers. In our study, we preferred
another part of the province and because he to ask the patients to qualify themselves using
has always felt excluded and underestimated three different terms of their choice and to
by his family, especially by his mother who comment on their significance and importance
has "always considered him as her inferior" for them.
and by his relatives who always treated him At first glance, the meaning associated
as a child. He recalls how insecure he felt when with certain expressions like "I am a biker,"
he first arrived alone in Montreal. Although he "wholehearted," "acting crazy/playing the
is afraid of the idea of work, because of past fool," and "mixed up" is difficult to decide.
experience where he felt ridiculed, belonging to In some cases, the meaning of the words
the religious group provides him with the hope appears straightforward, but an apparent dis-
of doing some missionary work later and pro- crepancy between the common meaning of
vides him with a frame through which he can the expression and the positive or negative
articulate a vague sense of having something to value associated with it suggests that it could
give to other people. More immediately, reli- possess a specific meaning for the respondent;
gious beliefs give him a great sense of release: for example, "a guy who wants to make his
"Light comes in you." way out" is rated negatively by a frequently
Each narrative reveals how the respondents' hospitalized patient.
sense of current alienation toward the world The analysis took into consideration the
has progressively evolved from a complex and kind of stance evoked by the qualifiers (for
difficult life history. Life strategies have to example, personal attributes versus inter-
be understood as attempts to renegotiate a actional processes) as well as patients' com-
place in the world and as restorative processes; ments. Particular attention was paid to the
they tend to be expressed in an idiom borrowed stylistic dimension of the discourses. Detailed
from their past and current social environment. results have been presented elsewhere (Corin
Some seem more skillful than others in and Lauzon 1994). These data provide add-
reassuming and reshaping a conflicting life his- itional access to the set of meanings which
tory within their current existence. A few of the constitute the patients' life-world described
nonrehospitalized patients we interviewed above. In the examples here, the terms or ex-
remained much more embedded in fusional pressions patients use for characterizing them
and dependent relationships or in a sick role, are indicated in brackets and are followed
their distancing toward the world appearing by what was actually said. FH designates a
essentially restricted to a stance of intentional response given by a frequently hospitalized
detachment toward normative social roles. patient and NR, a response by a nonrehospita-
In fact, two of the three patients corresponding lized patient.
116 ELLEN CORIN
Self-descriptions confirm the degree of ten- withdrawn position. They are often aware of
sion experienced by the frequently hospitalized the cultural or social abnormality of this mode
patients between a normative definition of per- of being but it does not deter them from valuing
sonhood and a sense of personal inadequacy it. (NR: "little self-confidence"): "I don't affirm
and failure. For them, ideal life is expressed my personality. I would like to find an inner
in terms of typical social roles; individuals space which could give me self-confidence. To
express a deep desire to conform to a "normal put my confidence in God will help me." (NR:
way of life'' while at the same time feel that this "calm"): "Most people need to speak. I can
ideal remains beyond their grasp. {FH: "a spend hours without saying a word. Sometimes,
normal man"): "I am normal but I do not lead it is a bad thing because if one become too
a normal life. I should like to get married, calm, one does not have feelings anymore. . ..
to have children, to have a normal life. . .. May be I am too calm sometimes but I like
A normal woman will not go out with a guy myself better too." (NR: "solitary"): "I do not
who has been in a psychiatric hospital.'' {FH: communicate much .... I know that I am more
"uncertain"): "I am apprehensive about my solitary than normal and that it is negative in
future. Will I end up alone, without a wife, people's eyes. I need to withdraw, to be alone
without children, alone in the street? I would occasionally."
have liked to succeed, to have a wife, children." At another level, responses of patients in
Sometimes, the feeling of inadequacy gets both groups confirm the crucial role played
blurred under an expansion of the positive by others' gaze in the construction of their
aspects of the self-image. (FH: "would like to self-image and the importance of the inter-
be rich"): "A guy who works, in excellent mediary space between self and others.
health, with a good position, with responsibil- Notions of reputation, trust, and respect are
ities, who invests in real estate." (FH: "smart"): emphasized in this context. (FH: "wam to
"Able to think, reasoning, know wrong make my way out"): "I still have difficulty in
from right; having your own way of saying commanding respect." (NR: "just"): "It gives
words. . . . If you were smart, you could be a me a chance of stability; people can trust me.''
genius, have a good IQ, have no problem with (NR: "honest"): "People respect you if you are
the speech of language." A feeling of doubt honest."
can also be expressed through the direct juxta- The value associated with this kind of public
position of a second qualifier that contradicts self-image brings out by contrast the damage
the first one {the FH patient who mentioned inflicted by a pervading feeling of being stigma-
"smart" and quotes as a second qualifier tized, sometimes at the level of physical appear-
"hyper"): "I talk quick, I don't give the person ance, or of not being recognized for personal
a chance, I should control myself. A person qualities or efforts. (FH): "Maybe it's true
who's too hyper, they have to give him some- that it is visible when I walk down the street."
thing to calm him down. He can't control (NR): "Most people are offensive, people
his speech." look at you, they stare at you . . . because it
Nonrehospitalized patients do not refer as shows that I am not somebody who has a steady
much to normative images of personhood. job." Psychiatric labeling and what it evokes
When they express the feeling of a discrepancy at the subjective level plays an important role
between their self-perception and others' image in this perceived process of marginalization.
of themselves, they appear more confident in Some frequently hospitalized patients feel
the value of their own perception, even if a totally trapped within a psychiatric world,
kind of uncertainty always remains. (NR: "in- which is a source of suffering and discour-
telligent"): "I understand things faster. I know I agement. (FH: "tired"): "I am tired being in
behave normally; I try to behave normally; I psychiatry . . . a feeling of discouragement.
look intelligent. I find myself very intelligent; it The doctor told me that I will have to take
doesn't show but me, I know it." medications for the rest of my life. Some morn-
Self-descriptions also confirm the value ings, I tell myself that I would rather die than to
the nonrehospitalized patients attach to a feel like that." Nonrehospitalized patients
THE THICKNESS OF BEING 117
appear to be more able to distance themselves significance of a term. Some patients deconstruct
from this characterization and to counteract it the conventional use of a word associated with a
at a personal level. (NH: "Not capable of taking particular context of speech and appear to
care of myself"), "I need help; day care, psych- "reopen" the language from within. A first
iatrist, doctor. There are two sides; you can example involves a frequently hospitalized
learn from being in the hospital. It's hard to find patient who characterizes himself as entier. This
a job. I am sick, mentally and physically; this French word means literally "entire" or
brings lack of confidence in everything. I think I "whole"; however, it also has a figurative
am wasting my time here (a day care center}. sense, "forthright" or "self-willed," which
(NR: "intelligent"): "In the hospital, it is as if would normally be the one built upon for char-
you were not intelligent when they see you; they acterizing somebody. In his comment however,
do not let you express your thinking.'' Nome- this person prefers to use the term in its literal
hospitalized patients also seem to be more able sense- intact or whole, for describing the phys-
to neutralize others' comments. {NR): "I don't ical integrity of his body, his true masculinity-
worry about what other people may think.'' he then moves toward asserting his integrity or
(NR): "The others, I have never cared what they sanity: "That means that I am a man, I lack
think.'' nothing. I think I have all my faculties, but
Self-descriptions also reveal a general open- there were periods where I was amnesic ...
ness toward others for nonrehospitalized to have all your limbs, not to be missing an
patients. This seems to accentuate the per- intestine. In other words, I am all my own." In
ceived importance of the "positive" dimension another example, a nonrehospitalized patient
of "positive withdrawal" and indicate that qualifies himself as "acting crazy," which he
withdrawal could concern an intentional uses first in its derivative sense as it would be
retreat from close interpersonal relationships appropriate in the context of self-definition;
without precluding a broader openness to the he then comes back indirectly to its literal
world. Whereas the frequently hospitalized sense in expressing a deep, anxious questioning
patients stress the value of normal social roles, regarding madness: "I will take the first step
the nonrehospitalized patients express a desire towards others, try to be the first one to speak.
to feel part of an interpersonal space and to I always try to make a joke of everything; it is
diffuse its potential hostility. (NR): "To act as a not easy to be funny. You have to try to guess
conciliator." {NR): "To go towards people, to the character of the person with whom you are;
try to speak first.'' {NR): "To gather around I try to figure out why I found myself in a
people who speak the truth, who are honest psychiatric hospital with the loonies, as they
with you." (NR): "I would like to please are called."
people." {NR): "I would like to make other At a similar semantic level, nonrehospita-
people happy." This kind of explicit intersub- lized patients introduce new valency into a
jective orientation is not as clearly expressed by word or they introduce an idea of intentional-
the frequently-hospitalized patients. ity within a seemingly negative feature,
An analysis of the stylistic characterization revealing their private attempt to reframe a
of the patients' self-descriptions allows a better problematic character into a positive dimen-
understanding of the strategies used by individ- sion of life. (NR: "easily anxious"): "I am too
uals who have been diagnosed as schizophrenic focused on what goes around me to be at peace
in their contact with reality. These stylistic with myself; going through such ordeals leads
strategies can be described as language games me to evolve.'' (NR: "lazy"): "You don't take
which play on the semantic and grammatical life too seriously, you relax better." (NR: "con-
dimensions of the discourse. ceited"): "In my dreams, I am the best. It en-
An infrequent but impressive first type of courages me rather than being discouraging."
language game that can be found in all groups At a more "grammatical" level, nonrehospi-
of patients is an ability to shift from one level talized patients tend to redefine a static attri-
of meaning of a word to another, from a literal bute as an active one, indicative of an
to a figurative one, from a static to dynamic intentional stance. (NR: "simple',): "I make
118 ELLEN CORIN
things simple. I don,t make a big fuss over illness narratives which allow them to explore
unimportant things. I am a peacemaker. I am the indeterminacy of reality and keep open a
able to stop verbal arguments." (NR: "senti- network of potential perspectives.
mental"): "To have sentiments towards the The combination of the importance of the
person that you,re with." others' gaze in self-perceptions and of its gen-
Finally, nonrehospitalized patients appear eral stigmatizing valency on the one hand, and
better able to inscribe their present situation the expression of an intentional movement
within a historical frame; they may describe toward others by nonrehospitalized patients
their present style of being as progress or on the other, suggests that "positive with-
view themselves as embedded in a dynamic drawn" orientation of their life-world could
movement toward greater participation in the also have in part a defensive and protective
world. (NR: "calm"): "In normal life, one has value in addition to expressing an intentional
to live with a certain amount of stress. Before stance toward the world.
becoming ill, I earned my life with stress .... In
the last 10 years, I have dropped out .... I
accept myself as calm and tranquil. . . . When
The thickness of being
I came out of the hospital, I came to terms with Although we began this research with a socio-
myself." (NR: "sincere, frank"): "I have logical perspective that emphasized the role
changed enormously. Now, I see qualities of external determinants in schizophrenic
rather than defects in people." (NR: "likes patients' ability to remain within the commu-
to communicate with people"): " ... like the nity, data led us in another direction. They indi-
Beatles, the people who are nice, who have cate the central role played by a personal stance
something to say." {The same: "likes change"): adopted toward the world and illustrate how it
"Generally, social change, change of people, of permeates various aspects of patients, life. This
society in general.,, invites us to reevaluate the very notion of
Self-narratives enlighten the extent to which coping and to expand it on the basis of a
people who have been diagnosed as schizo- broader approach to the notion of experience.
phrenic feel intimately marked by their contact In building on the approaches to experience
with psychiatric services and by the others' developed by European phenomenological
gaze. They also confirm the tragic dimension psychiatry and on the analytical strategies de-
of this process, especially for the frequently veloped by Ricoeur, we have explored how
hospitalized patients who feel trapped in a sick empirical details of daily life refer to a basic
role and a sense of their inadequacy. The few intentional position toward the world and how
examples presented here illustrate the range of that position is expressed and clarified through
strategies patients use to distance themselves the facticity of existence. Data collected in
from a static, "naturalistic" characterization Montreal illustrate how the surface elements
of themselves and, more particularly, the pri- of the patients' discourse refer to a more basic,
vate, significant, and sometimes poignant ways nontransparent way of being-in-the-world:
nonrehospitalized schizophrenics attempt to concrete behaviors and discourses reveal sim-
infuse intentionality into their self-image. This ultaneously a basic alteration of their subject-
echoes European phenomenological psych- ive world, which could be related by
iatrists' descriptions of the way some long-term hypothesis to the disorder, and the patients'
patients seem to have learned to "flirt" with personal response to it, in a particular social
psychosis, to play with it (Blankenburg 1991), environment; they illustrate the individuals' at-
the way they attempt to escape both the feeling tempt to reinstate this experience within a
of a static temporality and their timeless char- space of liberty. Understanding evolved in a
acterization as "schizophrenics" and to restore constant to and fro between concrete details
a valued sense of self and of their existence of their empirical lives and the underlying
(Maldiney 1986). Their "language games" structure of their being-in-the-world. Data also
evoke what Good (1994) has described as the indicate the potential value of a style of dis-
"subjunctivizing" function of certain styles of course and behavior that appears able to
THE THICKNESS OF BEING 119
"reopen" the experience while at the same time has few links to mainstream society (Carin
remaining in tune with the basic features of the 1986). On the other hand, if autonomy and
person's life-world. self-coherence are valued, cultural norms
In our research, the set of structural oppos- and our postmodern ethos leave little room
ites and similarities in the data on "social inte- for the creation of spaces of solitude to mature
gration'' indicate the strategic value attached to and retreat temporarily from society, to allow
a position of positive withdrawal toward the inner growth, self-gathering, and personal
world; the content of the patients' discourses development (Janicaud 1987). Moreover, the
indicates the network of meanings associated general stigmatization attached to psychiatric
with such a position. Self-descriptions reveal disorders converges with a pervading economic
the range of discursive and stylistic strategies marginality and pushes people who have been
resorted to by nonrehospitalized patients for diagnosed as schizophrenic coward a space of
evading a static, assigned definition of them- alienation which hinders their restorative at-
selves and for reintroducing some space of tempts. One could hypothesize that this social
"subjunctivization," freedom and play within and cultural context pervades and channels
their perception of themselves in a certain personal strategies and accentuates the with-
world. Fragments of life narratives illustrate drawn dimension of positive withdrawal; it
in how many ways nonrehospitalized patients over-determines its significance. Different cul-
attempt to negotiate a position at the margin of tures or societies might favor another form of
the common world, simultaneously inside and articulating the psychotic experience and give
outside, and to reshape a generally painful and it a different texture which could contribute to
conflicting life trajectory. shaping the further evolution of problems.
This article also illustrates the need to conju-
gate different perspectives for understanding
the subjective intentional world of people diag-
REFERENCES
nosed as schizophrenic and their attempt tore-
construct a viable life-world. Each of them Bibeau, G., and E. Corin
offers but an imperfect and partial image of the From submission to the text to interpretive vio-
individuals' subjective appraisal of themselves lence. In G. Bibeau and E. Corin, eds., Beyond
and of the world. Taken together, they illustrate Textuality. Asceticism and Violence in Anthro-
the "thickness'' of this experience, its paradox- pological Interpretation (pp. 3-54). Mouton de
ical and multidimensional character, its em- Gruyter, 1995.
beddedness within multiple texts and referents. Binswanger, L.
As a general feature, the patients' life-world Analyse existentielle et psychanalyse freHdi-
develops in the shadow of suffering, ambiguity enne. Gallimard, 1970. (Originally published
and perceived marginality within a larger in 1947)
social and cultural world. One wonders how Blankenburg, W.
much the life strategies patients try to construct La perte de /'evidence naturelle. Presses Univer-
on their own, through a precarious and solitary sitaires de France, 1991. (Originally published
in 1971)
bricolage, are constrained by social and cul-
Bruner, E. M.
tural features that appear to echo some central
Introduction. In V. W. Turner and E. M. Bruner,
cultural characteristics of North American eds., The Anthropology of Experience (pp. 3-
societies. On the one hand, achievement, per- 30). Urbana: University of Illinois Press, 1986.
formance, and conformity are valued, and dif- Carpenter, W. T.
ferences or discrepancies are subject to a wide Approaches to knowledge and understanding
range of normalizing techniques that tend to of schizophrenia. Schizophrenia Bulletin
dominate the philosophy of rehabilitation (1987) 13(1):1-8.
and psychoeducation; people who "do not fit" Ciompi, L.
and cannot be integrated in the dominant para- Is there really a schizophrenia? The long-term
digm tend to remain "unseen," almost socially course of psychotic phenomena. British journal
nonexistent and are left to a parallel life which of Psychiatry (1984) 145:636-40.
120 ELLEN CORIN
This paper rests upon a single claim: We make clinical time is not a script, as Holland and
as well as tell stories of our lives and this is of Quinn [7] speak of, for it is created within the
fundamental importance in the clinical world. clinical interaction, improvised from the avail-
Narrative plays a central role in clinical work able resources at hand and tailored, quite spe-
not only as a retrospective account of past cifically, to context.
events but as a form healers and patients ac- To say that narratives are lived before they
tively seek to impose upon clinical time. are told, or even to say that there is something
Narrative analysis is not new to medical narrative-like about the structure of lived ex-
anthropology. Most notable are the provoca- perience, is to make a contentious claim. Within
tive and illuminating examinations of patients' formal narrative theory, the overwhelming as-
representations and experiences of illness sumption is that all narratives are 'fictions', that
as revealed by the illness narratives they tell is, they construct a world rather than refer
[1-4]. However, the argument made here to one [8-10]. This anti-mimetic position, so
departs radically from the way narrative has fundamental to postmodernism, has been de-
been understood, not only within medical an- veloped even within disciplines whose business
thropology but in anthropology as a whole. is to tell 'true stories' about events that 'actually
Narrative has been studied as a mode of dis- happened', i.e. history and anthropology.
course- as text or as performance. Even narra- Within history, Hayden White has been central
tive theorists within the clinical community in claiming that history is also fiction [10, 11].
who argue for the narrative structure of experi- In anthropology, the fictional quality of ethnog-
ence also attend to stories as discourse. Schafer raphy has become a tenet of the 'reflexive' pos-
for example, speaks of "storied" lives but ition and has been especially persuasively
examines only those stories that are told, rather argued by the historian Clifford [12-14].
than analyzing social action itself [5]. In this The question of how narrative discourses
paper, however, the material analyzed is taken distort the world they purport to describe is
from field notes of a clinical interaction rather both interesting and important. However, the
than the therapist's or patient's story of that basic modern and postmodern premise that all
interaction [6]. The narrative structure of narrative as form is necessarily distortion
Cheryl Mattingly, "The Concept of Therapeutic 'Emplotment'," Social Science and Medicine 3816 (1994):
811-22. ©1994 Elsevier Science and Technology journals. Reproduced with permission of Elsevier Science &
Technology Journals in the format Textbook via Copyright Clearance Center.
122 CHERYL MATTINGLY
because our temporal existence lacks the coher- The term 'emplotmene has had a history
ence of a unity with beginning, middle and end which has enlarged its meaning. It was originally
fails to recognize an underlying homology be- coined by literary critic Northrop Frye [27] to
tween life in time and narrative structure. Phil- describe four archetypal plot structures for con-
osophers from two rather disparate camps struing experience - romance, tragedy, comedy
have considered the narrative structure of lived and satire. Any narrative was necessarily 'em-
experience, moral and political philosophers plotted' within one of these archetypal forms,
reinvoking pre-modern moral traditions, such Frye suggested. Hayden White then argued that
as Macintyre [15, 16] and Arendt [17], and history explains events by placing them within a
phenomenological and hermeneutic philoso- coherent archetypal plot. Historical narratives
phers who follow Husserl, Gadamer, and are organized in terms of specific plot structures,
Heidegger. The most notable of these contem- what might be called 'explanation by emplot-
porary theorists are Ricoeur [18-20], Carr ment'. Historical explanation, in White's view,
[21], Olafson [22], and also Arendt [17]. In is aesthetically grounded, gaining its plausibility
developing a notion of therapeutic emplot- and coherence by its placement within an arche-
ment, I rely heavily upon these two philosoph- typal narrative form. The poetics of plot do the
ical strains. Drawing from five years studying decisive explanatory work. It is the plot which
and working with occupational therapists, in- makes individual events understandable as part
cluding a two year ethnographic study of occu- of a coherent whole, one which leads compel-
pational therapists in an acute care hospital, I lingly toward a particular ending [10, 28].
claim that these healers actively struggle to But the notion of emplotment is developed
shape therapeutic events into a coherent form most intriguingly by the hermeneutic philoso-
organized by a plot. They attempt to emplot pher Paul Ricoeur. Ricoeur calls upon it to
clinical encounters by enfolding them into make the more radical phenomenological
larger developing narrative structures. The claim that the structure of human temporality
notion of emplotment clearly reflects an eric itself, of life in time, is fundamentally related to
framework far removed from medical dis- the structure of narrative because both of these
course, imported from literary theory, philoso- are tied to the structure of the plot. In his essay,
phy of history and phenomenology. And yet, 'Narrative Time', Ricoeur states that: "narra-
for occupational therapists at least, the lan- tiviry and temporality are closely related - as
guage of narrative has been provocative as a closely as, in Wittgenstein's terms, a language
vehicle for seeing practice in a new way [23-5]. game and a form·of life. Indeed, I take tempor-
ality to be that structure of existence that
reaches language in narrativity and narrativity
Emplotment to be the language structure that has temporal-
ity as its ultimate referent" [18, p. 165].
Most simply, emplotment involves making a He goes on to say that the narrative structure
configuration in time, creating a whole out of most associated with temporality is the plot
a succession of events [18, 20]. What we call a [18, p. 167]. This argument is systematically
story is just this rendering and ordering of an elaborated in his subsequent three volume
event sequence into parts which belong to a Time and Narrative [20, 29, 30].
larger temporal whole, one governed by a plot. My own use of the term emplotment differs
E. M. Forster visualized plot as "a sort of from the above discussions for I carry this term
higher level official" concerned that everything directly into the arena of social action. Frye
which happens is marshalled appropriately so and White are concerned with emplotment as
that it makes its contribution to the whole [26]. it pertains to the form of texts, quite specific-
Particular actions then take their meaning by ally written narrative texts. Even Ricoeur,
belonging to, and contributing to, the story. though considering the phenomenology of
This "making a whole'' is also making meaning time, focuses upon texts rather than social
such that we can ask what the point or thought actions. His use of the term emplotment is
or moral of the story is [10, 20]. developed through considering the narrative
THE CONCEPT OF THERAPEUTIC 'EMPLOTMENT' 123
structures of fiction and history rather than the action, too, demands that we plot. We are mo-
more chaotic and improvisational realm of tivated, as actors, to create stories while in the
everyday activity. Ricoeur hedges on the extent midst of acting. Locating ourselves within an
to which life in time does indeed take on a intelligible story is essential to our sense that
coherence provided by a plot, preferring in- life is meaningful. In any situation we, as
stead Wittgenstein's metaphors of close kinship actors, have a narrative interest in constructing
and the game. In bringing this term to a study an 'untold story' out of discrete episodes. We
of therapeutic intervention, I reinterpret Ri- have a need not only to make sense, as Goffman
coeur's claim, arguing that narrativity, and par- [31] says, but to create sense out of situations.
ticularly the work to create a plot out of a A fundamental way we create sense is by
succession of actions, is of direct concern to shaping the 'one thing after another' character
the actor in the midst of action. of on-going action into a coherent narrative
Applying the notion of narrative plot to an structure with a beginning, middle and end.
analysis of therapeutic time raises a host of The told narrative, Ricoeur argues, builds on
problems not addressed by theorists of narra- action understood as an as yet untold story. Or,
tive. Most significant, such an analysis must in his provocative phrase, "action is in quest of
consider the fragile and shifting nature of any a narrative" [20, p. 4]. Other philosophers,
emplotment in time. How do we speak of em- most notably Alisdair Macintyre and David
plotment as something made and unmade as Carr, make very explicit claims about thenar-
time unfolds? How do we characterize social rative structure of lived time. Carr takes it that
interactions as more or less narratively config- "narrative is our primary (though not our only)
ured, taking into account those minimally nar- way of organizing our experience of time" [21,
rative times when the actors find themselves pp. 4-5]. He further states "that narrative
lost, when there seems to be no 'point' to what structure pervades our very experience of time
they are doing, or when no ending appears and social existence, independently of our con-
desirable, when there is just one damn thing templating the past as historians" [21, p. 9].
after another? Such an analysis must also con- The interest in coherence and order is only
sider the social nature of action for narrative one motive for attempting to play out a situ-
time is multiply authored. How do we think of ation in such a way that a narrative (a desirable
emplotment when there is no single author to a one, the right kind of one) can be told. Being an
story created in action? How do actors, with actor at all means trying to make certain things
their own individual perspectives, desires, com- happen, to bring about desirable endings, to
mitments to a future, manage to create a sense search for possibilities that lead in hopeful dir-
that they are in the same story together? If ections. As actors, we require our actions to be
there is no one storyteller, what does it mean not only intelligible but to get us somewhere.
to think of stories that are created? Even the We act because we intend to get something
notion of a 'life story' is a misleadingly indi- done, to begin something, which we hope will
vidualistic construct, as though we lived our lead us along a desirable route. And we act
stories by ourselves. These questions are under- with what Kermode [32] calls the "sense of an
standably neglected in discussions of emplot· ending." Because we act with the sense of an
ment among narrative theorists who inevitably ending and because we care about that ending,
foreground the written text. we try to direct our actions and the actions of
other relevant actors in ways that will bring the
ending about. We try to make actions cumula-
Creating Stories in Time tive [22]. Because we plot, as actors, the struc-
ture of lived experience already contains a
When we tell stories, we intensify and clarify (partly) plotted shape. Even if our actions are
the plot structure of events as lived, eliminating taken up, reworked and redirected by the re-
events that, in retrospect, are not important to sponses of other actors, we still have some
the development of that plot- which do not, as success some of the time in working toward
we say, contribute to the ending. However, endings we care about. And sometimes we are
124 CHERYL MATTINGLY
even able to negotiate with other actors so that narrative time is structured when stories are
we can move in directions cooperatively, told. For if there is a basic homology between
cumulatively. lived time and time structured within narrative
discourse, as I am claiming, an analysis of how
time is organized in the told story should make
Six features of narrative time
key aspects of lived time visible. I propose six
The notion of plot, and of emplotted time, is features of narrative time.
most understandable by reference to its oppos- The principles of this sextet are as follows.
ite - linear or serial time. In arguing for the
fundamental role of plot in ordering our re-
(a) Narrative time is configured
membrances of times past and even our under-
standing of times present, Ricoeur and White Events belong to an unfolding temporal whole,
contrast emplotted time to chronological time. an evolving movement toward a telos. But the
A succession, that structure of linear time, of telos is not located in the literal ending, as a final
clock time, of one thing after another, is trans- stage of an action sequence. Rathet; it emerges
formed by a plot into a meaningful whole with through the figure as a whole, the form of be-
a beginning, middle and end. Any particular ginning, middle and end. This figure may be an
event gains its meaning by its place within this intricate webbing of multiple figures, like the
narrative configuration, as a contribution to the many smaller forms that comprise a complex
plot. This configuration makes a whole such dance. While built upon the relation of part to
that we can speak of the point of a story. Yet whole, no plot simply subsumes the parts such
this is an always shifting configuration for we that they are merely episodes contributing to a
live in the midst of unfolding stories over which single coherence. Narrative depth derives from a
we have a very partial control. Life in time is part-whole structure where episodes have their
neither predictable nor highly controllable. We own authority; they, too may be memorable. A
are readers as well as makers of our lives and single glance in a single moment can have its
the stories we think we are living through are own unforgetable charactet; conveying an image
subject to surprises, twists of the plot we never that sweeps across the surface of all other
even imagined. We may find ourselves at any events, and is never simply swallowed in a larger
one point contemplating an array of foreseeable action chain. Narrative form is based on the
endings, uncertain which will come to pass, vividness of events in themselves as well as on
scarcely knowing which we ought to desire. their contributions to the plot.
The actor's commitment to a plot does not
translate into the capacity to bring about a (b) Action and motive are key
particular plot. In what follows, I consider this
configuring of singular events into plot episodes
structuring devices
in the practice of occupational therapy. I look at Narrative time is human time, one might say,
a single encounter between an occupational time in which human actions are represented as
therapist and a head injured patient as the cre- central causes for the outcome of events. Mul-
ation of a therapeutic narrative, built in impro- tiple actors with multiple motives are operating
visational fashion from the actions of two upon the same stage and through their inter-
characters. In turning occupational therapists, actions, narrative time is created.
I consider the clinical utility of transforming
linear clinical time into narrative time. (c) Narrative time is organized
What is there to say about time demarcated
by plot, by a beginning, middle and end, that
within a gap
distinguishes it from time marked linearly, one Narrative time is that place of desire where one
moment simply succeeding the next? Or even is not where one wants to be, where one longs
from time marked predictably, one moment to be elsewhere. Another way of saying this is
progressing smoothly to the next? One way to that movement toward endings dominates the
answer this question is by looking at the way experience of time.
THE CONCEPT OF THERAPEUTIC 'EMPLOTMENT' 125
meaningful way into a life which is in radical phrase it, this episode illustrates the common
transition. Like many other therapies, occupa- task of getting a new and unconvinced patient
tional therapy is a vulnerable profession in the to 'buy in' to therapy.
sense that therapeutic efficacy depends not The analysis is based upon field notes. An
only upon what the therapist independently interview was also done with the therapist but
does to the patient, but on what patient and not the patient about what occurred in the
therapist are able to do together in therapy. If session. No claim is being made that the ther-
the patient does not view therapy as valuable, it apist's efforts at emplotment necessarily
will not be valuable. Patients and therapists yielded a meaningful experience from the pa-
need to come to some shared view about how tient's point of view or that the patient's way of
co live as a disabled person, or at least they making sense of the session mirrored the story
need negotiate a shared view a bout what role told below. Nor did the therapist speak of plots
therapy can play in facilitating a life with dis- and stories, a language entirely foreign to the
ability. Often this does not happen, and thera- conceptual framework of occupational ther-
peutic time becomes a place of struggle between apy. She did speak, however, of her concern to
therapist and patient, or is perceived by the motivate the patient, to give him a picture of
patient as yet another forgettable and useless what therapy would be like, and to solicit his
way to spend an hour in the hospital. Thera- interest and cooperation in future treatment.
peutic success depends in part upon the therap- My claim is that the therapist can be seen to
ist's ability to set a story in motion which is make a number of interventions which are
meaningful to the patient as well as to herself. directed to setting a certain sort of story in
One could say that the therapist's clinical task is motion, and that the patient's observed re-
to create a therapeutic plot which compels a sponses strongly indicate a willingness to take
patient to see therapy as integral to healing. At up the therapist's scoryline at critical junctures,
a more radical level, the task is to create a plot in at least for the space of this initial session. One
which the 'ending' toward which one strives of the most interesting features of therapeutic
invokes a sense of what it means to be healed emplotment is that while it can be guided by
when one will always be disabled. the therapist, it cannot be dictated. The 'untold
In the following example, an occupational story' that unfolds is not created by any simple
therapist works to emplot a series of actions in imposition of a preplanned treatment script but
a single therapeutic session, weaving them into structured from unanticipated responses by the
a meaningful whole. The session illustrates the patient to the therapist's interventions.
difference between treatment as mere sequence,
just one medical intervention after another, and
treatment structured narratively, one thing The Tour
building upon another. In this example, there is
a shift mid-session from a series of interactions The session begins in the hospital room of
in which therapeutic time looks like a linear Steven, a 20-year-old who has only awakened
succession of discrete acts ungrounded in con- from a coma a few days earlier [34]. Steven is
text or in a picture of the patient, to the narra- between 1 and 2 months post trauma from a
tive shaping of therapeutic interaction in which car accident where he suffered a brainstem
therapeutic time has been em plotted by the clin- contusion. He cannot talk but communicates
ician's picture of how to create a significant through signalling and writing. The occupa-
therapeutic experience for a patient. tional therapist, Donna, has seen this patient
The episode is familiar in the practice of oc- only twice before but very briefly since he was
cupational therapists. It is an everyday instance not yet ready for an 'OT' (occupational therapy)
of a therapist's efforts to create a meaningful session.
experience of the patient which foreshadows a As Donna comes into Steven's room, a phys-
larger therapeutic story, even a whole thera- ical therapist and a nurse are getting ready to
peutic process, in which she hopes to engage transfer from his bed to a wheelchair. This is
the patient. Or, as occupational therapists would the first time he has been out of bed since the
THE CONCEPT OF THERAPEUTIC 'EMPLOTMENT' 127
accident and he is reluctant to get up. Donna on his part during this phase. Neither do the
brings a student occupational therapist with professionals need much cooperation from one
her and they join the others around Steven's another since the tasks they are carrying out
bed. So, as the session opens, Steven lies in bed are quite discrete and distinct from one an-
surrounded by four medical professionals. other. They make no effort to build on what
During the first several minutes he is simultan- the others are doing because accomplishing
eously treated by each of them. He is: (a) given a their task does not require cooperative action.
shot; (b) introduced to the student occupational They are quite simply carrying out a pre-
therapist who puts on his sneakers; (c) has his planned set of fairly isolated activities. Their
lungs listened to by the physical therapist; and tasks are certainly neither meaningless nor
{d) asked questions about his height by Donna. formless and the physical therapist in a min-
The occupational therapists, nurse and imal sense 'emplots' her actions by informing
physical therapist have previously decided that the group, including the patient, that his
he needs to stand up and then spend an hour breathing capacity is improving and he now
sitting in a wheel chair. They are all there at the has the ability to help transfer himself to the
same time to help in transferring him from bed wheelchair. She thus places his immediate re-
to wheelchair. The patient cannot speak but he sponses within a temporal context that refers
is given a pad and marker and writes notes to to backward ("That was so much better than
them. Donna and the physical therapist tell yesterday.") and suggests a future based on
him they realize he does not want to get out steady physical improvements.
of bed. When given a pad and marker, he writes This bare chronicling can be contrasted
"Be careful of my back." All four professionals with the more fully narrative emplotting which
work together to stand him up. They give him subsequently occurs between Donna and
instructions about how to help, for example, Steven. When the nurse and physical therapist
"Don't forget to put your elbow down and leave, the following dialogue ensues. Donna
lean" or "Lift up your head. Straighten up your hands Steven a comb and says "Try to comb
knee. Bring the right foot up." Two of the your hair." He does not want to do it and hands
professionals congratulate him on how well her back the comb. She then tells him this will
he has done. The physical therapist does some help him improve balance; It's a kind of exer-
more checking of his breathing while one of the cise. She says, "It's good for balance practice."
occupational therapists tries to help him get At this explanation, he combs, but with great
more comfortable in the chair and asks him effort. When he stops, Donna points to places
questions about pain. (Most of the questions he has missed. "Try here/' she says, "Nurses
directed at him are yes or no questions to which can't do back here when you are lying down."
he simply puts thumbs up for yes, thumbs As she touches spots on the back of his head for
down for no.) The nurse and physical therapist him to comb she says, "rll guide you a little
then leave the room while the two occupa- bit." She compliments him several times as he is
tional therapists stay behind. combing. "Great job." "Nice." "Great.''
The initial medical checking of Steven and Finally, they are done. The patient motions
the transfer to the wheelchair form a sequence for paper. He writes, "Mirror.'' The therapist
of actions with little narrative integrity. This is gets a mirror and sets it up on a table so he can
most evident during the first minutes of med- see, correcting the angle just right. She asks him
ical check where each professional is doing jokingly, "Going to make yourself look good
something different, paying as little attention for your girlfriend?" He signals for paper
as possible to what the others are doing. The again. This time he writes, "Want to go for a
patient is treated primarily as an injured body, ride.'' The therapist agrees enthusiastically.
and is often referred to as "he," as in, "He is "Great! You want to check out your new
writing with his right hand. Was he a lefty? place." Their tour begins. She takes him dir-
That's good writing." The professionals are ectly to the main occupational therapy room
primarily doing 'to' the patient rather than and she wheels him in. "This is the OT room.
'with' him. Minimal cooperation is required You will be spending a lot of time here," she
128 CHERYL MATTINGLY
tells him. She points to the mat and tells him apparently satisfies him enough to accept the
that they will be working together there. She comb and do the task. When he finishes and
says, "You will learn to strengthen your trunk.'' she asks him to continue combing, pointing out
As they are about to leave, Steven expresses missed places, she subtly changes the meaning
discomfort and Donna stops to investigate. He of the task from a balance activity to a self-care
indicates that he has pain in his left shoulder activity by telling him that "Nurses can't do
when he moves his head. The therapist sup- back here when you are lying down." It may
ports his arm and begins moving it. She ex- be more accurate to say she adds a meaning,
plains the movements she is doing, asking him giving the activity a polysemic character. Hair
to hold and then let his arm go again. She combing becomes both a balance support exer-
notes, "Your left shoulder seems OK but that cise and self-care. And she decides to extend
pain makes you not want to move it. But the task so that by the end he has not just
moving it is good. Moving will get it stronger carried out an exercise, he has, in fact, combed
and reduce the spasm." his hair. By the end of this activity, he seems to
They leave the occupational therapy treat- accept this meaning because he asks for a
ment room, and the patient writes, "I want mirror to see himself, as one might do after
more of a tour before I go back to bed." The combing one's hair but not after doing an exer-
therapist says, "You've got it. This is University cise for balance practice. The therapist builds
Hospital." As they wheel down the hospital on his request by not only getting him a mirror
corridors the therapist says. "Today is Friday. but in carefully adjusting it for better viewing
Saturday and Sunday I am not here. But as you while simultaneously joking to him about
get stronger, your family will take you out." fixing himself up for his girlfriend.
They come to a large window looking out Donna em plots her actions and his by defin-
over the city. The therapist stops to let him look ing them as part of a therapeutic story she
out. She says, "Do you recognize the Pruden- wants to carry out. The meaning of combing
tial?" He motions for paper and writes, "Open his hair as preparation for being seen by others,
window." She explains that the windows can't a meaning he acknowledges by asking for a
be opened, which she also demonstrates to him mirror, is given emphasis by the therapist's
by going over to the window. She takes him joke. If you are able to comb your hair, her
past the nursing station and looks around to joke implies, you can feel ready to be seen by
find any nurses who know him. The patient people you care about.
writes, "Is Beth here?" Beth comes out and they The patient initiates the next phase of the
have a quick, warm conversation. The nurse session by requesting to go for a ride. Again the
tells him she's glad he is up. He writes down therapist not only agrees but builds on his re-
"Please visit" on a note to her. Then the occu- quest by announcing to him the meaning of his
pational therapist and the patient proceed on request. She tells him he wants to check out his
their tour for a few more minutes. The therap- new place. She thereby turns a ride, which
ist asks him if he is getting tired. He indicates might have meant going up and down the hall,
yes, thumbs up. As they return to his room the into a chance to see his new surroundings, a
therapist asks, "Do you remember which is chance to see and be seen.
your room?" The patient indicates thumbs up By the point where the ride begins, a "sense
when they reach his room. And there ends the of an ending" is also emerging. Discrete actions
session. are corning to take on a unity; a figure in time is
being sketched. For this whole session plays
upon the theme of reentry into the public
(a) Creating figures in time world. The therapist builds on her success at
Emplotment of this session begins when getting the patient to comb his hair, which
Donna asks Steven to comb his hair. He does succeeds not only in that he does it but in his
not want to do it. She persists, handing him subsequently asking to see a mirror and then to
back the comb and giving him a biomedical go for a ride. In her response to both his
sounding rationale - improving balance - that requests she not only enthusiastically agrees
THE CONCEPT OF THERAPEUTIC 'EMPLOTMENT' 129
but explicitly marks them as requests to move return home, there is work, work which may
out into the world. She "reads" them as moves be unpleasant, painful, work he may not want
within a story of reentry, and does so aloud so to do, but then there is strength and along with
that the patient hears her interpretation. To his strength, there is the possibility of seeing and
request for a mirror she replies by joking about being seen, of reentering what Arendt [35] de-
his girlfriend, signifying that he is getting ready scribes as the public world of appearing.
to be seen. She interprets his second request for Arendt takes it that our urge to appear, to see
a ride as his wanting to see and in seeing, to and be seen, is essential to what it means to be
take ownership, to "check out his new place." human. She writes, "To be alive means to be
She "emplots" his requests with a plausible but possessed by an urge toward self-display which
strong reading of the desires motivating them. answers the fact of one's own appearingness.
And she emplots his requests through her Living things make their appearance like actors
actions as well, not only bringing him a mirror on a stage set for them" [35, p. 21].
but adjusting it, not only taking him for a ride The figure of the session, then, opens with
but giving him a tour which includes stopping the patient combing his hair, rather against his
by the occupational therapy treatment room own wishes, and ends with a hospital tour. By
and stopping at the nurse's station to find a the end, everything that has happened, from
nurse he is friends with. She is personalizing the initial taking of the comb to the end of the
the hospital. She is showing him "his" particu- tour, becomes an extension or elaboration of a
lar version of the hospital, the version that story of making himself presentable and thus
includes a visit to a friend and the occupational reentering the public world. And by doing the
therapy room where he will be working with tour after he combs his hair, the therapist also
Donna to get stronger. extends the meaning of that hair combing.
She also uses his request for a ride to give What can look trivial to him becomes the very
herself the possibility of showing him what he thing that makes it emotionally possible for
will be doing with her. While both gaze toward him to leave his room for the first time.
the mat in the occupational therapy room, she One thing after another becomes, in narra-
quite literally points to a future story. She tive logic, one thing because of another. In
sketches, in the barest phrase, what kind of what Kenneth Burke [36] calls a "temporizing
story they are in. In this prospective story they of essence," earlier events become the causes of
work together and he becomes stronger. She later events. Because the session links one small
reiterates this same prospective story when he activity - hair combing - to another activity
complains about his shoulder. She says that which the patient requests and clearly cares
working, even working in pain, will make about, leaving his room for the first time, the
him stronger: "That pain makes you not want session becomes an argument in story form
to move it. But moving it is good, will get it about why occupational therapy activities
stronger and reduce the spasm." should matter to this patient. The therapist is
She uses his requests as places of possibility saying, through the experience, that something
to indicate a second story in which work, that might seem to him small for a large amount
though it will take time and cause pain, will of effort on his part is really worth the trouble
finally make him stronger. At this juncture of because it makes it emotionally possible for him
the session, the plot thickens. Two subplots are to feel presentable and venture into the more
interwoven and embedded into a more com- public world of hospital hallways.
plex causal chain. The first story of reentry, of
return home, of freedom from an immobile (b) Human time and the
body and an institutionalized existence, is con-
nected to a second story about work and pain.
centrality of motive
The first story offers the hopeful ending. The Story time is human time rather than physical
second, however, emphasizes the difficult path time; it is shaped by motive and intention. To
which the patient will have to travel if he is to see myself as in a story, or a series of stories, is
attain that ending. For before there is the to see my life in time as stretching out toward
130 CHERYL MATTINGLY
A story may be well formed from a purely struc- even embraced, offers a path to the outside.
tural point of view, and may have a clear 'poinf Or, at least, that is the narrative the therapist
but if the audience does not know why the point hopes will shape their clinical time together.
matters to them, if the events in the story never In this therapeutic interaction the therapist's
touch them, the story does not work. concern to generate desire for therapy is evi-
The parallel between the told story and dent in many of the actions she takes, including
lived time is easily drawn if life in time is char- how she interprets the meaning to be made of
acterized, following Heidegger, as a present the patient's own actions. When the therapist
located between past and future rather than asks the patient to comb his hair, he does not at
an endless succession of 'nows. ~ The meaning first cooperate. Perhaps her fundamental task
of the present is always a temporal situatedness in this initial encounter is to create in him a
benveen a past and a future which we await. desire to act and, quite specifically, a desire to
We are not passive in this waiting, however. act in therapy. Since there is no story where
Desire in the face of an uncertain future plays there is no desire, much of this initial session
a central structuring role. We hope for certain with the therapist can be seen as her effort at
endings; others we dread. We act in order to making therapy a place where there is some-
bring certain endings about, to realize certain thing to care a bout. She begins to sketch out
futures, and to avoid others. While we may not possible "endings" which she presumes the pa-
(ohen are not) successful, we act nonetheless, tient does, or will, desire - especially becoming
striving as far as we can to make some stories free of his role as patient and reconnecting to
come true and thwart others. In so acting we those he cares about (family, girlfriend), out-
may come to decide that endings we thought side the confines of the clinic.
we desired are not so desirable after all and
shift our teleological orientation in favor of a (d) Time of transformation- time
different future. But always we are situated
with an eye to the future and that future satur-
dominated by the ending
ates each present moment with meaning. This In a story, time is structured by a movement
is what Heidegger means when he describes us from one state of affairs (a beginning) to a
as always in the process of becoming, organ- transformed state of affairs (an ending). In
ized around Care. It is not merely that the story time, things are different in the end. The
agent, somehow, 'pictures' a future state which structure of beginning-middle-end presumes,
he then tries to attain. The future belongs to the of course, that time is marked by anticipation
present because we are, as Heidegger says, of some end, one which, to make another obvi-
"thrown forward" in a stance of commitment, ous point, does not exist at the beginning. So
of care, toward a future. We are always, in narrative time is marked by change, or by the
Heidegger's wonderful phrase, "ahead of our- attempt at change. It is time characterized by
selves" [41]. M. J. Good's work on the central an effort at transformation. Things may be
place of hope in the practice of oncology pro- changed in an outward, public way or there
vides an important perspective on the need for may be an inward difference. People may come
both clinician and patient to find something to to think and feel differently. But it is important
hope for [42]. that in the time of plot, the agency which most
Returning to the case given above, the ther- matters in creating change is human agency.
apist attempts to shift the patient into narrative Even if other factors are more determinant -
time by inviting the patient to be "ahead of physical and even structural conditions - these
himself." They take a tour into the future, both are background, the setting in which human
the future of therapeutic encounters and the actors take center stage.
future which matters, the one which leads out When Donna and Steven take their tour of
from the hospital back home. The therapy the hospital, the possibility of transformation is
room she takes him to represents a temporary at the heart of the drama they are playing out.
station, a purgatory, which, if endured and At first take, this point is so obvious that it goes
132 CHERYL MATTINGLY
without saying. If therapy is not about change, (suffering). Suffering is one name for experi-
what could it be about? What is powerful in ence. "Because the actor always moves among
examining the thirty minute interaction be- and in relation to other acting beings, he is
tween therapist and client is how the topic of never merely a 'doer,' but always and at the
transformation figures centrally, and the sort of same time a sufferer. To do and to suffer are
transformation that is emplotted. like opposite sides of the same coin, and the
Steven has awakened to a body horrifyingly story that an act starts is composed of its con-
transformed. Some further bodily transform- sequent deeds and sufferings" [17, p. 190]. The
ations will occur as part of a natural healing "trouble" that marks narrative time is the ne-
process, apart from his own actions. And some cessary counterpoint, a required antithesis, to a
will occur because of what others do to him. causal structure dominated by the concept of
But none of these changes form the core of the human agency. Actions may be the central
plot being sketched by Donna. This is not a cause within narrative structure, but their
narrative of passive awakening; there is no causal efficacy is anything but sure. Nothing
miracle cure and no magician healer. The plot is guaranteed in the realm of human action. We
is both more prosaic and more wrenching for it do what we can but - in the narrative at least-
centers on the body transformation which there are always impediments.
Steven can directly affect through painstaking The importance of trouble and suffering in
effort. Perhaps the greatest part of the pain will the narrative is due to the sort of actions narra-
be Steven's growing acquaintance with his in- tives recount, actions in which desire is strong
jured body, and his emerging recognition of the and in which there is a significant gap between
limits imposed upon him by that body. Through where I now am and where I want to be. If
trying to heal himself, he will discover time and narrative plots turned on the everyday easy-to-
again the limits he must live with and will have accomplish actions which form habitual life
to reckon with the loss of possibilities no longer (raising my arm to scratch my head, putting
available to him. This reckoning will precipitate up my umbrella in the rain, heating a can of
inner transformations, changes of personal iden- soup for dinner) suffering would not need to
tity, perhaps even changes of character. enter. The strength of our desire comes in part
from the length of the reach required to attain
what we want. Most stories we choose to tell
(e) Troubled time
feature difficult passages toward precarious
The very drama of narrative is based, in a destinations, journeys fraught with enemies
sense, on the experience of suffering. Even the who may defeat us at any moment. Upon
happy story, the one which ends well, takes us examination, it is surprising how regularly
through a drama of plight - a lack or need everyday stories carry this plot structure; even
which sets the story in motion, which propels tales of victory are set against this implicit
the protagonist in a quest to obtain his goal backdrop of what might have gone wrong.
through the overcoming of a series of obstacles. In attempting to set a therapeutic story in
The process of overcoming, however fortuitous motion, the occupational therapist need not, of
the result, almost inevitably engenders periods course, invent troubles or obstacles for the pa-
of suffering for the story,s heroes. This is such a tient. These come with chronic disability.
pervasive feature of the structure of narrative Suffering is paramount; adversaries are every-
that Propp made it central to his analysis of where. The difficult task for the therapist is
folktales and later narrativists expanded it to locating a space for action at all. Her problem
include many other kinds of narratives. And is how to offer sufficient hope to the patient
Arendt used it to characterize one moment in such that the struggle to overcome obstacles
a dialectical treatment of the nature of human becomes meaningful and bearable [41]. Occu-
action. pational therapists speak often of their need to
Narratives are about acting and suffering, transform "passive patients" into "active pa-
Arendt has said. They are about doing some- tients." What they mean is that their patients
thing (acting) and what happens as a result are organized in the hospital to suffer, to wait,
THE CONCEPT OF THERAPEUTIC 'EMPLOTMENT' 133
to be "done to," as they say. When Donna takes and looking backwards, plausible. "To follow a
Steven for a tour, she is inviting him into a story story," Ricoeur writes, "is to move forward in
in which he will not only suffer passively, as a the midst of contingencies and peripeteia under
victim of his injury, but one in which he goes the guidance of an expectation that finds its
out to battle, so to speak, actively incurring fulfillment in the 'conclusion' of the story. This
more suffering (certainly more physical pain) conclusion is not logically implied by some pre-
in a fight to overcome, where he can, the vious premises. It gives the story an 'end point,'
damage that has been done to his body. Within which, in turn, furnishes the point of view from
the therapeutic plot Donna hopes to initiate, which the story can be perceived as forming a
the patient becomes an aggressor of a sort, whole. To understand the story is to understand
engaging adversaries in an effort to become how and why the successive episodes led to this
healed, and treating the therapist as a valued conclusion, which, far from being foreseeable,
ally and trusted guide in this enterprise. Phys- must finally be acceptable, as congruent with
icians often see themselves as engaged in a the episodes brought together by the story"
dramatic fight with disease, waging war [20, pp. 66-7].
against cancer cells, for example [42-4]. But Story time is not, at least in any simple or
in the occupational therapisfs emplotment, it linear sense, about progress. It is not about
is the patient, in alliance with the therapist, building one thing onto another in some steady
who is designated as the narrative hero, the movement toward a defined goal. Time is char-
one who must wage the war. acterized by suspense, not only the suspense of
not knowing whether a desired ending will
(f) Suspenseful time: time of the come about, but even the suspense of not
knowing whether the ending one pictures is
unknown ending
the one which will still be desired or possible
The presence of powerful enemies, and of as the story unfolds.
dangers and obstacles, means that narrative In the therapeutic plot Donna enacts with
time is a time of uncertainty. Our desire for Steven, indications of an uncertain future are
an ending may be strong, but if our enemies minimized. If there is one place where thera-
are equally strong, or danger is prevalent, there peutic emplotment in this case diverges from
is no telling what will finally unfold. Hence, narrative time in the told story, it is over the
the fifth characteristic of narrative time is that issue of certainty. For Donna points toward
it is marked by doubt, by what Bruner [45] vivid and predictable endings. When they look
speaks of as 'subjunctivity.' This theme is won- out toward the Prudential, she speaks confi-
derfully developed by Good [4] in his discussion dently of Steven's return home to family and
of illness narratives. If lived experience positions friends. When they look into the door of the
us in a fluid space between a past and a future, therapy room, she speaks of the gains he will
then what we experience is strongly marked by make by working through pain. She does not
the possible. Meaning itself, from this perspec- raise doubts about what he will be able to
tive, is always in suspense. If the meaning of the accomplish, or what life he will return to. Her
present, and even of the past, is contingent on intent appears to be to offer him a hopeful
what unfolds in the future, then what is ending, a set of desirable images, to which he
happening and what has happened is not a might be able to attach himself. And yet, given
matter of facts but of interpretive possibilities the despair many patients feel over their ability
which are vulnerable to an unknown future. to transform themselves and their lives upon
Life in time is a place of possibility; it is this awakening from a coma or serious operation,
structure that narrative imitates. For narrative her cheerful certainty is set against the bleak,
does not tell us that what happened was neces- nearly silent uncertainty of a patient who, at
sary but that it was possible, displaying a reality the beginning of the session, did not even want
in which things might have been otherwise {46]. to get out of bed. Her brisk assertions can be
Endings, in action and in story, are not logically seen as a kind of whistling in the dark, an
necessary but possible, and seen from the end attempt to put a brave (or blind) face on a
134 CHERYL MATTINGLY
future which is anything but sure, one where possible in the shortest time possible. Certainly,
things will never be the same. the work of therapeutic emplotment is not
necessarily obvious; treatment can appear as
nothing more than a set of procedures. In this
Conclusion paper, I purposely chose a quite ordinary ther-
apy session because there is nothing narratively
Clearly, as research in medical anthropology interesting or of any particular moral import
has shown, listening to stories patients tell is which is immediately evident. While sometimes
essential to understanding their illness experi- encounters between occupational therapists and
ences. Healer's stories, too, reveal a great deal patients are quite dramatic, more often they
about both the clinician's experience as healer resemble the interaction between Donna and
and the culture(s) of biomedicine. What is Steven. Quiet and, at first glance, uneventful.
added by looking at therapeutic encounters Just a therapist wheeling a patient through the
themselves as proto-narratives, stories-in-the- hospital corridors. But an encounter such as this
making ? Why speak of therapeutic plots? begins to take on significance when recognized
The notion of therapeutic emplotment offers as an episode within a larger therapeutic story
one way to examine the social construction which is in the process of being constructed.
(and reconstruction) of illness and healing as Any therapeutic narrative, in turn, is but a short
a fluid, shifting process influenced not only by story in the larger life history of the patient,
molecular conditions, institutional structures a life story which is under radical reconstruction
and cultural meanings but also by the exigen- while therapy is on-going. Which therapeutic
cies of the concrete situation. story gets constructed, and what voice the
Equally important, narrative analysis of clin- patient has in that story-making, is not
ical interaction helps to uncover the moral di- inconsequential.
mensions of clinical practice. As Kleinman and
Kleinman [47] argue, therapeutic transactions Acknowledgements - I would like to thank
are fundamentally moral. A central difficulty Mary-Jo DelVecchio Good, Byron Good, Vin-
with the usual clinical depictions of patient suf- cent Crapanzano, Michael Fischer, Linda
ferings is that in their abstractness, the world of Hunt, Lindsay French, Arthur Kleinman, Jean
the patient is left out. This world is above all a Jackson, and Jim Howe for their helpful com-
practical and moral one in which patients have ments on earlier drafts of this paper.
life projects and everyday concerns, things "at
stake." lllness, from this point of view, creates a
"resistance" that hinders or prevents the sufferer NOTES
from carrying out plans and projects [46]. The
study of a clinical encounter as an unfolding 1. Early E. A.
The logic of well being: Therapeutic narra-
story leads easily to a recognition of its ethical
tives in Cairo, Egypt. Soc. Sci. Med. 16,1491,
content for "the moral" is integral to the mean-
1982.
ing of any story. What was that point of that
2. Price L.
story? we ask when the moral is apparently Ecuadorian illness stories: cultural know-
missing. A narrative analysis offers a way to ledge in natural discourse. In Cultural Models
examine clinical life as a series of existential in Language and Thought (Edited by Holland
negotiations between clinicians and patients, D. and Quinn N.). Cambridge University
ones that concern the meaning of illness, the Press, Cambridge, 1987.
place of therapy within an unfolding illness 3. Kleinman A.
story, and the meaning of a life which must be The I IIness Narratives: Suffering, Healing
remade in the face of serious illness. and the Human Condition. Basic Books,
This moral negotiation is easily hidden in New York, 1988.
the clinical world, disguised in the trappings 4. Good B.
of a clear-cut technical encounter where, pre- The narrative representation of illness. Chap. 6
sumably, the task is to get the patient as well as of Medicine, Rationality and Experience: An
THE CONCEPT OF THERAPEUTIC 'EMPLOTMENT' 135
No life is sufficient unto itself. A person is sin· My fieldwork in central Australia brought
gular only in the sense in which astronomers use me to an existential understanding of the way
the term: a relative point in space and time subjectivity inevitably entails intersubjectivity,
where invisible forces become fleetingly visible and vice versa. To come into one's own a person
(cf. Levi·Strauss 1990, 625-6}. Our lives belong must also feel at home in the world. Paradoxic-
to others as well as to ourselves. Just as the stars ally perhaps, one can only be one's own person
at night are set in imperceptible galaxies, so our to the extent that one belongs to a wider context
Jives flicker and fail in the dark streams of his· than the self - family, clan, circle of friends,
tory, fate, and genealogy. One might say that we workplace, or imagined community. Being at
are each given three lives. First is our conscious home in the world implies, therefore, a dialectics
incarnation, occupying most of the space be- of identity (Jackson 1977, 238). But this perpet·
tween our birth and death. Second is our exist- ual interplay between hermetic and open-ended,
ence in the hearts and minds of others - a life enstatic and ecstatic modes of subjective experi·
that precedes the moment of our birth and ence implies problems of feedback and control.
extends beyond our death for as long as we are These cybernetic adjustments between self and
remembered. Finally there is our afterlife as a other cannot, howeve.; be measured objectively.
barely remembered name, a persona, an element Rather they are consummated intersubjectively
in myth. And this existence begins with the as a sense of balance between one's experience
death of the last person who knew us in life. of the world as something alien, external, all-
These moments in a person's destiny find encompassing, and overbearing, and one's ex·
expression in different kinds of stories. What perience of having some place in the world,
begins as a body of raw experience, too hum- some say over its governance. Every human life
drum or perhaps too painful to be told, becomes drifts between two poles: the entirely egocentric
a narrative, and later takes on the lineaments of and totalitarian extreme of dominating others,
myth. In this metamorphosis of life into legend, and the masochistic extreme of self·abnegation,
the original figures fade and reform, and often inertia, and victimage. For most people, life is a
end up carrying the burden of our preoccupa· struggle for the middle ground where it is pos·
tions. As Michael Young notes in his brilliant sible to realize one's power to make a difference
study of the ways myth and life story are inter- in the world, to call it one's own, though within
leaved in Kalauna, "myth is reconstructed the limits of the needs of others, as well as the
through lived experience which mediates cul- constraints of history and genealogy.
ture; and culture is reconstructed through lived When in 1993 my wife, Francine, and I went
experience which mediates myth" (1983, 35). to live with an aboriginal family on an outstation
in the rainforests of southeast Cape York, these marginalization, incorporated as a habitual dis-
issues of home and belonging reclaimed my at- position toward guardedness and reticence, may
tention. The history of the social world we explain why the O'Rourkes resisted being
entered was as tragic and traumatic as any in moved to the mission (they were almost the last
aboriginal Australia: more than a hundred years to leave their land) and were the first to leave.
of conquest and violent dispossession, of racism Of all Kuku-Yalanji "mobs" in the late 1970s,
and murder, of the brutal breakup of families, of the O'Rourkes were, according to Christopher
dispersal and deportation, enforced missioniza- Anderson, "one of the mission's least powerful
tion, and the denial of basic civil rights (Laos and materially worst off" (1984, 385). Yet their
1982; Broome 1982; Rosser 1985; Rowley isolation implied considerable solidarity. "The
1972). Successive generations of aboriginal O'Rourkes, out in the scrub, sticking together,"
people had been drawn into a wider polity only was the way a local Aboriginal councillor once
to find themselves diminished and disadvan- described them to me.
taged within it. Their struggle to strike a balance
between a sense of their own ethnic solidarity One cannot begin to understand aboriginal ex-
and a sense of place in the national community perience of what we call history without under-
had been frustrated and often futile. standing their conception of the past. As I had
The traces of this history were everywhere seen in central Australia, custom and law exist
apparent, not in physical relics or ruins but in in potentia - as the Dreaming - but must be
the lived forms of aboriginal sociality itself, continually brought back into sentient being
particularly where outsiders were involved. (in presentia) through concerted ritual activity.
Story after story bore upon the vexed history This perennial recovery of the past is often
of black-white relations, though it was clear described metaphorically as a drawing out,
that this categorical opposition merged with waking up, growing up, and giving birth. A
an older and deeper dialectic between self and person's relation with the past is thus lived as
other, insider and stranger. The family with a social relation with the forebear whose name
whom we lived was a case in point. Although he or she carries, as well as with the site with
the O'Rourkes 1 had endured the mission years which that forebear is ever-presently associ-
stoically, they had been marginalized long ated. In so far as the vital energy of ancestral
before. Traditionally, a retaliatory and retribu- (past) events is embodied in the land, time is
tive killing was demanded if an imponant man spatialized. In so far as the past is felt to con-
died and sorcery was suspected, and the people tinually reenter the present, time is synchron-
living at Banabila - so-called because of the ous. As Veena Das so aptly puts it, the present
swift tidal current that ran at the mouth of is constituted as a "spectral present rather than
the Bloomfield River - had been the scape- a point present" (1989, 324). Put another way,
goats. Deemed "the weakest and most friend- "there are not two worlds- the world of past
less" Kuku-Yalanji group, Roth, writing in happenings and the world of our present
1907, noted of them: "one of this tribe is gen- knowledge of those past events - there is only
erally, as a last resource, fixed upon as the one world, and it is a world of present experi-
culprit; the latter is enticed away on some ence" (Oakeshott 1933, 108).
hunting expedition, for a corroboree, etc. and The implication is that we must understand
then mercilessly speared from behind'' (Roth time and space intersubjectively. Many abori-
1907, 387; cf. 1910, 92). ginal people express bafflement and dismay at
Like many aboriginal people, the O'Rourkes the ease with which Europeans seem co turn
sought isolation as a survival strategy. But seg- their backs on the past - as if it were outside
regationalist and assimilationist government lived experience. As if by implication the
policies left them and others like them no injustices and grief that white settlers visited
place to hide. Forced into a Lutheran mission on aboriginal people were now over and
in the 1970s, the tactic of physical retreat meta- done with, dead and buried. For aboriginal
morphosed into social stratagems of with- people, however, this "history" is reiterated
drawal and subterfuge. Their long history of and embodied in the very condition of their
MYTHs/HISTORIES/LIVES 139
contemporary lives, which is why people so actually experienced events that took place
readily fuse accounts of their own experience before they were born.
and accounts of their forebears' experiences as The psychology of separation trauma helps
if past and present were effectively one. us understand what hastens this fusion of per-
Although many scholars still tend to separate sonal and collective memory.
history and myth- the first supposedly made up As in any other human society, an abori-
of series and successions of events that have ginal child's primary orientation is to his or
actually occurred, the second largely invented, her immediate family and community. These
reconstructed, or imagined - it is necessary to constitute the significant others who mirror
set aside or bracket out this kind of distinction if and affirm a child's developing sense of who
one is to understand aboriginal ways of narrat- he or she is. In aboriginal Australia this positive
ing experience. Phenomenologically, any "cut" identification was often negated by white
between historic and myrhopoeic, objective prejudice and propaganda, which relentlessly
event and interpreted event, is untenable. His- emphasized that such modes of belonging were
tory is a mode of experience, a world of coexist- the stigmata of primitiveness and dependency
ent facts, in which the past is continually re- and could only perpetuate a state of abori-
presented (Oakeshott 1933, 108-18). ginal fallenness, ignorance, ill health, and infer-
The key to understanding this phenomenon ior being. In short, the very loci of people's
is memory. As Maurice Halbwachs showed, ontological security - kin, land, language, an-
individual memories, like dreams, are continu- cestry- were systematically invalidated. And if
ally being reshaped and reconstructed in the the stigma of aboriginal origins were not
course of a person's social engagement with enough, punishment was meted out in the form
others (Halbwachs 1980). This may occur in of assimilationist policies that permitted chil-
the context of dialogue as well as in the course dren to be taken from their birth parents and
of bodily and ritual interaction (Connerton licensed police to physically remove aboriginal
1989). In these processes personal memories people from their land and incarcerate them on
become collectivized and historicized; they reserves, missions, and penal settlements.
cease to be properties of individual minds and Existentially, these subversive strategies, pu-
enter into intersubjectivity. As such, the line nitive measures, and criminalizing and stigma-
between immediate and interpreted experience tizing procedures often had the very opposite
effectively disappears. effects to those that were intended. Rather than
Just as aboriginal people tend to gloss make aboriginal people ashamed of themselves
over the boundary between biography and and determined to break with tradition, they
myth, so too the line between the historical drove people back to their roots for security
and the personal is rarely clear-cut. Indeed, and survival. It was in this way that "the stolen
there is an onus on the living to actively generation" came to extol their aboriginality
integrate the past into the present (Rose over the so-called golden opportunities they
1992, 30). As Ronald Berndt observed of had been given by well-meaning white foster
Western desert peoples, the existential and parents for whom traditional aboriginal soci-
moral actualization of the received wisdom in ety offered nothing but illiteracy and alien-
myth is something the living must accomplish ation. If mythology, land, and language were
in the way they choose to live (Berndt 1979, not available as a matrix in which to place
28).Just as this fusion of Dreamtime and life- oneself, history was. History became the onto-
time is achieved through storying, so the past logical surrogate of mythology. And the white
and present are continually collapsed in the world was made the dialectical negation of
stories with which people render accounts of aboriginality. In so far as it had denied blacks
their social and personal reality. One is any place in it, any rights in it, any choices over
reminded of the way many young Jewish its governance, blacks would now define them-
people speak of their suffering during the selves by turning that denial against those who
Holocaust, or African-Americans speak of had first used it. Reinventing white history was
their enslavement, as if they themselves part of this oppositional process.
140 MICHAEL JACKSON
In this sense the fusion of biographical and transformation from victimage to advantage.
historical horizons is not merely a way of Consider, for instance, the following comments
understanding one's situation; it is, more im- by an aboriginal woman on the subject of rape:
mediately, a strategy of actively coping with it.
In translating my suffering into the suffering of white girls complain if they are raped. Our girls
my people, I is transformed into we. By the are ashamed of it. They prefer that no one
same token, the person who caused my knows because they're afraid to be ridiculed.
Others laugh. rve talked to Aboriginal women
suffering is stripped of his or her particular
who've been raped by whites, Greeks, Japan-
identity and transformed into an instance of
ese, Chinese or whatever, and they just toss it
they, or further depersonalized as it. This trans- off as a joke. A lot of these stories come to us in
formation of particular subjective experience pidgin English and it does sound funny. It turns
into a universalized and transsubjective out that's one way of covering up their shame,
category enables one to grasp and control a ... by laughing at it. The actual part of a rape,
situation one experienced first in solitude and the horrible part, rve never heard that laughed
powerlessness. It is always easier to bear per- about. But the tricks that lead up to it, the
sonal suffering if one can experience it as some- goings on. They talk about it in such a way
thing shared by many others. Through the that it belittles the man who did it. (Gilbert
sense of kinship born of this identification with 1978, 20)
fellow sufferers one is able to find common
cause against a common foe. The belittling In her account of her journey by camel across
sense of having been singled out and persecuted the Western desert, Robyn Davidson writes of
because of some failing in oneself yields to an how her Pitjantjatjara traveling companion,
empowering sense of being part of a collective Eddie, dealt with an incident in which a white
tragedy, a shared trauma. No matter what the tourist denigrated him by calling him "Jacky-
wound, it is easier to act as one of many who jacky" and "boy" and ordering him to "come
have been victims of a historical wrong than it and stand alonga camel" for a photograph.
is to act as the isolated and sole victim of a While Davidson was consumed by indignation
personal slight. and anger, Eddie "turned himself into a perfect
But another transformation is implicated parody of a ravingly dangerous idiot boong,"
here. For as long as a traumatized person feels playing the tourists' stereotypes back at them
isolated and alone, his or her suffering is ex- as burlesque. In this way he turned the tables
perienced and dealt with intrapsychically. This on the tourists, making them the victims of their
may take the form of repression, self-blaming, own ignorance. Laughing hysterically at the epi-
self-loathing, self-abuse, and self-destruction. sode later, Davidson saw how bitterness and
But solidarity with others in whom one recog- victimage could be averted through ludic action
nizes one's own suffering tends to move the (1980, 182-4).
locus of these defenses from the intrapsychic Richard Broome has written perceptively of
to the intersubjective. First, even seemingly this strategy of the trickster, the ways in which
self-destructive behavior such as binge drink- aboriginals mimicked European bosses, assigned
ing and fighting comes to conform to complex them derisive nicknames, or used subterfuge as
rules of sociality (Collmann 1988). Second, payback:
one may appropriate the language with which The unhappy peanut farmer in the north saw
one is vilified and derogated, and use it half- his best peanuts disappear all day into the
joking against oneself and one's own kind, so mouths of Aboriginal pickers. Aboriginal
tearing it from the oppressor's grasp, asserting stockmen on a muster could kill a prime cow,
control over it, and nullifying its effects (Jack- enjoy the good beef and then disguise the car-
son 1995, 13; Carter 1991). Third, one may case to look like a natural death or a dingo
rework events that one suffered in impassivity killing. Aboriginal boys were expert at
and silence as shared narratives in which one spearing vegetables through the cat door of
plays the heroic role of trickster. Self-deprecat- the station store, or at tunnelling under the
ing humor and parody tend to characterize this floor to drain out the flour and sugar from
MYTHSIHISTORI ES/LIVES 141
the bags on the bottom row. Others sabotaged analogous to the argument ecologists make
the bosses, equipment. One manager daimed against genetically engineered and global
that his "dumb, and "lazy, Aboriginal monocultures and for indigenous biodiversity
workers could not be trusted to apply even a as the only effective way of sustaining life on
few drops of oil periodically to the bore-water earth. And it echoes the argument Michael
rigs and that 25 had blown up in two years at a Oakeshott makes in his famous essay on con-
cost of $5000 each. Strangely, the bore at the versation. The task of science, he writes, is not
Aboriginal camp never broke down. (Broome to deliver us from the polyphony of Babel but
1982, 135)
to accommodate disparate voices, disagreeing
Warlpiri informants described similar strat- with being disagreeable, as in conversation
egies to me, detailing how they used all manner (Oakeshott 1991, 488-9).
of underhand methods - trickery, mimicry, Put otherwise, the task of ethnography is not
theft, recalcitrance - to counter exploitation to know the Other in any final sense nor even to
and prejudice (Jackson 1995, 96-100). And know the self through the other. Nor is it to
as many first-contact accounts testify, abori- change the lives of others, or even to critique
ginal people often told self-disparaging, mimet- one,s own culture. Its warrant and worth lie in
ically inventive, and ludicrous stories about its power to describe in depth and detail the
their own initial ignorance of whites as a way dynamics of inter-subjective life under a variety
of dealing with their traumatic loss of control of cultural conditions in the hope that one may
(Dawson 1981, 105-6). thereby be led to an understanding of how those
Another mode of "oppositional practice," rare moments of erasure and effacement occur
sometimes spoken of as a culture of resistance when self and other are constituted in mutuality
(Cowlishaw 1988), may arise from everyday and acceptance rather than violence and
coping strategies, though it should not be ana- contempt.
lytically conflated with or reduced to them. Stopped on a road in order to listen and take
Here the ethos of the "oppressor" is openly notes.
scorned, political activism appears, and nation-
alism takes hold. The vilified self is now pro- NOTE
jected onto a vilified other. Self-hatred becomes
a hatred of another, self-blaming is replaced by 1 I use pseudonyms for all the aboriginal fam-
a search for scapegoats. Instead of withdraw- ilies and individuals mentioned in the
ing into oneself, one now withdraws socially following pages.
from the other, who has become the paradig-
matic not-self who once categorized and classi- REFERENCES
fied oneself as an abhorred alien.
[... ] Anderson, Jon Christopher
1984 "The Political and Economic Basis of
Here/Now Kuku-Yalanji Social History!' Ph.D. diss. Uni-
versity of Queensland, Australia.
Berndt, Ronald M.
But the test of anthropological understanding
1979 "A Profile of Good and Bad in Austra-
is wordly, not epistemological. Its truth lies in its
lian Aboriginal Religion., Charles Strong Me-
capacity to help us see that plurality is not inimi- morial Lecrure. Australian and New Zealand
cal but necessary to our integrity, so inspiring us Theological Review 12:17-31.
to accept and celebrate the manifold and contra- Broome, Richard
dictory character of existence in the knowledge 1982 Aborigi1zal Australians: Black Response
that any one person embodies the potential to be to White Dominance. Sydney: Allen and Unwin.
any other. As Terence's famous stoic dictum has Carter, julie D.
it, humani nil a me alienum puto - being 1991 "Am I Too Black to Go with You?" In
human, nothing human is alien to me. Being Black: Aboriginal Cttltures in "Settled,
The argument is for a view of Being as Australia. Ed. Ian Keen. Canberra: Aboriginal
complex, ambiguous, and indeterminate. It is Studies Press.
142 MICHAEL JACKSON
You think this mountain is beautiful? I hate it. To me it means war. It's nothing
but a theater for this shitty war ... (Response of Comandante Jonas to a foreign
journalist's request to take pictures of the mountains, eastern front, El Salvador,
1983. (Quoted from Manlio Argueta's Cuzcatlan: f<!here the Southern Sea Beats
(1987:1}.))
One can be a virgin with respect to Horror as one is virgin toward Voluptuousness.
(Celine, Journey to the End of the Night. (Quoted in Julia Kristeva's (1982:140)
essay on Powers of Horror: An Essay on Abjection.))
1anis Hunter jenkins, "The State Construction of Affect: Political Ethos and Mental Health among Salvadoran
Refugees, Culture, Medicine and Psychiatry 15 (1991): 139-65. With kind permission from Springer Science
+Business Media: Culture, Medicine and Psychiatry, The State Construction of Affect: Political Ethos and
Mental Health Among Salvadoran Refugees, 15, 1991, pp. 139-65.
144 JANIS HUNTER JENKINS
an inseparability of ideas and sentiments, northeastern United States. The newly emergent
cognition and affect, thoughts and feelings discourses on culture, self, and emotion were not
(Jenkins 1988b; Lutz 1988; Rosaldo 1984). adequate to the task of interpreting the senti-
The present essay seeks to expand the ments of persons whose lifeworlds are framed
emerging scholarly discourse on the emotions by chronic political violence, extreme poverty,
by examining the nexus among the role of the state unrelenting trauma and loss. It became apparent
in constructing a political ethos, the personal that the role of the state and other political,
emotions of those who dwell in that ethos, religious, and economic institutions must be
and the mental health consequences for refu- examined to interpret the dominant ethos of a
gees. By political ethos, I mean the culturally people. In the context of Salvadoran life-
standardized organization of feeling and senti- worlds, I understand the state construction of
ment pertaining to the social domains of power affect in relation to a pervasive dysthymic
and interest. Recognition of the essential inter- ethos and a culture of terror (Jenkins 1990a).
relations between the personal and the political In this paper I propose a problematic to
has long been central to feminist scholarship advance and refine our understandings of state
(see Rosaldo and Lamphere 1974) but has yet and politicized sentiments. My argument about
to be more fully integrated in culture theory in the state construction of affect is intended as a
medical and psychological anthropology. bridge between analyses of discourses about
In a recent special issue of this journal con- affect, on the one hand, and the phenomen-
cerning discourses on emotion, illness, and ology of those affects, on the other. I begin with
healing, Mary-Jo DelVecchio Good and col- a brief description of the political ethos in con-
leagues raise, among other issues, the problem temporary El Salvador, the process of flight by
of state control of emotional discourse, defined refugees to the United States, and the reasons
as "the role of the state and other political, for their flight cited by some of those refugees. I
religious, and economic institutions in legitim- then examine mental health consequences of
izing, organizing, and promoting particular life within the Salvadoran political ethos, with
discourses on emotions" (DelVecchio Good, special attention to the underlying ethnopsy-
B. Good, and Fischer 1988:4). These authors chology of emotion. I suggest a framework
note that examination of politicized passions for the analysis of pathogenic trauma that at-
has been slow in coming. In an ethnographic tempts to bridge the collective level of the state
study of the role of the state in authorizing and construction of affect and the individual level
sustaining discourses on sadness, they examine of a phenomenology of affect. I conclude with
how the current Iranian Islamic state has ap- a discussion of the implications of resilience in
propriated a traditional religious discourse on the face of the most trying circumstances for a
grieving, martyrdom and the tragic by redefin- theory of human nature, and several sugges-
ing it as part of the official state ideology for tions for further research.
the Iranian citizenry concerning ideal, morally
upstanding affective comportment. In another
study of Iranian immigrants to the United La Vida in El Salvador: La Situacion
States, B. Good, DelVecchio Good, and Moradi
(1985) document the interplay of cultural In the refugees' narratives of their emigration
themes, sociopolitical events, and depressive from El Salvador, they often speak of escape
disorder. A similarly convincing case for the from Ia situaci6n. La situaci6n is the most
social production of affective disorders (in common way of referring to the intolerable
China) has been presented by Kleinman (1986). conditions within the country, and condenses
The need to make a theoretical move from a set of symbols and meanings that refer to a
the state control of emotional discourse to the nation besieged by both devastating economic
state construction of affect became particularly problems and violence. Although violence and
evident to me in the course of recent fieldwork civil warfare have been common throughout
with Salvadoran refugees seeking psychological this century, the last eleven years in El Salvador
help at an out-patient psychiatric clinic in the represent the most intensive sustained conflict
THE STATE CONSTRUCTION OF AFFECT 145
to plague the country. Since 1979, the new extreme brutality, re-focused attention on the
wave of warfare and terror has decimated the widespread human rights abuses that occur with
population by death and emigration. At least impunity in El Salvador.
some 75,000 persons have been killed in the The emotional atmosphere of Ia situaci6n is
past 11 years, with several thousands more constructed by a variety of actions and prac-
"desaparecidos" or disappeared, 500,000 dis- tices. During the offensive, strict enforcement
placed within its borders, and an estimated of a curfew from 6:00PM to 6:00AM ensures
1,000,000 more who have fled to other coun- that no one can be on the streets or in any
tries such as Mexico, Honduras, Panama, the public place. Failure to adhere to this injunc-
United States, and Canada. In a country that, tion can, and often does, have mortal conse-
as of 1979, had a population estimated at 5.2 quences. In the private sphere, no socializing of
million persons, one begins to appreciate the any sort - family gatherings, parties, religious
horror of the decimation of the Salvadoran sessions - can be convened. Cross-cutting the
people (Fish and Sganga 1988). public and private domains are "disappear-
El Salvador is a poor country, heavily reliant ances" and the ever-present evidence of violent
on agriculture. This most notably includes coffee death: decapitated heads hanging from trees
exports. The other principal economic source is or on sticks, mutilated dead bodies or body
American aid, amounting to $1.4 million per parts on the roadside, or on one's own door-
day. Recently, in November 1989, there was a step. Nearly all of my informants spontan-
major guerilla offensive, the largest coordinated eously narrate their personal experiences of
attack in almost ten years, aimed at dozens of everyday encounters in a landscape of violence.
targets throughout the country, including the Habituation to Ia situaci6n amounts to a denial
capital, San Salvador. Counterattacks on the of its reality- a bomb going off may be inter-
part of the Salvadoran army were swift and preted as a car backfiring. The reality of Ia
pervasive, escalating in intensity to extensive sitt-taci6n is noteworthy for its profound sense
daily bombing and strafing of villages and neigh- of unreality. Mistrust abounds on all sides, and
borhoods. I remember all too vividly the month people commonly say "You can trust no one."
of November 1989 as I watched my Salvadoran A sketch of the situation and habituation to ir is
friends and research participants, inseparably only a first step, however, toward inferring a
chained to their telephones, desperately seeking political ethos, which must be fleshed out by
the fate of their parents, children, grandparents, considering both preexisting ethnopsychology
and other family. Not surprisingly, the escalation and the phenomenology of psychopathology in
in the violence at home coincided with a pro- situations where the defense of habituation fails.
nounced increase in all kinds of exacerbations of To my knowledge, no anthropological study has
distress and symptomatology. ever been made of the emotional climate of
In November 1989 also we saw the assassin- populations under martial law, though analyses
ations of six Jesuit Priests (faculty of the Na- are beginning to appear on the specific transmu-
tional University), their cook and her daughter. tations of grief and paranoia in countries where
The priests, faculty from the University in San "disappearances" have been institutionalized
Salvador who supported a negotiated peace, (Scheper-Hughes 1990; Suarez-Orozco 1990).
were also widely regarded as the leading intel- A repertoire of affective themes and strat-
lectuals of the country. The late Ignacio Martin- egies for constructing the emotional atmos-
Barb, for example, was the leading social phere is more directly evident in the onslaught
psychologist interested in the mental health con- of media communications that is an important
sequences of long-term civil war in his country. tool in the state programming of sentiment. For
As a research scholar, Martin-Bar6 was also par- a poor people with little formal education
ticularly interested in the psychological rehabili- (90% non-literate or semi-literate), the princi-
tation of children who were orphaned by the pal media sources are radio and television.
war, displaced or traumatized by the endless These sources suggest to a people how they
violence. The manner of the Jesuits' assassin- might or ought to feel about Ia situaci6n.
ation, which apparently included torture and Under conditions of civil war and martial law,
146 JANIS HUNTER JENKINS
these state-controlled media convey rigid and The Salvadoran populace is pointedly
dogmatic messages leaving little doubt about instructed not to listen to competing counter-
which affective sensibilities are being commu- discourses- so-called "clandestine" radio broad-
nicated and why a truly moral person should casting of the opposition of the Farabundo
justifiably feel them. Marti National Liberation Front or the
Quite revealing in this respect is a sample of FMLN - on the grounds that these illicit radio
regular programming from an audiotaped broadcasting stations seek only "to create con-
radio broadcast on the official Radio Nacional, fusion and uncertainty', in the Salvadoran
San Salvador, on November 16, 1989 - the family. The state construction of the eminently
very day during the guerrilla offensive that the evil "other" (implied or stated as the FMLN
Salvadoran military assassinated the jesuit and "Marxist" doctrines) is accomplished
Priests. Both moraVpolitical and affective through reference to "savages" and "mental
rhetorics (explicit and implicit) are operant illness" - indeed, the listening audience is
in the broadcast. In response to the repeated informed that adherence to Marxist doctrine
rhetorical question, Porque lucha Ia fuerza causes mental illness. Religious officials are
armada? (Why are the armed forces fighting?), interviewed summarizing the barbarism and
several sociocultural, nationalistic, and capit- hideous crimes against humanity that the FMLN
alist values are cited. Most saliently, these in- are accused of committing. They assert that
clude: a right to "keep on believing in God;" these crimes (alleged, for example, to include
the preservation of the "nuclear family as the placing bombs in hospitals) are worse than any-
center of the Salvadoran social life;" "the right thing Christopher Colombus may have commit-
to live in liberty and freedom;" "the right to ted when he "discovered" America. The Spanish
'equal opportunity, in work, education, health conquistadors, we are informed, would never
and development;" "the right for citizens to have gone so far as to place a bomb in a hospital.
have the right to choose." Appeals are made In announcing the assassination of the Jesuit
to the personal and societal value of capitalism priests, the murders were attributed to the
and the evident need for a military response to FMLN and denounced as irrational acts of sav-
the opposition forces that would overturn the agery committed for the purpose of destabilizing
very fabric of society. Subtly distributed among the democratic process. (In the foreign press,
these overt patriotic declarations are messages these attributions of blame to the FMLN were
that allude to the emotional substrate of these later retracted and ultimately replaced with ad-
values as they exist imperiled by Ia situaci6n. missions by the President that the military armed
We are informed that the Salvadoran military forces had, in fact, committed these atrocities).
forces are fighting to put "friendships without
mistrust into practice.,, Repeated again and
again are the emotional themes of fear, anxiety, Flight from La Situacion:
and confusion said to be engendered by guerilla Forced Migration and Emotional
forces. Proper sentiments of hatred and disgust Distress
toward the latter and loyalty and love to one,s
patria (mother country) are also salient. A gen- Migrants are typically considered in two cat-
eralized feeling of insecurity is inculcated by egories: as immigrants and as refugees. While
constant reiteration that the armed forces are immigrant implies some degree of choice con-
"protecting you, providing for your security, cerning the decision to leave one's natal country,
that everything is under control, that the armed the designation of refugee is meant to signal that
forces exercise total control over all the departure from one's native country is involun-
national territory.,, Such messages would tary, and repatriation, all but impossible. Al-
doubtless be unsettling even if there was no though the flight of refugees is not a new
immediately perceptible threat, and must be phenomenon, the dimensions of this problem
doubly so when they are so immediately con- have recently intensified. Whether we look to
tradicted by destruction, aggression, and assas- Cambodia, Liberia, Haiti, Argentina, or East
sination in all quarters. Germany, the world's populations are relocating
THE STATE CONSTRUCTION OF AFFECT 147
in vast numbers. In a recent report from the U.S. their economic furore and are not acknow-
Committee for Refugees (1990a), it is estimated ledged to be in personal danger. As Alvarez
that there are today more than 15 million refu- (1989:61) has eloquently stated," ... the offi-
gees worldwide. In the last five years alone, the cial stance of the U.S. government and the
worldwide refugee population has increased by societal attitudes prevalent in this country are
50%. Many of these refugees leave their home- characterized by massive denial, invalidation
lands under the press of conditions that threaten and indifference towards the collective experi-
their personal, familial, and cultural survival. ences of violence which the Central American
This is true for Salvadorans. The Central Ameri- community has endured . . . The ever present
can situation of long-term economic conflicts threat of deportation and their ongoing
and political violence often compel them not exploitation leads many refugees to live lives
only to leave their natal country but also to live marked by invisibility, frozen grief and des-
with little or no prospect for safe repatriation. pair." Not until late 1990, by act of Congress,
Refugees from the present study arrive in were Salvadorans in the United States able for
the United States from El Salvador through a the first time to gain temporary legal status and
variety of means. One common route is a series avoid the threat of deportation.
of bus trips to the U.S.-Mexico border. Arriving As part of our ethnographic-clinical study,
there, refugees make use of a coyote or guide twenty persons were interviewed at least two
who, for a fee, assists groups of people in times each. Most have been in the United States
crossing the border without drawing the atten- for at least one year and have family, including
tion of immigration officials. These journeys young children, who still reside in El Salvador.
are typically narrated as long, arduous, and Most work very long hours- sixty or more - in
dangerous. Sexual violence against solitary two jobs, in vigorous efforts to make as much
women is apparently commonplace. Moreover, money as possible to send back home to rela-
coyotes are infamous for taking advantage of tives. In spite of these strong economic
the persons they claim to serve. Some of the motives, the reasons given for their flight from
women in the study reported being abandoned El Salvador fall equally under the three cat-
or robbed by coyotes. egories of escape from political violence,
Popular destination points for Salvadoran escape from economic conditions, and escape
refugees in the United States include Los from domestic violence. However, as is clear
Angeles, San Francisco, Washington D.C., from the following vignettes, all three reasons
New York City, and Boston. Reliable demo- for leaving are closely bound up with the over-
graphic data are currently difficult to acquire arching political ethos of Ia situaci6n.
since this population is, by necessity, largely Escape from political violence has compelled
underground. Following the immigration law refugees to leave their homelands in search of
of 1986, legal residence has become particu- safe haven. Nearly all of the women report that
larly difficult to obtain. Under the law, they had regularly encountered brutal evidence
165,000 Salvadorans sought legal residence in of the war: mutilated bodies lying on the road-
the United States. Aside from the 1986 immi- side or in the doorsteps to their homes, family
gration law, many Salvadorans have sought and friends who had disappeared, and the terror
political asylum from the U.S. government. of military troops marching through their towns
These court cases are largely unsuccessful: in shooting at random and arresting others who
1985, for example, only 3% of these applicants would be incarcerated. For many of the women
won their appeals. This is so because despite in the study, their narratives of fleeing political
the well-documented and widespread human violence are suggestive of the relationship be-
rights violations in El Salvador, the U.S. gov- tween state constructed affects of fear and anx-
ernment does not consider their emigration to iety, on the one hand, and indigenously defined
be based on a flight from political violence. conditions of nervios (nerves), on the other.
Rather, such cases are typically considered These narratives also vividly portray everyday
"economic" in nature; the official view is that encounters with and habituation to truly hor-
refugees have come here merely to enhance rific lifeworlds.
148 JANIS HUNTER JENKINS
1. From a 36 year old married woman, not reassured her. Whenever her daughter gets
mother of three: angry her nose bleeds profusely. This problem
began in El Salvador, but now recurs most
In my country I had un susto (a fright) when a
often when she sees movies or TV about war
man was dying. Already the man couldn't
speak (but) he made signs to me with his eyes. or violent situations.
It was during the daytime, and I was going to Whenever possible, I don't permit her to watch
get some chickens for a Baptism. He could this. Another thing I think is related to her nervios
barely move his eyes. He had been shot in the is that she laughs uncontrollably for a long
forehead. It was the time of the fair in Novem- time- for an hour or two -laughing to herself.
ber. When I came back he was already dead. I She can't stop laughing. Afterward, she cries.
returned home with a fever, and it wasn't
something I'd ever experienced. Since it was When I asked her what she thought might have
carnival time, strangers came. They kill caused this problem, she provided a thoroughly
strangers. They saw him throwing away some embodied account:
papers. Yes, I have seen various dead bodies. I imagine that it probably happened while I was
Since then, I became sick from nervios. Ner- pregnant (with her). I had a lot of psychological
vios, upon seeing the dead bodies. problems. When one is very fearful, a nervous
2. From a 38 year old woman, mother of two: tension that the army is going to come, they're
This informant survived a series of tortures going to come through the streets, you're going
subsequent to three arrests and imprison- to get hit by a passing bullet or the army is
ments in the early 1980s. At the time of her bearing someone and taking them away - all of
first imprisonment, her husband was also this affects a little baby you have inside. I feel that
taken away by the military, his head covered when you're pregnant all the nervous things, all
the things that are imponant to you, all the things
with a black hood, and assassinated:
you see, the baby feels too. Because it's some-
When they told me that my husband was dead, thing inside. I think that everything I went
for me it was like, like a dream, like something through while I was pregnant is now part of her
unreal. Yes, there are times he comes into my nervous system. When I was pregnant and we
mind, but I know it's something that will never had a strike at the factory. The army would
exist. He's a person that doesn't exist. It's arrive, begin shooting, and throw bombs of tear
something that I have to try to do, to forget him. gas to make us leave. Yes, all this affects you. The
tension we had. We had 7 months without
Still, on other occasions she has told me,
working, without receiving a salary, so much
"I think about him, I dream about him. I hear worry.
his voice calling to me." She now resides with
their two children in the metropolitan area. Escape from unrelenting hunger and
She came to the clinic to seek assistance for poverty has impelled refugees to leave their
some intense psychological suffering that has country in search of income-generating work.
remained with her, in the form of major depres-
1. From a 54 year old woman, mother of
sion, anxiety, and trauma.
four:
She also reported that her eleven year old
daughter has un problema de nervios. Nervios In El Salvador it was very hard. I used to wash
(nerves) is an indigenous cultural category clothes at the river by the dozens. I would do
widely used in Latin America for a variety of five dozen. I would get up at 5:00A.M. and go
forms of distress and disease, including every- to the bakery where I got leh over bread I used
day worries, depression, and schizophrenia to take the mercado to sell until 9:00 A.M.
(Jenkins, 1988a, b) and may refer to a variety Then I would go to the river. I had no help. I
of bodily and affective complaints (Low 1985; didn't like it because I was hungry and some-
Guarnaccia and Farias 1988). Although the times I wouldn't get paid on time. And I would
daughter's doctor told her it was probably worry because I wouldn't have enough to feed
nothing and not to worry about it, this has my children.
THE STATE CONSTRUCTION OF AFFECT 149
I came here because the situation wasn't 1. From a 27 year old married woman,
good, there were strikes by the teachers, there mother of two:
were no classes and then the teachers got to-
gether with the students and started to protest. (I have felt un susto) when my husband was
After that, you would find dead bodies without drinking a lot, already before he would arrive
heads and eyes on the roads. In 1980, on my home. Then I would feel my heart, pum, pum,
own doorstep, I found many people dead. My pum. If you are fearful it can make you sick
son was here (in the metropolitan area), so because it can cause you a crisis de nervios.
I came. I feel that my body isn't me. It can cause a
person to go crazy. It makes me have stomach
2. From a 38 year old mother of two: pain, shaking of my body, and it makes me
As immigrants in this country, the conditions of cold.
life are very different. There are so many eco- 2. From a 34 year old married woman,
nomic problems, like health care. Employers
mother of two:
don't pay MEDICAID, and we can't afford it.
We don't have good (enough) jobs to pay for it. was pregnant at that time (expecting my
The bills add up and add up. It's very difficult, life second baby), when he (my husband) started
and health, these days in this country. drinking ... (and) he beat me. I was 'very fat'
(Back home) sometimes we say to ourselves, (in a very advanced stage of pregnancy), and he
'fine, I'm going to the U.S. I am going to earn mistreated me. But later, he regretted it because
money, to work.' But it isn't easy. I know per- the baby was born unhealthy, with a problem of
sons who come and pass 3-5 months without nervios. He mistreated me for no reason when
working. They're new, and especially because of he was drunk. He was treating me like that
the language they are not able to speak. If you because his mother told him very bad things
want to work in a restaurant washing dishes or about me, but the truth is that his mother
work in cleaning, sure, it's an honest job, but never loved him, she was always telling him
sometimes ies really difficult. that I was very bad for him, that she paid his
Because it's the only thing you can do as an studies so he would marry a 'worthy woman,'
immigrant. To clean, wash dishes, or work in a not somebody like me because I was nothing
factory, where they pay minimum wage, $4.25 ... he mistreated me and beat my stomach and
an hour. And it's little pay for so much work. then, when the baby was born, he had like a
It's very difficult. In one factory, for example, yellow color in his skin, and the doctor told me
they don't give benefits, health care, nothing. it was necessary for my baby to remain in the
Sometimes out of necessity you, as an immi- hospital for some time because he was ill. But
grant have to accept it. If you're a parent, it's when my husband found out about the baby's
very difficult. illness he blamed me as well; so you know, I
We come here from our country because of was guilty for everything ... so I began having
the conditions of living there (in El Salvador), problems with my nervios, since I was preg-
the same situation, always through persecu- nant, because his mother as well was treating
tion, bombings, and the rest. For so many me as if I was an animal, never like a person
things that perhaps someone hasn't seen and . . . and then when my baby was born I started
at other times for others they have lived it, en to have nightmares ... my daughter was 10
carne propia (in one's own flesh or lived, years old by then, and I was suckling my baby
bodily experience). and when he arrived home completely drunk
then ... she noticed all what was happening
Many of the women in this study also and she cried, she became sick from nervios,
reported that they had fled their homelands to she became very ill. My daughter, sick with
escape family violence. The following vignette nervios, was screaming, throwing things
also provides a further sense of how both soci- around ... it made me sick but I couldn't say
etal and familial representations of violence a word to him because he would beat me, so
become part of the em bodied experience of that I knew that I just had to cry and keep
women. quiet.
150 JANIS HUNTER JENKINS
violence and inhospitable life conditions in "(t)he savage danger of madness is related to the
North American urban settings. While forced danger of the passions and to their fatal concat-
uprooting and culture conflict are sources of enation." A contemporary parallel of Foucault's
distress, political oppression and turmoil also observation is our simultaneous understanding
clearly have an effect independent of migra- of, for example, depression as an emotion and
tion. In addition, the refugees experience great as a disorder (Kleinman and Good 1985). The
psychic and bodily suffering in the aftermath of problem of understanding the pathogenic con-
having fled Ia situaci6n. Despite life in what sequences of trauma and the character of the
ostensibly one may have hoped for as a "safe resulting disorder is thus compounded by vari-
haven/' Ia situacidn remains vivid in their ations in the psychocultural bases of emotional
dreams (often nightmares), is constitutive of life. In the present context, I can offer only the
their memories, and is present in the apprehen- briefest summary of the Salvadoran ethnopsy-
sion of everyday life. chology of emotion:
According to psychiatric diagnostic and re-
search criteria (DSM-III-R and the SADS}, 1. In terms of what would be clinically cat-
nearly all of the patients in the study had egorized as the "chief complaint" or pre-
experienced at least one major depressive epi- senting problem when coming to the
sode in their lifetime. Most had suffered one or clinic, nearly all of the refugees in
more major depressive episodes within the past the study report that they suffer from a
two years, and some have struggled with either variety of problems related to nervios.
chronic depression or dysthymia. The women The cultural category nervios is deeply
voice a variety of themes of sadness and sorrow embedded within the life contexts of
in relation to loss and bereavement, helpless- chronic poverty and exposure to violence.
ness and hopelessness. The language of loss and Nervios refers at once to matters of mind,
mourning, however, is often communicated body, and spirit and does not make good
through somatic means, as insomnia, lack of cultural sense in relation to mind-body
appetite, fatigue, or psychomotor agitation or dualisms.
retardation. As Kleinman (1986, 1988) has 2. Salvadorans can in general be character-
demonstrated, somatized expression of depres- ized in terms of a strongly kin-oriented
sive disorders is very common for most of the and relatively sociocentric (Shweder and
world's population. Many of these women also Bourne 1982) or referential (Gaines 1982)
report symptoms of post-traumatic stress dis- sense of self, with the experience and ex-
order (PTSD), including recurrent nightmares pression of symptoms framed in reference
of traumatic violence, a sudden feeling chat the to the family context.
traumatic event (or events) are recurring, and 3. Spanish provides a rich lexicon for emo-
irritability or outbursts of anger. Psychiatrists tions of sadness and sorrow. Suffering
refer to these "active" symptoms as part of the may be reported through language rich in
"intrusive" phase of PTSD, whereas symptoms descriptive detail, and with a distinctly
such as restricted range of affect, feeling of es- existential flavor. In Salvadoran culture,
trangement from others, and efforts to avoid ethnopsychoJogical elaboration of tristeza
feelings associated with the trauma are associ- (sadness) or pena (sorrow) .and an
ated with the so-called "numbing phase." As I underlying sense of life's tragedy invari-
argue below in greater detail, the traumatic ably color Ia situaci6n.
event in these instances may be construed 4. On a phenomenological level, Salvadorans
broadly - as the chronic presence of warfare describe their emotional experiences in
and destruction - and discretely - as particular terms of bodily sensations. The body sites
instances of extremely traumatic events such as are often both specific and generalized. It
wimessing an assassination or actually under- is not uncommon to voice one's suffering
going torture and interrogation. as a totalizing bodily experience. Reports
In Foucault's essay (1973:85) on the relation of various bodily sensations may be inter-
between "Passion and Delirium," he mused that preted as signs of malevolent spiritual
152 JANIS HUNTER JENKINS
influence, and one's suffering could well be only el calor but also the sensation of electric
related to spirit activity. shocks throughout their body. Nevertheless,
5. Also common is the preoccupation with we have also been given these same phenom-
protection from the malevolence of others, enological accounts by some persons who have
as manifest in the ethnopsychologically not undergone torture. The clinical relevance
salient themes of envidia (envy) and witch- of understanding el calor was made all to evi-
craft. dent recently in a clinical case conference.
6. Salvadorans evidence a great deal of in- While waiting for the resident to come into
volvement in dream life, and this serves the hospital examining room, a patient was
as a means for communicating with dis- overcome by intense heat throughout her body.
tant, missing, or dead loved ones. Some- To relieve herself she took off her blouse and
times these communications are reported soaked it in cold water from the sink. When the
as comforting experiences, as dream mem- resident entered the room and saw she was not
ories focus on past family fiestas and Sal- only distressed but also half-nude, he appar-
vadoran love of the land and nature. The ently assumed she was "psychotic'' and imme-
dysphoric and distressing quality of dream diately transferred her to the local state
life becomes evident, however, in the psychiatric hospital, where she remained with-
alarmingly high incidence of dreams of out the benefit of an interpreter for several days
disembodied and mutilated bodies, knives until her family discovered her whereabouts.
and other weapons, and a full array of war- The fact that el calor is a culturally elaborated
related horrors. Especially noteworthy is total body experience leads me to conceive of it
the fact that most of the dream life situates not merely as the embodiment of affective dis-
Salvadoran refugees back home, not in the tress but also what Csordas (1997) has called a
United States. culturally specific "somatic mode of attention."
7. In Salvadoran ethnopsychology there is the
belief that the experience of anger and hos-
tility, whether directed by intimates or in Meaning, Sense,
witchcraft, may lead to serious illness or, in and Representation:
extreme cases, death. The Traumatized Body
violence. Although the trauma and suffering until it takes on a character and consequences
are manifest in individual psychic suffering, it quite its own. This understanding parallels that
is more appropriate to speak of psychosocial made by biological psychiatrists about the exist-
trauma or "the traumatic crystallization in per- ence of a threshold the crossing of which consti-
sons and groups of inhuman social relations" tutes a pathogenic alteration of neurological
{1988:138}. The trauma and suffering become biochemistry. Related to this process is another,
manifest in psychic suffering, dysphoric affects, more distinctly qualitative threshold associated
and a variety of forms of psychopathology. with the shift in the immediacy of self-reference.
Psychosocial trauma is particularly evident in The generalized situations of terror or distress
the collective experience of anxiety, fear, para- bear a relatively diffuse reference to the self,
noia, terror, and above all, denial of reality. which is precisely the condition for the possibil-
Martin-Bar6 (1990) interpreted the constella- ity of denial so characteristic of a political ethos
tion of state-constructed affects, ills, and de- such as that of El Salvador. Stated another way,
fenses as a potent means of psychological one may be terrorized by a situation that in-
warfare. His insight is that, through its own cludes the torture of others, and distressed in a
peculiar dynamic, war unfolds into a more situation that causes mental illness in others, but
global phenomenon and is the dominant pro- these can also become immediate events of tor-
cess that subordinates all other social, economic, ture or disease for the self.
political and cultural processes. Moreover; this Despite the profound differences in degree
process affects all members of a society, either and self-reference, the essence that terror and
directly or indirectly. For example, to a greater torture, disease and distress retain in common
or lesser extent, all members of the society may is their fundamental dependence on the problem
experience the war en carne propria. The point of meaning, sense, and representation. Michael
is that no one remains untouched, or un- Taussig (1987), in trying to define the culture of
changed, by Ia situaci6n. terror that existed during the rubber boom in
Understanding the human meaning of trau- colonial Colombia, discovered that:
ma, especially as it affects refugees from political
violence, is frequently clouded by failure to dis- ... terror provided only inexplicable explan-
tinguish between a relatively enduring traumatic ations of itself and thrived by so doing ... this
situation and relatively discrete traumatic problem of interpretation is decisive for terror,
not only making effective counterdiscourse so
events. I would suggest that this distinction is
difficult but also making the terribleness of
relevant in two critical dimensions, namely the
death squads, disappearances, and torture all
state construction of affect and the phenomen-
the more effective in crippling of peoples' cap-
ology of affect. In the first of these dimensions, acity to resist (1987:128).
the conditions of trauma established by the state
and resistance to it come under the distinction If as Taussig says, terror nourishes itself by des-
between the situation of terror and events of troying sense, Elaine Scarry (1985) shows that
torture. In the second, the modes in which those this is doubly so in the structure of torture. Inter-
conditions are taken up into human lives come rogation and the infliction of pain, the two basic
under the distinction between the situation of features of torture, are both language--destroying,
distress and events of disease. Torture is different and hence destructive of the three principal loci of
from terror, and disease from distress, by degree human meaning: world, self, and voice. Pain
and by self-reference. With reference to degree, creates a "discrepancy between an increasingly
we might posit that there is a simple continuum palpable body and an increasingly substanceless
between the diffuse effects of the generalized wor1d" (1985:30), as even familiar objects such
situation and the intensely focused effects of as walls, doors, furniture become weapons. Inter-
the discrete event. However, torture and disease rogation is not designed to elicit information but
take on their unique configuration in contrast to to destroy the voice, creating expressive instabil-
terror and distress as a result of what Marx ity in its conflation of interrogatory, declarative,
termed the "transformation of quantity into and imperative modes and the exclamatory of
quality," the amplification of a phenomenon each (1985:29), until every question becomes a
154 JANIS HUNTER JENKINS
wounding and every answer regardless of its families of desaparecidos experienced more
content becomes a scream. The self's complicity symptoms than refugees, not only because of
in its own destruction is represented as self-be- the stress of uncertainty but perhaps because
trayal in that a transformation occurs between they still lived in the mode of terror that stifles
the experience that "my body hurts" and "my resistance and expression of distress. In other
body hurts me," and as betrayal of others in the words, the authors suggest that families of des-
signing of an unread confession. The effect of aparecidos have more symptoms than do refu-
the confession is compounded insofar as it is gees because, unlike those who have escaped,
likewise understood as a "betrayal" by the gen- they must continue to repress even their dis-
eral populace (1985:47). tress for fear the authorities will construe its
The same essential dependence on represen- expression as a sign of subversiveness, and pos-
tation is true of distress and disease. Persons in sibly kill the desaparecido. This study has
a situation of terror are not necessarily in a methodological flaws, and does not arrive at
situation of distress unless the terror repre- particular diagnoses, but I cite it as an example
sented as such: distress is a particular stance of a struggle to represent the consequence
toward the situation, a consequence of the con- of political violence as disease in face of the
strual of terror as terror. When the political ease of denying that someone in distress is
structure of terror is recognized for what it is, persecuted, or even that persecution is wrong.
the only self-preserving stance is either to take Someone who is distressed might still deserve
up arms or to flee. The only other solution is to that distress, but, as Young (1982) has noted,
find collectively acceptable ways not to recog- someone who is sick is relieved of culpability.
nize it. Thus, it is no accident that Salvadorans The distinction between distress and disease
use precisely the vague word Ia situaci6n to can also be used to delegitimize the relation of
refer to the state of affairs in their country, for suffering to disease, as has been shown by
it is of necessity rhetorically neutral in its non- Brown and Harris (1978). They argue against
acknowledgment of distress. This is especially those who - in standard dualistic fashion -
relevant insofar as the acknowledgement of would consider depression a disease only if
distress is itself considered a subversive act by caused biologically and not through stressful
the authorities. Jennifer Jean Casola, the life events. They point out that depressive
American church worker detained and interro- symptoms are prevalent in the general popu-
gated by Salvadoran authorities in 1989, lace as well as among psychiatric patients, and
reported that when she cried upon hearing the the former may never reach treatment or be
moans of detainees in neighboring rooms, her cared for by general practitioners precisely be-
captors quickly asked if she was "crying for her cause the origin of their illness is understand-
subversive friends." Her insistence on the able as depression originating in stress, or
human legitimacy of distress was summarized distress. Emphasis on biological causes can
in her response that she would cry for her misrepresent the impact of distress and trauma
interrogator if the same was done to him. by opening the claim that those who develop
Disease too is bodily representation, a constel- pathology had a biological predisposition to
lation of symptoms constituting a clinical entity the disease, or had pre-existing or other com-
that may occur in episodes - and with respect to pounding pathology. This problem of distress
refugees, what counts as disease is a rhetorical and disease is all the more tenacious because it
and political issue. A recent study of Latin is not only relevant to the refugee situation,
American refugees in Toronto and Mexico City but is inherent in medical thinking. As
and of families of desaparecidos ("disap- Kirmayer (1989) argues, "... the definition
peared") in Santiago and Buenos Aires found of discrete disorders remains an artifact of
that "victims of torture and refugees from vio- sometimes arbitrary criteria that leave the
lent political persecution within a period of ten classification of milder and intermediate forms
years following the traumatic experience are of distress ambiguous ... both the lay and
impaired by psychosomatic and mental symp- medical diagnosis and treatment involve se-
toms" (Allodi and Rojas 1983:246). Moreover, lective interpretations that hide some causes
THE STATE CONSTRUCTION OF AFFECT 155
and consequences of distress while revealing find the proverbial light at the end of the
others" (1989:327, 328). tunnel. Things were not going well: her apart-
ment building was burned to the ground (there
was the strong suspicion by many residents
Suffering and Resilience that the match was tossed by the owner of this
dilapidated unit for insurance purposes). The
It is evident that questions of the parameters new city-owned building she had moved into
of human nature abound in studies of refugees was populated mostly by norteamericanos
from war-torn countries. What are the (Anglo-Americans) whom she perceived as
limits of human endurance, suffering, and considerably less than enthusiastic about
tolerance for conditions and practices (such having Latinos in the building. Moreover, she
as torture) that must, by any standards, only had just learned that her daughter-in-law was
be characterized as horrific? How do we come again engaged in a "job" (that is, "witchcraft")
to know and understand the human capacity against her, causing her no end of difficulties.
for extraordinary strength and resilience in Her therapist, empathetically frustrated and at
the face of human horrors? These basic exist- her own wits end, said, "Ay, Rosa, I just don't
ential queries have been quite striking to me, a know what you can do. I say it's time to get the
middle class North American female anthro- candles out and light up as many as you can."
pologist, who has imperfectly attempted to (Candles are religious objects with spiritual
know my informants' worlds of phenomenal powers that provide protection and good luck.)
suffering, on the one hand, and resilience, on Rosa responded by saying, "But doctor: don't
the other. you know, I've already tried it! I want to, but I
Martin-Bar6 also concerned himself with can't: If I light the candles, it sets the smoke
the paradox that the suffering inherent in war detector off!" Following this, both patient and
also offers to some people the opportunity to therapist reported bursting out in peals of
further develop what we are fond of calling our laughter. Thus humor and perseverance in the
"humanity'' and strength. This process seems midst of disaster and misfortune serve as
to almost completely elude social science con- powerful tools for survival. (Also see Argueta
cepts of adaptation, or worse yet, adjustment 1987 on this point.)
and assimilation. These seem wholly inad-
equate to the task of understanding how refu-
gees attempt to reconstitute their lives and Concluding Remarks
construct new meanings. For refugees, the
kinds of personal, existential, and cultural I can suggest the following issues for further
losses they face virtually guarantee a (poten- theoretical elaboration of the role of the state
tially unresolvable) grief reaction of profound in constructing affective experience and ex-
sorrow and anger. It also seems to me that if, as pression: (1} covert (in addition to overt} mech-
Obeyesekere (1985) has argued, culture pro- anisms for promoting and legitimating emotion
vides for the working through of grief that discourses. Analysis of the covert and indirect
guards against depression, it would seem that affective communications (and meta-communi-
many cultures necessarily fail in the face of cations) from the state and other political groups
circumstances so extreme. is required since, in many or most instances, such
Yet this is not always how it goes. The messages go purposefully unacknowledged.
persistence of strong love of life, family, and Direct knowledge of purposeful intent in com-
native land, in the face of what would seem municating a given emotional message would,
from a North American point of view over- in many instances, be explicitly disavowed
whelming circumstances, constitutes a puzzle if brought publicly to the foreground; (2) affect-
in understanding bodily and spiritual resist- ive communications including symbolic acts
ance and resilience. Despite a sometimes dizzy- and practices that "set" a particular affective
ing array of losses, traumas, somatic symptoms tone; (3) the "redundancy" or apparent degree
and life crises, Rosa, for example, manages to of accord in the nature of affective
156 JANIS HUNTER JENKINS
Alice is a fortyish native of New England who stress, fear, and distractions, has led me to
lives in a shelter of cots and partitions set up question one of the basic goals of my ethno-
on a basketball court in the basement of a graphic work there. I set out to understand
large government center in downtown Boston. what Alice and her companions experience
If she is not staying in the shelter, she is sleep- every day. But the apparent absence of
ing in a psychiatric hospital or on the city's some of the distinguishing features of
streets. She considers herself "estranged from "experience" - reflexive interiority, hermen-
society" since the state took her child away eutical depth, narrative flow - leads me to
ten years ago; she now spends much of her question the universal relevance of the term.
time bumming cigarettes and reading the The concept of experience is one of the most
Bible. She bums cigarettes because she lacks problematic in contemporary anthropology,
money and does not want to start buying with the problems relating- at least in part-
packs of her own lest she pick up an expen- to the rhetorical and analytic needs it serves.
sive habit. The Bible helps to lessen the noise, Some use the word experience because it
worries, and distractions that are part of shel- appears relatively free of the baggage that con-
ter life. "If I can just read the Bible for 15, 16 cepts such as "self" or "mind" or "affect" carry
hours a day," she says, "and just block out all (Kleinman and Kleinman 1991). Some rely
the rest, then I'm okay." Given the lack of on it to provide the "missing term," as E. P.
calm in the shelter, and Alice's own troubles, Thompson found, through which "structure is
the task is not an easy one. When we cross transmuted into process, and the subject re-
paths in the building and I ask how she is enters into history" (1978:170). And some
doing, she often says she is "struggling along." build theories on its turf because they find it
Her response aptly describes what life is like gets at something more immediate than "mean-
for her and many of the 50 other "homeless ing" or "discourse" (Desjarlais 1992; Jackson
mentally ill" who sleep on the basketball 1989). The word is of such value that even
court. The nature of the struggle, where scholars critical of experiential approaches fear
people live a routine existence marked by that without it, "cultural analyses seem to float
Raben Desjarlais, "Struggling Along: The Possibilities for Experience among the Homeless Mentally Ill,"
American Anthropologist 9614 (1994): 886-901. Reproduced by permission of the American Anthropological
Association from American Anthropologist 9614 (1994), pp. 886-901. Not for sale or further reproduction
STRUGGLING ALONG 161
several feet above their human ground'' Since this way of being is only one possibility
(Geertz 1986:374; Scott 1991). Experience, it among many, some people live in terms differ-
seems, is a crucial element of contemporary ent from experience. This appears to be the
academic thought; to try to write about case with Alice and many of her companions.
humans without reference to experience is like Their worlds, to be sure, are marked by inter-
trying to think the unthinkable. Yet despite its iority and a sensate reflexivity, but the subject-
apparent necessity, as something that can and ive and temporal contours of their lives are
must be thought, its universality remains in distinct from the act of experiencing as it is
question. We must ask if experience is as essen- commonly defined. If we take experience to
tial or as commonplace as many take it to be. be simply a sensate awareness of life, or "to
In anthropology the ontology of experience be alive when something happens" (which is
has taken a back seat to its epistemology. Per- the traditional meaning of erleben, a German
spectives on the study of experience generally word for experience), then the people in the
divide anthropologists into two camps. There shelter certainly do experience. But today, ex-
are those who advocate an anthropology of perience tends to mean something more, and I
experience to investigate, through phenomeno- want to understand what conditions are neces-
logical means, domains of life - pain, bodies, sary if people are to experience or, alterna-
emotions- that one can only poorly apprehend tively, to struggle along.
through cultural analysis. And there are others The etymology of experience hints at the
who find that such an anthropology is epi- changing uses of the word. Experience, like
stemologically unfounded, since one can never experiment and expert, comes from the Latin
really know the felt immediacies of another experiri, a compound verb formed from the
person or society, and irrelevant to more prefix ex- ("out") and a prehistoric base .. per-
important social and political concerns. In ("attempt, trial") that meant "to try, test" (Ayto
listening to the debates sparked by these differ- 1990). The modern English word experiment
ent orientations, one gets the sense that every- best preserves the original meaning of experi-
one knows what is meant by experience. Yet it ence, though the latter also meant at first "put-
is rarely defined and, when it is defined, it ting to the test." From this came the idea of
involves a generic "we." Indeed, the very fact having "actually observed phenomena in order
that the category "experience" goes undefined to gain knowledge of them," which in turn led
or is couched in universalist terms suggests that to the more subjective "condition of having
it is taken as a fundamental, authentic, and undergone or been affected by a particular
unchanging constant in human life. event" (Ayto 1990). The subjectivist connota-
The problem with taking experience as a tions of experience are only a recent innov-
uniquely authentic domain of life is that one ation; the idea that to experience is to feel, to
risks losing an opportunity to question the social suffer, or to undergo was first recorded in 1588
production of that domain and the practices (Barnhart 1988:357). Similar to the trajectory
that define its use. Connotations of primacy of the Western self, which initially marked an
and authenticity lend legitimacy to the anthro- exterior relationship to one's environment but
pologises crah, but they can simultaneously later came to entail a moral, reflexive agent,
limit inquiries to descriptions of the terrain of experience evolved from a verb denoting an
experience when what we need are critical re- external engagement with or testing of one's
flections on how the terrain comes about. 1 surroundings to a template marking a person's
Asking about experience can tell you about subjective awareness of that engagement. As
some things, such as how the everyday comes Levy-Bruhl, Hallowell, and others have pointed
together, just as asking about labor relations or out, however, human functioning need not
clan lineages can tell you about other things. depend on such reflective assessments but
In asking a few questions here, I want to can assume a wealth of nonintrospective forms.
suggest that experience is not an existential Experience involves only one, rather inward-
given but rather a historical possibility predi- looking arrangement of human agency among
cated on a certain way of being in the world. many. 2
162 ROBERT DESJARLAIS
The stress on interiority ties into the affirm- exhausted by conceptual determination"
ation of ordinary life that has earmarked hu- (1975:67). The import of experience is inex-
manist thought and literature and correlates haustible because experience, like a text or a
with the Romantic notion that the most au- work of art, carries a wealth of meanings that
thentic truths lie in ourselves (Taylor 1989). A can never be conclusively interpreted (Ricoeur
focus on the truths of personal revelations re- 1970).
lates closely to modern religious concerns, par- The hermeneutical depths of experience dis-
ticularly the Pietist emphasis on religious tinguish it from the subject matter of trad-
devotion, with personal experience, as a state itional cultural analysis. Human experience
of mind or feeling, forming an integral part of eludes analysis and resists symbolization. The
the inner religious life. The inner states culti- idea of an excessive, hermeneutically rich plane
vated through such devotion reveal truths of being entails the view that the only way to
worth talking about. Raymond Williams notes, safely study experience is to attend to the per-
for instance, that in 19th-century Methodism imeter of expressions, stories, and social for-
there were experience-meetings: classes "held mations in which it is cloaked. 4 To say that
for the recital of religious experiences" thick description is the best method of analysis
(1983:128). Today, as well, experience is largely here is not to denigrate the available methods
rooted in individual agency. A person "has," but simply to point out the kinds of phenomena
"learns from," or "discloses" an experience. in question: experience is too complex, too
Privacy, individuality, and reflexive interiority subtle, and too private to be understood through
are intrinsic to experience; no one else can ex- anything but phenomenological assessments.
perience my toothache, though they might em- Even then, "it's all a matter of scratching sur-
pathize with my suffering. Experience thus faces," as Clifford Geertz puts it (1986:373).
readily equates with a person's inner life or Talk of surfaces and cores suggests a shadow
consciousness and is often synonymous with play of interiors and exteriors: we cannot pene-
subjectivity. 3 trate the containers of experience. The body is
The notion of interiority encourages some often held to be one such container, with the
to try to understand the essence of experience skin serving as an envelope within which,
(Desjarlais 1992) and leads others to suggest Faulkner writes, "the sum of experience" resides
that "experience is sensual and affective to the (1986:54).
core and exceeds objectification in symbolic The sum coheres. Despite the immediacy,
forms" (Good 1994:139). The excessiveness richness, and contingency that characterize
of experience points to a second distinguishing lived experience, experience works on a princi-
feature: experience possesses hermeneutical pal of unity. Dewey (1926) talks about the
depth. The sense of depth, like that of interior- "inclusive integrity" of experience, while
ity, ties into the Western genealogy of the self. Oakshott (1985) ponders its "concrete total-
While the writings of Augustine, Descartes, ity." James, Dilthey, Husserl, Merleau-Ponty,
and Montaigne brought successively stronger and others agree that the sum of experience is
declarations of human inwardness, only with greater than its parts. Joyce's Leopold Bloom,
the expressivist yearnings of Wordsworth, Freud's Wolfman, and Prousfs remembrances
Holderlin, and others to discover and articu- exemplify the integrity of experience; memor-
late our inner nature does this interiority come ies, dreams, and sensations snowball into a
to possess significant depth. In modernist times unified, epiphanic whole. The appeal to whole-
the grounds of experience, rather than those of ness apparently relates, for many, to a modern-
the self, have possessed the richest depths be- ist desire to develop a concept that might safely
cause experience is often seen as the foundation absorb the many select features of human
of human agency (Taylor 1989:465}. As Gada- agency, such as thought, feeling, and sensation. 5
mer describes the philosophy of Dilthey and Experience builds to something more than a
Husser!, "essential to an experience [erlebnis] transient, episodic succession of events. The
is . . . something unforgettable and irreplace- in transience of experience ties into the fact that
able, something whose meaning cannot be it effects a lasting and memorable impression
STRUGGLING ALONG 163
on the person who undergoes it. Heidegger conditions that make the process possible.
suggests that "to undergo an experience with Thinkers such as Taylor and Foucault, who em-
something - be it a thing, a person, or a god - phasize the priority of language in shaping our
means that this something befalls us, strikes us, lives, tend to speak of incarnations of self or
comes over us, overwhelms and transforms us" power as generic to an age. Yet these kinds of
(1971:57). Experience is fundamentally trans- theories seldom consider the plurality of social,
formative; an experience "does not leave him sensorial, and technological forces that occasion
who has it unchanged," or so says Gadamer in diverse ways of being within a society. I find
his specification of a "genuine experience" cultural discourses as well as day-to-day contin-
(erfahrung) (1975:100). To have an experience, gencies to be evident in the shelter where Alice
or to learn by experience, suggests an educa- stays. Experience there is a possibility, not a
tion that can accrue in certain skills, know- given, and certain conditions are necessary if
ledge, or wisdom, though the education people are to experience.
hinges on a flux of subjective reflections that
other kinds of learning, such as operant condi-
tioning, do not. The Shelter
To experience, writes Heidegger, "is to go
along a way. The way leads through a land- The shelter was set up in the early 1980s by the
scape (1971:67). "6 The landscape is organized Massachusetts Department of Mental Health
through temporal and spatial lines. Experience, to provide temporary housing for persons
by definition, collects itself through the rhyth- troubled by mental illness. To gain a bed, one
mic pacings of time. As Carr puts it, "Our must be both homeless and mentally ill, which
experience is directed towards, and itself as- means owning a diagnosis of "schizophrenia,"
sumes, temporally extended forms in which "bipolar disorder/' or the like. An individual
future, present, and past mutually determine arrives from a local hospital, another shelter, or
one another as parts of a whole" (1986:30-1). the streets to sleep on one of 52 cots set up in
Narrative typically helps to form the sense of the gym of a mental health center that occupies
temporal integration. The idea that experience one third of a vast government center. A staff
accumulates in time through stories builds desk guards the entrance to the shelter, which
chiefly upon the relation between forms of life abuts a lobby where many residents spend
and narrative orderings of time. From Aristotle much of their time talking, sitting, and pacing.
to Heidegger to Ricoeur, the interpenetration Within the shelter, standing partitions separate
of narrative and experience has grown stronger the men's and women's sleeping areas. Some
in correlation with the predominance of litera- stay in the shelter for a few weeks, while a
ture in the lives of the educated. The present handful have been there over five years. They
state of the art is that we can only grasp our typically leave when they return to the hos-
lives through narrative, though few question to pital, find a more permanent place to live, hit
what degree this inescapable fact applies out- the street, or get kicked out due to infractions
side the modern West. 7 of the shelter's rules concerning drugs or theft.
Experience as a whole is subject to similar I frequented the shelter at a time when there
queries. In much the same way as the truth was great interest - among psychiatrists,
of sexuality grew out of an economy of dis- policy-oriented academics, and the general
courses that took hold in 17th-century Europe population - in the improvement of services
(Foucault 1978), so a set of phrasings of depth, for the chronic and persistent mentally ill, des-
interiority, and authenticity; sensibilities of pite severe cuts in health services for the poor
holism and transcendence; and practices of read- and a general push for privatization. 8 Program
ing and writing have crafted a mode of being cuts affected the shelter in two ways: residents
that many in the West would call experience. In lost case managers and treatment programs,
taking experience to have a specific meaning and and staff worried about losing their jobs.
to possess a limited reality, the task is to identify The staff maintain that the shelter is per-
where and when people experience and the ceived as the Rolls Royce of shelters. While
164 ROBERT DESJARLAIS
their guests do not hold the same level of en- group of residents, "Take Freddy, for instance.
thusiasm, many do find it to be one of the He has choices. If he wants to stay here instead
better shelters in the Boston area. Part of its of in-patient [a locked psychiatric ward on the
appeal lies in the safety it provides. The strat- fifth floor], then when he's feeling nervous and
egy of the staff, however, is to maintain the anxious, he can either come up to us and ask
impermanence of the shelter and make it clear, for more medication, or he can try to throw a
at meetings and in conversations, that it is "not door through a window." Freddy nodded his
a home. " 9 For the most part, they are success- head and smiled in accommodating agreement.
ful in getting their point across by balancing To understand why people stay in the shel-
safety with a modicum of comfort and a set of ter for months or for years, one needs to know
rules. Disciplines include throwing a person something about "the street," which is where
outside the shelter for an hour (typically for many come from and where they go if they
acting up, swearing, or talking too loud for leave without locating an apartment. The shel-
too long} or sending them out for the night ter residents talk about the street as if it were a
(for more egregious acts}. single location with a singularly forced sensor-
The staff's proclivity to displace people ium of cold weather, fear, anonymity, transi-
contributes to a distinct political system. In ence, and a constant, unsettling tendency to get
contrast to Foucault's model of "disciplinary" on one's nerves. Roy, who used to panhandle in
power in the age of reason, which centered on front of Dunkin Donuts and who kept mostly
acts of confinement and panoptic visibility, to himself for safety reasons, said, "If you're on
power in the shelter typically involves acts of the street, you get beat up, cheated, robbed,
displacement and obscurity. 10 And whereas the disrespected. You end up sleeping in subways
staff, who maintain a proper and durable with people stealing money from your pockets,
place, rely on strategies that enable them to and eating at McDonald's, Burger King, or
keep to themselves in a position of withdrawal, even out of trash cans if you're desperate."
foresight, and self-collection, the residents lack Fred was sleeping in a warehouse before he
such a place and so have few grounds - spatial, came to the shelter. "I had all my utensils there,
political, economic - on which to stand. 11 To a shelf, a bed, but it was getting cold." When
get something done or to effect something in the warehouse burned down, he slept in one of
their own interests, they resort to tactical the trains behind North Station. julie, who
actions that depend less on appropriation of lived on the streets for several weeks before I
space and concerted technology of knowledge met her, says the isolation snuffs out a person's
than on diverse opportunities in time, rhet- will to talk and be with others. "People in the
orical phrasings, and other isolated actions. street don't talk to anyone." She wore a Red
The strategic orientation of the staff in- Sox T-shirt, twisted a piece of paper, and
cludes a range of rules and protocols that set paused after each sentence. "A part of you dies
the tempo of everyday life. A resident must on the street. Your spirit dies. You lose the
shower every other day, leave the shelter from wanting to live inside, the wanting to talk with
9:30 in the morning to 3:30 in the afternoon, someone. That part dies too. Once you're out-
perform a rotating set of chores, dine at 5:00, side, you can't come back inside. The street is
take medications in the evening, and return to tough. Homeless people are dying out on the
the shelter by 9:00 at night. Staff maintain that streets. You lose everything but a sense of
"the rules are there to provide structure to your survival."
lives," as a nurse told several residents one The street tends to reduce people to a few
evening. Residents find the multiplicity of re- material possessions, a couple of friends, and
strictions, as well as the way in which they are the redundancy of walking, hiding, eating,
asserted, unpleasant and infantilizing. Fred, for bumming for cigarettes or change, and sleeping
instance, says that the shelter is "not a home. on benches, in the subways, in the woods, or in
There are too many rules and regulations.'' The shelters. For many, the fears and discontinuities
management's philosophy is that it's a question of the streets are amplified, on both the math-
of choices. As one staff member put it to a ematical and sensory scales of the word, by
STRUGGLING ALONG 165
concerns commonly associated with mental ill- But when you're sick, ifs hard to start off fresh
ness, such as hearing voices, anxiety, or fear of each day."
harm. Bruce hears voices, "Young women tell- Given these concerns, many people come to
ing me they're easy to sleep with. That scares stay in the shelter because there are simply "less
me, it scares me." Julie fears that people are worries" there, as one man put it. "I feel safe as
planning to kill her on the street. One day she long as I'm in the building," Joey once said
and her daughter escaped from two men in the when I asked how he was doing. Louise, who
subway. She fears the voices would get worse if is "desperate to find an answer to the ram-
she lived on the streets. "Right at this bling" of her mind, is looking for a place "to
moment," Martin said one day, "I have this recover from the shock of the elements out-
impending sense of doom - that something side." She says she will stay in the shelter until
terrible is going to happen in a few minutes, she feels it is safe for her to move out. Some
like this ceiling could fall in on us." stay for years for similar reasons.
"When you're homeless," Richie says, "you Within the shelter, much of everyday life
end up with just your body, cause you don't orbits around efforts to keep shocks to a min-
own anything else." With the loss of many imum and to hold oneself together. "Hypersen-
possessions, and the public slant to physical sory residualness wants to be within equatorial
movements and functions, the body becomes, lines,'' goes the last line of one of Charles's
at times, the most prominent instrument of poems. For many, there is a common and prag-
engagement, awareness, and retrospection. matic need to keep the senses within equatorial
"Look what I did to my arm," Fred says of a lines - to seek comfort and safety in the rou-
track of scars up his forearm. Some scars are tines of shelter life, and so spend one's days in a
fresher than others. "I did it to prove that I'm way that skirts the fears, worries, and afflic-
sick, the government's sick, the state is sick, tions that impinge. Some try to stay calm by
and you're sick." Nadia, an aging Polish holding onto a thought, a word, a gesture, or a
woman who speaks of concentration camps, cigarette. Jimmy says he used to pick up a
says she is losing her voice because of a thyroid newspaper and hold onto a word and that
problem. One day she lies on the grass with a would calm him down. Chuck works on
necklace, an ankle bracelet, and a wrist brace- puzzles for the same reason.
let made out of interlocking safety pins. "I By 3:00 in the afternoon, five to ten tired
thought I would adorn my tortured body," she people are waiting for the shelter doors to
tells me. open. When they do, many lie in their cots for
Distinct as the residents' concerns are, they an hour or so. One of the chief complaints of
suggest that everyday life is marked by a frail shelter life is that it is hard to find time and
sensitivity toward the noises, activities, and space to oneself. "I suppose you can't ask for
potential violence of the streets. The states of much," says Julie. "It's a place for people with
feeling common to those who are homeless problems. And it's a place where everybody's
result less from inherent dispositions than from together. You have to be together." But being
the constant and tiresome afflictions of the together has its problems: each resident must
street. A basic orientation, the product of cold sleep with 20 other same-sex fellows on the
nights and fearful sounds, pivots on the sensory same half of the basketball court; no partitions
range between nervousness and staying calm. separate the beds from one another. During the
People talk of being emotionally tired when day, they share six tables, four armchairs, one
they arrive in the building and refer to an in- couch, a TV room, the lobby, and the far
ability to deal with distractions. "We're sensi- reaches of the building. Most confrontations
tive," Joan says at a group meeting one day. within the shelter involve disputes over these
"We can't deal with things. That's why we're limited resources. One day Matthew, a middle-
here. We're not like the people outside." She aged man from Mississippi, sat down at a table
says she needs to be familiar with an area where Barbara was seated. "l want to be
before she is comfortable. "It's the adjustment alone," she said. "Alone?" he asked. "How
that's the problem. It's okay when you're well. can you be alone here? Everybody's together.
166 ROBERT DESJARLAIS
You could be off somewhere by yourself." A For Joseph, pacing up and down is the way
minute later, Matthew walked off. to change his luck. His advice for a newcomer
On the basketball court, much of the ten- is, "Live one day at a time, don't get ahead of
sion builds on distracting sights and sounds - yourself, and don't get too worried." Worries
the hypersensory residuals of which Charles for him are the main problem in the shelter;
spoke. "There are 50 tensions here," Sally tells they throw off the equilibrium, the balance. "If
me, one for each person living in the shelter. you have to get copies for something, or
"It's hard to get a decent sleep here," she added. records at the hospital, it can get compressed
"Someone is always singing a song." Matthew in here, because of the close quarters and tight
likes to sit in the plaza on the third floor. spaces." He gets to feeling tight inside, con-
"There's too much going on downstairs," he stricted, and pacing helps because it uses up
says. "There's two televisions on, radios. I can't energy, "so much energy from the medication."
see how you can watch TV with all that going Psychotropic drugs are a clear presence in
on." A similar distraction nags Jimmy. "The the sensory range of everyday life. Almost
building," he says, "keeps you out of your everyone who sleeps in the shelter takes medi-
own little world. It's kind of distracting." cations prescribed by a psychiatrist and given
"What do you do when the building dis- by a nurse. Those who refuse risk a trip to a
tracts you?" I asked. hospital. The medications help with the voices
"Play dead." and lower anxiety, but they can also cause the
People pace, play dead, or hold onto a word body to stiffen or to shake. There is no "gray
or the Bible to get through the day. The staff line" with Ralph's medications. Not enough
think the routine is self-defeating, but for many and he gets to hearing voices; too much and
who live in the building, it is a question of he walks around stiffly in a stupor. "I got coffee
survival. "It's all right; it's better than nothing," coming, I got coffee coming. I just took my
Joey said of a new coat bought at a discount medication - to smooth out the joints," Joey
market. "I'm trying to hang in there, you know. tells me. Leona takes her medication to make
Hanging in is good. I'm all right as long as I'm the chemicals connect with one another "like
busy. My father says an idle mind is an ill mind." fingers tied together."
For most, hanging in there is good enough. Shelter life, despite its many distractions,
People stay busy by talking, smoking cigar- can be too mundane; it is difficult, at times, to
ettes, and pacing. The goal of many of these keep from playing dead. Martin says he walks
activities is to be doing something. Time con- around too much because he has nothing to do
sists of concrete activities marked by expanses with his time. One day he shows me a poem he
of silence and waiting. "I smoke cigarettes, wrote called "Sheol," the word for the Hebrew
drink coffee, listen to music, talk with people, netherworld. The poem tells of the Los Angeles
you know," Roy says of his daily routine, with street scene, where "people are hanging out,
the phrase "you know" referring to activities with no thoughts, no feelings." Others refer to
taken for granted. I ask Patty what she did similar affinities between mood and setting.
today. "Oh, you know, the usual boring stuff, "Sometimes I go to my bed area," Leona says,
smoking and eating and talking. In and out, in "and it seems so kinda gloomy, dark. It looks
and out, and I paced a bit today." Pacing helps moldy, though it isn't really moldy, you
people to keep busy and calm their nerves. knowt' Vicki finds that the shelter is like death
Warren finds that "there's too much pressure row and says you sometimes see the same faces
sometimes" from staying in the building and in different shelters. "I lost my mind," Lisa said
spends much of his time walking around the in introducing herself one day. "What does that
city. One of Joseph's poems, jotted in a note- feel like?" I asked. "I don't feel, I don't feel. I
book, consists of four lines: feel numb." Richie says he acts crazy to stop
Pacing the floor from being bored. He gets the "shelter blues"
pacing my mind when he feels depressed and worthless and tries
walking the floor to make himself and others feel more alive by
walking my thoughts touching and talking to them.
STRUGGLING ALONG 167
The mundane distractions of shelter life, Words are therefore some of the key com-
and the occasional deadening of feeling, turn modities; they can be bought, sold, shared, or
on caffeine, footsteps, touches, and the con- stolen by peddlers, psychiatrists, or ethnog-
stant exchanges between bodies and voices. raphers alike. Words spoken often relate to
With these exchanges, abrupt interactions the exchange of money, and talking to someone
grow tiresome. Matthew was talking one day, can entail an ongoing social and financial
partly to me, partly to himself: "Moses was a contract.
wise man ... " Nancy walked up and inter- Bruce walks up to Larry one afternoon and
rupted: "Matthew, can I have a cigarette?" He says, "Larry, can you talk to me today?"
replied, "I don't want to hear that, Nancy. "Yeah, can I give you 12 [dollars]?"
We're doing the same old song and dance." "That's great, that will make the week
Much of everyday life repeats the same old easier."
song and dance: the bumming, selling, and Later, Bruce tells Larry not to be too stern in
sharing of food, cigarettes, and Walkman lending out money. You have to "work in inter-
radios. The staff give out paper tokens to guests national waters," give "some room in be-
if they take showers, make their beds, or water tween," and tend to "the give and take." The
the plants. People use the tokens to pay for advice captures well the ethics of a place where
snacks, soda, or soap in the evening; they also money can be tight and debts are not soon
use them to buy cigarettes from each other. forgotten.
People walk over to a convenience store to buy One reason for the brevity of conversations
coffee, cigarettes, or food for others; their cut in the shelter is that residents find it difficult to
is 55 cents or so, or a share of the bounty. follow through on them. As Julie asked me,
The going interest on a loan is 100 percent; if "Would you want to have a conversation with
Sally loans Chuck five dollars today, he should someone who is talking to themselves, who is
pay her ten by next week. Cigarettes can be caught up with their own conversation?"
exchanged for conversation, radios for friend- While some hear and respond to voices, others
ship- and sex, at times, for money. "If you have "talk ragtime," which, Peter explains, is talk
the money," Martin said, "you can get anything "about the sky falling down or cows on the
you want on the street.n Last spring, he bought roof. It doesn't make any sense. How can you
valium for a dollar a pill and was trying to get a listen to that?" "It's awkward," Joseph said.
constant supply set up in the building. Drugs, "People seem rational when they first sit down
cash, food, and bodies flow in and out of the with you, but then, the next thing you know,
building in a vast common market. they're bouncing off the walls." As it is, con-
Language is an integral part of this political versations frequently involve two planes of dis-
economy. A few kind words can set someone course, with the distinction leading either to
up for a free cigarette or a cigarette can be arguments, miscomprehensions, or a complex
offered in exchange for conversation. The ambiguity of meaning.
street value of words was brought home to Helen, who sometimes uses a cane, walks
me one October evening when I was talking, slowly through the lobby.
in Harvard Square, with someone who fre- "Where's your cane?" Philippe asks.
quents the government center. He was selling "You shut your mouth!" she says to him,
flowers, which he found in a trash bin behind a and then to me, "He's talking dirty."
florist's shop, for 25 cents each. He said he Edward was telling Sally and me about the
could offer people bits of his poetry or transla- nonfiction novel he intends to write "about
tions of Chinese characters he wrote on a piece making it in the city, today, not yesterday, you
of cardboard, but they might steal his words. know what I mean?" Leona walked by, held a
"How do I know,'' he asked, "that if I put my cross at him for several seconds, and flicked
words on this cardboard, or put them into the her head. "I thought you was a demon," she
air, you or someone else won't take my words said, "I thought you was a demon! We don't
and sell them somewhere else? No, you gotta understand one another. We don't understand
be more careful than that these days." one another!" And then more to me than to
168 ROBERT DESJARLAIS
Edward, "We live in the same place, but we lottery tickets, and negotiations on those ex-
don't know one another. And that's how most changes. In August, Larry moved into a halfway
arguments get started around here!" house while Bruce stayed on in the shelter. Two
The risk of conflict caused by "loose tongue days after Larry left, Bruce sat down with me
fits" (as one woman put it) and the struggle for and a staff member who asked what he thought
many "to hang in there" leads to the general a bout Larry's departure.
consensus that the shelter is "not a place to "I think a lot about him leaving," Bruce
make friends," as Julie puts it. "Everyone here said. "He bummed a lot of cigarettes from
has problems. Each goes their own individual me, you know."
way. So I have no real friends here." While "Oh yeah, you also seemed to get a lot in
many lament the lack of friends in the shelter, return."
many also find comfort in the detached but "Yeah, we treated each other right. I don't
constant companionship that characterizes know, he kind of let it go the last week. I lent
shelter life. "I like it here," said Sally. "It's good him some money the last week, ten dollars one
here because I don't feel lonely. There's always day and some cigarettes the next, but I guess he
people to talk to here. In an apartment by thought I was setting him up."
myself, I was going crazy, losing my mind." "Maybe, you know, he was trying to get
Another man, who lives alone in a single-room some distance from this place."
apartment and can be found riding the subway "Yeah. Maybe so."
during the day, hangs out in the building at As with Bruce and Larry, many ties between
nights for reasons similar to Sally's. "I come shelter residents rest on an ethos of exchange.
here to see Warren and socialize," he told me. The most significant consequence of this eco-
"He does his thing and I do mine." His thing is nomics has to do with typical activities in and
to stand in the stairwell, talk under his breath, around the building, which often center on acts
and watch Warren pace the lobby. Like others, of collecting. People bum for cigarettes, pan-
he likes to be around people but cannot hold handle for money, and scavenge back alleys for
onto a conversation for too long. 12 The build- clothes, food, and empty soda cans. Patty is
ing provides an arrangement where he can keep known to wear up to five hats, even in the
to himself in the company of others. Others summer. Emily walks by a table, spies the
also tend to share a word here and there but Boston Globe, looks at an ad for a department
largely go their own ways. Except for a few store, reads it, tears it off the page, and carries
close ties and love interests, lives are kept sep- the clipping to her locker.
arate. Anonymity is more the rule than the The tendencies to collect or to hoard relate,
exception. as do many aspects of shelter life, to the eco-
Since social ties are so difficult to maintain, nomics of homelessness. Joan, for instance, lost
acquaintances are often made out of economic her apartment, her library, and her record col-
exchanges -loans, payments, negotiations. With lection when she fell ill. "It's all gone now."
these exchanges, companionship, like words, Without a home to keep things, possessions
can be for sale. Gary walks over and sits down soon fill bags and lockers. "It's not right to take
with Janie. "Do you have an extra cigarette?" all the things we have," Leona said on hearing
"Only if you sit with me." that the staff were going to limit the articles
"Okay." guests could keep in their bed areas. "We don't
Janie slides out a cigarette and hands it to have enough money for a place. That's why we
Gary, saying, "You better remember me when I have all our things here, and we can't even keep
need a cigarette." our own things or our own children." Collecting
"I will." also arises from marginal shares of Boston's
They smoke in silence. makeshift economies (Hopper et al. 1986).
The economic bases of friendship are evident Spending money can be gained by collecting
in the exchanges between Bruce and Larry. The bottles or selling the few quality items found in
main interactions between these two involve the trash. A lack of money leads a few to pick
a constant exchange of money, cigarettes, and through dumpsters in search of food, blankets,
STRUGGLING ALONG 169
or clothing. And food or drink that cannot be Like Phil, many residents learn to use their
immediately consumed tends to be given away memories in ways distinct from most nonho-
or hidden until it can be eaten in privacy. meless people. Much of the education relates to
The principles of accumulation do not end the pragmatics of time that comes with living in
with economics. At a basic level, shelter lives shelters. The episodic quality of shelter life,
tend to consist of the repetitive collection of the where you need to live one day at a time and
elements of those lives. Memories, for instance, not get ahead of yourself and where nobody
often involve such a collection. Gathered like does anything, fixes time as a diffuse and spor-
so much spare change, they are characteristic- adic order. There are eddies when the mundane
ally dreamy and drifting. "One night I was occurs, and whirlpools when someone is re-
scared of something," Peter says of his nights strained or hospitalized, but much of the day,
on the street. "I pulled an alarm because I was week, and month consists of a vast ocean of
scared, and the fire engines came. I told them I routine, more so than in the street. 13 Chuck
was scared and alone and I thought that if I says he drinks coffee to keep up with it, but
pulled this alarm, they would be able to make for the most pan, it is only a routine: out by
me feel good. They threw me in jail for that." 9:00, lunch at noon, back by 3:00, dinner at
Patty recalls, with a similar opacity, an apart- 5:00, snacks at 7:00, checks in on the first of
ment she fixed up in the North End before she the month. Because of this event-dependent
got sick. "Oh, it was beautiful," she says. organization of time, people recall specific dates
"There were chairs there, and a table, and a and events, and everyone talks about the time
tablecloth. I had all my things there. But people Walter punched a nurse, but there is little reason
were trying to break in, they were trying to kill to notice the potential links between events and
me." With Patty and Peter, each image shines the motivations for actions. The poetics of time
like a new coin- this alarm, that tablecloth- are more like those found in Beckett than in
but the memory as a whole lacks a dominating Proust; recollections depend on momentary oc-
narrative fabric. Many other memories have a cupations more than any defdy woven remem-
similarly strong eidetic quality. People remem- brances of times past. When the occupations
ber dates, names, and specific acts and dia- change, the memories take new forms. "You
logues as if reciting a court docket: "On have a child?!" Joan asked a woman she was
December 5, 1987, I broke into a real estate talking to. "Yeah? Excuse me, I forgot. I've been
office," Phil says one day. But experiential or moving back and forth between hospitals,
motivational underpinnings often do not play a moving back and forth between the hospital
role: "I don't know why I did this," he adds. and this place, and I forgot."
"Maybe cause I wanted money, I can't remem- As with Julie, who found that the lack of
ber." And then, as if an afterthought: "See, structure in the shelter led her to forget how
that's why I wonder about these drugs." boring it actually was, a constant migration
The inability to clearly remember an inci- leads Joan to forget something she once knew,
dent or why it occurred relates to several as if a person needs a solid footing to remem-
factors: the wear and tear of pharmaceuticals, ber. The structure of memory relates to the
the affective and cognitive disturbances of structure of time. In the shelter, the routines
mental illness, the tactical focus on single en- of the clock, the realities of power, the influ-
counters, and, most important, a training dis- ence of pharmaceuticals, the constant ex-
tinct from the more mainstream arts of changes, and the relative lack of privacy and
memory. I once asked Phil where he slept the structure create a sensitivity toward singular
night before he returned to the shelter after a moments and exchanges and desires. We
hospital stay. "I forgot." How could he forget? cannot speak of a strong narrative line here,
"I can't use my memory all the time," he said. for while people tell stories and events tumble
"You see, I never learned how to use my along, the episodes rarely add to a narrative
memory like most people do. I have to think wholly dependent on a poetics of coherence,
about something at least three times before I continuity, and climax- as narrative is usually
can remember it." defined. 14
170 ROBERT DESJARLAIS
Barbara and Walter are sitting on the Too much calm can get to a person after a
benches in the lobby outside the shelter. She while. An idle mind, after all, is an ill mind, and
asks him to go to the store to buy her some pacing and other activities help to lessen the
cigarettes and a soda. He returns to the lobby, worries that come with living in the shelter.
hands her a can of Pepsi, a pack of cigarettes, The trick is to keep the senses within the equa-
and some coins, and sits down on the far bench torial lines, to find the grey line between sens-
with a soda of his own. ory vitality (which can include hearing voices)
"Where's the rest of my change?'' she asks. and walking around in a stupor. A desire for
"What's a few pennies?" balance is evident in other aspects of shelter
"A few pennies are a few pennies, that's life, including the benefits of bargaining with
what they are, especially when they're mine." one's colleagues and the perceived need to keep
The two sit and drink their sodas. There is a certain distance from others. In the realm of
no catharsis to the dispute. They are both economics, relations, and the senses alike, the
angry, but everything seems to diffuse abruptly. residents of the shelter tend to work toward
The conversation entails a transfer of words points of equilibrium, which often come down
that involves less a narrative frame (as I would to a sense of stasis. The stasis, which makes a
have anticipated) than a poetics of exchange, good deal of sense given how much is imper-
confrontation, finite acts, and momentary manent and transient in their lives, tends to
occupations. grow more fundamental the longer people stay
in the shelter.
How does all this compare to the act of
Conclusions experiencing? Although experience and strug-
gling along are not mutually exclusive categor-
All told, the themes common to many shelter ies, in which the elements of one would imply
lives are a political agency built out of tactical the absence or negation of corresponding elem-
movements, an acutely tactile engagement with ents in the other, the two processes do involve
the world, a constant focus on daily concerns, a distinct aesthetic, temporal, and phenomenal
distanced style of communication, a poetics of features. Experience entails an aesthetics of
pacing and talking centering on unconnected integration, coherence, renewal, and tran-
episodes, a makeshift economy of cigarettes scendent meaning - of tying things together
and loans and conversations, and a ragtag col- through time. A good day for someone who
lection of words, memories, images, and pos- experiences might be one in which there is a
sessions. These basic orientations, in tandem novel integration of personal undertakings, a
with other cultural, linguistic, and political tale to be told about events bordering on the
forces, pattern the conditions of, and the adventuresome. The features of such a day
grounds for, what is possible in people's lives. build on the stuff of novelty, transformation,
They set up a form of life that we might gloss as emplotment, and movement. A good day for
struggling along. someone who struggles along, in contrast,
The aesthetics of this form of life center on might be a smooth one, where nothing much
the pragmatics of stasis, expediency, staying happens, where a few bucks are earned, where
calm, and holding oneself together. Given the the voices are not too bad, where pressure is
basic conditions of life on the streets, finding a relieved through pacing, and where there are
smooth day where nothing much happens has enough cigarettes to last the day. The ingredi-
its value. Since one way to stop thinking about ents of such a day draw from the forces of
the cold or other distractions is to step out of expediency, equilibrium, and stasis.
the flow of time, the acme of this predilection Sitting in the same place for several hours
is the pursuit of timelessness. For many, there is each day has its consequences. The temporal
a need for days where hanging in there is good order of experience, involving as it does a cu-
enough. To get away from the constant ten- mulative layering of events that builds to a
sions and the fleeting distractions, some sus- whole greater than its parts, proceeds along
pend the minutes of a day. narrative lines of an Aristotelian bent. The gist
STRUGGLING ALONG 171
of experience is that it goes beyond the situ- orientation toward time, with each incidence
ation at hand. The temporal order of struggling taking precedence over any larger temporal
along, in contrast, involves a succession of en- context, as well as to the need, at times, to stop
gagements, which can include a constant but the rush of events and find some point of equi-
purely episodic unfolding of events. In the shel- librium or stasis. Much of the difference rests
ter, economic concerns, the press of everyday on the kind of environment in which a person
distractions, and a tactical mode of agency lives: a condition of permanence, detachment,
directs the struggles toward temporally finite and security gives rise to a process that entails,
forms in which future, present, and past need among other things, a sense of transcendence,
not have much to do with one another. of going out into the world and being trans-
The phenomenal plane of experience is a formed through those movements. A state of
thoroughly reflexive one; to experience is to unsettledness, unrest, and constant engage-
engage in a process of perception, agency, and ment, in turn, necessitates the act of holding
reflection that is couched in mindful introspec- onto a word or a Bible to get through the day.
tion. Struggling along also entails a firm sense of Each of these ways of being are context-
interiority and reflexivity, but the reflections are dependent, with the contexts themselves
not as incense as they are with experience. The framed by a mix of political and economic
distracting sights and sounds of the building, forces. In the shelter, struggling along relates
which draw or drag a person in different direc- directly to a politics of displacement, to a
tions, prompt an acutely tactile mode of percep- world of acutely public spaces, and to an eco-
tion with little room or need to introspect or to nomics of exchanges and ragtag collectibles.
contemplate. Day in, day out, things happen Living in the shelter for any length of time
much more with the retina, on the skin of the prompts a way of being that enables most
eardrums, and in the tips of the fingers than in people to attend to these concerns.
any detached haven of mind or body. Experience When the context changes, so do the fea-
implies a contained, integrative, and occasion- tures of one's life. Henry, for instance, spends a
ally transcendent adaptation of sensations, lot of time away from the building. Son of a
images, and lessons; struggling along entails a New Orleans doctor, he prefers smart clothing
diffuse and external rain of distractions that and "proper" people and long walks through
prompts a retreat from the world rather than Boston. "Tension builds if you stay in one place
an incorporation or an assimilation of its parts. all day," he says, "whether you're mentally ill
What occasions the differences? While the or not." He typically walks about five miles
disabling troubles of mental illness surely play each day, drifting from the park to Newbury
a role here, it is a set of specific political, social, Street to the Fenway, and returns around 5:00
cultural, and environmental forces, rather than p.m. to speak of his adventures. "I kissed a
any inherent will or disposition, that leads woman on the lips today," he said one evening.
people to either experience or struggle along. 15 "She was sitting on a bench, and she was
Both processes are patterned by long-standing crying, and so I kissed her. Now she wants to
cultural orientations, strengthened through a know where I live.,, As Heidegger might put it,
lifetime's interactions, such as a sense of per- the kiss befalls Henry, strikes him, overwhelms
sonhood as something unique, interior, and and transforms him. He goes along a way. The
well contained. Yet different formations of way leads through a landscape. The journey
time, space, and agency are also at work. through this landscape, with its own land-
Whereas experience derives from environ- marks, education, and suspenses, is what we
ments that offer a lasting sense of privacy, in call "experience." Like Henry, a few other resi-
which a person can dwell within his or her own dents, principally those who are new to the
world for some length of time, acts of strug- streets and spend a lot of time away from
gling along are borne of extensively public the building, also carry on in continued refer-
spaces, with agency taking shape through con- ence to a constellation of inwardness, hermen-
stant concerns with one's surroundings. Those eutical depth, renewal, and narrative orderings
concerns can contribute to an episodic of time. A quite different constellation of
172 ROBERT DESJARLAIS
moving, sensing, and remembering takes form, tend to question the legitimacy of the research
however, among the majority of those who more than the universality and relevance
spend most of their time in the building, of the concept. Finding that experience de-
making do with day-to-day contingencies. notes a subjective realm that can be only
The presence of two distinct ways of being, poorly comprehended, they uphold the view
with their own defining features, conditions, and that experience is interior, private, and ubi-
constraints, suggests that anthropologists need to quitous.
rethink their approaches toward the everyday. 4 See Bruner 1986, DelVecchio Good et al.
The ordinary-language notion of experience as 1992:199, 200, and Jackson 1989.
5 See Williams 1983:127-28, where he notes
the phenomenal, palpable charge of life will prob-
that the concept of "culture" holds a similar
ably thrive in anthropology as long as the meta-
attraction.
physic motivating it has its uses- as long, that is,
6 Heidegger is drawing on the fact that erfah-
as practice opposes theory and the sensate parries rung comes from the Old High German in-
meaning. But for those who figure out what the faran, to travel, traverse, pass through, to
process of experience might imply, a revaluation reach or arrive at (see Needham 1972:171).
of methods and motives is called for. Rather than 7 Becker 1979, Good 1994, and Rosaldo 1986
take experience as an authentic, intensely human, offer three studies that systematically inquire
existential given, we need to bracket the category. into the forms of, and conditions for, narra-
We need to consider how the word serves certain tivity in, respectively, Javanese, Turkish, and
rhetorical needs that help carve out a way of Ilongot societies.
looking at the world. And we need to consider 8 Much of my research involved participant ob-
how the process itself relates to specific social, servation in the daily life of the shelter and its
cultural, political, and material forces. surroundings several afternoons and evenings
For the residents of the shelter, a politics of each week. Because I could not and did not
displacement, an episodic sequence of events, want to use a tape recorder, and structured
and a world of constant public transactions interviews made both residents and staff un-
contribute to a certain tack in life. Indeed, comfortable, I spent much of my time hanging
some of the most fundamental constellations about, listening to and entering into conversa-
of time, space, and agency behind this and tions and then immediately finding a place to
other struggles appear to be changing in the write down the content of these exchanges. See
Aviram 1990, Dennis et al. 1991, Goldfinger
late-20th century. In the modern industrial
1990, and the special issue on homelessness in
era, experience might have seemed an essential
the New England Journal of Public Policy
part of human nature for some people because
(1992, Vol. 8, no. 1) for recent assessments
its defining features- reflexive depth, temporal of homelessness among persons considered
integration, and a cumulative transcendence - to be mentally ill.
blended so well with the reigning aesthetics of 9 Consequently, my research interested the
that age. But the poverty, transience, and con- shelter manager in part because he wanted
tingency that increasingly characterize life on to learn if there was any way he could make
the fringes of postindustrial societies suggests shelter life less accommodating to his guests.
that experience might become, at least in some 10 See Desjarlais n.d.l and Foucault 1977.
circles, a relic of the past. 11 The words in quotes and the idea of "strat-
egies" and "tactics" come from de Certeau
NOTES 1984; see Desjarlais n.d.2.
12 The common desire to be alone in the com-
1 See Scott 1991 and Williams 1979:164-70. pany of others compares to Carin's (1990)
2 See Crapanzano 1977, Hallowell 1955, finding that many people with schizophrenia
Kleinman and Kleinman 1991, Leenhardt seek out a stance of "positive withdrawal"
1979, Levy-Bruhl1938, and Lienhardt 1961. toward their worlds. Estroff (1981) and
3 It is the private aspects of experience that make Strauss and Carpenter (1981} come to similar
some wary of experiential approaches in an- conclusions in their phenomenologies of
thropology. Those critical of such approaches mental illness.
STRUGGLING ALONG 173
"To make live or to let die," was Michel Foucault's formula for how populations and
individual bodies are the subjects of power, governance, and apparatuses of classifi-
cation. Who counts as mad and should be in an asylum, and who has post-traumatic
stress disorder and should receive reimbursed psychiatric care? Which warlord is (de
facto) allowed to access international food aid while allowing his opponents to die?
Which diseases receive urgent research funding while others, perhaps more common
albeit in populations without the means to pay for drugs, are deemed insufficiently
"cost-effective"? In recent decades, such questions of "biopolitics" - the topic of
social statisticians and epidemiologists since the eighteenth century- have taken on
renewed urgency in the hands of medical anthropologists and medical practitioners,
whose ethnographic work provides new windows of insight, new opportunities for
ethical debate, and new avenues of possible intervention into spaces of "structural
violence" (Farmer 1997, 2003, 2004) and the "biologization of inequality" (Nguyen
and Peschard 2003); "social suffering" (Kleinman et al. 1997; Das et al. 2000; Das
et al. 2001); "bare life" (Fassin 2001; Biehl 2005; Passin 2005; Comaroff 2007;
Willen 2010); the "violence continuum" (Scheper-Hughes and Bourgois 2004); and
"vital technologies" (Lock and Nguyen n.d.).
Ethnography has also generated a panoply of new perspectives on "medical
citizenship," or how membership in a state, a society, or even humanity itself is
mediated by prevailing regimes of health-related power and knowledge. Following
Foucault, unspoken and under-recognized inequalities are often cast as "biopoli-
tics" (Foucault 1990 [1978]); inversely, following Paul Rabinow, subjects who
organize around common illness experiences to fight for recognition, therapy, or
reparations enact "biosociality" (Rabinow 1996). Such new modalities of engage-
ment with (or subjugation to) state health care systems or other regimes of power
include "psychiatric citizenship" (Rhodes this volume), "biological citizenship"
(Petryna 2002, this volume), pharmaceutical citizenship (Biehl 2007), "therapeutic
citizenship" (Nguyen 2005; Nguyen, Ako, et al. 2007) and even, as medicine is
targeted to become ever more individualized or personalized, "anti-citizen"-ship
178 GOVERNMENTALITIES AND BIOLOGICAL CITIZENSHIP
(Rose 2000). In one sense, we are all "patients-in-waiting" learning to see ourselves
through a post-genomics understanding of illness; in this new era, we are all
carriers of mutations associated with various risk probabilities, and pharmaceutical
and diagnostic regimes are becoming ever more biopolitical (Dumit n.d.).
The five essays in this part take up respectively, a case of "psychiatric citizenship"
in a US maximum-security prison; a case of disability-validated "biological citizen-
ship" in the aftermath of the nuclear radiation disaster in Ukraine; a case of social
abandonment that is unpacked to reveal not only a series of social exclusions and
denials involving a genetic disorder (ataxia) but also, despite all, a vital and expres-
sive "experimental self"; a case of struggle between the state and families over the
honor of women in the aftermath of widespread abduction and return after Partition
in India; and a case of "medical humanitarianism" illustrating the widespread
contemporary dilemmas of triage of asylum seekers and unauthorized migrants in
France in which, perhaps counter-intuitively, those who are ill have better claim to
refuge than the merely able-bodied.
Building upon her 2004 monograph, Total Confinement: Madness and Reason in
the Maximum Security Prison, Lorna Rhodes examines the case of a maximum
security prison inmate, "Sam," who is the product of multiple disciplining insti-
tutions: foster care, juvenile detention, psychiatry, criminal justice, and now super-
max. Exploring his subjugation to overlapping, often competing, institutional logics,
Rhodes shows how prisoners can become caught between contradictory institutional
impulses for punitive discipline or therapeutic healing. Rhodes shows that "even the
most disturbed individual" can choose to seek relationships through the medium of
"traumatic" or "psychiatric citizenship."
Adriana Petryna 's essay, which draws from her 2002 ethnography, Life Exposed:
Biological Citizenship After Chernobyl, describes the aftermath of the nuclear re-
actor meltdown at Chernobyl, the resulting spread of radiation disease, and the
heightened form of biosociality that emerged as affected Ukrainians claimed medical
and financial benefits from the fledgling Ukrainian state on the basis of biological
damage they have suffered. Radiation disease and other enduring consequences of
this "technogenic catastrophe" are not mere diseases; rather, they extend far beyond
the immediacy of individual bodies, across generations, and into complicated local,
national, regional, and even global spheres of politics and economics.
In the third essay, Joao Biehl offers a powerful indictment of how multiple regimes
of power, knowledge, and authority - the family, the welfare system, the medical
profession, the state - can become so disconnected from an individual's suffering as
to produce terrifying forms of "social abandonment," a theme explored in his
monographs Vita (2005} and Will to Live (2007). Biehl's previously unpublished
essay interlaces four theoretical threads: (1) the spoken language and written "dic-
tionaries" of Catarina, long-time resident of Vita, a Brazilian facility for the physic-
ally and mentally ill and socially abandoned; (2) Giorgio Agamben's powerful but, in
the author's view, subjectively vacant notions of "bare life" and homo sacer; (3)
Jacques Lacan's notion of the "sinthome," or displaced symptoms; and (4) Gilles
Deleuze's contention that we must take desire - not power, a Ia Foucault - as
theoretical point of departure. Biehl's ethnography reveals not only the intimate
consequences of structural violence in Catarina's family and in Vita, but also one
of medical anthropology's hallmark capacities: to foreground subjectivity and
agency, in part by showing how Caterina's struggles to articulate herself and her
medical history create "holes in dominant theories and policies" (her misdiagnosis by
INTRODUCTION 179
physicians and her family, and consequently her failure to achieve recognition or help
until she found a sensitive and patient listener in Biehl). Subjectivity, in this context,
"is neither reducible to a person's sense of herself nor necessarily a confrontation
with the powers that be"; rather, it is "the material and means of a continuous
process of experimentation."
Veena Das takes up an equally complicated set of subjectivities and subjectivations
among women who suffered rape and abduction during the India-Pakistan partition
and who were subject by their respective states to retrieval and rehabilitation, often
facing rejection and stigma within their families. Here the intimate linkages among
political notions of citizenship, patriarchal conceptions of family and authority, and
governmental powers show how "sovereignty continues to draw life from the family"
and from "the notion of the sexed individual as the basis of the political." Some
abducted women faced the "disciplining of sentiment according to the demands of
the state" in a manner that violated their will, voided their capacities for subjectivity
and agency, and forced them to re-inhabit the forms of embodied trauma that
accompanied their kidnapping in the first instance.
Miriam Ticktin's examination of "medical humanism" in the case of sans papiers,
or unauthorized migrants and refused asylum seekers in France, pivots on the "illness
clause," a legal provision that has enabled some sans papiers to remain in France
temporarily on humanitarian grounds. Despite its purported beneficence, some
migrant patients end up "trading in biological integrity for political recognition"
either by refusing needed treatment in order to remain sick enough to retain permis-
sion stay or, in the most extreme cases, by willingly becoming injured or infected-
even with HIV- in order to establish valid grounds for a health-related humanitarian
claim. Under these circumstances, damaged biology becomes a ~~flexible resource"
that sick migrants and health care providers can leverage in an effort to stake
political claims vis-a-vis the state. Humanitarianism thus emerges as an inherently
political form of moral discourse, despite all protestations to the contrary, with
potentially "discriminatory, even violent consequences" for its ostensible beneficiar-
ies (see also Pandolfi this volume; Fassin this volume; James this volume; Willen this
volume; Passin 2001, 2005; Fassin and Rechtman 2009). Again medical citizenship is
at issue. As Ticktin, following Agamben, writes: "the struggle to define citizenship
and the borders of the nation-state is now also a struggle to define the threshold of
humanity and life itself."
REFERENCES CITED
Biehl,Joao
2005 Vita: Life in a Zone of Social Abandonment. Berkeley: University of California Press.
Biehl, joao
2007 Will to Live: AIDS Therapies and the Politics of Survival. Princeton: Princeton
University Press.
Comaroff, Jean
2007 Beyond Bare Life: AIDS, (Bio)Politics, and the Neoliberal Order. Public Culture 19
(1): 197-219.
Das, Veena, Arthur Kleinman, Margaret Lock, Mamphela Ramphele, and Pamela Reynolds, eds.
2001 Remaking a World: Violence, Social Suffering, and Recovery. Berkeley: University of
California Press.
Das, Veena, Arthur Kleinman, Mamphcla Ramphele and Pamela Reynolds, eds.
2000 Violence and Subjectivity. Berkeley: University of California.
180 GOVERNMENTALITIES AND BIOLOGICAL CITIZENSHIP
lf.{ s J c; ,.._ cl J
constructed - those "tests" he mentions - During the research that forms the background
cannot be separated from their historical for this paper, I carried out interviews as part
roots in the clinic, the asylum and the of our team and also worked alone as an eth-
prison itself, nor can they be separated nographer, observing everyday operations,
from the coercive environment in which he attending meetings, and talking with prisoners
is held (Foucault 1979).2 But what of the case and staff in supermax and mental health units
report when it has become a self-crafting pro- in several prisons. The eighty-seven prisoners
ject for its subject? In this article I consider we interviewed formally were randomly
psychiatric case-making as it serves to organize selected, and Sam was not in our sample; he
and generate meaning under profoundly had met me during one of my first visits to a
isolating and dehumanizing conditions; for supermax unit, however, and wanted to be
Sam, in fact, it is precisely the enmeshment of included when he heard about our interviews
knowledge with power that affords a small from other prisoners. 3
ray of hope. Two related contexts frame Sam's situation
In 1993 I and a group of colleagues became as a long-term supermax prisoner. The first is
participants in a collaborative relationship the dramatic rise in the incarceration of the
between the University of Washington and the mentally ill over the past thirty years, with its
Washington State Department of Corrections. accompanying increase in the employment of
We have worked on initiatives to change the psychiatrists, psychologists and other mental
treatment of mentally ill prisoners and con- health professionals in prisons. Our work, as
ducted research on prisoners and staff in the well as recent court cases, demonstrates that
state's mental health and supermax units. mentally ill prisoners are disproportionately
DREAMING OF PSYCHIATRIC CITIZENSHIP 183
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confined in supermax prisons (Lovell et al. My goals in this paper are twofold. First,
2000; Human Rights Watch 2003 ). Sam, how- aim to unpack, through a single detailed
ever, is not unambiguously "mentally ill." example, a specific form of supermax confine-
Rather, he falls into an indistinct zone in which ment in which psychiatric knowledge figures
he is neither accepted by psychiatry nor en- as a protagonist but not as a solution. 4
gaged in the various forms of "rational" bad My presentation of Sam as a case study
behavior (such as fighting) that send many depends on the fact that he is already a richly
prisoners into intensive confinement. Prisoners documented "case" within the system, and I
like Sam have been little studied, although they draw on the corrections department records,
often spend years in solitary as never-resolved psychiatric case report, and court documents
"behavior problems." Thus the second context he provided, as well as brief access to his
for understanding this case is the discourse on full department case file. 5 Clearly these mater-
risk that pervades correctional management. ials suggest that Sam is disturbed and a danger
"Behavior problems" are regarded as "risky,, to others; remedies, if they exist at all, are
for the systems in which they are held and unclear and contested. However, I do not at-
rejected by general population units because tempt to diagnose or prescribe. Rather I hope
they have harmed or frightened staff and other to show the inconclusive role of diagnosis
prisoners. Though relatively few in number, itself and the multiple contradictions that con-
these prisoners often serve to justify the exist- tribute to his situation. My second aim is to
ence and expansion of intensive confinement consider the way in which Sam is engaged with
(DeMaio 2001 ). himself as a "case.,, Here I use his letters,
184 LORNA A. RHODES
poems, and drawings, some of which already When I interviewed Sam he was living in the
existed and others created specifically for us, control unit of a new prison outside an isolated
to show how - in an environment almost rural town. Accompanied by a retired prison
devoid of materials from which to forge an official, I interviewed him in a visiting booth
identity and with his only horizon a solitary that had been specially remodeled for the occa-
cell -Sam finds a way to "give an account of sion with a new, steel-reinforced ceiling. Staff
himself to another." His case becomes a form at the prison considered him exceptionally un-
of work, not only for the correctional workers predictable and violent, and Sam had never had
who produce it, but for him as he embraces it a visitor. Cuffed and wearing the white jump-
and, reaching out for a form of "psychiatric suit of the control unit prisoner, he was
citizenship" that privileges trauma, struggles brought by two officers to his side of the booth.
to frame a coherent narrative out of irretriev- As soon as he had signed the consent form and
able harm. given permission for access to his record, he
gazed at us intently through the thick Plexiglas
window and said:
Anatomy of a Stand-off
It's too bad I can't sit with you and point out
Supermaximum prisons are specifically some things in my central file that I think you
designed to separate prisoners from the general would find very interesting ... you'll see a
prison population and isolate them from one pattern ... They [prison staff] make promises
another. In Washington, seven prisons (that is, and then they don't hold 'em and instead of
complexes of buildings making up more than making themselves look like a liar they will
one security level) include these control or poke poke poke poke poke and then I will
"intensive management" units. Separated by buckle and then - I'm not saying my behavior
razor wire and other fortifications from the main is justified - but then I will buckle and then it
institutional environments to which they are justifies them not honoring their promise and
it puts it all upon me and it's been like that for
attached, these "prisons within prisons" oper-
ten years.
ate tightly controlled, technology-intensive
regimes. 6 Supermax prisoners are confined for Sammy's central file ran to nine fat volumes,
twenty-three or more hours a day in small taking up a whole shelf in the records room. It
single cells and removed - cuffed, tethered contained the record of his brief incarcerations
and under escort - only for brief showers or at the ages of twenty and twenty-two, descrip-
solitary exercise. Their lives are characterized tions of the double murder he committed
by lack of physical and mental stimulation, shortly after his second release, and his steadily
minimal social contact, and extreme depend- worsening relations with prison staff over sub-
ence on prison staff. Defiant or disturbed pris- sequent years. One item, the computerized
oners are subjected to forcible removal from record maintained by the corrections department,
their cells ("cell extraction"), the use of pepper was eighty pages long. This fragment shows Sam
spray or electronic controls (tasers, electric committing infractions - "threatening" staff,
shields), confinement in restraint chairs, and "interfering" with staff, "throwing" - every day
the imposition of "isolation time" during during mid-December of 2001. Years of identi-
which they receive no exercise ("yard") or cal entries follow one another; as he provokes
showers. Surveillance is intense, and food, yard his keepers they, in turn, bury him in isolation. 7
time, showers, toilet paper, and all other items The correctional rationale for supermax
are delivered - sometimes erratically or arbi- confinement is that it addresses bad behavior
trarily- based on the schedules and attitudes in prison. The reality is that much confusion
of staff. The relationship between supermax and obfuscation surrounds this form of incar-
assignment and prisoners' status and behavior ceration, with some prisoners undergoing long
is complex, but in general the seriousness of terms of isolation that are unconnected to their
the crime does not determine supermax behavior. In Sam's case, his chronically unpre-
placement. dictability, violent outbursts, and bad
DREAMING OF PSYCHIATRIC CITIZENSHIP 185
reputation throughout the state system meant This stand-off between Sam and the
that risk-averse prison officials would not con- "system" occurs in parallel with a systemic
sider returning him to general population. And contradiction. In theory the Washington
in the meantime, everything about supermax prisons provide psychological services that
has become personal to him. Everything feels could redefine his behavior as a sign of illness
like a "poke." He recounts frequent incidents and enable him to receive treatment in special-
in which "I [felt] I was being messed with," ized mental health facilities. But these sites are
"I got mad," and "I went to war with the overwhelmed with the seriously mentally ill
guards." As he described these events: and their staffs vigorously resist admitting pris-
oners like Sam, whom they regard as predatory
It's after so much pressure they put on me and and dangerous to weaker inmates. It was in this
it's almost like my blood is absolutely boiling context that administrators ordered a psycho-
and I get so much strength built up in me.
logical assessment for Sam, hoping that it
I have to get it out of my system. I try to avoid
would provide ammunition for a plan to send
getting gassed [with pepper-spray] and getting
him to an out-of-state prison. 8 A prison psych-
gooned . . . but mostly I want to fight them
people that are hurting me. ologist, Dr. Stratton, interviewed and tested
him over a four month period, creating a 45-
The more Sam fights, the more he loses. Yet page, densely written, "Neuropsychological
fighting seems to him the only way to preserve Evaluation." Although the assessment was
what little autonomy he has, and thus he conducted in an environment of surveillance
tightens his isolation and punishment and constraint, it also constituted one of the
186 LORNA A. RHODES
few opportunities Sam ever had to talk at and some other names. Most of the doctors see
length with another person. me under bad terms and they go, this guy he's
just a trouble maker, he's no good. They don't
never dig under surface.
My Beautiful Report In her report Dr. Stratton provides results
from her extensive psychological testing,
When I interviewed him in 2002, Sammy had including the Hare Psychopathy Checklist
been in possession of his neuropsychological (with a score of 30),9 the MMPI (Minnesota
report for more than five years. In fact, since Multiphasic Personality Inventory), and the
official papers are one of the few possessions Personality Assessment Inventory. Of the
supermax inmates are allowed, he had lived in results of this last test she notes: "Mr. Andrews
close proximity to it in an environment almost tended to endorse items that made him look
devoid of other sources of stimulation. Sam said: bad and represented extremely bizarre or un-
Dr. Stratten wrote probably one of the most likely symptoms . . . it is likely that he was
fair reports on me, her neuropsychological producing a 'cry for help' . . . [but] even
report. Because of the way I look and talk, though his pathology may be overrepresented
people write that there's nothing wrong with on this profile, he appeared to be experiencing
this guy. But she said my first problem was marked distress and severe impairment in func-
post traumatic stress syndrome. I [also] had tioning. He is depicted as a person who is
other diagnoses like depression in remission, angry, resentful, impulsive ... and sensitive in
I had a characteristic like behavioral problem, social interactions." Dr. Stratton quotes
Figure 16.4 Supermax cell with box of official papers (author photo)
DREAMING OF PSYCHIATRIC CITIZENSHIP 187
extensively from previous evaluations going suggestions for treatment are further compli-
back to Sam's first hospitalization at the age cated by the fact that Mr. Andrews is imbued
of ten, producing a palimpsest of the voices and with such a level of psychopathy (Hare,
diagnoses of other professionals. I will turn to 1985) 11 that he is unlikely to benefit from
the portrayal of other aspects of Sam's history therapy without first altering his ideas/stance.
in the next section, but first I want to show This certainly presents a double bind for him.
how the report represents and extends his diag- In a note to me and my colleagues, Sam gives
nostic profile. his version of this bind:
In the final three pages of Dr. Stratton's report
she lists all the diagnoses Sam has ever received, I believe that IMU is a catch 22, a no-
ending with her own. These pages not only reflect win situation. It breaks inmates it is not meant
complex symptoms but also changes occurring in for and its makes inmates it is meant for. When
the diagnostic system itself as the Diagnostic and I say it makes them I mean, it strengthens their
Statistical Manual of Mental Disorders (DSM) resolve. You're damned if you do and damned
is reorganized in the mid-1980s around a if you don't.
system of "axes." On Axis I (major mental
disorders), Sam has problems that are con- That is, supermax (or "intensive management'')
sidered mental illness - states of being that units harm the mentally ill- who do not belong
might lend themselves to change with medica- in them - while strengthening the character
tion or treatment. On Axis II, Sam's behavior is disordered for whom they are intended. 12
understood in terms of personality disorder - Writing about the development of the con-
traits of character based on the older, more temporary case study format in the late nine-
psychoanalytically oriented diagnostic system teenth and early twentieth centuries, Elizabeth
that the DSM replaced (APA: 2000). 10 These Lunbeck notes that "The case, in which the
are regarded as intractable, if not impossible to facts of psychiatry were embedded, was ... a
change. Sam's long supermax confinement heuristic fiction that was at the same time real"
results from his position between the cracks (Lunbeck 1994, discussing the writings of the
of these two ways of looking at him. Acknow- psychiatrist E. E. Southard circa 1912). One
ledged as disturbed but without the potential way this reality manifests for Sam is in the
for any kind of amelioration, he has fallen into matter of simple attention. The supermax pro-
an extreme form of what Nikolas Rose calls the duces an impoverished social economy in
"continuous and unending management of per- which attention is the scarcest of resources.
manently problematic persons in the name of ... Staff is invested in efficiency and rewarded
safety" (Rose 2002). for withholding themselves from inmates. But
At the end of her report, Dr. Stratton offers as Sam, cuffed to a metal table, sits with
her own view of Sam's diagnostic picture. I will Dr. Stratton he undergoes a 30 hour process
come back to her final conclusion, but in order of interviewing and testing that both "pins him
to understand why this report had no effect on down in his individuality" (Foucault 1979) and
Sam's confinement, we need to consider her expands his world.
recommendations. She does not include anti- This attention also emerges in the report
social personality disorder in her summation, itself, in which we see a layered - both con-
but this is what she says: flicted and complementary - accretion of diag-
nostic labels as psychiatrists and psychologis[s
work with Sam at various stages in his life. As a
Mr. Andrews is certainly in need of therapy.
He needs to resolve both his early sexual child and teenager he inspires a disagreement
trauma and the abuse/neglect at the hands of over whether he is schizophrenic, with a reso-
both of his biological parents. His personality lution that settles gradually on conduct dis-
structure/traits that have developed as a result ... order, borderline personality disorder, and the
are such that they/he would require extensive, possibility of organic damage. In its filtering
frequent and intense individual psychotherapy and congealing of these possibilities, the report
to resolve . . . [But] all the aforementioned becomes a "work of abstraction," a heuristic
DREAMING OF PSYCHIATRIC CITIZENSHIP 189
fiction that organizes events around the indi- I ... [am able to] speak only the words
vidual and highlights those elements that con- I've been programmed alJ my life to speak ...
firm certain diagnostic presuppositions (Smith Chains attached to my limbs everywhere I go
1990: 92). 13 This relationship of "looping" is Might as well be attached to my mind
what gives the case its weight as both expertise Because it doesn't feel like I have one of my
and common-sense. 14 own
Dr. Stratton's report makes clear that only For Sam, the report "speaks," in a way that
one side of Sam's being- the same side that is bypasses, at least in part, his sense of having
broken by supermax confinement- might be been programmed, chained, and left with noth-
helped by long-term therapy. The other side, ing but rage. To understand why, we need first
defined by psychopathy and damned by his to consider its account of his life and then
score on the Hare (a score precisely at the revisit the diagnostic resolution offered by
marker for the disorder), is both strengthened Dr. Stratton's effort of summation.
by supermax and necessarily suited to it. 15
Thus she is saying to the administrators who
are her official readers: do not even think of
returning Sam to the general (prison) popula- Anointed with Bad Karma
tion, and use the system's scarce resources to
help, not him, but the mentally iJl. Sam lives in an environment governed by a
Why, then, does Sam so cherish his report? powerful ideology of "personal choice." For
He writes in a poem: the prison workers around him, as well as for
190 LORNA A. RHODES
Figure 16.7 Table with "bullring" where Sam was interviewed by Dr. Stratton (attthor photo)
the U.S. press and public, criminals are exem- first hospitalized before the age of ten, already
plars of autonomy, individualism, and free will. neglected and abused by his mother, rejected by
No matter how seemingly senseless the acts his father, raped by his father's friends, and
that brought them to prison, these are under- possibly suffering head injuries. He has spent
stood to represent "freen and rational choices. all but two or three years since in foster homes,
Attending to the circumstances - familial, eco- hospitals, youth detention or prison, going to
nomic, or political - under which such choices prison initially at age twenty for theft.
occur is considered by many tantamount to These bleak facts recur in the report as
"coddling" or being "soft on crime.'' It is only Dr. Stratton quotes from the psychiatrists and
in this context that we can understand Sam's psychologists who described Sam during his
attachment to the picture of his life underwrit- childhood and teenage years. This note was
ten by Dr. Stratton's assertion that his "com- written when he was 11:
plex symptoms/behaviors [are] a result of Sammy is ... a child who has had virtually no
numerous and diverse influences." opportunity to develop adequate bonding with
a mothering person from infancy onwards.
11
1nfluencell His mother . . . can recall1ittle of his early Jife
because, she says, "I was real sick ... "Intense
In a poem entitled "Anointed with Bad anger and frustration around issues of controls
Karma," Sam speaks of the "unimaginable when Sammy was two or three has continued
emotional monsters" that torment him with a to be a focal point . . . Frequent shifts of the
"constant reminder that all things are not caretaker role from mother to natural father
forgot.'' Much of his psychological report cata- and on to hospitalizations, residential care,
logues this negative karmic territory. He was and home care have certainly played a role in
DREAMING OF PSYCHIATRIC CITIZENSHIP 191
distorting the structuralization of ego and people but [that he] had hurt somebody who
super ego components as the boy has matured. had been guilty of something."
Here is a later entry, explaining Sam's Sam draws an explicit connection between
continuing hospitalizations, consignment to his experience of his mother and his relation-
special programs for wayward teens, and ex- ship to the Department of Correction.
treme violence toward staff and other patients. I've done months in the strip cells because
they've started something but they want me
At no time in Sammy's life has he experienced
to learn a lesson, rthey want to] make me
a stable environment maintained by reliable
learn. That's kind of like what my mom did
parenting figures . . . Therefore [he) has not
and I'm real resistant to that now 'cause
been able to develop any stable internal
I wasn't resistant [then] ... She would make
objects, nor to internalize any limits or stand-
me stay on the front porch all night 'cause she
ards for behavior. Basic trust does not exist
didn't want me in the house, she singled me
and he consequently has developed a manipu-
out like that to go sleep on the floor in the back
lative, ruthlesslessly competitive and oppor-
room, she was very violent. I don't understand
tunistic lifestyle that enables him to survive,
why she did what she did. I was her convenient
but puts him in constant conflict with his en-
punching bag. Just like I don't understand
vironment. It is possible that this sociopathic
DOC, it's very, very similar. A lot of what she
character has developed around a core of
did to me DOC does on a bigger scale now but
primitive ideation and poor reality testing,
now I can stand up for myself. I do get mad,
which results in severe anxiety and further
my anger is being pulled back from when I was
prevents the conditions that would permit the
a kid. My current anger it's all mixed so like
development of object attachments.
mv blood boils I mean I get it all out. I was
Borrowing from Erving Goffman, we could ce~tainly put on that assembly line for a manu-
say that Sam's social identity was spoiled long factured human monster.
before he knew he had one (1963). Identity, as The child who was excluded, confined, and
judith Butler points out, always takes shape tormented by all-powerful adults becomes an
not only in relation others' influence but also adult excluded, confined and tormented by an
in relation to the requirement - produced by all-powerful institution. Inserted into circuits
social relations themselves- that one "give an of hostility then, he perpetuates them now. He
account of oneself" (2005). Most of us do not knows it- and has perhaps had enough contact
have in our possession a professional account with mental staff to have heard of the compul-
of our early development. Sam not only has sion to repeat - yet he cannot extricate himself
such an account, but one that speaks of him from the bad mother that is supermax. About
in semi-adult terms as someone with a "ruth- his second short incarceration as a young adult
less lifestyle" before the age of fifteen. At this he says, "I told them don't let me out of prison
point any effort of self-crafting in which he because I was so angry and so mentally dis-
engages must take this report as a resource. turbed. I said please don't let me out because
But what in it can offer him a sense of value? I am going to kill . . . If I could go back and do
it over I wouldn't have did what I done [but]
I just know there were a lot [of] influences."
The bad mother
Dr. Stratton writes that Sam is unsure of his The crime
biological father and was the fourth of six
children born to his mother who was, during Sam has spent almost none of his adult life
his childhood, a "bad person, a prostitute." He outside of juvenile facilities or prisons. In the
tells Dr. Stratton, "I stay away from my mother brief interlude after he begged not to be let out,
because I can't stand her ... she's wicked." He he lived a wildly disorganized life characterized
thinks about "taking her ouf' because he now by confused and hostile relations with others,
believes "that would have solved most of my unsuccessful efforts to obtain psychiatric help,
problems ... I still fantasize about this." He and a deep fear that his negative trajectory was
says he "wishes he had not hurt innocent unstoppable. He imagines, in fact, that it could
192 LORNA A. RHODES
have been even worse, and that he might have an "exemplary manifestation" of pathology
become the kind of serial killer he had read (1994: 131). Sammy clings to his years-old,
about. "I used to go out late and night and "beautiful" evaluation for all these ways in
walk and walk and walk. Deep down inside I which it allows him to be a person, but espe-
feared I could go on a serial murder spree, cially to his status as an "exemplary manifest-
maybe [of] child molesters to get back at what ation." The idiom of psychology becomes a
happened to me as a kid. I thought that maybe I resource that allows him to project a lost self-
could become something like that that I didn't a generic, different self - into the dismal
want to become." expanse of his future. If we return to Dr. Strat-
Instead, he went on a less extended killing ton's final summation, we see how her inser-
spree whose motivation still eludes him. tion of Post Traumatic Stress Disorder into the
list of diagnoses suggests both retrieval and
So suddenly it is as if I am in a dream, watching
irreversibility.
over myself. I go driving and drinking ... I head
out for a crime spree. At first I got it in my head As these diagnoses are reviewed some sense of
that I am going to make a list of everyone who his development is gained. The travesty of the
did me wrong and kill them one by one. [But] in intervening years is that had the earlier profes-
my state of mind I couldn't ... find anyone else sionals known then what is known now, An-
to kill ... so I drove to a [convenience store] ... drews might have been an entirely different
I said give me all the money, which he did- then individual.
I shot at him once and missed ... I walked up to
It is this comment that is the source of Sam's
where he was laying on the floor and shot him in
attachment to his report.
the head again.
Dr. Stratton says it beautifully: Had they
Sam went on to murder a second convenience known how to work with trauma victims of
store clerk, then drove to the sheriff's office and sexual and physical abuse when they were
turned himself in. treating Andrews as a juvenile and young kid -
It is clear from Dr. Stratton's report and if they knew back then what they know now,
from Sam's telling of the crime that although Mr. Andrews would have been an entirely dif-
he revisits it compulsively he is confused about ferent individual. Ails I can say is when my
responsibility. "I'm not tormented by it," he mom didn't want me she just threw me into the
tells me, "because it's easier for me to blame system and the system don't care. I just went
everybody else. I guess when you do something through the machineries of the system - what
horrendous like that you don't want to accept you've got here is what the system has created.
it." To Dr. Stratton he says that he knows
Abandoning the diminutive and becoming
"someone is guilty" but he is uncertain just "Mr. Andrews" to himself, here Sam finds the
who that is. Despite his unusual access to child-
one point of redemption in his past. Of all the
hood sources, his account breaks up and be- diagnoses in the DSM, PTSD is the most
comes opaque (Butler 2005: 38) just at the
overtly social. It references a specific rather
point of its most painful revelation. As Sam
than a non-specific past, one in which, as Allan
describes an unhealed inability to recognize Horowitz notes, "environmental causes can
himself in his acts, all he can conclude is that lead to dysfunctional psychological mechanisms"
"a lot has been done to me."
(2002:30). PTSD offers Sam a quasi-middle-
class deliverance from what he describes as
The Manufactured Human Monster "stress" that might be relieved by the "healing
process" of therapy. He is not merely culpable,
In her description of Boston Psychopathic Hos- for he might have been otherwise. Echoing
pital in the early twentieth century, Lunbeck Dr. Stratton, he says, "lf I knew [then] what I
notes that the "case" emerged simultaneously know now . . . I would be out on the streets
on three fronts: as a description of a real, living doing something productive and living a life
person; as a life story rendered into narrative and married with children. Psychology and all
by social workers and psychiatrists; and as that."
DREAMING OF PSYCHIATRIC CITIZENSHIP 193
Nikolas Rose uses the term "anti-citizen" to for his bad "choice," he can offer himself to
describe how we represent those whose con- us as a contribution to the larger world of
duct is "thought to arise from a diminution of science.
self-control, reasonableness, maturity [and] Complementing the diagnosis of trauma as
judgment" (2000: 18). 16 Almost everything in an antidote to the position of anti-citizen is a
Sam's environment points to his position as an drawing Sam sent me shortly before my inter-
anti-citizen - someone both profoundly ex- view with him. Here he imagines a perfect
cluded and, at the same time, made to hold still prison, named for himself, that extends the
as an icon of the risk posed by dangerous panoptical interior in which he spends his days.
"others.'' But by naming him a "trauma On the back he has written about the "pro-
victim" and offering PTSD as that which con- gram" such a prison should follow.
nects him, however tenuously, to something This is the "decent prison" of his letter- a
beyond himself, Dr. Stratton offers a narrow huge facility offering both intensified surveil-
opening through which Sam can claim what lance and opportunities for softball and yoga,
Lauren Berlant calls "traumatic citizenship'' the very space and movement Sammy is denied.
(Berlant 1997). 17 Although psychiatric classifi- This fantastical prison represents his request
cation has worked mostly to deny him any kind for something better while at the same time
of coherent treatment, and although he cannot suggesting a totalizing identification with the
escape the constant reiteration of his culpabil- prison's structure and administrative preoccu-
ity, here he finds some possibility for social pations, including a replication of its division
membership. Provided with an explanation of the weak from the strong. This is, however, a
194 LORNA A. RHODES
regime even more punitive than the one he is in. many Sams in the national prison complex -
His descriptive note insists, in fact, that here suffering in isolation, hard to classify or place,
there will be no second chances, only "no more and living indefinitely between the cracks of
choices'' if "you screw up." Sam offers this psychiatric and correctional management. 18
vision to an imagined audience as a contribu- Sam's story suggests that we might organize
tion to a meaningful future in which he might our thinking about such prisoners into three
be trusted precisely, and only, because he has so domains.
thoroughly internalized the terms of his own
captivity. The institutional stand-off
Sam is in a particularly stark, no-exit bind, the
Conclusion catch-22 of his letter, in which the very things
that most trap him are also most "strengthened"
In the end, the state of Washington State found by his confinement. The fortified ceiling of the
a solution of sorts. Sam Andrews was trans- visiting booth is symbolic of the way in which
ferred to a federal prison about a year after my the prison environment has been progressively
interview with him and given a chance to extri- "hardened" in recent decades, becoming in-
cate himself from his toxic engagement with a creasingly mechanical, punitive, and techno-
system in which he was all too well known. He logically driven. At the same time, in a toxic
wrote that he liked it, and that he hoped even- feedback loop, Sam has settled into the chronic
tually to enter a program for personality-dis- reactivity, impulsive violence, and "war" with
ordered prisoners. But this specific, local staff endemic among many who are locked
resolution does not tell us much; there are down and institutionalized. We can see in
DREAMING OF PSYCHIATRIC CITIZENSHIP 195
inmate is serving a life sentence. Sam was an 15 More on the meaning of psychopathy in the
"intensive management" prisoner assigned to prison context can be found in Rhodes
the state's various supermax (or, in Washing- (2002) and Toch (1998).
ton, "intensive management") units; in 16 In variations on this theme, jonathan Simon
theory this status is administrative, not puni- writes of the "waste management prison"
tive, and "isolation" was being added as pun- (2007) and Ruth Wilson Gilmore describes
ishment. "Isolation" means that a prisoner the racialized policies of the US incarceration
continues to be held in his supermax ceJl complex as exposure to premature death
but is denied his daily out-of-cell time for (2007).
yard and showers; prolonged isolation in- 17 Berlant's definition of citizenship is helpful
volves periodic suspension to allow for occa- for understanding Sam's interest in diagnosis
sional showers and limited exercise. as a form of relationship: "By citizenship I
8 Such transfers, though difficult to arrange, are refer . . . both to the legal sense in which
not uncommon for those prisoners who persons are juridically subject to the law's
become "problems" -for a variety of reasons- privileges and protections by virtue of na-
within a particular system. In Sam's case, tional identity status but also the experien-
he had filed a lawsuit against Washington tial, vernacular context in which people
State that resulted in a strong recommenda- customarily understand their relation to
tion from the court to seek out of state state power and social membership" (Berlant
placement. 2002:108).
9 Robert Hare is a Canadian psychologist 18 For accounts of prisoners similar to Sam see
who has written extensively about psychop- Butterfield (1995) and Porter (1998).
athy (an unofficial and extreme variant of 19 Jones 'EI v. Berg (164 F. Supp. 2d1096, 1098
antisocial personality disorder). His theories [W.D. Wis. 2001].
about the disorder are behind many popular
representations of "psychopathic killers" REFERENCES
and his diagnostic "checklist" is widely used
in corrections. See http://www.hare.org/ American Psychiatric Association
Accessed July 14,2009. 2000 Diagnostic and Statistical Manual of
10 For a fuller picture of the use of the DSM in Mental Disorders: DSM-IV-TR. Washington,
prisons see Rhodes 2004. For an anthropolo- DC: American Psychiatric Association.
gist's interpretation of the DSM classifica- Berlant, Lauren
tion of the personality disorders, see 1997 The Queen of America Goes to Washing-
Nuckolls 1992. ton City. Raleigh: Duke University Press.
11 Probably Hare 1985. Berlant, Lauren
12 Sammy participates here in a distinction - 2002 The Subject of True Feeling: Pain, Privacy,
and set of assumptions about what is and is and Politics. In Wendy Brown and janet Halley,
not "mental illness" - that is pervasive in eds., Left Legalism, Left Critique. Durham,
prison systems and criminal justice more NC: Duke University Press, pp. 105-33.
generally. These diagnostic categories are Butler, judith
enacted not only through assessments such 2005 Giving an Account of Oneself. New
as Dr. Stratton but also in spatial and labor York: Fordham University Press.
arrangements that reinforce their seeming Butterfield, Fox
inevitability. See Rhodes 2004, Kurki and 1995 All God's Children: The Bosket Family
Morris 2001. and the American Tradition of Violence. New
13 Both Smith (1990) and Lunbeck (1994) note York: Avon.
that the case study format took its contem- DeMaio, J. R.
porary shape in institutional contexts in 2001 If You Build It, They Will Come: The
which auxiliary professionals (social workers Threat of Overclassificarion in Wisconsin's Super-
and psychologists, especially) reported to max Prison. Wisconsin Law Review: 207-47.
physicians. Flyvbjerg, Bent
14 For discussion of looping effects see Ian 2006 Five Misunderstandings About Case-Study
Hacking (1986) and Erving Goffman (1961). Research, Qualitative Inquiry 12(2): 219-24.
198 LORNA A. RHODES
~~common sense is what is left over when all the more articulated sorts of symbol
systems have exhausted their tasks." (Clifford Geertz, Local Knowledge 1 )
Adriana Petryna, "Biological Citizenship: The Science and Politics of Chernobyl-Exposed Populations," Osiris
19 (2004): 250-65. Reprinted by permission of the publisher, The University of Chicago Press.
200 ADRIANA PETRYNA
market transition. More generally, it showed weeks, the radioactive plume moved to an esti-
that in this new state, science and politics were mated height of eight kilometers. Subsequent
engaged in a constant process of exchange and attempts to extinguish the flames of the burn-
mutual stabilization. 2 This essay builds on that ing graphite core proved only partly successful.
material by showing how contested attempts to By most accounts, they even exacerbated the
intervene and to quantify radiation risk shaped danger of the situation. For example, an
the nature of the postdamage legal and polit- attempt was made to suffocate the flames with
ical regime. Viewed longitudinally, the Chemo- tons of boron carbide, dolomite, sand, clay,
byl aftermath exemplifies a process wherein and lead dropped from helicopters. As a result,
scientific knowability collapses and new cat- the core's temperature increased. The cloud of
egories of entitlement emerge. Ambiguities re- radiation rose dramatically and moved across
lated to categorizing suffering create a political Belarus, Ukraine, Russia, Western Europe, and
field in which a state, forms of citizenship, other areas of the Northern Hemisphere. 5
and informal economies of health care and An official announcement of the disaster
entitlement are remade. This appropriation of came almost three weeks after the event. In that
suffering at all levels is one aspect of how time, roughly 13,000 children in contaminated
images of suffering are becoming increasingly areas took in a dose of radiation to the thyroid
objectified in their legal, economic, and polit- that was more than two times the highest
ical dimensions. 3 This essay is specifically con- allowable dose for nuclear workers for a year. 6
cerned with how these objectifications become A massive onset of thyroid cancers in adults
a form of common sense and are enacted by and children began appearing four years later.
sufferers in ways that can intensify the political Had nonradioactive iodine pills been made
stakes of suffering and promote protection, as available within the first week of the disaster,
well as new kinds of vulnerability, in domestic, the onset of this disease could have been sig-
scientific, and bureaucratic arenas. nificantly reduced. Soviet administrators con-
tradicted assessments of the scale of the plume
made by English and American meteorological
The Event groups. The Soviets claimed the biomedical
aspects of Chernobyl were under control.
The Chernobyl nuclear reactor's Unit Four Dr. Angelina Guskova of the Institute of Bio-
exploded in Ukraine on April 26, 1986. The physics in Moscow initially selected 237 victims
damages from this disaster have been mani- to be airlifted to her institute's acute radiation
fold, including immediate injury in the form sickness ward. Acute radiation syndrome (ARS)
of radiation burns and death to plant workers, was diagnosed among 134 of them. The official
damaged human immunities and high rates of death toll was set at 31 persons, most of them
thyroid cancer among resettled populations, fire fighters or plant workers.
and substantial soil and waterway contamin- The disaster continued, especially among
ation. Soviet reports attributed the cause of the groups of workers who were recruited or
the disaster to a failed experiment. According went voluntarily to work at the disaster site.
to one official report, "The purpose of the Among the hundreds of thousands of paid and
experiment was to test the possibility of using unpaid laborers/ work ranged from bulldoz-
the mechanical energy of the rotor in a turbo- ing polluted soil and dumping it in so-called
generator cut off from steam supply to sustain radiation dumpsites (mohyl'nyky), to raking
the amounts of power requirements during a and shoveling pieces of the reactor core -
power failure. " 4 Many of the reactor's safety radioactive graphite- that had dispersed over
systems were shut off for the duration of the a vast area, to constructing fences around the
experiment. A huge power surge occurred as reactor, to cutting down highly contaminated
technicians decreased power and shut off the surrounding forests. By far the most dangerous
steam. The unit exploded once at 1:23 A.M. work involved the adjacent reactor's roof.
and then again. Due to particular wind-pres- In one-minute intervals, workers (mainly
sure gradients that day and in the following military recruits) ran onto the roof, hurled
BIOLOGICAL CITIZENSHIP 201
radioactive debris over parapets into contain- I traveled to the country. He identified himself
ers below with their shovels, and then left. as a "sufferer," a legal classification instituted
Many of these volunteers called themselves in 1991 for Chernobyl-affected individuals. He
"bio-robotsn; their biologies were exploited complained about how little his compensation
"and then thrown out." Based on extensive (about five U.S. dollars a month) was in rela-
interviews, some laborers felt trapped and tion to rising food prices. 8 The man was in
unable to leave the disaster area; this sentiment absolute despair, trapped because he had no-
was particularly felt by unpaid military recruits where else to work. He said he had attempted
and local collective farmworkers recruited to to find employment elsewhere, but nobody
do the most menial and dangerous of tasks. would hire him on account of his bad health
Some said they went gladly, believing their and work history. The man linked his suffering
tripled salary more than compensated for their to first a precarious and dangerous Soviet man-
risk. However, it cannot be definitively said agement of the aftermath, and then a complex
that money truly compensated them for the medical and legal apparatus he felt unable to
suffering that was to come. navigate. He then showed me a work injury, a
Five months after the disaster, a so-called flap of skin that had puckered and formed a
sarcophagus (now simply called the Shelter) kind of ring just above his ankle. Direct contact
was built to contain the 216 tons of uranium with a source of ionizing radiation had appar-
and plutonium in the ruined reactor. At pre- ently caused it. His sense of violation and loss
sent, the power plant is decommissioned. Some were clear when he referred to himself as a
fifteen thousand people conduct maintenance "living dead," whose memory of who he was
work or service the Zone of Exclusion. Most of in a former life "is gone.,
the exclusion zone is located in Ukraine. The In 2000, I interviewed the director of the
zone circumscribes the disaster site and covers Shelter complex. What I learned was that
thirty kilometers in diameter. Zone entry is almost a decade after independence, worker
limited to the plant's workers. protections, in spite of some improvements,
Ukraine inherited the power plant and most were still deficient. The director told me that
of the Zone of Exclusion when independence norms of radiation safety were inoperative. In a
was declared in 1991. The government an- place of tremendous economic desperation,
nounced new and ambitious standards of people competed for work in the Zone of Ex-
safety. It focused its resources on stabilizing clusion, where salaries were relatively high and
the crumbling Shelter, implementing norms of steadily paid. Prospective workers engaged in a
worker safety, decreasing the possibility of troubling cost-benefit assessment that went
future fallout risk, and decommissioning all something like this: if I work in the Zone, I lose
units of the Chernobyl plant. These acts were my health. But I can send my son to law school.
important from a foreign policy standpoint. "Taking this risk is their individual problem.
Showing that it could adhere to strict safety No one else is responsible for it,', the director
standards, Ukraine became the recipient of told me. He compared Ukraine,s mode of en-
European and American technical assistance, forcing safety standards with European modes
loans, and trading partnerships. The legacy of and told me that the "value,, of a dose exposure
Chernobyl has been used as a means of signal- remained untallied in Ukraine. In Europe,
ing Ukraine's domestic and international legit- such values are calculated on the basis of the
imacy and staking territorial claims; and as a rem-expenditures workers incur; international
venue of governance and state building, social safety standards limit the amounts. Despite the
welfare, and corruption. existence of these international limitations, the
Some maintenance workers lived in director's comment suggests that norms of
government-constructed housing units in Kyiv, worker exposures are in fact being decided
the country's capital, sixty miles south of the locally and within the constraints of a national
disaster area. They work in the zone for two economy. In effect, he was revealing to me the
weeks and then return home for two weeks. I extent to which workers' lives are undervalued
met one such worker in 1992, the first time by being overexposed (for much less pay). Yet
202 ADRIANA PETRYNA
however undervalued his workers' lives may ethnographic mode of engagement is in itself
be, they are still driven to work by a situation meant to question the possibility of a linear
in which economic forces are overwhelming. In account or an all-or-none moral or political
such an environment, physical risks escalate solution to this complex reality. Instead, its
and risky work is seen as acceptable and even dynamics are approached from a prismatic
normal. point of view to gain a broader perspective on
"As a result of all the compounding un- the interests and values involved in particular
certainties in the factors involved," wrote claims and sites.
Frank von Hippel, "our estimates of the
long-term health consequences of the Cher-
nobyl accident are uncertain even as to Experimental Models and
the order of magnitude. " 9 Indeed, available Ethnographic Methods
models of assessment could not account for
the scope of the disaster. As the short history Between 1992 and 1997, I conducted archival
of the disaster indicates, rational-technical and field research in Ukraine, Russia, and the
responses and political administrations (both United States. In Ukraine, I worked with reset-
in the Soviet and Ukrainian periods) have tled families and radiation-exposed workers.
been compounding factors in the medical I also carried out archival research in the coun-
and welfare tragedy that now affects more than try's new Chernobyl Ministry, the Health
3.5 million people in Ukraine alone. Contested Ministry, and Parliamentary Commissions on
scientific assessments of the disaster's extent Human Rights. I conducted interviews with
and medical impact, the decision to postpone key scientific and political actors in Kyiv
public communication, and the economic and Moscow, comparing scientific standards
impetus to work in the exclusion zone have informing concepts of biological risk and
made Chernobyl a tekhnohenna katastrofa safety in the Soviet and post-Soviet administra-
(a technogenic catastrophe). This is a term that tions of the aftermath. The very nature of the
was used among my informants, including problem, that is, understanding the everyday
people fighting for disability status, local lived aspects of the Chernobyl aftermath,
physicians, and scientists. It suggests that not led me to a number of different sites and
only radiation exposure but also political challenges. One of those challenges involved
managements have produced new biological understanding how scientific knowledge about
uncertainties. radiation risk was being circulated, assimi-
Ulrich Beck noted that Chernobyl was an lated, or rejected at the various levels
"anthropological shock" in Western Europe. (international, national, and local) in which
The shock came from the fact that everyday interventions were being made.
knowledge proved useless in the face of this I examined claims about the scale of the
catastrophe, as did expert knowledge. 10 This disaster made by scientific experts affiliated
"collapse' of knowledge also occurred, but in with the International Atomic Energy Agency.
another way, in the other Europe. Chernobyl I compared expert knowledge with that of
was associated with the collapse of Soviet life basic scientists in U.S. radiation laboratories
in general. Knowledge about risk, how to and learned about how radiobiologists went
deliver it, how to value it, became something about evaluating radiobiological effects at the
of a political resource. In this disaster's wake a cellular and subcellular levels.
state, a society, and knowledge and experience As a consequence, I could better situate
of health have been reconfigured. expert claims and their measures in the context
In exploring this aftermath, I use a meth- of their laboratory production and testing. I
odological approach that involves moving soon discovered that there was a "black box''
back and forth between vulnerable persons separating knowledge about the effects of low-
and the everyday bureaucracies and procedures dose radiation at the animal (laboratory) level
by which they express their desires, claims, and and human (field) level. The dose-effect curves
needs for protection and security. Such an for high doses of radiation were one to one and
BIOLOGICAL CITIZENSHIP 203
fairly straightforward. The same could nor be Today, approximately 8.9 percent of Ukraine
said for ongoing exposures at low doses (a is considered contaminated. On average, 5 per-
typical condition after Chernobyl). On the cent of its state budget is spent on Chemobyl-
one hand, experts promoted their authority, related expenses. This includes costs related to
based in part on their mastery of what com- the environmental cleanup and technical support
posed appropriate evidence of Chernobyl- of the destroyed reactor. The majority of funds
related iniury. On the other hand, there was (65 percent), however, are spent on social com-
considerable disagreement at the laboratory pensations and financial maintenance of the
level over what the terms for interpreting Chernobyl public health and scientific apparatus.
radiation-induced biological risk in human Belarus was much more heavily affected than
populations are. International experts' projec- Ukraine. Nearly 23 percent of its territory is con-
tions about the health effects of Chernobyl taminated. Contrastively, Belarus expends much
often contradicted people's lived sense of those less than its southern neighbor does on affected
effects. For Ukrainian scientists, the lack of populations; it has curbed its sum of Chemobyl
consensus at the basic science level meant that claimants - as has Russia. 11 Dr. Guskova, who
the criteria of evaluation of injury were, in oversees the Russian compensation system for
essence, contestable. workers of nuclear installations, including
Ukraine became a most compelling place to Chernobyl, is a well-known critic of Ukraine's
examine the relations between risk, rational- compensation system. She told me that Ukrain-
technical power, and the emergence of new ians were inflating their numbers of exposed
populations. Indeed, a new political, eco- persons, that their so-called invalids "didn't
nomic, and moral arena had been thrown open want to recover." She saw the illnesses of this
owing to the absence of consistent evaluative group as a "struggle for power and material
criteria. During the period of my field research, resources related to the disaster."
the country saw the growth of a population In response to her former colleague,s indict-
claiming radiation exposure qualified them ment, Dr. Angelina Ceanu, a neuro-physiolo-
for some form of social protection. Social pro- gist and physician to Chernobyl victims in
tections included cash subsidies, family aJlow- Kyiv, told me, "It is inconceivable that an
ances, free medical care and education, and organism of any kind is passive to its own de-
pension benefits for sufferers and the disabled. struction." Her response was based on evidence
This new population, named poterpili (suffer- from experiments conducted by the Soviet
ers), numbered 3.5 million and constituted radiobiologist V. L. Komarov. In one experi-
7 percent of the population. A political econ- ment conducted in the late 1950s, he observed
omy of Chernobyl-related illnesses with new that sleeping rats, without provocation, woke
kinds of social categories and hierarchies of up when exposed to small amounts of ionizing
entitlement was emerging. An individual clas- radiation. From these examples one can begin
sified as "disabled" received the best entitle- to appreciate how competing scientific models
ment package as compared with a mere (animal vs. human; psychometric vs. biological;
"sufferer." Nonsufferers, that is, people outside laboratory vs. field-based), financial agendas,
the Chernobyl compensation system, had even and distinct moral attitudes regarding the need
less or no chance of receiving state social bene- for scientific work in this arena were not simply
firs. Scientific know-how became essential to at odds with each other. Their confrontation
the negotiation of everyday life and the main- opened up a novel social arena consisting of
tenance of one's status in the Chernobyl contested claims around radiation illness.
system. One had to know one's dose and be Indeed, a number of civic organizations lobby-
able to relate it to one's symptoms and work ing for the right to compensation for such ill-
experiences in the Zone of Exclusion. The nesses evolved with the biomedical and
effectiveness of this knowledge determined political institutions promoting "safe living" in
the place one could occupy and how long one Ukraine. These so-called fondy (funds) were
could occupy it in the system of management of conduits of international charity and repre-
Chernobyl populations. sented the concerns of exclusion zone workers
204 ADRIANA PETRVNA
and resettled persons living in Ukraine. These in a person's work ethics and level of commit-
funds enjoyed tax-exempt status and with their ment to a collective of laborers, 12 the effects
numbers (more than 500 in 1996) established such changes had on domestic life, and the
an informal economy of a variety of imported techniques household members used to have
goods, including vehicles, drugs, and frozen their illnesses count in the rational-technical
and dry food-stuffs. In short, the Chernobyl domain in which their futures came to be
aftermath became a prism of the troubled pol- addressed.
itical-economic and social circumstances that These anthropological concerns illustrate
typified the Ukrainian transition to a market the extent to which definitions of health and
economy. The production of scientific know- illness are embedded within spheres of politics
how, markets, and state formations were mu- and economics and are almost always con-
tually embedded, generating new inequalities nected with dimensions that go beyond the
and opportunities in the redefinition of citizen- immediate body, such as interpersonal and
ship and ethics. domestic relationships. Arthur Kleinman has
This work is based on multiple lengthy re- elucidated the "social course" of illness. 13
search visits to various state, scientific, and do- Other anthropologists, such as Veena Das and
mestic contexts during 1992-1995, fieldwork Nancy Scheper-Hughes, have been concerned
conducted during 1996-1997, and a follow-up with constructions of health as they indicate
visit in 2000. The Radiation Research Center, discrepancies in power, social position, and
also known as Klinika, became a primary focus inequality, particularly as lived by marginal
of the field research. The center was estab- groups and individuals. Recent ethnographies
lished in 1986 to monitor the health of of science have portrayed how, more and more,
zone laborers; shortly afterward it began pro- biomedical technologies play a key role in that
viding similar services for resettled persons. constructedness. PET scans, genetically based
Its national-level Medical-Labor Committee diagnostics, and sonograms image biological
(Ekspertiza) comprises scientists, physicians, facts and are therefore inseparable from the
and administrators who have the authority to objects they recognize and remake as disease. 14
diagnose illnesses as Chernobyl-related (there Social problems, health problems, and the
are twelve regional committees). Patients with technologies that image them are also linked.
illnesses diagnosed as such receive a document, Anthropologist Paul Farmer has shown how
the so-called Chernobyl tie, which qualifies patterns of "structural violence" affect the con-
bearers to receive compensation privileges as struction and expansion of populations at risk
a result of their Chernobyl-related illnesses. for diseases. Deteriorating health care, limited
By 1996, the center had become the site of treatments, and inequalities are worsened
intense scientific and legal disputes. I observed by structural adjustment programs and have
physicians, nurses, and patients as they negoti- led to epidemics of preventable infectious dis-
ated over who should receive the tie. I looked eases such as multidrug-resistant tuberculosis.
into current research, particularly in the Indeed, "social forces and processes come to be
center's neurological division. I also carried embodied as biological events." 15 In Ukraine,
out interviews with sixty middle-age male and efforts to remediate the health effects of
female patients and reviewed their medical his- Chernobyl have themselves contributed to
tories, their illness progressions, and their social and biological indeterminacy and novel
experiences in attempting to qualify for disabil- formations of power. Radiation exposures and
ity status. A significant aspect of my research their unaccountability, bureaucratic interven-
focused on the daily lives of the clinic's male tions by the state and failures to intervene, the
patients and their families. I was concerned growth of clinical regimes, and harsh market
with how their belonging to a political econ- changes intensified the course of illness and
omy of illness displaced their self-perceptions suffering. Thus in the Chernobyl aftermath,
and roles as breadwinners and paternal figures. illness and health are engendered and made
I traced changing experiences of lichnost', a sense of within the technical and political
Russian-Soviet model of personhood evidenced domain in which they come to be addressed.
BIOLOGICAL CITIZENSHIP 205
crisis that was being successfuJiy controlled by international authority. Legislators assailed the
cutting-edge scientific applications. In an effort Soviet standard for determining biological risk
to alleviate the public's fear, Dr. Gale appeared to populations. The Soviets had established a
on television and walked barefoot in the zone high of 35 rem (a unit of absorbed dose), spread
with one of his children. over an individuaPs lifetime (understood as a
As this internationalization of science standard seventy-year span}, as the threshold of
ensued, however, the physical management of allowable radiation dose intakes. This threshold
contamination at the accident site was internal- limited the scale of resettlement actions. Ukrain-
ized - to the sphere of Soviet state control. One ian law lowered the Soviet threshold dose to 7
policy statement released by the Soviet Health rem, comparable to what an average American
Ministry at the height of these cooperations, would be exposed to in his or her lifetime. In
for example, directed medical examiners in the effect these lowered measures for safe living in-
Zone of Exclusion to "classify workers who creased the size of the labor forces going to the
have received a maximum dose as having "ve- exclusion zone (since workers had to work
getovascular dystonia/' that is, a kind of panic shorter amounts of time if they were to avoid
disorder, and a novel psychosocial disorder exceeding the stricter dose standards}. The
called "radiophobia" (or the fear of the bio- measures also expanded territories considered
logical influence of radiation). These categories contaminated. A significant new sector of the
were used to filter out the majority of disability population would want to claim itself as part
claims. 23 Substantial challenges to this Soviet of a state-protected post-Soviet polity. A bio-
management came from certain labor sectors physicist responsible for conducting retrospect-
in subsequent years. At the end of 1989 only ive dose assays on resettlers told me: "Long lines
130 additional persons were granted disability; of resettlers extended from our laboratory
by 1990, 2,753 more cases had been con- doors. It wasn't enough that they were evacu-
sidered, of which 50 percent were authorized ated to 'clean' areas. People got entangled in the
on a neurological basis. Levels of political in- category of victim, by law. They had unpredict-
fluence of specific labor sectors are reflected in able futures, and each of them wanted to know
the order they received disability: coal miners, their dose."
then Ministry of Internal Affairs workers (the Statistics from the Ukrainian Ministry of
police), and then Transport Ministry workers. Health gave evidence of the sharp increase in
These various labor groups would soon realize 1991 of zone workers, resettled persons and
that in the Ukrainian management of Cherno- inhabitants of contaminated territories regis-
byl, forms of political leveraging had to be tering their disability, and the annual patterns
coupled with medical-scientific know-how. of enrollment of this new population for which
Arguably, the new Ukrainian accounting of the state committed itself to care. The statistics
the Chernobyl unknown was part and parcel of also show that the sharpest increase in the
the government's strategies for "knowledge- clinical registration of illnesses occurred under
based" governance and social mobilization. In the category "symptoms and other inad-
1991 and in its first set of laws, the new parlia- equately known states," Class 16 in the Inter-
ment denounced the Soviet management of national Classification of Disease, lCD 10 (see
Chemobyl as "an act of genocide." The new Figure 17.1}. These states typically include
nation-state viewed the disaster as (among other afflictions such as personality changes, prema-
things) a key means for instituting domestic and ture senility, and psychosis.
Figure 17.1 Symptoms and other inadequately known states {per 10,000)
1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992
1.3 1.7 1.7 1.9 2.3 2.7 5.9 34.7 108.3 127.4 141.3
for, but limited access to, a form of social wel- dose, a protective tie with the state, which is
fare based on medical, scientific, and legal cri- founded on a probability of sickness, a bio-
teria that recognize injury and compensate for logical tie. What she could offer, perhaps the
it. These demands are being expressed in the most precious thing she could offer her child in
context of losses of primary resources such as that context, is a specific knowledge, history,
employment and state protections against in- and category. The child's "exposure" and the
flation and a deterioration in legal-political knowledge that would make that exposure an
categories. Struggles over limited medical empirical fact were not things to be repressed
resources and the factors that constitute a le- or denied (as had been tried in the Soviet
gitimate claim to citizenship are part of post- model) but rather things to be made into a
socialism's uncharted terrain. Against a stark resource and then distributed through informal
and overwhelming order of insecurity, there are means.
questions to be asked about how the value of Specific cases illustrate how these economic
another's life is being judged in this new polit- and state processes, combined with the tech-
ical economy, about the ability of scientific nical dynamics already described, have laid the
knowledge to politically empower those seek- groundwork for such "counter-politics." 29
ing to set that value relatively high, and about Citizens have come to depend on obtainable
the kinds of rationalities and biomedical prac- technologies and legal procedures to gain pol-
tices emerging with respect to novel social, itical recognition and admission to some form
economic, and somatic indeterminacies. The of welfare inclusion. Aware that they had fewer
indeterminacy of scientific knowledge about chances for finding employment and health in
the afflictions people face and about the nature the new market economy, these citizens ac-
of nuclear catastrophe materializes here as counted for elements in their lives (measures,
both a curse and a source of leverage. Ambigu- numbers, symptoms) that could be linked to a
ities related to the interpretation of radiation- state, scientific, and bureaucratic history of
related injury, together with their inextricable mismanagement and risk. The tighter the con-
relations to the social and political uncertain- nection that could be drawn, the greater the
ties generated by Soviet interventions and cur- chance of securing economic and social entitle-
rent political-economic vulnerability, make the ment. This dimension of illness as counterpoli-
scope of the afflicted population in Ukraine tics suggests that sufferers are aware of the way
and its claims to injury at once plausible, politics shapes what they know and do not
ironic, and catastrophic. know about their illnesses and that they are
One instance of how these scientific and put in a role of having to use these politics to
political dynamics operated in the everyday: curb further deteriorations of their health,
the country's eminent expert on matters related which they see as resulting, in part, from a
to the disaster, Symon Lavrov, was well- collapsing state health system and loss of ad-
regarded internationally for having developed equate legal protections.
computerized fallout models and calculating Probability in relation to radiation-related
population-wide doses in the post-Soviet disease became a central resource for local sci-
period. He told me, however, that "when a entific research. This play with probability was
crying mother comes to my laboratory and being projected back into nature, so to speak,
asks me, Professor Lavrov, 'tell me what's through an intricate local science. Young neu-
wrong with my child?' I assign her a dose and ropsychiatrists made the best of the inescap-
say nothing more. I double it, as much as I ability of their political circumstances (they
can." The offer of a higher dose increased could not get visas to leave the country) as they
the likelihood that the mother would be able integrated international medical taxonomies
to secure social protection on account of into Soviet ones and developed classifications
her potentially sick child. Lavrov and the of mental and nervous disorders that in expert
grieving mother were two of the many figures literatures were considered far too low to make
whose efforts I documented. The point is the any significant biological contribution. For
following: the mother could offer her child a example, neuropsychiatrists were involved in
BIOLOGICAL CITIZENSHIP 209
a project designed to find and assess cases of were at work at the state level, at the research
mental retardation in children exposed in utero clinic, and at the level of civic organizations
in the first year after the disaster. In the case of were making their way into the couple's kvar-
one such child, a limping nine-year-old boy, tyra (apartment). Anton's identity as a worker,
researchers and parents pooled their know- his sense of masculinity, and his role as a father
ledge to reconstruct the child's disorder as and breadwinner were being violently dis-
having a radiation origin. Even though the located and altered in the process. In 1986,
boy's radiation dose was low, he was given the state recruited Anton to work for six
the status of sufferer because of his mother's months in the Zone of Exclusion, transporting
occupation-related exposure (she was an emer- bags of lead oxide, sand, and gravel to the
gency doctor who elected to work in the zone reactor site. The bags were airlifted and de-
until late in her pregnancy) and also because a posited using helicopters. He had no idea how
PET scan did reveal a cerebral lesion that was much radiation he absorbed during those
never hypothesized as being related to anything six months. From 1991 on, Anton routinely
other than radiation. (It could have been birth passed through the clinical system, monitored
trauma.) As researchers constructed a human like any "prospective" invalid. His symptoms
research cohort, they were also constructing mounted over time. He had chronic headaches,
a destiny for the newly designated human re- lost his short-term memory, exhibited anti-
search subjects. It was precisely the destiny the social behavior, developed a speech disorder,
parents were intent on offering to this child - a and experienced seizures and impotence, as
biological citizenship. well as many other problems. Despite the
These radiation-related claims and practices growing number and intensity of his symp-
constituted a form of work in this market tran- toms, his diagnosis did not "progress" from
sition. A clinical administrator concurred that an initial listing as a "psycho-social" case.
claims to radiation illness among the Ukrainian When I met Anton and his wife, Halia, they
population amounted to a form of "market were trying to manage on a small pension he
compensation." He told me, "If people could received as a sufferer. Anton saw himself as
improve their family budgets, there would be a bankrupt, morally as well as economically:
lot less illness. People are now oriented to- "The state took my life away. Ripped me off,
wards one thing. They believe that only gone. What is there to be happy about? An
through the constitution of illnesses, and par- honorable man cannot survive now. For what?
ticularly difficult illnesses, incurable ones, can For what? We had a life. We had butter. We had
they improve their family budgets." Adminis- milk. I can't buy an iron. Before I could buy fifty
trators such as he informed me that they should irons. The money was there. My wife's salary is
not to be "blamed too much" for fueling an less than the cost of one iron." He told me that
informal economy of diagnoses and entitle- he did not know "how to trade goods" or to sell
ments. Complicities could be found at every petty goods on the market. His meager pension
level, and the moral conflicts they entailed left Anton with few options. He found himself
were publicly discussed. Another administrator confronting the shameful option of breadwin-
who authenticated compensation claims told ning with his illness in the Chernobyl compen-
me illnesses had become a form of currency. sation system or facing poverty. Over time, and
"There are a lot of people out of work," he in a concerted effort to remove Anton's psycho-
said. "People don't have enough money to social label, the couple befriended a leader of a
eat. The state doesn't give medicines for free disabled workers' activist group in a clinic.
anymore. Drug stores are commercialized.'' He Through him they met a neurologist who knew
likened his work to that of a bank. "The diag- the director of the local medical-labor commit-
nosis we write is money." tee. The couple hoped this individual would pro-
The story of Anton and Halia (age forty- vide official support for Anton's claim of
two in 1997) shows the ways such complicity Chernobyl-related disability.
functioned in the most personal arenas. The The economic motives for these actions
new institutions, procedures, and actors that were clear. Yet it was difficult for me to see this
210 ADRIANA PETRYNA
man giving up everything he knew or thought from the zone do not want to be associated
about himself to prove that his diffused symp- with groups of sufferers as this association
toms had an organic basis. Neurology was a makes it more difficult for them to find
key gateway to disability; neurological dis- employment.
orders were most ambiguous but most possible Chernobyl was a key political event, gener-
to prove using diagnostic technologies, self- ating many effects, some of which have yet to
inducements, and bodily display. At each step, be known; its truths have been made only
Anton was mentally breaking down; he fell partly known through estimates derived from
into a pattern of abusive behavior. His legal- experimental science. The immediate postinde~
medical gamble - this gaining of life in the new pendence discourse in Ukraine centered on the
market economy through illness- reflected the "truth" of Chernobyl. Ukrainians tried to put
practices of an entire citizenry lacking money their suffering in perspective vis-a-vis the
or the means of generating it. This approach repressive model of science and state: the
has become common sense, in Clifford Geertz's number of people who died, how the govern-
words, or that which is "left over when all [the] ment deceived citizens about the scale of the
more articulated sorts of symbol systems have disaster, how the maps of contamination were
exhausted their tasks. " 30 misrepresentative, and so on. As harsh market
When I returned in 2000 to Kyiv to conduct realities entered everyday life, this model of
further research, I discovered that current organizing suffering quickly gave way to a dif-
democratic politicians, many of whom drafted ferent kind of scientific and political negoti-
the original compensation laws as sovereignty- ation, one which had directly to do with the
minded nationalists, now saw the Chernobyl maintenance, and indeed the remaking, of a
compensation system as a dire mistake that has postsocialist state and population.
"accidentally" reproduced a socialist-like If, at the level of the modern state, spheres
population. Funds and activist groups were of scientific production and politics are in a
now supported by socialist and communist constant process of exchange and mutual sta-
leaderships, who lobbied for continued aid in bilization, then what I have suggested here is
an increasingly divided parliament. Mean- that stabilization proves to be a much more
while, international agencies such as the World difficult task. At stake in the Chernobyl after-
Bank cited the Chernobyl social apparatus as a math is a distinctive postsocialist field of
"dead weight" to Ukraine's less-than-ideal power~in-the-making that is using science and
transition to a market economy. Bank officials scientific categories to establish the state's
were so ill-disposed toward the system that reach. Scientists and victims are also establish-
they made its quick extinction a condition of ing their own modes of knowledge related to
future loan contracting. The disappearance of injury as a means of negotiating public
this exposed population from the state's radar accountability, political power, and further
seems ever more likely. Once "protected" by a state protections in the form of financial com~
safety-conscious state, this exposed population pensation and medical care. Biology becomes a
is being left alone to their symptoms and social resource in a multidimensional sense- versatile
disarray. material through which the state and new
Opinions about how the state should ad- populations can be made to appear. This post-
dress the fate of these Chernobyl victims also socialist field of power has specific physical,
serve as a kind of barometer of the country's experiential, political, economic, and spatial
changing moral fabric. Rural inhabitants who aspects. It is about knowledge and constructed
normally received the least in terms of socialist ignorance, visibility and invisibility, inclusion
redistribution tended to be sympathetic to the and exclusion, probabilities and facts, and the
victims' struggles. Among inhabitants of Kyiv parceling out of protection and welfare that
and other urban centers, there is a growing do not fit predictive models. It is also about
consensus that the invalids are "parasites of how individuals and populations become part
the state, damaging the economy, not paying of new cooperative regimes in scientific re-
taxes." Many youths who had been evacuated search and in local state-sponsored forms of
BIOLOGICAL CITIZENSHIP 211
human subjects protection. In this context, exchange rates were as follows: 1997
suffering is wholly appropriated and objecti- Hrn1.84:US$1; 1998 - 2.04:$1; 1999 -
fied in its legal, economic, and political dimen- 4.13:$1; 2000-5.44:$1.
sions. At the same time, these objectifications 9 Frank von Hippe!, Citizen Scientist (New
constitute a common sense that is enacted by York, 1991), 235.
sufferers themselves in ways that can promote 10 Ulrich Beck, "The Anthropological Shock:
protection as well as intensify new kinds of Chernobyl and the Contours of a Risk Soci-
vulnerability in domestic, scientific, and bureau- ety," Berkeley Journal of Sociology 32
(1987): 153-65.
cratic spheres.
11 In Russia, the number of people considered
affected and compensable has been kept to a
NOTES minimum and remains fairly stable (about
350,000, including 300,000, Zone of Exclu-
Clifford Geertz, Local Knowledge: Further sion laborers and 50,000 resettled).
Essays in Interpretive Anthropology (New 12 Oleg Kharkhordin, The Collective and the
York, 1983), 92. Individual in Russia: A Study of Practices
2 Adriana Petryna, Life Exposed: Biological (Berkeley, Calif., 1999).
Citizens After Chernobyl (Princeton, 2002). 13 Arthur Kleinman, Social Origins of Distress
3 Arthur Kleinman and Joan Kleinman, "The and Disease (New Haven, Conn., 1986).
Appeal of Experience; The Dismay of Images: 14 Emily Martin, Flexible Bodies: Tracking Im-
Cultural Appropriations of Suffering in Our munity in American Culture from the Days
Times," Daedalus 125 (1999): 1-24. See also of Polio to the Age of AIDS {Boston, 1994 );
Veena Das, Critical Events: An Anthropo- Rayna Rapp, Testing Women, Testing the
logical Perspective on Contemporary India Fettts: The Social Impact of Amniocentesis
(Oxford, 1995). I use pseudonyms for the ma- on America (New York, 1999); Joseph Du-
jority of people interviewed for this essay. mit, Picturing Personhood: Brain Scans and
Names that appear in scientific and legal print Biomedical Identity (Princeton, N.J., 2004).
are in some cases actual. 15 Paul Farmer, Infections and Inequalities: The
4 See Soviet State Committee on the Utilization Modern Plagues (Berkeley, Calif., 1999), 5.
of Atomic Energy, Report to the IAEA 16 One Decade After Chernobyl (Vienna,
(Vienna, 1986), 16. 1996).
5 See Alexander Sich, "The Denial Syndrome 17 ARAC is a national emergency response ser-
(Efforts to Smother the Burning Nuclear Core vice for real-time assessment of incidents in-
at the Chernobyl Power Plant in 1986 Were volving nuclear, chemical, biological, or
Insufficient)," Bulletin of Atomic Scientists 52 natural hazardous material.
{1996): 38-40. 18 Sullivan's team offered technical assistance
6 See Yurii Shcherbak, "Ten Years of the through a Swedish intermediary, but the
Chernobyl Era," Scientific American, April offer was refused by Soviet administrators.
1996,46. 19 Soviet State Committee on the Utilization of
7 Estimates vary from 600,000 to 800,000. Atomic Energy, The Accident at Chernobyl
These workers came from all over the Soviet Nuclear Power Plant and Its Consequences.
Union. The labor pool, however, drew heavily Information complied for the IAEA Expert's
from the Russian and Ukrainian populations. Meeting. Aug. 25-29, 1986, Vienna; Zhores
8 The karbovanets (Krb) was Ukraine's legal Medvedev, The Legacy of Chernobyl (New
tender from 1992 to 1996. Exchange rates York, 1990).
per US$1.00 plunged between 1992 and 20 Loren Graham, What Have We Learned
1993. In March 1992, the exchange rate was about Science and Technology from the Rus-
Krb640:$1. By March 1993, that rate had sian Experience? (Stanford, Calif., 1998).
fallen to Krb12,610:$1. Subsequent rates 21 Symptoms of acute radiation sickness begin
were as follows: 1994 - Krb104,200:US$1; at 200 rem. At 400 rem, bone marrow fail-
1995- 179,900:$1; 1996- 188,700:$1. The ure sets in. Lethal dose {LD100) is a dose
hryvnia (Hrn) replaced the karbovanets at exposure that causes 100 percent of the
Hrn1: KrblOO,OOO in September 1996. The death of cells or the human. LDS0/30 is a
212 ADRIANA PETRYNA
dose exposure that causes 50 percent of the 26 For an elaboration of the concept of blat, see
death of cells or the human within thirty Alena Ledeneva, Rttssia's Economy of
days. Favours: Blat, Networking, and Informal
22 Robert Proctor, Cancer Wars: How Politics Exchange (Cambridge, 1998).
Shapes What We Know and Don't Know 27 Michael Burawoy and Katherine Verdery,
about Cancer (New York, 1995), 7. Uncertain Transition: Ethnographies of
23 In my interviews, I heard instances of workers Change in the Postsocialist World (Lanham,
mimicking symptoms of ARS (vomiting, for Md., 1999), 2.
example). This shows the level of desperation 28 Dominique Schnapper, "The European Debate
on the part of some of them to receive permis- on Citizenship," Daedalus 126 (1997): 201.
sion to leave the zone. 29 Colin Gordon, "Government Rationality:
24 World Bank, Managing the Legacy of Cher- An lntroduction," in The Foucault Effect:
nobyl (Washington, D.C., 1994), 7:6. Studies in Governmentality, ed. G. Burchell,
25 Ian Hacking, Taming of Chance (Cam- C. Gordon, and P. Miller (Chicago, 1991), 5.
bridge, 1990). 30 Geertz, Local Knowledge (cit. n. 1).
18
Human Pharmakon
Symptoms, Technologies,
Subjectivities
]oao Biehl
joao Biehl, "Human Pharmakon: Symptoms, Technologies, Subjectivitics." Written especially for this volume.
214 JOAO BIEHL
"They say that it is better to place us here so social ties. People's practices of survival and
that we don't have to be left alone at home, in inquiry, their search for symbolic authority,
solitude . . . that there are more people like us challenge the analytic forms we bring to the
here. And all of us together, we form a society, field, forcing us to articulate more experience-
a society of bodies." And she added: "Maybe near and immediately relevant conceptual
my family still remembers me, but they don't work.
miss me." I picked up the dictionary and read aloud
Catarina had condensed the social rea- some of her free-associative inscriptions: "Docu-
soning of which she was the human leftover. I ments, reality, truth, voracious, consumer,
wondered about her chronology and about saving, economics, Catarina, pills, marriage,
how she had been cut off from family life and cancer, Catholic church, separation of bodies,
placed into Vita. How had she become the division of the estate, the couple's children."
object of a logic and sociality in which people The words indexed the ground of Catarina's
were no longer worthy of affection and ac- existence; her body had been separated from
countability, though they were remembered? those exchanges and made part of a new
And how was I to make sense of these intimate society.
dynamics if not by trusting her and working What do you mean by the "separation of
through her language and experience? bodies"?
Philosopher Giorgio Agamben (1998) has "My ex-husband kept the children."
significantly informed contemporary biopoliti- When did you separate?
cal debates with his evocation of the homo "Many years ago."
sacer and the assertion that "life exposed to What happened?
death" is the original element of Western dem- "He had another woman."
ocracies (p. 4}. This "bare life" appears in She shifted back to her pain: "I have these
Agamben as a kind of historical-ontological spasms, and my legs feel so heavy."
destiny - "something presupposed as nonrela- When did you begin feeling this?
tional" and "desubjectified" (1999). A number "After I had Alessandra, my second child, I
of anthropologists have critiqued Agamben's already had difficult walking . . . My ex-hus-
apocalyptic take on the contemporary human band sent me to the psychiatric hospital. They
condition and the dehumanization that accom- gave me so many injections. I don't want to go
panies such melancholic, if poignant, ways of back to his house, he rules the city of Novo
thinking (Das and Poole 2004; Rabinow and Hamburgo."
Rose 2006). Did the doctors ever tell you what you had?
Whether in social abandonment, addiction, "No, they said nothing.'' She suggested that
or homelessness, life that no longer has any something physiological had preceded or was
value for society is hardly synonymous with related to her exclusion as mentally ill, and that
a life that no longer has any value for the her condition worsened in medical exchanges.
person living it (Biehl 2007; Bourgois and "I am allergic to doctors. Doctors want to be
Schonberg 2009; Garcia 2008}. Language and knowledgeable, but they don't know what
desire meaningfully continue even in circum- suffering is. They only medicate." Catarina
stances of profound abjection. Such difficult knew what had made her an abject figure in
and multifaceted realities and the fundamen- family life, in medicine, in Brazil - "I know
tally ambiguous nature of people living them because I passed through it."
give anthropologists the opportunity co de- "When my thoughts agreed with my ex-
velop a human, not abstractly philosophical, husband and his family, everything was fine,"
critique of the non-exceptional machines of Catarina recalled, as we continued the conver-
social death and (self) consumption in which sation later that day. "But when I disagreed
people are caught. Against all odds, Catarina with them, I was mad. It was like a side of
and many others keep searching for contact me had to be forgotten. The side of wisdom.
and for ways to endure, at times reworking They wouldn't dialogue, and the science of the
and sublimating symptoms in their search for illness was forgotten. My legs weren't working
HUMAN PHARMAKON 215
well . . . My sister-in-law went to the health to untie it all: "Science is our consciousness,
post to get the medication for me." heavy at times, burdened by a knot that you
According to Catarina, her physiological cannot untie. If we don't study it, the illness in
deterioration and expulsion from reality had the body worsens .... Science ... If you have a
been mediated by a shift in the meaning of guilty conscience, you will not be able to dis-
words, in the light of novel family dynamics, cern things."
economic pressures, and her own pharmaceut- "After my ex-husband left me," she con-
ical treatment. "For some time I lived with my tinued, "he came back to the house and told
brothers ... But I didn't want to take medica- me he needed me. He threw me onto the bed
tion when I was there. I asked: why is it only saying, 'I will eat you now.' I told him that that
me who has to be medicated? My brothers was the last time . . . I did not feel pleasure
want to see production, progress. They said though. I only felt desire. Desire to be talked
that I would feel better in the midst of other to, to be gently talked to."
people like me." In abandonment, Catarina recalled sex.
You seem to be suggesting that your family, There was no love, simply a male body
the doctors, and the drugs played an active role enjoying itself. No more social links, no more
in making you "mad," I said. speaking beings. Out of the world of the living,
!"I behaved like a woman. Since I was a her desire was for language, the desire to be
housewife, I did all my duties, like any other talked to.
woman . . . My ex-husband and his family
got suspicious of me because sometimes I left
the house to attend to other callings. He Contemporary Symptoms
thought that I had a nightmare in my head.
He wanted to take that out of me, to make a In this essay, I explore Catarina's ties to
normal person. I escaped so as not to go to pharmakons and chart the interpersonal and
the hospital. I hid myself; I went far. But the medical crossroads in which her life chances
police and my ex-husband found me. They took took form. As she wrote:"Not slave, but
my children. I felt suffocated. I also felt my legs housewife. Wife of the bed. Wife of the room.
burning, a pain, a pain in the knees, and under Wife of the bank. Of the pharmacy. Of the
the feet." Catarina added that "He first placed laboratory . . . The abandoned is part of life."
me in the Caridade Hospital, then in the Sao Her "ex-family," she claims, thinks of her as a
Paulo - seven times in all. When I returned failed drug regimen. The family is dependent
home, he was amazed that I recalled what a on this explanation as it excuses itself from
plate was. He thought that I would be uncon- her abandonment. In her words: "To want my
scious to plates, plans, and things and conscious body as a medication, my body." Catarina
only of medications. But I knew how to use fights the disconnections that psychiatric drugs
the objects.'' introduced in her life - between body and
Through her increasing disability, all the spirit, between her and the people she knew,
social roles Catarina had forcefully learned to in common sense - and works through the
play - sister, wife, mother, worker, patient - many layers of (mis)treatment that now com-
were being annulled, along with the precarious pose her existence. While integrating drug
stability they had afforded her. To some degree, experience into a new self-perception (the
these cultural practices remained with her as drug AKINETON which is used to control
the values that motivated her memory and her the side effects of anti-psychotics is literally
sharp critique of the marriage and the extended part of the new name Catarina gives herself
family who had amputated her as if she had in her notebooks: CATKINE) she keeps seeking
only a pharmaceutical consciousness. But she camaraderie and another chance at life.
resisted this closure, and in ways that I could I find Jacques Lacan,s theoretical investiga-
not fully grasp at first, Catarina voiced an tion of "Le Sinthome, (an ancient way of
intricate ontology in which inner and outer writing what would later be called symptom -
state where laced together, along with the wish 2005} especially helpful for this inquiry into
216 JOAO BIEHL
the relationship between symptoms, medical the creat1v1ty of ethnography arises from
technologies, and subjectivities. In his 1975- this effort to give form to people's own pains-
76 Seminar, Lacan elaborated on the concept taking arts of living and the unexpected
of the sinthome as the enigmatic fourth elem- potentials they create, and from the descrip-
ent that tied the imaginary, the symbolic and tive work of giving these observed tensions
the real together (p.21). With a nature of an equally powerful force in our own
their own, symptoms convey the inextricably accounting.
knotted processes of identity. They are the Catarina's "little pieces of writing'' evince
support of subjects trying to organize the com- pain and an ordinary life force seeking to break
plex relationship between body and language; through forms and foreclosures and define a
in Lacan's words, "We recognize ourselves only kind of subjectivity that is as much about
in what we have. We never recognize ourselves swerves and escapes as about determinations.
in what we are" (p. 120). By working with Catarina I came to see that
In classic psychoanalysis, symptoms are subjectivity is neither reducible to a person's
addressed to the analyst and might be dissolved sense of herself nor necessarily a confron-
through interpretation and analytic work- but tation with the powers that be. It is rather the
the sinthome, Lacan argues, testifies to the material and means of a continuous process
persistence of the traumatic Real. Trauma is of experimentation - inner, familial, medical,
an event that remains without the possibility and political. Always social, subjectivity en-
of symbolization. Or as Zi:zek (1989) puts it, compasses all the identifications that can be
the sinthome is "an inert stain resisting com- formed by, discovered in, or attributed to the
munication and interpretation, a stain which person. Although identity-making mechanisms
cannot be included in the circuit of discourse, are quite difficult to detect, this process of
of social bond network, but is at the same subjective experimentation is the very fabric
time a positive condition of it" (p. 75). Lacan of moral economies and personal trajectories
said he learned from Joyce ("he was the that are all too often doomed not to be ana-
sinthome") that it is only through art and lyzed. I am thinking here of a diffused form
"these little pieces of writing" that we can "his- of control that occurs through the remaking
torically enter the Real" (2005, p.68), undo of moral landscapes as well as the inner trans-
supposed truths, and reinvent and give sub- formations of the human subject (Biehl et al.
stance to the sinthome. As Lacan states, "it is 2007; Jenkins and Barrett 2003 ).
the knot that gives writing its autonomy" Subjectivities have quickly become "raucous
(p.140). terrae incognitae" for anthropological inquiry,
This attention to the vision and work of writes Michael M. J. Fischer: "landscapes of
sublimation can also inspire ethnographers: explosions, noise, alienating silences, discon-
Listening as readers and writers, rather than nects and dissociations, fears, terror machin-
clinicians or theoreticians, our own sensibility eries, pleasure principles, iiJusions, fantasies,
and openness become instrumental in spurring displacements, and secondary revisions, mixed
social recognition of the ways ordinary people with reason, rationalizations, and paralogics -
think through their conditions. While Lacan all of which have powerful sociopolitical di-
builds on Joyce, anthropologists bring back mensions and effects" (2007: 442). As Catarina
the everyday stories and writings of characters conveys, subjectivity does not merely speak as
that might otherwise remain forgotten, with resistance, nor is it simply spoken (or silenced)
attention to the ways their own struggles and by power. It continually forms and returns in
visions of themselves create holes in domi- the complex play of bodily, linguistic, political,
nant theories and policies. Ethnographic and psychological dimensions of human ex-
details reveal nuanced fabrics of singularities perience, within and against new infrastruc-
and the worldliness, rather than exceptional- tures and the afflictions and injustices of the
ity, of people's afflictions and struggles; they present {see Corin 2007; M. Good et al. 2008;
make explicit the concreteness of processes Kleinman 2006; Petryna 2009; Tsing 2004 ). To
and failed or foreclosed anticipations. Perhaps grasp the wider impact of how medical
HUMAN PHARMAKON 217
technologies are becoming interwoven in the conceptions of political belonging and ideas of
very fabric of symptoms and notions of well- what life is for begin to take shape. As interrela-
being, we must account comparatively for the tions such as kinship become mediated by
ways such life forms are fundamentally altering technology in new ways, we need to account
interpersonal relations, domestic economies, for novel social realities as pharmaceuticals
and identity-making processes in both aff- and other health technologies open up and
luent and resource-poor contexts (Fassin and relimit family complexes and human values -
Rechtman 2009; Pinto 2008; Reynolds Whyte as well as for the agency that solitary and chem-
2009). The study of individual subjectivity as ically submerged subjects such as Catarina/
both a strategy of existence and a material CATKIN£ express and live by.
and means of sodality and governance helps In a 1972lecture, Lacan said that capitalism
to recast totalizing assumptions of the work- was now the new discourse of the master and
ings of collectivities and institutions (Scheper- as such it overdetermined social bonds (see
Hughes 2008). It also holds the potential to Declercq 2006; Zizek 2006). He spoke of the
disturb and enlarge presumed understandings effects of an absolutization of the market: Sub-
of what is socially possible and desirable. jects do not necessarily address each other to be
In many ways, Catarina was caught in recognized but experience themselves in the
a period of political economic and cultural market's truths and commodities (increasingly
transition. Since the mid-1990s, Brazilian pol- a bioscientific market - Petryna 2009, Rajan
iticians have deftly reformed the state, com- 2006). Although people might have access to
bining a respect for financial markets and the products of science, those countless objects
innovative and targeted social programs. Many are made to never completely satiate their de-
individuals and families have benefited from sires or the desires of those who mediate the
pharmaceutical assistance and income distribu- access to technologies (Biehl et al. 2001 ). A few
tion programs, for example. An actual redistri- years earlier, Lacan stated, "The consumer so-
bution of resources, powers, and responsibility ciety has meaning when the 'element' that we
is taking place locally of these large-scale qualify as human is given the homogenous
changes and for larger segments of the pop- equivalent of any other surplus enjoyment that
ulation, one could argue, citizenship is increas- is a product of our industry, a fake surplus
ingly articulated in the sphere of consumer enjoyment" (1991, p. 92). Or, as Catarina sug-
culture (Caldeira 2000; Edmonds 2007). Yet, gests, these days one can conveniently become
without adequate investments in infrastruc- a medico-scientific thing and ex-human for
tural reforms, many families and individuals others. In the contemporary version of the
are newly overburdened as they are suffused astute capitalistic discourse we seem to be all
with the materials, patterns and paradoxes of proletariat patient-consumers, hyperindividua-
these various processes and programs, which lized psycho-biologies doomed to consume
they are, by and large, left to negotiate alone. diagnostics and treatments (for ourselves and
As institutional care becomes increasingly surrounding others) and to experience fast suc-
outsourced to entrepreneurs and local commu- cess or self-consumption and lack of empathy.
nities, and as powerful pharmaceutical drugs Or, can we fall for science and technology in
circulate without even a doctor visit, human different and more lively and caring ways?
relationships to medical technology are increas- By staying as close as I could, for as long as I
ingly constituted outside the clinical encounter. could, to Catarina's struggles to articulate
New populations and forms of intimacy are desire, pain, and knowledge, I also came to
now emerging around technology at commu- see the specificity and pathos of subjectivity
nity and domestic levels, as in the case of and the possibilities it carries. While her sense
large-scale AIDS treatment and the massive of herself and of the world was perceived as
and often unregulated dissemination of psychi- lacking reality, Catarina found in thinking and
atric drugs. Amid the "pharmaceuticalization writing a way of living with what would other-
of public health, (Biehl 2007) and in the daily wise be unendurable. Thus, subjectivity also
rituals of medication and adherence, new contains creativity, the possibility of the subject
218 JOAO BIEHL
and ways of being that have emerged in the to show that drugs have an entirely different
wake of this pharmaceuticalization of mental causality" than sexuality or the oedipal theory.
health in the service of a diffused form of gov- The libido folJows world-historical trajector-
ernance and of market expansion. ies, be they customary or exceptional. And
Back to Deleuze, for a moment, to the time real and imaginary voyages compose an inter-
when psychiatric markets had not yet further stitching of routes that must be read like a
confounded the drug scene. For him, the ques- map. These internalized trajectories are insep-
tion about whether drugs do have a "specific arable from becomings (Deleuze 1997:61-67).
causality" does not imply exclusively a scien- Deleuze thus distinguishes his cartographic
tific (i.e., chemical) cause on which everything conception of the unconscious from the arch-
else would depend. Likewise, Deleuze makes aeological conception of psychoanalysis.
clear that he was not after a metaphysical "From one map to the next, it is not a matter
causality or identifying transcendental organ- of searching for an origin, but of evaluating
izational planes that would determine popular displacements" (1997:63). Every map is a re-
drug use. After all, Deleuze did not share Mi- distribucion of impasses, of breakthroughs,
chel Foucault's confidence concerning power thresholds and enclosures on the ground. "It
arrangements. In a 1976 article called "Desire is no longer an unconscious of commemoration
and Pleasure," Deleuze reviewed Foucault's but one of mobilization" (idem). Unconscious
then recently published The History of Sexual- materials, lapses and symptoms are not just to
ity (1976). In that book, Foucault took a be interpreted, but rather it is a question of
new step with regard to his earlier work in identifying their trajectories to see if they can
Discipline and Punish (1975): now power ar- serve as indicators of a new universe of refer-
rangements were no longer simply normaliz- ence, "capable of acquiring consistency suffi-
ing; they were constituents of sexuality. But "I cient for turning a situation around." Maps
emphasize the primacy of desire over power," should not only be understood in terms of
wrote Deleuze. "Desire comes first and seems extension, of spaces constituted by trajectories,
to be the element of a micro-analysis ... adds Deleuze: "There are also maps of inten-
Desire is one with a determined assemblage, a sity, of density, that are concerned with what
co-function" (2006:126). fills the space, what subtends the trajectory"
Attentive to historical preconditions and (64).
singular efforts of becoming, Deleuze said that Thus, when it comes to studying the do-
he pursued "lines of flight." For him "all organ- main of drugs, Deleuze brings desire into view
izations, all the systems Michel calls biopower, as part and parcel of drug assemblages. He
in effect reterritorialize the body" (2006:131; speaks of specific "drug-sets" engendered by
see Foucault 2007). But a social field, first and the flows of drugs and people and of the need
foremost, "leaks out on all sides" (ibid.: 127). to map their territory or contours. "On the one
In an interview with Paul Rabinow in the mid- hand, this set would have an internal relation-
1980s, Deleuze once again emphasized that ship to various types of drugs and, on the
he and Foucault did not have the same concep- other to more general causalities" (2006:151).
tion of society. "For me,'' he said, "society is Deleuze is particularly concerned with "how
something that is constantly escaping in every desire directly invests the system of perception''
direction.... It flows monetarily, it flows ideo- of both drug users and non-users (families
logically. It is really made of lines of flight. So and experts, for example) and how systems of
much so that the problem for a society is how perception (especially space-time perception)
to stop it from flowing. For me, the powers are connected to more general external cau-
come later" (2006:280). salities (contemporary social systems, chem-
The analytics of biopolitics and of normal- ical research, and therapeutics). This project
ization cannot fully account for the drug phe- would require, it seems, a distinctive ethno-
nomenon, nor can the Freudian unconscious. graphic sensibility and new analytical tools.
The failure of psychoanalysis in the face of This sensibility and tools would address the
drug phenomena, Deleuze argues, "is enough ways drug consumption/dependence are at
220 JOAO BIEHL
once a chemical, intimate, social, and eco- 2003, I took numerous trips to southern Brazil
nomic matter, and how historical changes and to work with Catarina, sometimes for weeks,
techno-political apparatuses coalesce around sometimes for months. Catarina's puzzling
drugs and in the emergence of new kinds of language required intense listening. And I have
subjectivities and social pathways as well as chosen to listen to her on a literary rather
new kinds of expertise and authority. than on a clinical register. Since the beginning,
Deleuze is also concerned with the extent I have thought of her not in terms of mental
to which "microperceptions are covered in illness but as an abandoned person who,
advance" and whether there is variation in against all odds, was claiming experience on
dependence built into drugs (2006:153). "The her own terms. She knew what had made her
drug user creates active lines of flight. But these a void in the social sphere - "I am like this
lines roll up, start to turn into black holes, with because of life" - and she organized this know-
each drug user in a hole, as a group or individu- ledge for herself and for her anthropologist,
ally, like a periwinkle. Dug in instead of spaced thus bringing the public into Vita. "I learned
out" (idem). For Deleuze, two things must be the truth and I try to divulge what reality is.''
distinguished: the domain of vital experimen- Catarina's free and elusive verse slowly
tation and the domain of deadly experimenta- began to shape the terms of my own inquiry
tion. "Vital experimentation begins when any and cognition. "]oao Biehl, Reality, CAT-
trial grabs you, takes control of you, establish- KINE." I studied all the twenty-one volumes
ing more and more connections, and opens you of the dictionary Catarina was composing and
to connections'' (idem). This kind of experi- discussed the words and associations with her.
mentation can blend with other flows, drugs, Her knowledge revealed complicated realities.
and dangers. "The suicidal occurs when every- In her recollections and writing, I found clues
thing is reduced to this flow alone: 'my' hit, to the people, sites, and interactions that
'my' trip 'my' glass. It is the contrary of con- constituted her life. As an anthropologist, I
nection; it is organized disconnection'' (idem). was challenged to reconstruct the worldliness,
In what follows, I revisit my ethnographic the literality of her words. With Catarina's
data and Catarina's writing. I further explore consent, I retrieved her records from psychi-
1) the treatment constellation (or "drug-set" in atric hospitals and local branches of the univer-
Deleuze's words) in which Catarina became the sal health care system. I was also able to locate
woman who no longer exists - "My ex did her "ex-family" members in the nearby city of
everything to get medication;" "I am a seda- Novo Hamburgo. On a detective-like journey,
tive" - and the knowledge she produced as I discovered the threads of her life. Everything
an abandoned psychopharmaceutical subject; she had told me about the familial and medical
2) How Catarina redirected her clinical and pathways that led her into Vita matched with
familial abandonment and invented a new the information I found in the archives and
name and an alternative existential stage for in the field. As I juxtaposed her words with
herself with whatever means she had available, medical records, family versions and consider-
particularly writing - "The pen between my ations, I was able to identify those noninstitu-
fingers is my work. I am convicted to death., tionalized operations that ensured Catarina's
Writing as a therapeutic means, as a possibility exclusion and that are, in my view, the missing
of life: "To be well with all, but mainly with contexts and verbs to her disconnected words.
the pen." The verb to km was being conjugated and
she knew it: "Dead alive, dead outside, alive
inside."
The Body as Medication Catarina was born in 1966, and grew up in
a very poor place, in the western region of the
People's everyday struggles and interpersonal state of Rio Grande do Sui. After finishing
dynamics exceed experimental and statistical fourth grade, she was taken out of school and
approaches and demand in-depth listening became the housekeeper as her youngest sib-
and long-term engagement. From 2000 to lings aided their mother in agricultural work.
HUMAN PHARMAKON 221
The father had abandoned the family. In the applied medical technologies blindly, with little
mid-1980s, two of her brothers migrated and calibration to her distinct condition. Like many
found jobs in the booming shoe industry in patients, Catarina was assumed to be aggres-
Novo Hamburgo. At the age of eighteen, Cat- sive and thus was overly sedated so that the
arina married Nilson Moraes, and a year later institution could continue to function without
she gave birth to her first child. Shady deals, providing adequate care.
persistent bad harvests and indebtedness to Although Catarina's diagnosis has softened
local vendors forced Nilson and Catarina to over the years (mimicking psychiatric trends),
sell the land they inherited to take care of she continued to be overmedicated with power-
Catarina's ailing mother, and in the mid- ful antipsychotics and all kinds of drugs to
1980s, the young couple decided to migrate treat neurological side effects (such as Akine-
and join her brothers in the shoe industry. In ton). On several occasions, nurses reported
the coming years, she had two more children. hypotension, a clear indicator of drug over-
As her illness progressed and her marriage dis- dose. Consider this entry from March 9,
integrated, her eldest two children went to her 1992: "Patient is feeling better, dizzy at time.
husband's family, and her youngest daughter She keeps saying that she needs to sign her
was given up for adoption. divorce. She says that she is no longer hearing
Catarina was first hospitalized at Porto Ale- God talking to her. As patient walks, she
gre's Caridade Hospital in April 27, 1988. The stumbles and leans against the walls. Patient
psychiatrist who admitted her recalled what complains of strong pains in her legs." For
he heard from the neighbor who brought her Catarina, as for others, treatment began
in: "Patient experienced behavioral changes in with a drug surplus and was then scaled down,
the past weeks, and they worsened two weeks or not, through trial and error. As I read her
ago. Patient doesn't sleep well, speaks of mys- medical records, I could not separate the
ticaUreligious matters, and doesn't take care symptoms of the psychiatric illness from the
of herself and the house. She says that God effects of the medication, and I was struck that
gives signs to her when people mock or doubt doctors actually did not bother to differentiate
her, and that she has received a gift of transmit- between the two in Catarina.
ting her thoughts to people." The doctor To say that this is "just malpractice," as a
reported that she "had no clinical ailments local psychiatrist puts it, misses the productive
and no psychiatric history." Catarina was quality of this unregulated medical autom-
placed in a unit for chronic schizophrenic pa- atism and experimentalism: Pharmaceuticals
tients. The doctor prescribed: Hal dol, Neozine, are literally the body that is being treated.
Mogadon, and Akineton. At discharge, her And the process of overmedicating Catarina
diagnosis was "Acute paranoid reaction." caused many of the symptoms that she called
In multiple admissions at the Caridade and "rheumatism." As doctors remained fixated
Sao Paulo Hospitals between 1988 and 1995, on her "hallucinations," the etiology of her
the diagnosis given to Catarina varied from walking difficulties, which nurses actually
"schizophrenia" to "post-partum psychosis" reported, remained medically unaddressed.
to "unspecified psychosis" to "mood disorder" The medical records also showed that her
to "anorexia and anemia." In tracing Catari- husband and family were difficult to contact,
na's passage through these psychiatric institu- that they left wrong telephone numbers and
tions, I saw her not as an exception but as a addresses, and that, on several occasions, they
patterned entity. Caught in struggles for dein- left Catarina in the hospital beyond her desig-
stitutionalization, lack of public funding, and nated stay.
the proliferation of new classifications and I visited the Novo Hamburgo psychosocial
treatments, the local psychiatry didn't account service where Catarina was serviced in be-
for her particularity or social condition. Thus, tween hospitalizations. I found the following
she was subjected to the typically uncertain record by a nurse, written in December 12,
and dangerous mental health treatment re- 1994: "I drove Catarina home. But as she
served for the urban working poor. Clinicians now lives alone, I left her at the house of her
222 JOAO BIEHL
mother-in-law, called Ondina. Catarina was Dr. Justus then expanded on the family's
badly received. The mother-in-law said that Cat- role in fostering illness: "When patients im-
arina should die, because she was stubborn and proved - and we saw this quite often at the
aggressive, didn't obey anyone, and didn't take Caridade - families discontinued treatment,
her medication." and the person had to be hospitalized again."
"We have at least five hundred Catarinas Crisis situations were constantly induced. The
in here right now," told me Simone Laux, the relation between the family and mental illness,
coordinator of the service, after I told her I was told, is made explicit in the cui ture of
about Catarina and my work with her. By psychopharmaceuticals: "In our group ses-
"five hundred Catarinas," she meant most sions, we can see that the fragility of a minimal
of the female clientele of the service which social integration is revealed in everyone's rela-
was treating around fifteen hundred people a tion to the medication, the fight over its discon-
month. About half of the clients got free psychi- tinuation, the lack of money to buy it, or the
atric drugs at the city's community pharmacy. problems with forgetting to take it." Families,
"When the service began in the late 1980s, it in fact, come into the service demanding medi-
was meant to deal mainly with schizophrenia cines: "When I ask them to tell their story," said
and psychosis," reported psychologist Wildson Ruckert, "many times they say, 'No, I came
Souza, "but this has changed a lot, both diag- here to get a medication for her.' They want
nostically and numerically. There is an im- to leave with a prescription."
mense growth of mood disorders." Souza In sum, the family crystallizes its way of
cited "unemployment, harsh struggle to sur- being in the ways it deals with psychiatric
vive, no opportunities for social mobility, drugs. "Bottom line," Ruckert continued, "the
urban violence" as contributing to this "epi- type of ethics the family installs serves to guar-
demic of mental suffering." And suggested that antee its own physical existence.'' The decision
the service had become the vanishing social to make persons and things work or to let them
world, the welfare state, and the social medi- die is at the center of family life. And science, in
cine that was no more: "Many factories are the form of medication, brings a certain neu-
closed, people don't have jobs or health plans trality to this decision-making process. "In the
or family support ... They need some form of meetings/' added Ruckert, "the patient quite
recognition and help, and they demand it from often realizes that, given the continuing process
SUS [the universal healthcare system]. Nothing of exclusion, she has already structured her
is isolated." own perception and codification of reality."
"We have three women's groups here," con- Rather than psychosis, out of all these pro-
tinued Laux: "Most of them are not psychotic. cesses a para-ontology comes into view - a
But at some points in their lives, they had a Being beside itself and standing for the destiny
crisis or were at risk of committing suicide. of others. The "irreversible" condition of the
All of them have a story that resembles Catar- mentally afflicted gives consistency to an
ina's." Daniela Justus, the service's psychiatrist, altered common sense (Geertz 2000). "She died
replied: "Catarina is not searching for a diag- socially," said Laux pushing the conversation
nostics, but for life." Catarina's story shows back to Catarina. "That is the pain that aches
that the patterning of the mass patient and her in us . . . when we realize this: she cannot opt
dying at the crux between abandonment and to live."
overmedication are both public and domestic
affairs, I noted. "Indeed," replied psychologist
Luisa Ruckert, "families organize themselves Biological Complex
so that they are no longer part of the treatment
and care." The major exception is when cash is In August 2002, I was able to get the genetics
involved, stated Andreia Miranda, the service's service of the Hospital das Clinicas, one of
occupational therapist. "Families keep their the ten best in the country, to see Catarina.
mentally ill relatives as long as they can manage Fourteen years after entering the maddening
their disability income." psychiatric world, molecular testing revealed
HUMAN PHARMAKON 223
that she suffered from a genetic disorder called condition was part of a regularity, forged in
Machado-Joscph disease, which causes degen- all those public spaces and hazy interactions
eration of the central nervous system (Jardim where a rapidly changing country, family, and
et al. 2001). Her brothers had the same cliag- medicine met.
nostics. I was happy to hear the geneticists who In ancient Greece, every year two men -
saw Catarina say that "she knew of her condi- "true scum and refuse" - were chosen to be
tion, past and present, and presented no path- cast out of cities, as part of the festival of the
ology." Dr. Laura Jardim was adamant that Thargelia (Harrison 1921: 97). Initially, they
"there is no mental illness, psychosis or demen- were seen as the remedy for a city suffering
tia linked to this genetic disorder. In Machado- from famine or pestilence; later, they became
Joseph your intelligence will be preserved, the means through which cities prevented mis-
clean, and crystalline." Of course, biopsychia- chief (Girard 1996). These men were called
trists could argue that Catarina may have been pharmakoi, and, for them, there was no return
affected by two concomitant biological pro- to the city. Historians disagree over the ways
cesses, but for me the discovery of Machado- in which they were chosen for this scapegoat
Joseph was a landmark in the overwhelming role and whether they were actively killed or
disqualification of her as mad and shed light on simply allowed to die (Harrison 1921: 104,
how her condition had evolved over time. 105; Derrida 1981: 132).
While reviewing the records of the one hun- Catarina is, in a literal sense, a modern day
dred families that are cared for by Dr. Jardim's pharmakos. The handling of her defective body
team, I found that spousal abandonment and was at the heart of the various scenarios people
an early onset of the disease were quite com- empirically forged and in which they saw
mon among women, just like it had happened themselves with her through institutions such
with Catarina, her mother, her younger aunt as medicine, city government, and law. Con-
and a cousin. Affective, relational and eco- sider the words of her ex-husband: "After we
nomic arrangements are plotted and realized married, they told me the problems the family
around the visible carriers of the disease, and had. My mother's cousin said 'Poor Nilson, he
these gendered practices ultimately impact doesn't know what he has got his hands in.' I
the course of dying. I also learned that after didn't believe it until I saw it. Deus me livre
the onset, Machado-Joseph patients survive on [May God free me from this] ... I got to know
average from 15 to 20 years, most dying from her relatives. An aunt of hers died of this prob-
pneumonia in wheelchairs or bedridden. Scien- lem, and so did some of her cousins . . . I told
tists have firmly established that the graver the myself, 'Ah, that's how it is ... they will see.'"
gene mutation, the more it anticipates disease. These were revenge-laden words - as if
And while the gravity of the gene mutation can through Catarina the man had taught them all
account for 60 percent of the probability of a lesson. In retrospect, Catarina has meaning
earlier onset, the unknown 40 percent remains. not as a person but as a representative of a
Among siblings, Dr. Jardim told me "the age of collective and its pathology. Her growing social
onset is almost always the same." How then to irrelevance took form around this medical un-
explain Catarina's early onset, in the late teens, known and its physical expressions, allowing
and her brothers' onset in their mid to late 20s? Nilson now to read family ties as a retaliatory
The various socio-cultural and medical pro- exchange.
cesses in which Catarina's biology was embed- And what are your plans? I asked Nilson.
ded, I thought, pointed to the materiality and "To make my life. To progress. I am content
morality of this "unknown 40 percent" - in with my family now. This woman doesn,t give
other words: the social science of the biological me the problems I had before. A person must
mutation. To this Dr. Jardim responded: "At help herself. As I said, the doctor gave Catarina
the peak of her suffering, they were dismem- treatment so the illness would not come back.
bering her... this dying flesh is all that It was just a matter of taking the medication,
remained." Rather than being the residue of but she didn,t help herself ... What has passed
obscure and undeveloped times, Catarina's is over. One must put a stone over it."
224 JOAO BIEHL
Catarina is physically cast out, a stone set figure excluded from the political body. Derri-
over her in life. As her naturalized destiny da thus brings to light the scapegoat figure of
reveals, medical science has become a tool of the pharmakos, which, interestingly, is absent
common sense, foreclosing various possibilities from Platonic philosophical reflection. "The
of empathy and experience. Pharmaceutical city body proper thus reconstitutes its unity,
commerce and politics have become intimate closes around the security of its inner courts,
to lifeworlds and it is the drug- the embodi- gives back to itself the word that links it with
ment of these processes- that mediates Catar- itself within the confines of the agora, by vio-
ina's exclusion as a pharmakos. Both the lently excluding from its territory the represen-
empirical reality through which living became tative of an external threat or aggression. That
practically impossible for Catarina and the representative represents the otherness of the
possibility of critique have been sealed up. evil that comes to affect or infect the inside by
As Catarina repeatedly told me: "They all unpredictably breaking into it'' (Derrida
wouldn't dialog and the science of the illness 1981:133}.
was forgotten. I didn't want to take the medi- The figure of the pharmakos in philosoph-
cation ... Science is our conscience, heavy at ical thought is quite pertinent, but the place
times, burdened by a knot that you cannot kept by the death of the Other in city govern-
untie. If we don't study it, the illness in the ance also remains a key problem to be ad-
body worsens." dressed. In speaking of Catarina as a modern
In Plato's Pharmacy, Jacques Derrida day human pharmakon, I argue that her life
follows the term pharmakon as it stands for and story is paradigmatic of a contemporary
writing in Platonic philosophy. Acting like a familial/medical/political structure that oper-
pharmakon, both as remedy and as poison, ates like the law and that is close to home.
writing is the artificial counterpart to the truth Pharmaceutically addressed, she was now the
of things that speech allegedly can apprehend evil cast out, both subjectively and biologically.
directly. According to Plato, argues Derrida, In the end, Catarina was a failed medication
writing is considered "a consolation, a com- that, paradoxically, allowed the life, senti-
pensation, a remedy for sickly speech" - ments, and values of some to continue in other
"writing is the miserable son" (1981: 115, terms.
143). While living speech is conformity with The ethnography of Vita and Catarina also
the law, writing is a force wandering outside makes it painfully clear that there are places
the domain of life, incapable of engendering today, even in a state founded on the premise of
anything or of regenerating itself: "a living- guaranteeing human rights, where these rights
dead, a weakened speech, a deferred life, a no longer exist, where the living subjects of
semblance of breath ... It is like all ghosts, marginal institutions are constituted as some-
errant" (143}. For Derrida, however, writing thing other, between life and death. Such places
qua pharmakon is an independent order of demonstrate how notions of universal human
signification. Operating as differance - "the rights are socially and materially conditioned
disappearance of any originary presence" - by medical and economic imperatives. Vita
writing is at once "the condition of possibility also confirms that public death remains at the
and the condition of impossibility of truth" center of various social structures, animating
(168). and legitimating charity, political actors, and
The term pharmakon that Plato used has economic strategies.
been overdetermined by Greek culture, Derrida The being of the people in Vita is fundamen-
points out: "All these significations nonetheless tally ambiguous. This ambiguity gives the an-
appear ... Only the chain is concealed, and to thropologist the opportunity to develop a
an inappreciable extent, concealed from the human, not philosophical, critique of the ma-
author himself, if any such thing exists" chine of social death in which these people are
(1981:129). The contemporary philosopher caught (see Rancic~re 2004). This entails: (1}
sees as a concealed connection between phar- Making explicit that Vita and zones of social
makon as writing and pharmakos, the human abandonment elsewhere, in both poor and rich
HUMAN PHARMAKON 225
contexts, are not spheres of exceptionality but paying close attention to the words and expres-
rather extensions of what is becoming of sions clustered around it.
family, state, medicine- they are the negative At times, Catarina's writings relate her
nature, so to speak, of common sense in this growing paralysis to a kind of biological and
moment of capitalism; (2) Illuminating the familial marker, alluding to a certain "blood
paradoxes and dynamism involved in letting type becoming a physical deficiency," "a cere-
the other die; (3) Repopulating the political bral forgetfulness," and an "expired brain and
stage with ex-humans; (4) Bringing into view aged cranium" that "impede change." Most of
the insights, ambiguities, and desires (alterna- the time, however, Catarina conveys the man-
tive human capacities) they also embody and made character of her bodily affections. In the
inquire into how they can be part and parcel of following inscription, for example, she depicts
rhe much needed efforts to redirect care. rheumatism as a mangling of the threads
people tinker with:
"People think that they have the right to put
Literature and Health their hands in the mangled threads and to mess
with it. Rheumatism. They use my name for
Catarina's vision was co be absolutely real. But good and for evil. They use it because of the
while trying to speak she was overwhelmed rheumatism."
by the chemical alterations of drugs, layers
and layers of chemical compounds that ocher Her rheumatism ties various life-threads to-
people used to work on her and drug side- gether. It is an untidy knot, a real matter that
effects that were her body and identity now. makes social exchange possible. It gives the
To speak the unspeakable, she resorted to body its stature and it is the conduit of a mor-
metaphors and to writing. In the following ality. Catarina's bodily affection, not her name,
dictionary entry, for example, she tries to break is exchanged in that world: "What I was in the
open the reader's blindness and brings a Greek past does not matter." Catarina disappears and
tragic figure and her three brothers and three a religious image stands in her place: "Rheuma-
children together with her renamed self and the tism, Spasm, Crucified jesus." In another frag-
always lacking clinical register: ment, she writes: "Acute spasm, secret spasm.
Rheumatic woman. The word of the rheumatic
"Look at Catarina without blindness, pray, is of no value."
prayer, jocastka, there is no tonic for CAT- Catarina knows that there is a rational-
KINE, there is no doctor for any one, Altamir, ity and a bureaucracy to symptom manage-
Ademar, Armando, Anderson, Alessandra,
ment: "Chronic spasm, rheumatism, must be
Ana."
stamped, registered." All of this happens in a
Medical science is part and parcel of Catar- democratic context, "vote by vote." We must
ina's existence - the truths, half-truths, and consider side by side the acute pain Catarina
misunderstandings that brought her to die in described and the authoritative story she
Vita and upon which she subsisted. "Pharmacy, became in medicine and in common sense - as
laboratory, marriage, identity, army, rheuma- being mad and ultimately of no value. The
tism, complication of labor, loss of physical antipsychotic drugs Haldol and Neozine are
equilibrium, total/ass of control, govern, goal- also words in Catarina's dictionary. In a frag-
keeper, evil eye, spasm, nerves., "In the United ment, she defiantly writes that her pain reveals
States, not here in Brazil, there is a cure, for the experimental ways science is embodied:
half of the disease." "The dance of science. Pain broadcasts sick
Catarina's dictionary is filled with references science, the sick study. Brain, illness. Busco-
to deficient movement, to pain in the arms and pan, Haldol, Neozine. Invoked spirit."
legs, to muscular contractions. In writing, as in An individual history of science is being
speech, she refers to her condition, by and large, written here. Catarina's lived experience and
as "rheumatism." I followed the word rheuma- ailments are the pathos of a certain science, a
tism as it appeared throughout the dictionary, science that is itself sick. There has been a
226 JOAO BIEHL
breakdown in the pursuit of wisdom, and there lived" (p.t ). He thinks of language as a system
is commerce. The goods of psychiatric science, that can be disturbed, attacked, and recon-
such as Haldol and Neozine, have become as structed - the very gate through which limits
ordinary as Buscopan (hyoscine, an over-the- of all kinds are crossed and the energy of the
counter antispasmodic drug) and have become "delirium'' unleashed.
a part of familial practices. As Catarina's ex- The "delirium" suggests alternative visions
perience shows, the use of such drugs produces of existence and of a future that clinical defin-
mental and physical effects a part from those itions tend to foreclose. Language in its clinical
related to her illness. These pharmaceutical state has already attained a form, says Deleuze:
goods - working, at times, like rituals - realize "We don't write with our neuroses. Neuroses
an imaginary spirit rather than the material or psychoses are not passages of life, but states
truth they supposedly stand for: medical com- into which we fall when the process is inter-
modities are then supposed subjects. There is a rupted, blocked, or plugged up. Illness is not a
science to Catarina's affects, a money-making process but a stopping of the process" (p.3).
science. As transmitters of this science, her The radical work of literature, however, moves
signs and symptoms are of a typical kind. away from "truths" and "forms" (since truth is
In Catarina's thinking and writing, global a form in itself) and towards intermediate, pro-
pharmaceuticals are not simply taken as new cessual stages that could even be virtual.
material for old patterns of self-fashioning. Writing is inseparable from becoming, repeats
These universally disseminated goods are en- Deleuze, and becoming "always has an element
tangled in and act as vectors for new mechan- of flight that escapes its own formalization"
isms of sociomedical and subjective control (p.t). To become is not to attain a form
that have a deadly force. Seen from the per- through imitation, identification, or mimesis,
spective of Vita, the illnesses Catarina experi- but rather to find a zone of proximity where
enced were the outcome of events and practices one can no longer be distinguished from a man,
that altered the person she had learned to a woman, or an animal - "neither imprecise,
become. Words such as "Haldol" and "Neo- nor general, but unforeseen and nonpreexis-
zine" are literally her. As I mentioned earlier, tent, singularised out of a population rather
the drug name Akineton (biperiden) is reflected than determined in a form" (ibid.). In Deleuze's
in the new name Catarina gave herself: "I am words: one can institute such a zone of indiffer-
not the daughter of Adam and Even. I am. the entiation with anything "on the condition
Little Doctor. CATKINE." that one creates the literary means for doing
Abandoned in Vita to die, Catarina has ties so" (p.2).
to pharmakons. Her desire, she writes, is now a While I tried to restore context and meaning
pharmaceutical thing with no human exchange to her lived experience of abandonment,
value: Catarina was herself producing, in her diction-
ary, a theory of the abandoned subject and
"Catarina cries and wants to leave. Desire,
her subjectivity that was ethnographically
watered, prayed, wept. Tearful feeling. fearful,
grounded. Consider this stanza:
diabolic, betrayed. My desire is of no value.
Desire is pharmaceutical. It is not good for the "Catarina is subjected
circus." To be a nation in povert)'
I find Deleuze's insights on literature and Porto Alegre
Without an heir
health (1997) quite helpful in reflecting on
Enough
Catarina's work of sublimation and the values
I end"
it creates in Vita. Deleuze says that writing is "a
question of becoming, always incomplete, In her verse, Catarina places the individual
always in the midst of being formed, and goes and the collective in the same space of analysis,
beyond the matter of any livable or lived ex- just as the country and the city also collide
perience. It is a process, that is, a passage of in Vita. Subjection has to do with having no
Life that traverses both the livable and the money and with being part of a nation gone
HUMAN PHARMAKON 227
awry. The subject is a body left in Vita without A tool is innocent. You dig, you cut, you do
ties to the life she generated with the man who, whatever you want with it. . . . It doesn't
as she states, now "rules the city'' from which know if it hurts or doesn't. But the man who
she is banished. With nothing to leave behind uses it to cut the other knows what he is
and no one to leave it to, there remains Catar- doing."
ina's subjectivity - the medium through which She continued with the most forceful words:
a collectivity is ordered in terms of lack and in "I don't want to be a tool. Because Catarina is
which she finds a way to disentangle herself not the name of a person . . . truly not. It is the
from all the mess the world has become. In name of a tool, of an object. A person is an
her writing, she faces the concrete limits of Other."
what a human being can bear, and she makes Psychopharmaceuticals had mediated Cat-
polysemy out of those limits - "I, who am arina's expulsion from the world of ex-
where I go, am who am so." changes (as if she were ignorant of the
One of the guiding principles of Deleuze's language she spoke) and were now the thing
philosophy is the link between the real and the through which she recounted bodily frag-
imaginary as always co-existing, always com- mentation and withering. This was what
plementary. They are like two juxtapositional she was left with: "enjoyment enjoying
or superimposable parts of a single trajectory, itself" (se goza gozo), as she wrote in the dic-
two faces that ceaselessly interchange with one tionary. "Pleasure and desire are not sold,
another, "a mobile mirror" . . . "bearing wit- cannot be bought. But have choice.'' The op-
ness until the end to a new vision whose pas- portunity to "restart" and a human choice were
sage it remained open to" (1997: 63). In all she wanted. This was what Catarina
Catarina's words, real and imaginary voyages affirmed in her love stories in Vita. "I dated a
compose a set of intertwined routes. "I am a man who volunteered as a security guard
free woman, to fly, bionic woman, separated." here," she told me. "He bought me a ring and
r•when men throw me into the air, I am already a bracelet, shampoo, many things. We met at
far away." These trajectories are inseparable night and had sex in the bathroom. But people
from her efforts of becoming. "I will leave the were trying to separate us. Vera began to say
door of the cage open. You can fly wherever that he was her boyfriend, too. So I gave him
you want to." the ring back. He refused to take it back. I said,
Actualized by literature, this mobile mirror 'I will not throw this into the garbage,' so I put
reveals beneath apparent persons the power of it in my suitcase. After we split, he had other
an impersonal, says Deleuze, "which is not a women here . . . But as far as I am concerned, I
generality but singularity at the highest point: a was not his prey. I didn't fall to him. I wanted
man, a woman, a beast, a child . . . It is not the it. I have desire, I have desire. I am with Clovis
first two persons that function as the condition now."
for literary enunciation; literature begins only Catarina refused to depict herself as a
when a third person is born in us that strips us victim. Her body experienced, along with
of the power to say 'I'" (1997:3). The shift to hunger, spasms, and pain, uncontrollable de-
the indefinite - from "r' to "a" - leads to the sires, an overflow unthinkable in terms of
ultimate existential stage where life is simply common sense. While exposing Vita as a place
"immanent," a transcendental field where man of total annihilation, she also spoke of the
and woman and other men and women/ vitality of sexuality and affirmed agency. She
animals/landscapes can achieve the web of spoke openly of having sex "in the bathroom
variable relations and situated connectedness and in the pharmacy" with Clovis, a man who
called "camaraderie." after passing through the rehabilitation areas
"There, in Novo Hamburgo it is Catarina. became the infirmary's "nurse." For her, desire
Here it is CATKINE," she told me when I asked and pleasure were gratifying, "a gift that one
her why she invented this name. feels." During sex, she said, "I don't lose my
"I will be called this now. For I don't want head, and I don't let my partner lose his head.
to be a tool for men to use, for men to cut. If it is good for me, I want to make it good
228 JOAO BIEHL
for him, too." She was, in her own words, replied, "the pieces stay lost for the rest of life.
"a true woman" (mu/her de verdade): "Female They then rust, and the rust terminates with
reproducer, reproduces, lubrification, anonym- them." Neither free from nor totally deter-
ous reproducer, to fondle the aggressive lust, mined by this machinery, Catarina dwelt in
and manias." the luminous lost edges of human imagination
that she expanded through writing.
"Scientific decadence, kiss, electricit)~ wet,
Catarina remarked that other people might
mouth kiss, dry kiss, kiss in the neck,
to start from zero, it is always time, to begin
be curious about her words, but she added
again, for me it is time to convert, that their meaning was ultimately part of
this is salvation day, Clovis Gama, CATKIN£, her living: "There is so much that comes with
Catakina Gam a, Ikeni Gam a, Alessandra time . . . the words . . . and the signification,
Gomes, Ana G., to restart a home, a family, you will not find in the book. It is only in my
the spirit of love, the spirit of God, the spirit memory that I have the signification . . . And
becomes flesh inside." this is for me to untie." Catarina refused to
be an object of understanding for others.
"Nobody will decipher the words for me. With
the pen, only I can do it . . . in the ink, I
Coda decipher."
We might face Catarina's writing in the
As fieldwork came to a close, Oscar, one of same way we face poetry. She introduces us to
Vita's volunteers on whom I depended for a world that is other than our own, yet close to
insights and care, particularly in regard to home; and with it, we have the chance to read
Catarina, told me that things like this research social life and the human condition via phar-
happen "so that the pieces of the machine makons differently. To engage with her life and
finally get put together." Catarina did not writing is also to work upon oneself. "I am
simply fall through the cracks of various do- writing for myself to understand, but, of
mestic and public systems. Her abandonment course, if you all understand I will be very
was dramatized and realized in the novel inter- content."
actions and juxtapositions of several contexts. Catarina refused to be consigned to the
Scientific assessments of reality (in the form impossible, and she anticipated an exit from
of biological knowledge and psychiatric diag- Vita. It was as difficult as it was important to
nostics and treatments) were deeply embedded sustain this anticipation: to find ways to sup-
in changing households and institutions, port Catarina's search for ties to people and
informing colloquial thoughts and actions the world and her demand for continuity, or at
that led to her terminal exclusion. The sub- least its possibility. With an eye to the possi-
jects in Vita are literally composed by morbid bilities and noninevitability of people's lives,
scientific - commercial - political changes. we must also continually address the concrete
Following Catarina's words and plot was a powers that bury anticipation and that turn
way to delineate this powerful, noninstitutio- flows into systematic disconnection rather
nalized ethnographic space - the crossroads - than new circuits of recognition and care.
in which the family gets rid of its undesirable Out of this intricate ethnographic tension
members. The social production of deaths emerges a sense of the present as embattled
such as Catarina's cannot ultimately be and unfinished, on both sides of the conversa-
assigned to any single intention. As ambiguous tion and of the text.
as its causes are, her dying in Vita is nonethe-
less traceable to specific constellations of
forces and human values. ACKNOWLEDGMENTS
Once caught in this space, one is part of a
machine, suggested Oscar. But the elements of Excerpts of this essay appeared in my book
this machine connect only if one goes the extra Vita: Life in a Zone of Social Abandonment
step, I told him. "For if one doesn't," he (University of California Press, 2005) and in
HUMAN PHARMAKON 229
Writing in 1994, the well-known historian of the scholarly effort to show how anxiety about
the subaltern Gyanendra Pandey took the neg- Hindu-Muslim relations, especially about sexu-
lect of the Partition in the social sciences ality and purity of women, circulated in the
and in Indian public culture as a symptom of public domain in the late nineteenth and early
a deep malaise. Historical writing in India, twentieth centuries in the popular forms of car-
he argued, was singularly uninterested in toons, comic strips, posters, and vernacular
the popular construction of the Partition, the tracts. Part of the burden of this chapter is to
trauma it produced, and the sharp division try to understand how public anxieties around
between Hindus, Muslims, and Sikhs it left sexuality and purity might have created the
behind. He attributed this blindness to the grounds on which the figure of the violated
fact that the historian's craft has never been woman became an important mobilizing point
particularly comfortable with such matters as for reinstating the nation as a "pure" and mas-
"the horror of the Partition, the anguish and culine space. 2 At stake, then, is not simply the
sorrow, pain and brutality of the 'riots' of question of "silence" but also that of the genres
1946-47." The analytical move in Indian his- that enabled speech and gave it the forms it
toriography, Pandey further argued, was to took. It is instructive that there has been no
assimilate the Partition as an event in the attempt to memorialize the Partition in the
intersecting histories of the British Empire form of national monuments or museums. No
and Indian nation, which left little place for attempt was made, for that matter, to use the
recounting the experience of the event for legal instruments of trials or public hearings to
ordinary people. 1 allow stories of mass rape and murder to be
In recent years, many writers, including Pan- made public or to offer a promise of justice to
dey, have produced impressive testimonial lit- the violated persons. There was no dramatic
erature on the Partition in an attempt to bring enactment of "putting history on trial" that
ordinary people's experiences into the story of Shoshana Felman sees as the particular feature
this event. Corresponding to this development is of twentieth-century collective traumas. 3 In
Veena Das, "The Figure of the Abducted Woman: The Citizen as Sexed," in Life and Words: Violence and the
Descent into the Ordinary. Berkeley: University of California Press, 2007. © 2007 by the University of
California Press - Books. Reproduced with permission of the University of California Press - Books in the
format Textbook via Copyright Clearance Center.
THE FIGURE OF THE ABDUCTED WOMAN 233
fact, the trope of horror was deployed to open circulated in the political debates soon after
up the space for speech in the formal setting of the Partition of the country and ask how this
the Constituent Assembly debates and in popu- was anchored to the earlier figures that were
lar culture, and it gave the recounting of the available through myth, story, and forms of
event a tonality of rumor. print culture in the early-twentieth-century dis-
Consider first the numbers and magnitudes course on this figure. How was the figure of the
as these are cited in official reports. As Pandey abducted woman transfigured to institute a
argues, numbers are not offered here in the social contract that created the nation as a
sober register of a judicial tribunal or a bureau- masculine nation?
cratic report based upon careful collection of One of the earliest accounts of the violence
data - rather, these function as gestures toward of the Partition rendered the story in the
the enormity of the violence. I might add following terms:
that this mode of reporting was not peculiar
to the Partition. It was part of a wider bureau- The great upheaval that shook India from one
cratic genre that used numbers and magnitudes end to the other during a period of about fifteen
to attribute all kinds of "passions" such as
months commencing with August 16, 1946 was
an event of unprecedented magnitude and
panic, incredulity, or barbarity to the populace
horror. History has not known a fratricidal
when faced with a crisis such as an epidemic or
war of such dimensions in which human hatred
a riot - thus constructing the state as a rational
and bestial passions were degraded to the levels
guarantor of order. We shall see how the figure witnessed during the dark epoch when religious
of the abducted woman allowed the state to frenzy, taking the shape of a hideous monster,
construct "order'' as essentially an attribute stalked through the cities, towns and country-
of the masculine nation so that the counterpart side, taking a toll of half a million innocent
of the social contract becomes the sexual con- lives. Decrepit old men, defenseless women,
tract in which women as sexual and reproduct- helpless young children, infants in arms, by
ive beings are placed within the domestic the thousand were brutally done to death by
sphere under the control of the "right" kinds Muslim, Hindu and Sikh fanatics. Destruction
of men. and looting of property, kidnapping and ravish-
ing of women, unspeakable atrocities, and
indescribable inhumanities, were perpetrated
in the name of religion and patriotism.4
The Abducted Woman in the
Imaginary of the Masculine Nation The government of India set up a Fact Find-
ing Organization on the communal violence.
How did the gendering of suffering allow a Although the files containing these reports were
discourse of the nation to emerge at the time never made public, G.D. Khosla, who was a
of the Partition? What precise work does the justice of the Punjab High Court and was in
figure of the abducted woman and her recovery charge of producing this report, interviewed
do in instituting the relation between the social liaison officers of the Military Evacuation
contract and the sexual contract at the advent Organization in charge of the large-scale evacu-
of the nation? While I am sympathetic to the ation of the minorities from one dominion to
question of repression of women's voices in the another. Based on this information, Khosla put
accounts of the Partition that has animated the the figure of loss of life in both warring commu-
work of many feminist historians, I would like nities between 200,000 and 250,000 and
to frame this in a different model than that of the number of women who were raped and
trauma. Instead of deploying the notion of abducted on both sides as close to 100,000.
trauma, I ask what kind of protocols for telling Some support for this is provided in information
their story might have been imported into the given to the House in the context of legislative
task of making visible (or audible) the suffering debates of the Constituent Assembly, where it
of women in the nationalist discourse? I cake was stated on December 15, 1949, that 33,000
the figure of the abducted woman as it Hindu or Sikh women had been abducted by
234 VEENA DAS
Muslims and that the Pakistan government had The state of war, akin to the Hobbesian state
claimed that 50,000 Muslim women had been of nature, comes to be defined as one in which
abducted by Hindu or Sikh men. Hindus and Muslims are engaged in mutual
Joint efforts made by the governments of warfare over the control of sexually and repro-
India and Pakistan to recover abducted women ductively active women. The origin of the state
and restore them to their relatives led to the is then located in the rightful reinstating of
recovery of a large number of women from proper kinship by recovering women from the
both territories. It was stated on behalf of the other side. If one prefers to put it in the termin-
government in the Constituent Assembly on ology of Levi-Strauss, one could say that the
December 15, 1949, that 12,000 women had state reinstates the correct matrimonial dia-
been recovered in India and 6,000 in Pakistan. logue of men. The foundational event of the
The figures given by Khosla on the basis of the inauguration of the state brings something new
Fact Finding Organization were that 12,000 into existence, but the event does not come
Hindu or Sikh women were "recovered" from from nowhere- it is anchored to imageries that
the Punjab and the frontier regions in Pakistan already haunt Hindu-Muslim relations.
and 8,000 Muslim women from the provinces
of Indian Punjab.
As I said earlier, Pandey makes the subtle The Discourse of the State
point that numbers function here not as forms
of reporting in which we can read bureaucratic A conscious policy with regard to abducted
logic but rather as elements of rumor in which women and children born of sexual and repro-
the very magnitudes serve to signal both excess ductive violence was first initiated in the ses-
and specificity. He argues that in the official sion of the Indian National Congress on
reports as well as in reports by prominent pol- November 23 and 24, 1946, when delegates
itical leaders, the circulation of such stories expressed grave concern about the fate of
served to transform hearsay into "truth." What women who were violated during the commu-
Pandey misses in his analysis, it seems to me, is nal riots. Dr. Rajendra Prasad, who was later to
that the magnitudes established that violence become the first president of independent
was taking place in a state of exception, which, India, moved a resolution that received wide
in turn, opened the way to authorize the state support from prominent leaders of the Con-
to undertake extraordinary measures by gress Party, including Jawaharlal Nehru:
appeals to the state of exception. I argue that
the circulation of the figure of the abducted The Congress views with pain, horror and
woman, with its associated imagery of social anxiety the tragedies of Calcutta, in East
disorder as sexual disorder, created the condi- Bengal, in Bihar and in some parts of Meerut
tions of possibility in which the state could be district. The acts of brutality committed on
instituted as essentially a social contract be- men, women and children fill every decent
tween men charged with keeping male violence person with shame and humiliation. These
against women in abeyance. Thus, the story new developments on communal strife are dif-
about abduction and recovery acts as a foun- ferent from any previous disturbances and
dational story that authorizes a particular rela- have involved murders on a mass scale as also
tion between social contract and sexual mass conversions enforced at the point of a
dagger, abduction and violation of women
contract - the former being a contract between
and forcible marriage.
men to institute the political and the latter the
agreement to place women within the home
The operative part of the resolution then stated
under the authority of the husband/father
the obligation of the Congress Party toward
figure. 5 The "foundational" event of inaugur-
such women:
ating the nation then is itself anchored to the
already circulating imaginary of abduction of The immediate problem is to produce a sense
women that signaled a state of disorder since it of security and rehabilitate homes and villages,
dismantled the orderly exchange of women. which have been broken up and destroyed.
THE FIGURE OF THE ABDUCTED WOMAN 235
Women, who have been abducted and forcibly against women. To some extent this obligation
married, must be restored to their homes. was generated by the expectations of the
Mass conversions, which have taken place for- affected population. The devastated refugees
cibly, have no significance or validity and the who had lost their homes, their families, and
people affected by them should be given every their possessions in the bloody riots and were
opportunity to return to their homes and the housed in refugee camps in Delhi thought it
life of their choice. 6 appropriate to address the leaders of independ-
ent India as appropriate recipients of their
This resolution was adopted in November laments. In this manner, they were not only
1946. The situation, however, worsened from creating a framework for the state to legitim-
March 1947, so that three weeks after India ately take up the task of recovery of abducted
and Pakistan achieved their independence as women but also learning that claiming entitle-
separate states, the representatives of both do- ments over women of one's own community
minions met on September 3, 1947, and agreed could be seen as a legitimate affair of the state.
that steps should be taken to recover and re- Khosla reported that refugees in distress
store abducted persons. Both sides pronounced made loud and frantic appeals to all depart-
themselves against recognition of forced ments of government. Pandit Nehru received
marriages. letters in the months of August, September, and
The All India Congress Committee met in October seeking his personal intervention to
the middle of November and reiterated that save a relative left behind or to recover a piece
"during these disorders large numbers of of property or a precious possession aban-
women have been abducted on either side and doned in Pakistan. People wrote to him, accus-
there have been forcible conversions on a large ing him of enjoying a victory that had been
scale. No civilized people can recognize such won at the expense of the Hindus of the west
conversions and there is nothing more heinous Punjab. Khosla quoted a letter by a retired
than abduction of women. Every effort, there- schoolmaster addressed to Pandit Nehru:
fore, must be made to restore women to their "What has compelled me to write this to you
original homes, with the co-operation of the is the fact that in casting about my eyes I fail to
Governments concerned." 7 find anyone in the world except you who can
An interdominion conference followed the help me in my calamity. " 8 How was the nation
Congress session, at which the two dominions to respond to such investment of both despair
agreed to the steps to be taken to recover and hope in its leaders?
abducted women and children. The implemen-
tation of these decisions led to a recovery of
large number of women from both sides - The Question of National Honor
between December 1947 and July 1948,
9,362 women were reported to have been re- For the new nation state of India, the question
covered in India and 5,510 in Pakistan. At this of the recovery of abducted women and chil-
time both governments worked toward the cre- dren then became a matter of national honor.
ation of a legal instrument for the work of There was a repeated demand, publicly enun-
recovery. As a result, appropriate ordinances ciated, that the state must take the responsi-
were issued in India on January 31, 1948, and bility of the recovery of women and children
in Pakistan in May 1948. The ordinance in upon itself. The new government in India tried
India was renewed in June 1949. In December to reassure the people of its intention in this
1949 the Constituent Assembly passed the regard through several press releases. For in-
Abducted Persons (Recovery and Restoration) stance, Rajashree Ghosh cites a press release
Act of 1949, which remained in force until published in The Statesman of November 4,
October 31, 1951. 1947, that "forced conversions and forced mar-
The events outlined above point to the riages will not be recognized and that
manner in which the state took cognizance of women and girls who have been abducted
the sexual and reproductive violence directed must be restored to their families. " 9 Various
236 VEENA DAS
administrative mechanisms for the recovery of The families with whom I worked related stor-
women were operative in the early stages of the ies of a generalized nature in which the heroic
recovery operations including the Office of the sacrifices made by women were lauded, but to
Deputy High Commissioner, the Military speak in the first person on the facts of abduc-
Evacuation Organization, the Chief Liaison tion and rape was not easy. [ ... ] Elsewhere I
Officer, and the Organization for Recovering explore the specific ways in which stories were
Abducted Women, consisting of social workers framed in the first person, and especially the
and other officials. All these efforts culminated place of silence in the "telling." 11 Here I am
in an interdominion agreement signed on Sep- interested in the logic of the state of exception
tember 3, 1947, and finally the Abducted Per- with regard to the way that law was instituted
sons (Recovery and Restoration) Act of 1949. to shape the nation as a masculine nation, so
Through these legal instruments, each country that the social contract became a contract be-
provided facilities to the other for conducting tween men conceived as heads of households.
search and rescue operations. Both agreed that As so many statements that I have quoted
the exchange of women should be equal in show, normality was seen as restoration of
number. Wide powers were given to the police women "to their families." Men appear here
to conduct the work of recovery, and arrange- as heads of households rather than as individ-
ments were made for housing the recovered uals sprung from the earth, as in the famous
women in transitory camps. Disputed cases mushroom analogy favored by Hobbes in con-
were to be referred to a joint tribunal for final ceptualizing the makers of the social contract.
settlement. It is my contention that once the problem of
In terms of procedure, the Indian govern- abducted women moved from the order of the
ment set up Search and Service Bureaus in family to the order of the state (as in the
different cities in the Punjab where missing demand for legislation), it sanctified a sexual
women were reported. This information was contract as the counterpart of the social con-
then passed on to the relevant authorities, and tract by creating a new legal category of
a search for these women and children was "abducted person" (applicable, however, only
mounted. The Indian government accepted to women and children) who came within the
the help of several women volunteers, espe- regulatory power of the state. There was an
cially those with a Gandhian background, to alliance between social work as a profession
help in the recovery process. Prominent among and the state as parens patriae, which made
these women were Mridula Sarabhai, Ramesh- the official kinship norms of purity and honor
wari Nehru, and Kamlabehn Patel. In her much more rigid by transforming them into the
memoirs of this period Kamlabehn Patel law of the state.
reports that "in those days it wasn't prudent The discussion on the Abducted Persons
to trust any male, not even policemen as far as (Recovery and Restoration) Act of 1949 in
the safety of women was concerned." 10 Several the Constituent Assembly focused on three
transit camps were set up, such as the Gang- issues. 12 The first was the definition of a civil-
aram Hospital Camp in Lahore and Gandhi ized government and especially the responsibil-
Vanita Ashram in Arnritsar. Kamlabehn herself ity of the state to women on whom violence
was in charge of the transit camp in Lahore to had been unleashed. The second was the defin-
which recovered women and children were ition of an abducted person, and the rights of
brought. They were then transferred to India women abducted by men. The third issue was
or Pakistan, as the case might be, under police the rights of children born of "wrong" sexual
escort. A woman or child who was claimed by a unions and the obligations of the state toward
close relative in the case of an Indian citizen them. The connecting thread between these
could be handed over to the relative only at three issues is the notion of national honor
Jullundher in the presence of a magistrate. and preservation of purity of the population
Taken at face value it would appear that the through which the sexual contract is made the
norms of honor in the order of the family and grounds for a social contract that institutes the
the order of the state were mutually supportive. nation as a masculine nation.
THE FIGURE OF THE ABDUCTED WOMAN 237
In introducing the bill, Shri N. Gopalaswa- of control over the sexual and reproductive
mi Ayyangar, the then Minister of Transport functions of women. The social contract that
and a distinguished lawyer, stated that there would legitimate both nations was seen as one
were experiences associated with the partition instituted by men in which they were capable
of the country in regard to which "most of us of recovering their own place as heads of
will have to hang our heads down in shame." households by placing the sexuality and repro-
He went on to say that "among the many ductive powers of women firmly within the
brutalities and outrages which vitiated the at- family.
mosphere . . . none touched so low a depth of Thus the figure of the abducted woman
moral depravity as these mass abductions of signals the impossibility of the social contract
women on both sides. . . . Those of us who because the sexual contract that would place
think of civilized government and want to con- men as heads of households (not as a matter of
duct the government on civilized lines should kinship but as matter for the state) was in
feel ashamed." jeopardy. Pandit Thakur Das Bhargava expli-
As is clear from this statement, the state citly drew on this figure when he stated during
distanced itself from the "depths of moral de- the debates, "You will remember, Sir, how
pravity" that the population had shown and when one Ellis was kidnapped by some Pathans
took upon itself the task of establishing a civil- the whole of Britain shook with anger and
ized government. Part of the definition of this indignation and until she was returned English-
civilized government was to not only recover men did not come to their senses. And we all
women defined by the new nation as "our" know our own history, of what happened at the
women but also to restore to the opposite side time of Shri Ram when Sita was abducted.
"their" women. The interest in women, how- Here, where thousands of girls are concerned,
ever, was not premised upon their definition as we cannot forget this. We can forget all the
citizens but as sexual and reproductive beings. properties, we can forget every other thing
As far as recovery of women held by the but this cannot be forgotten., 13
"other'' side was concerned, what was at stake Then there was the question of whether
was the honor of the nation because women as Muslim women needed to be returned to their
sexual and reproductive beings were being for- own families. It is interesting to note the par-
cibly held. This was explicit in the demands ticular tonality that crept into Pandit Thakur
made by several members that not only should Das Bhargava's statement that "I don't suggest
the recovery of women on both sides be more for a moment that the abducted Muslim girls
or less equal but also that women in their re- should be kept here because I believe that not
productive years should be "recovered." Shri only would it be good for them to be sent away
Gopalaswami Ayyangar especially referred to but it is equally good for us to be rid of them.
this criticism, saying that several critics alleged I don't want immorality to prosper in my
that "while in India we have recovered women country."
of all ages and so forth, in Pakistan they had It is important to note here that to be a
recovered for us only old women or little chil- citizen as a head of the household demands
dren." He went on to counter this criticism by that men's own sexuality be disciplined,
citing figures to show that the distribution by oriented to the women who have been placed
age of recovered women from both dominions "correctly" within the family, and that children
was, in fact, roughly equal. Of the total women who would claim citizenship are born of the
recovered, he said, girls below the age of twelve right kind of union of men and women. Else-
from Pakistan and India were 45 and 35 per- where I have analyzed courtroom talk in the
cent, respectively. In the age group 12 to 35 cases of rape in Indian courts of law to argue
years old, the recovery was 49 percent in Paki- that "male desire" is construed as a natural
stan and 59 percent in India, while the percent- need in the judicial discourse on rape, so that
age dropped to about 10 percent for women whenever the cultural and social constraints
older than 35. This discussion clearly shows are removed, men are seen as falling into a state
that national honor was tied to the regaining of nature in which they cannot control their
238 VEENA DAS
appetite for sex. I quote here from an earlier stated, "You want to take away the rights of a
paper, where I argued that major woman who has remained here after the
partition. . .. My submission is that the law of
it is male desire which is considered as "nat- nations is clear, the law of humanity is clear, the
ural," hence "normal," and the female body as Indian Penal Code is clear, the Constitution we
the natural site on which this desire is to be have passed is clear, that you cannot force a
enacted. Women are not seen as desiring sub- woman who is above 18 to go back to Pakistan.
jects in the rape law - as wives they do not This Bill offends against such a rule."
have the right to withhold consent from their In addition to the manner in which the
husbands, although the state invests its rights of a woman to decide her future course
resources in protecting them from the desires of action were taken away by the state to pro-
of other men. Paradoxically, women defined in tect the honor and purity of the nation, there
opposition to the wife or the chaste daughter, was also the question that the bill gave wide
i.e. women of easy virtue, as the courts put it, powers to the police to remove a woman for-
also tum out to have no right to withhold cibly if she came under the definition of an
consent. . . . A reading of female desire as abducted woman under its clauses. This, as
interpreted by the courts demonstrates, that
Shri Bhargava pointed out, took away the
while men are seen to be acting out their "nat-
rights of habeas corpus from a person who
ural" urges when engaging in "illicit" sex,
was treated as an abducted person even if she
women who show any kind of desire outside
the confines of marriage are immediately con- were mistakenly so labeled.
sidered "loose." By escaping the confines of When several members of the House pointed
male-centered discourses of sexuality and alli- to the increasing evidence that many women
ance, these women are then castigated by were refusing to go back to their original fam-
becoming the objects of any kind of male ilies and were practically coerced by social
desire. Rape is not a crime but is reduced to workers to return, Shrimati G. Durgabai,
an act that she herself deserves or seeks. 14 speaking on behalf of both the social workers
and the women's movement, defended the
Clearly, the deeply rooted assumptions about social workers on the grounds that they knew
the husband/father figure continue in the jurid- best what the women's true preferences were.
ical unconscious even when the figure of the Durgabai's statement is worth quoting in detail:
abducted or raped woman appears in the sin-
gular in post-Independence India. Questions are also asked: Since these women
Let us consider the next question - Who is are married and settled here and have adjusted
an abducted person? According to the bill, "An themselves to the new environment and to their
'abducted person' means a male child under the new relatives here, is it desirable that we should
age of sixteen years or a female of whatever force them to go back? It is also argued: These
women who have been able to adjust themselves
age, who is, or immediately before the 1st day
to their new surroundings are refusing to go
of March 1947 was, a Muslim and who, on or
back, and when they are settled, is it desirable
after that day, has become separated from his
that we should force them to go back? ... These
or her family and is found to be living with or are the questions we have to answer. May I ask:
under the control of a non-Muslim individual Are they really happy? Is the reconciliation
or family, and in the latter case includes a child true? Can there be a permanent reconciliation
born to any such female after the said date." 15 in such cases? Is it not out of helplessness, there
We shall take up the question of children being no alternative that the woman consents or
defined as "abducted" under the provisions of is forced to enter into that sort of alliance with a
the bill later. As for the women, it was clear that person who is no more than the person who is a
the bill failed to make any provision for ascer- murderer of her very husband, her very fathet;
taining whether a woman wished to return to or her very brother? Can she be really happy
her original family or not. This question was with that man? Even if there is reconciliation, is
raised by several members. The sharpest criti- it permanent? Is this woman welcomed in the
cism came from Thakur Das Bhargava, who family of the abductor?
THE FIGURE OF THE ABDUCTED WOMAN 239
Paradoxically the authority of the woman came under the definition of an abducted
social worker was used to silence the voice person. These, in short, were children born
of the woman as subject and to put upon her through "wrong" sexual unions. The discus-
an obligation to remember that the abductor sion in the Constituent Assembly focused on
to whom she was now married was the mur- several issues. First, how were rights over a
derer of her husband or her father. The discip- child to be distributed between the male and
lining of sentiment according to the demands the female in terms of their relative contribu-
of the state collapsed the duty to the family tions to the process of procreation? Second,
with duty to the state. The women themselves what legal recognition was to be given to chil-
seem to have been caught in the impossible dren whose parents were not considered to be
situation where the obligation to maintain a legally married since the bill held all forcible
narrative continuity with the past contradicted marriages to be null and void? Third, was there
the ability to live in the present. Durgabai her- a contradiction between the legality estab-
self testified to the apprehensions of the women lished by the state and the customary norms
at the prospects of returning to their original of a community regarding the whole question
homes: "Sir, we the social workers who are of determining the legitimacy of a child?
closely associated with the work are con- Finally, if only one parent was entitled in these
fronted with many questions when we ap- cases to transmit filiation as a basis for estab-
proach a woman. The women say, 'You have lishing citizenship, was it the relationship with
come to save us; you say you have come to take the mother or the father that was to be con-
us back to our relatives. You tell us that our sidered relevant for creating the necessary cre-
relatives are eagerly waiting to receive us. You dentials for citizenship?
do not know our society. It is hell. They will kill Although there was no explicit enunciation
us. Therefore, do not send us back.' " of a theory of procreation and the relative
Yet at the same moment that these appre- contributions of the male and the female to
hensions were expressed, the authority of the the procreative process, analogies drawn from
social worker was established by the statement nature were sometimes used. For instance,
that "the social workers associated with this Pandit Thakur Das Bhargava stated at one
work know the psychology of these abducted point in the discussion that he did not under-
recovered women fully well. They can testify to stand how a general rule could be formulated
it that such a woman only welcomes an oppor- by which the child was to be handed over to
tunity to get back to her own house." The the mother rather than the father: "It takes
refusal of many women to go back and the only nine to ten months gestation during
resistance that the social workers were encoun- which the child has to remain in the mother's
tering in the field was explained away by an womb .... It should not be made a rule that
attribution of false consciousness or a kind of in every case the child is to be given over as a
misrecognition to the women. The appropriate matter of rule. It is something like the rule
sentiment in all such cases was coercively es- that when you plant a tree it grows on the
tablished as a desire for the original home that ground; therefore the tree goes with the land
alJowed men on both sides of the border to be and the fruit of the tree goes with the tree. A
instituting the social contract as heads of child is the fruit of the labour of two persons.
households in which women were "in their There is no reason why the father should be
proper place . ., deprived in each case. Why should we make
this rule?"
Analogies from nature, especially from the
Children and Reproductive Futures activities of agriculture or horticulture to con-
ceptualize procreation, are part of the reper-
We come now to the category of children de- toire of ideas contained in Hindu texts and in
fined as abducted. As stated earlier, the bill the popular ideas regarding procreation. 16
defined any child born to a woman after March What is important here is that a theory about
1, 1947, as an abducted person if its mother the "labor" of reproduction enters into the
240 VEENA DAS
state's repertoire of ideas even as it is articu- would be a mockery to the country if children
lated in opposition to the provisions of the bill. born to Muslim women were sent away on the
Although Durgabai did not pose the question grounds that they would be mistreated as
in these terms, she questioned the rights of the illegitimate children here. "There is a general
male on the grounds that he was an abductor. custom in our Punjab," he stated, "particularly
Men who had forcibly abducted women, sold in the community to which I and Sardar Bhu-
them, and used them for commercial purposes, pinder Singh Man belong, that, regardless of
she argued, could not claim rights over the religion or community of the woman one
children born to these women. In contrast to marries, the offspring is not regarded as illegit-
the earlier argument, Durgabai's interpretation imate, and we give him an equal share."
would be that it was not the joint labor of a Clearly a wide variety of customary norms
man and a woman that had created such a regarding children born to women through
child but the plunder by men of women's proscribed sexual unions existed that were
bodies. Hence, "What right has the abductor now standardized into one single law by which
to keep the child? The child has to go with the illegitimacy was defined.
mmher." How are we to understand this moment as
Another member, Shri Brajeshwar Prasad, foundational in terms of the relation between
also evoked the notion that in nature there the social contract and the sexual contract in
was no question of illegitimacy or legitimacy defining the nation-state? I suggested earlier
of a child, and that it was only the conven- that the figure of the abducted woman had
tions of society that made children legitimate circulated in the late nineteenth and early
or illegitimate. In his words, "Sir, I do not twentieth centuries as the site of anxiety for
know how a child born of a man and a defining the place of men as heads of house-
woman can ever become illegitimate. This is holds.17 It is important to note that the ques-
a notion I have not been able to grasp, but tion of a father's rights over his children after
still knowing full well the attitude of the pre- his conversion to another religion was not a
sent Government, knowing full well the atti- new question - it had legal precedents. For
tude of the Hindu society, we have to take the instance, whether a man who had converted
facts as they are and the illegitimate children to Christianity could continue to claim conju-
if they are to live in India, they will remain as gal rights over his wife had been debated before
dogs, as beasts." the colonial courts as well as the issue of
In the above discussion it was clear that the whether a man's "natural" rights over his child
question of the legitimacy or illegitimacy of the overrode the dissolution of marriage after con-
children was related to the fact that it was the version. I have argued elsewhere that although
provisions of the bill that had made all unions the courts were reluctant to apply English
that may have started with abduction and common law to these cases, arguing that the
ended with marriage illegal and thus the chil- legal imagination must contend with people of
dren born to such unions illegitimate. As one one faith living under a political sovereign who
member, Shri Brajeshwar Prasad, put it, even if owes allegiance to another faith, the general
a natural attachment had developed between consensus was that the father's right could not
the abductor and the abducted woman, the law be denied. 18 It now became possible to set aside
did not recognize such marriages. Therefore, a the legal precedents on these questions and to
woman could continue to stay with her take away custody from the father in the case
abductor "only as a prostitute and a concu- of children born to women who had been for-
bine," while her children could only remain in cibly possessed, precisely because the founda-
the country as illegitimate children who would tional event was located within an imagination
be a "standing blot on Hindu society." of a state of emergency when normal rules were
A contradiction between state-defined set aside. In the next section I discuss these
legality and community-based legality was issues briefly and then conclude with the ques-
pointed out by Chaudhari Ranbir Singh, at tion: Why is the state interested in women as
least as he saw the matter, for he thought it sexual and reproductive beings?
THE FIGURE OF THE ABDUCTED WOMAN 241
effect, a neutralization of his power to kill. By It is from Emile's journey into citizenship
grounding the power of the father in the con- that we learn the multiple chains of significa-
sent of the family, Hobbes is able to draw a tion in which the figure of Sophie is inserted.
distinction between fatherly and sovereign au- She is the chimera who is inserted into the text-
thority as two distinct but artificial spheres. figure of seduction, the future mother of a
However, this is done within the framework family, and one through whom Emile learns
of the seventeenth-century doctrine that women that to be a good citizen is to overcome his fear
are unfit for civil business and must be repre- of death by giving a law to the desires of his
sented (or concluded) by their husbands. The heart. Hence, she is the seductress in the pre-
sexual contract and the social contract are then sent, the maternal in the future, and the teacher
two separate realms. As Severance notes, how- of duty and code of conduct. Without her, he
ever, the idea of the state of nature as that in can overcome physical ills, but with her and
which every man is in a state of war with every then despite her, he will become a virtuous citi-
other man should be modified to read that every zen: "When you become the head of a family,
father, as the head of the family, is at war you are going to become a member of the state,
against every other father. In her words, "the and do you know what it is to be a member of
members of each individual family 'consent' the state? Do you know what governmem,
not to the sovereign's but to the father's abso- laws, and fatherland are? Do you know what
lute rule; they are not parties to the 'contract' the price is of your being permitted to live and
that brings the commonwealth into existence. "24 for whom you ought to die?'' 27
I would claim that this war of "fathers" is what There are two thoughts here. The first is
we witness in the acts of abduction and rape. that to be a citizen of the state, you must be
The state's commitment to the recovery of the head of a household; the second is that you
women is the acknowledgment of the authority must know for whom you ought to die. For the
of the father as the necessary foundation for the woman, the duty as a citizen is confounded
authority of the state. I find it useful to think of with her duty to her husband. A woman's com-
Rousseau's analysis of the figure of the woman portment must be such that not only her hus-
in the discussion on sovereignty in Emile to band but also his neighbors and friends must
show that the notion of the sexed individual believe in her fidelity. When she gives her hus-
as the basis of the political has a deep linkage band children who are not his own, we are
with the idea of the life of the sovereign. 25 told, she is false both to him and to them and
As I have argued elsewhere, 26 the figure of her crime is "not infidelity but treason. " 28
the woman in Rousseau is introduced not so Thus, woman as seductress holds danger for
much as the symmetrical opposite of the man the man, because she may use her powers of
but rather as the obligatory passage through seduction to make the man too attached to life
whom the man moves along the road of mar- and thus unable to decipher who and what it is
riage, paternity, and citizenship. While the worth dying for. In her role as mother, she rna y
scene of seduction is necessary for the pupil in deprive him of being a proper head of the
Emile to be inserted inca the social, his capabil- household by giving him counterfeit children.
ity to be a citizen is proved by learning how to That this is treason and not infidelity shows
renounce the very lure of the woman who was how the mother, who was completely excluded
his passage into sociality. The parable of as a figure of thought in Hobbes, comes to be
Sophie, whom Emile must both learn to love incorporated into the duties of citizenship. For
and through whom he must learn to overcome Rousseau the individual on whose consent pol-
his fear of death, points to the close relation for itical community is built is, no doubt, a sexed
a man between learning how to inhabit society individual, but the woman has the special role
through the engagement with sex and how to of not only introducing the man to forms of
become a good citizen by overcoming the fear sociality but also teaching him how to re-
of separation and death. It is worth pausing nounce his attachment to her in order to give
here to reflect on this. life to the political community.
THE FIGURE OF THE ABDUCTED WOMAN 243
Within this scheme, women's allegiance to love and produced a child, today they leave
the state is proved by their role as mothers who their husband and go to the dead Ghazi Mian
bear legitimate children (recall the remark and at his defunct grave ask for a child. It is
about the crime of bringing illegitimate chil- not women but men who are to be blamed for
dren into the world being not about infidelity this hateful act. Even when they are alive,
but about treason); and men learn to be good instead of asking their wife to become a true
citizens by being prepared to die to give life to pativrata [a woman devoted exclusively to her
husband, regarding him as a god], they allow
the sovereign. Once the individual is recog-
her to go to the dead grave of a Turk to ask for
nized as social because he is sexed, he is also
a child and become an infidel. 29
recognized as mortal. In Rousseau, we saw that
man is said to receive life from the sovereign. In the introduction to this chapter, I juxta-
Political community as population is depend- posed the problem of the silence on the Partition
ent on reproduction: thus, the citizen's invest- with the excess of speech in the mode of rumor-
ment of affect in the political community is encountered not only in popular imagination
attested by his desire to reproduce and to give but also at the heart of the official documenta-
the political community legitimate "natural" tion of the event. The analysis offered here takes
children. A corollary is that a woman's infidel- the legal and administrative discourse on the
ity is an offense not only against the family but abducted woman as an important site for under-
also against the sovereignty of the state. standing how the social contract was grounded
We can see now that the mise-en scene of in a particular kind of sexual contract. The trope
abduction and recovery places the state as the of horror through which this space of (excess)
medium for reestablishing the authority of the enunciation and action was opened up under the
husband/father. It is only under conditions of sign of the state not only drowned out the voices
ordered family life and legitimate reproduction of women but also recognized their suffering as
that the sovereign can draw life from the relevant only for the inauguration of sover-
family. Gupta's work allows us to see that the eignty. [ ... ]
earlier imagination of the Hindu woman as
seduced or duped by the Muslim man is com-
plemented by the idea that her attraction to NOTES
Muslim practices is an offence against the
patriarchal authority of the Hindu man, im- 1 Gyanendra Pandey, "The Prose of Otherness,"
in Subaltern Studies, ed. David Arnold and
agined within the scene of colonialism. Thus,
David Hardiman (Delhi: Oxford University
for instance, Gupta gives examples from many
Press, 1994), vol. 8, 188-221, quotation from
vernacular tracts in which the practice of
205.
Hindu women praying to the Muslim pirs (holy 2 Rada Ivekovic, Le sexe de Ia nation (Paris:
men given the status of saints, especially Non & Non, Editions Leo Scheer, 2003).
among Shra Muslims), a common religious 3 Shoshana Felman, The juridical Unconscious:
practice of Hindus and Muslims alike, is con- Trials and Traumas in the Twentieth Century
strued as a betrayal of the Hindu man - a (Cambridge, MA: Harvard University Press,
mocking of his potency - that to my ears 2002), 7.
sounds remarkably akin to the act of treason 4 G.D. Khosla, Stern Reckoning: A Survey of
that Rousseau attributes to women who bring the Events Leading Up to and Following the
"wrong" children into the world. The Partition of India (Delhi: Oxford University
following quotation from a vernacular tract Press, 1989; first published in 1949).
offers a particularly telling example: 5 See Veena Das, "Narrativizing the Male and
the Female in Tulasidas's Ramacharitamana-
God believes in the worship of only one hus- sa," in Social Structure and Change: Ritual
band for women, but they pay service to Ghazi and Kinship, vol. v, ed. A.M. Shah, B.S. Ba-
Mian for many years.... Where before Hindu viskar~ and E. Ramaswamy (Delhi: Sage Pub-
women worshipped their husband for a lor of lications, 1998), 67-93.
244 VEENA DAS
6 Proceedings of the Indian National Congress 19 See Paola Bachetta, La construction des
1946-1947 (New Delhi: Government of identites dans les discours nationalists hin-
India, 1947). dotts (1939-1992): le Rahstriya Swayamse-
7 Ibid. vak Sangh et Ia Rashtriya Sevika Samiti
8 Khosla, Stern Reckoning, 234. (Lille: ANRT, Universite de Lille ill, 1996),
9 Rajashree Ghosh, "The Constitution of and Charu Gupta, Sexuality, Obscenity,
Refugee Identity," unpublished M. Phil. dis- Community: Women, Muslims, and the Hindu
sertation, University of Delhi, 1991. Public in Colonial India (New York: Palgrave,
10 Kamlabehn Patel, Mula Suta Ukhledan 2002; first published, Delhi: Permanent
(Bombay: R. R. Seth, 1985). Black, 2001). Page references are to the
11 Veena Das, Life and Words (Berkeley: Uni- Palgrave edition.
versity of California Press, 2007). 20 Gupta, Sexuality, Obscenity, Community,
12 The following quotations from these discus- 248.
sions are taken from Constituent Assembly 21 Gupta, Sexuality, Obscenity, Community,
of India (Legislative) Debates (New Delhi: 267.
Government of India, 1949). 22 Claude Levi-Strauss, The Elementary Struc-
13 The mythic motif of the abduction of the tures of Kinship, rev. ed. trans. J. H. Bill and
innocent Sita by Ravana and her subsequent J. R. von Sturmore, ed. Rodney Needham
banishment by Rama was evoked as a meta- (London: George Allen & Unwin, 1969).
phor in popular literature as well as popular 23 Mary Laura Severance, "Sex and the Social
Hindi films. Contract," journal of English Literary His-
14 Veena Das, "Sexual Violation and the tory, 67, no. 2 (2000): 453-513. I remind the
Making of the Gendered Subject," in Dis- reader that in Filmer's theory fatherly power
crimination and Toleration, ed. K. Hastrup is the basis for kingly power - hence, the
and G. Urlich (London: Kluwer Law Inter- father had the right to kill the son without
national, 2002), 257-73, quotation from incurring any legal penalty. See Sir Robert
271. Filmer, Patriarcha and Other Writings
15 The text of the Abducted Persons (Recovery (Cambridge: Cambridge University Press,
and Restoration) Act, 1949 (Act No. LXV of 1991; first published in 1680). I discuss this
1949), is reproduced as Appendix 1 in Me- in some detail in my essay "Paternity, Sover-
non and Bhasin, Borders and Boundaries, eignty and the Argument from Nature."
261. 24 Severance, "Sex and the Social Contract,"
16 On the relative weight given to men and 456.
women in the procreative process in Punjabi 25 Jean-Jacques Rousseau, Emile (New York:
kinship, see Das, "Masks and Faces.'' Everyman's Library, 1974; first published in
17 I owe this insight to the important work of P. 1911). Page numbers are from the 1974
K. Dutta and Charu Gupta. Everyman's Library edition.
18 See Veena Das, "Paternity, Sovereignty and 26 Das, "Paternity, Sovereignty and the Argu-
the Argument from Nature," in Powers of ment from Nature."
the Secular Modern: Tala/ Asad and His 2 7 Rousseau, Emile, 448, emphasis added.
Interlocutors, ed. David Scott and Charles 28 Rousseau, Emile, 325.
Hirschkind (Stanford: Stanford University 29 Cited in Gupta, Sexuality, Obscenity, Com-
Press, 2006, 93-113). munity, 292 (translation by Gupta).
20
Where Ethics and Politics
Meet
The Violence of
Humanitarianism in France
Miriam Ticktin
While I was conducting fieldwork in Paris, the made illness a primary means by which to
former president of the gay-rights activist obtain papers in France. I open with the
group Act-Up Paris told me that he had received HIV anecdote to introduce the notion of the
phone calls from undocumented immigrants in- often-unintended consequences of ethical dis-
quiring how they could infect themselves with courses such as humanitarianism or practices
HIV and thereby obtain legal status in France. that claim to further social justice. More
Although this particular account of HIV self- broadly, I use this example as an entryway
infection is anecdotal, the rhetoric of willed into what I see as an incipient or emergent
self-infection can be located in the larger reality ethical configuration in which people end up
I observed during the course of my research trading in biological integrity for political
between 1999 and 2001: I increasingly saw un- recognition.
documented immigrants, or sans papiers (liter- The sacred place of biological integrity in
ally those without papers), turn to physical this emergent ethics became apparent to me
injury or infection to claim the basic rights over the course of my fieldwork with undocu-
supposedly granted to all "human beings.'' 1 mented immigrants. I initially went to Paris to
This tendency to turn to illness for papers oc- examine the promises and failures of human-
curred in the wake of the limited success of the rights discourse in the sans papiers movement
social movement by and for undocumented and, more broadly, to understand transnational
immigrants in France to secure basic human ethical and legal regimes. Thus, in addition to
rights. It also coincided with the introduction working with sans papiers organizations and
of a humanitarian clause in French law- what I nongovernmental organizations (NGOs), I
call the "illness clause' -that gives people with conducted research at various hospitals, state
serious illnesses the right to stay in France and medical offices, and clinics both within and
receive treatment. 2 just outside of Paris that focused on marginal-
In this article, I examine the role of hu- ized populations (those en situation de precar-
manitarianism and compassion in the develop- ite). In the clinics, social workers and doctors
ment of an ethical configuration that has worked hand in hand, driven by the conviction
Miriam Ticktin, "Where Ethics and Politics Meet: The Violence of Humanitarianism in France," American
Ethnologist 3311 (2006): 33-49. Reproduced by permission of the American Anthropological Association
from American Ethnologist 33/1 (2006), pp. 33-49.
246 MIRIAM TICKTIN
that social and medical issues are intertwined, examples of how humanitarianism works
particularly for those designated "les exclus" on the ground, in "a space of concrete prob-
by the French - society's excluded. Early on lems, dangers, and hopes that are actual,
in my observations, however, I noted that emergent, and virtual" (Rabinow 2002:145),
the first question many social workers asked I trace its contours and its often-counterintui-
their undocumented clients was, "Are you tive consequences.
sick?" and if an individual answered yes, they My argument has two main theoretical
would ask almost too eagerly, "How sick?'' I points. First, I suggest that humanitarianism,
gradually understood that the answer they although driven by the moral and ethical
hoped for was "Very sick," because it provided imperative to relieve suffering, can have dis-
clients with the one clear means by which to criminatory and even violent consequences in
apply for papers. A woman from an immi- the absence of guiding political principles and
grant-rights association confirmed this conclu- practices. These consequences are all the more
sion at a workshop on sans papiers and HIV/ striking because they are unexpectedly found
AIDS, stating, "Isn't it terrible? We almost at the very heart of the compassion that
wish for illness when we talk to sans papiers." grounds humanitarian action. Here, I engage
This wish for illness, of course, was not born of in a debate about the contemporary resurgence
malice but of a desire to better help the of discourses of moralism and how they
undocumented. blur boundaries between legal, political, and
The illness clause is a provision of the ethical- moral orders. I am particularly inter-
1998 amendment to the Ordonnance of ested in the growing emphasis on the role of
2nd November 1945 no. 45-2658 on Condi- compassion, sympathy, and benevolence in
tions of Entry and Residence of Foreigners that political life - sentiments that play a crucial
grants legal residency permits to those in part in the discourses of what some call "global
France with pathologies of life-threatening civil society." NGOs fighting in the name of
consequence if they are declared unable to human rights, environmentalism, and cultural
receive proper treatment in their home coun- preservation, among many other causes, inter-
tries. The logic behind this provision was hu- vene on behalf of a moral order, each fighting
manitarian and exceptional; indeed, legal for a role in "the global meritocracy of
permits for illness are officially given for "hu- suffering" (Bob 2002).
manitarian reasons." The French state felt it One of the most prominent of these
could not deport people if their deportation movements is humanitarianism, which grew
had consequences of exceptional gravity, such in global importance and visibility over the
as their deaths. course of the 1990s. The massive proliferation
Despite the goal to keep it exceptional, the of humanitarian organizations, the awarding
illness clause - instituted as a humanitarian of the 1999 Nobel Peace Prize to Medecins
provision - has come to play an important Sans Frontieres (MSF, or Doctors Without
role in the politics of immigration. In this Borders), and the entry of humanitarianism
article, therefore, I explore the consequences into common political discourse - illustrated
of a politics of immigration largely grounded by British Prime Minister Tony Blair's govern-
in a humanitarian logic. How does humanitar- ment calling the bombing of Kosovo a
ianism function as politics - how does it "humanitarian bombing" - are just a few
address inequality and injustice? My main examples of its growing presence., There has
contention is that, when humanitarianism, been a concomitant focus on suffering, in the
often enacted through a moral imperative of name of which humanitarianism intervenes. 3
compassion, fills in for the failure of political- As just one example, the diagnosis of posttrau-
rights discourses and practices, the exclusion- matic stress disorder (PTSD) has increased ex-
ary effects can be brutal; indeed, I argue that, ponentially in recent years, giving public
rather than furthering human dignity, the prominence to the suffering and trauma en-
result is a limited version of what it means dured in a variety of contexts, from military
to be human. By drawing on ethnographic interventions co domestic disputes. Yet how
WHERE ETHICS AND POLITICS MEET 247
does the recognition of suffering result in a practical example of the turn to a humanitarian
political program for change? Although politics.
the question of how moral demands translate I focus in the second half of the article on
into politics has a history as long as political the consequences of humanitarianism as polit-
philosophy itself, I am interested in its cur- ics. I fill out my argument that the joining of
rent manifestation precisely because moral ethics and politics actually limits rather than
demands have increasingly filled the space of expands notions of humanity. Thus, I describe
political action. new biopolitical practices and the unexpected
[ ... ]My second point is that this moralism diseased and disabled citizens that are pro-
has created another type of politics, even duced by humanitarianism as a system of gov-
while being labeled apolitical. I engage here in ernance, and I end by discussing how a limited
the contemporary debate about biopolitics humanity is produced on the ground by a pol-
and humanitarianism, which relies heavily on itics of compassion. I show that the humanity
work done by philosopher Giorgio Agamben. protected is one of suffering bodies and bio-
Agamben, in turn, builds on the intersection logical life devoid of social and political con-
of works by Michel Foucault and Hannah tent; yet this is a notion of humanity that,
Arendt. Agamben (1998:133) suggests that hu- even in its minimalism, keeps intact racial and
manitarian organizations can only function by gender hierarchies. Indeed, the struggle to
grasping human life as "bare life," the Greek define citizenship and the borders of the
zoe, the fact of living common to all beings - nation-state is now also a struggle to define
life unqualified by the political and social com- the threshold of humanity and of life itself.
munities that distinguish humanity from other My intention in this article is not to caH into
types of life. Bare life is life excluded from the question people's illnesses or disabilities as
polis, and insofar as human beings are political somehow inauthentic but, rather, to under-
or social beings, the polis marks the boundary stand the effects of a new "biosocial" space,
between human and nonhuman. In fact, my and here I draw on Paul Rabinow's (1996)
research suggests that humanitarianism does concept not only to refer to a social commu-
not simply produce or reproduce bare life as nity created by shared illness but also to indi-
separate from political life, even if the protec- cate the way that biology is used as a flexible
tion of bare or biological life is its goal; rather, social resource. For instance, once an undocu-
it allows for the recombination of bare life and mented immigrant is given papers for illness,
political life in new ways, such that the polit- he or she might choose to escape this biological
ical dimension of human life is never lost. Pol- community in favor of another political or
itical subjects can be found in the most cultural identity. Biosociality here becomes
"apolitical" of spaces. The political aspect of the socially framed choice to draw on one's
life, however, is radically transformed -often biology. 4
in undesirable ways. In other words, the polit- I write, finally, with the recognition that
ical choices allotted to sans papiers, although in exposing the violence at the heart of this
still choices, are composed of undesirable humanitarian practice, I may be helping to fur-
options: poverty, exploitation, exclusion, or ther undermine a key opening to legality that
illness. sans papiers have benefited from. Yet I do so
In this article, I first discuss how humanitar- because the underlying regime of which it is a
ianism has been transformed into a form of part is, ultimately, inherently destructive, not
politics, functioning as a transnational system only reproducing a racially stratified society
of governance tied to capital and labor even built on the colonial legacy but also maintain-
while purporting to be apolitical. To this end, ing certain people as less than human. More-
I examine the distinction between human over, the violence inherent in this particular
rights and humanitarianism, or between a jur- French ethical configuration has larger global
idical and a humanitarian logic, grounding my echoes. Ultimately, my underlying question
argument in the context of French immigration concerns the notion of humanity promoted by
policies. I then examine the illness clause as a a politics based on humanitarianism- what is
248 MIRIAM TICKTIN
the image of the human that this politics transnational institutions, practices, and dis-
projects? cursive regimes, in a broad sense, human-rights
institutions are largely grounded in law, con-
structed to further legal claims, responsibility,
The Shift from Human Rights to and accountability, whereas humanitarianism
Humanitarianism is more about the ethical and moral imperative
to bring relief to those suffering and to save
The issue of illegal immigration erupted into lives; here, the appeal to law remains opportun-
the French public imagination in 1996, when a istic. Although both are clearly universalist dis-
powerful social movement calling for basic courses, they are based on different forms
human rights for illegal immigrants gained of action and, hence, often institute and protect
world media attention through the occupation different ideas of humanity. The political dis-
by 300 African immigrants of the Saint Ber- course of human rights has its origins in
nard church in Paris. The ensuing violent evic- the French Revolution and the Enlightenment
tion by French police of the immigrants, many movement away from religion and toward
of whom were women and children, caused a secular vision of humanity, whereas humani-
an uproar. The movement organized by and tarianism was initially a form of religiously
for these immigrants changed their labeling inflected charity. Even the "new" humanitar-
from illegal immigrants to sans papiers. This ianism- which can be dated to the 1970s and
was a self-conscious move away from the the founding of MSF, followed by the develop-
image of criminality and suspicion associated ment of an industry of NGOs- often perceived
with clandestinity to one of people deprived of reason to be an "enemy of humanity., because
basic human rights. [ ... ] this medical humanitarianism advocated action
To understand the terms chosen by the sans on the basis of emotion; founders such as Ber-
papiers, the place of both human rights and nard Kouchner and Xavier Emmanuelli both
humanitarianism in the French imaginary and identify the Catholic Church as a forerunner
in French public debate is crucial to note. and inspiration (Taithe 2004). 5
France is the originator of both the NGO Human rights and humanitarianism do, of
MSF (now nearly synonymous with humani- course, overlap, and humanitarianism cannot
tarianism in the contemporary world} and the be defined accurately just in terms of religion,
1789 Declaration of the Rights of Man and or emotion, or as outside the political or legal
Citizen, on which the 1948 UN Declaration realms it necessarily engages with: Indeed, hu-
of Human Rights is largely based. The French, manitarianism is Legally instituted through the
therefore, have much invested in their identity laws of war. [ ... ] Such a separation, however,
as global moral leaders, especially in today's is seldom possible in practice.
climate in which geopolitics and moral codes The French situation reveals such a shift in
are intimately intertwined. Perhaps even more emphasis from rights to the practices of hu-
important for my purposes is the distinction manitarianism in regulating immigration. The
between human rights and humanitarianism - issue of "les sans papiers" was one of the major
a distinction that is not always evident in the platforms on which the Socialists entered into
U.S. context but is more clear in the French power in 1997; Prime Minister Lionel Jospin's
one. My focus here is on what happens when government promised to deal with sans papiers
humanitarianism is forced to take on a primary more generously, respecting their basic human
role in government, largely subsuming a system rights. Despite this rhetoric, the promised reex-
based on rights. Without advocating for a amination of cases of undocumented immi-
regime of human rights at the expense of hu- grants in 1997 and the new law in 1998 on
manitarianism, I am interested in the conse- entry and residence of foreigners were both
quences of a humanitarian logic filling in for much less generous than promised. [ ... ] Des-
the failure of rights discourses and practices. pite the proliferation of human-rights NGOs,
Although both human rights and and regardless of the protests that take place at
humanitarianism are complexly constituted a rate and level rarely attained elsewhere, very
WHERE ETHICS AND POLITICS MEET 249
little ground has been gained. These cries for people who have been trying to erase any trace
human rights faJI on now-deaf state ears. of their presence so as not to be deported,
Indeed, the social movement seems to have providing official proof of each month of resi-
come to an impasse with its appeals to human- dence for over ten years is a nearly impossible
rights principles. The larger context is one in task - practically a contradiction in terms.
which refugees have been increasingly viewed The inscription of this article in the law,
with suspicion by both the French state and thus, in many ways simply legitimized the arbi-
the French public and conflated with economic trariness practiced by the prefectures (local
migrants. This conflation has been made expli- governments), working along the lines of what
cit in recent policies of restricting asylum to immigrant-rights lawyer Danielle Lochak
control migration flows, joining two proc- (2001) calls a "humanitarian" logic rather than
esses that should be entirely independent. As a juridical one. Law always involves interpret-
Hubert Vedrine, the minister of foreign affairs ation, and it is always enacted in specific con-
stated, "The practice [of asylum] followed texts that help determine its meaning; the
must maintain a j usc balance with our desire difference here is that, because the law is so
to control migration flows" (1997; cf. Delou- open-ended, those asking for the protection it
vin 2000:70). More broadly, asylum policies affords are entirely dependent on eliciting the
must be seen as part of prohibitionist, restrict- compassion or pity of those enacting it. Indeed,
ive immigration policies, in which the state this open-endedness takes on even more signifi-
seeks to close all doors. In this climate cance in the French context, in which the civil-
of closure, many examples can be cited of law tradition involves applying the law, not
human-rights violations by the state itself, not interpreting or building on it.
to mention by nonstate actors; for instance, The new clause is not alone in being subject
immigrants are imprisoned in detention centers to arbitrary application; family reunification
without trial, despite condemnations of the and asylum have been equally compromised.
inhumane and insalubrious conditions in the [ ... ]The creation of a new type of asylum-
centers. 6 Similarly, immigration officials are "subsidiary asylum" - which comes with fewer
known to be utterly arbitrary in their dealings. attendant rights, is another example of the in-
My interviews with both sans papiers and im- creasing attempt to limit people's ability to
migration officials, combined with my experi- claim rights. This is the consequence of a polit-
ence in accompanying sans papiers to state ics of immigration based on closure (Lochak
offices, revealed that how one is treated 2001:41).
depends on which immigration office one goes To understand the nature of this politics of
to, the official one meets at the desk, how many closure, which has resulted in an increasingly
that official decides to admit that day, the important role for humanitarianism, it helps to
"look, of the immigrant, and so on. Undocu- take a step back [ ... ]. At an event to support
mented immigrants are subject to entry on a sans papiers, Ahmad, an ex-sans papiers, said
case-by-case basis and have to prove their merit to me incredulously, "It was so much easier
without knowing the rules being applied. to find work on the black market! I never
Paradoxically, this arbitrariness was exag- had trouble. Now that I have papers, I can't
gerated by the new law that went into effect in find work." In France, as elsewhere in the
1998, which added Article 12bis, the right to industrialized world, a significant tension has
"private and family life," to the two previously emerged: As increasingly restrictive legislation
existing conditions for legal immigration - has forced borders closed, transforming the
family reunification and asylum. [ ... ] In the so-called open European space into Fortress
absence of a spouse or children in France that Europe, the black market and informal econ-
would allow one to enter under the family omies have grown, and labor conditions are
reunification clause, Article 12bis 3 gives those otherwise changing to favor temporary, inse-
who have lived in France for ten consecutive cure forms of labor with no legal protection. In
years the right to papers. Residency, however, this sense, the increased demand for workers
must be proven, not simply declared. [ ... ] For in the agricultural, garment, and construction
250 MIRIAM TICKTIN
industries in France is met by closed juridical grants legal residency permits to those already
doors: Undocumented immigrants are desired living in France who have pathologies that
precisely because they can be denied all rights entail life-threatening consequences if they are
(Fassin 2001b). Ahmad exemplifies this ten- declared unable to receive proper treatment in
sion between industry wanting and needing their home countries; the goal is to permit them
labor and the nation-state refusing to let people to receive treatment in France. Indeed, it was
legally onto its territory. The French state is the lobbying of medical humanitarian groups
complicit in this process, having passed laws such as MSF and Medecins du Monde (Doctors
that produce a category of persons who are of the World) that helped turn the illness clause
neither legalizable nor deportable. On another into law in France in response to what was
register, this liminal status is part of an increas- perceived as arbitrary treatment of those who
ing tension between regimes of circulation for were sick - sometimes helping them, some-
capital and people - capital circulates freely, times deporting them.
whereas people cannot - a consequence of the The "illness permit" was instituted formally
changed relationship between states and cap- in 1998. That is, only in 1998 did the Ministry
ital (cf. Sassen 1996). of Health officially become involved in the
How does this political economy relate immigration process, which normally falls
to the shift to humanitarianism? Both the dis- under the rubric of the Ministry of Interior.
course and practice of medical humanitarianism Nevertheless, the banlieue (suburb) outside
have followed this flow of exploitable labor Paris that receives the highest number of claims
from the South into the urban centers of the for legal status began the practice of taking
industrialized North; just as MSF started by illness into account in claims for papers in
intervening in crises of governance and econ- 1990. I conducted my fieldwork primarily in
omy in the South, so, too, it now intervenes in this suburb and in Paris. I followed sans papiers
industrialized centers like Paris- cities in which through the different steps of the trajectory to
it has established offices for local concerns. Just papers: To access the illness clause, the sans
as it protects a particular vision of life in war- papiers are referred by their own doctors to
torn zones, working to ease the immediacy of immigration authorities and then by the immi-
suffering, so, too, it now intervenes to ease gration officers at the prefectures to state
suffering when the larger societal and political health officials. 9 It is ultimately the job of these
structures of the North fail to do their job - officials to ascertain if people's conditions are
when they let increasingly large portions of of sufficient gravity to merit granting papers
their population fall through the cracks. Here, for treatment in France, although the permits
medical humanitarianism governs the less de- are actually issued by the prefectures, with the
sirable portions of the population when the understanding that they rely upon the state
state abandons them (cf. Ong 1999). In this health officials' opinions. The state office in
sense, ethical systems in the form of medical which I did a large part of my research is one
humanitarianism are part of the transnational of the few in which nurses receive the sans
circulation of capital and labor, linking the pol- papiers in person. Other offices receive sans
itical economy of immigration to the political papiers' files by mail; the files are initially
economy of health and illness. 7 sorted through either by nurses or administra-
tors and then passed to doctors. The state med-
ical doctor can recommend that a medical
The Illness Clause certificate be granted for varying lengths of
time, from a period of three months to an
The illness clause emerged as an alternative to indeterminate (long-term) period, depending
human-rights discourse and discourses of on the illness and the doctor's interpretation
social injury for those whose appeals to rights of the length of treatment needed. People can
did not easily coincide with state interests or claim citizenship after a period of five years on
whose positioning has not allowed their claims the basis of their residency on French soil; thus,
to be heard. 8 To reiterate, the 1998 amendment continual renewal of illness permits may
WHERE ETHICS AND POLITICS MEET 251
eventually lead undocumented immigrants to little difference to the nature of the process.
citizenship. Instead, a different logic has been instituted,
Very little about the process is systematic. one based on benevolence and compassion.
The law states that people should receive With the possibility of obtaining papers
papers if they suffer from a pathology that effectively shut off to new immigrants and
has life-threatening consequences and they do refugees - who, as I have mentioned, are
not have access to treatment in their own coun- seen as either criminal or economically burden-
try. Yet there are no lists of life-threatening some- those already in France without papers
pathologies and no easily accessible informa- have turned to the illness clause as a means to
tion on whether people can receive treatment ease the exploitation that is a regular part of
in their home countries. The doctors are urged being undocumented, believing - rightly or
to contact the Direction de Ia Population et des wrongly- that papers will solve all their prob-
Migrations (Office of Population and Migra- lems. Statistics back up my ethnographic work,
tions) for information. But no source takes into demonstrating the increasing importance of
account people's substantive ability to access the illness clause. The local statistics from
medical treatment: Do they live far away from [ ... ] the state medical office in which I did
city centers? Do they have the means of trans- my research show that applications for the
port to hospitals or doctors? Do they have illness residency permit increased seven times
the money to get treatment or to continue over the course of the 1990s and that three-
treatment if it involves subsequent trips to quarters of applications were given positive
medical facilities? These questions are not ad- responses. More recent statistics are even more
dressed in the guidelines. They are asked at the striking. [ ... ] Table 20.1 shows that the
discretion of the medical officials receiving the number of positive responses increased by 44
case or at the prefecture beforehand. Already, percent just in that particular departement,
one sees the discretionary power of the nurses, from 889 in 1999 to 1,287 in 2000. Table
doctors, and immigration officials and the ad- 20.2 shows the types of illnesses admitted
vantages and disadvantages that sans papiers and their frequencies and the type of permit
derive from being able to interact face to face granted - top among the illnesses is HIV, but
with state officials. Ultimately, the immigration cardiovascular illnesses, cancer, diabetes, and
officers at the prefecture make the decision tuberculosis are all included.
about who will receive an illness permit and How does the French state reconcile the
for what duration, and although, in theory, denial of papers to immigrants who are per-
they should follow the advice of state doctors, ceived to be economically burdensome with
they do not necessarily do so. Thus, although the decision to give papers and social services
legalizing the process was an attempt to sys- to immigrants who are sick? Stated otherwise,
tematize the arbitrary treatment of the sans why is it that illness is allowed to travel across
papiers, in practice, the illness clause has made borders, whereas poverty cannot? The framing
Table20.1 Distribution of recommendations for illness permits given by the state medical doctor (MISP) in
the region where I observed: 1998, 1999, and 2000
Table 20.2 Most frequently encountered pathologies in the state medical office where I observed: 1998,
1999, and 2000
of the illness clause helps to explain this. Al- the most extensive of all those granted to im-
though the French state instituted the illness migrants, whatever their legal status - more
clause out of "respect for human dignity," it comprehensive than any civil, political, or
was only ratified because it was perceived as social rights (Fassin 2001a). 10
outside the political realm. That is, it was insti- As proof that this clause is humanitarian
tuted in May 1998 under the right to "private and apolitical in nature and that it remains in
and family life." Placing this clause under the the realm of the private, the French state does
aegis of the "private" exempts it from debates not automatically include a work permit with
about the politics of immigration, citizenship, the illness visa - initial attempts to do so
and notions of the French nation and ignores rendered the clause too politically contentious.
the structural problems and economic demand [ ... ] The visa given for illness is thereby isol-
that may have caused the immigration in the ated from all other aspects of life - it is nar-
first place. Instead, the clause focuses attention rowly focused on the healing of suffering,
on what is construed as an apolitical, suffering injured, or disabled bodies, disqualifying its
body. This clause is based on the notion of the recipients from taking any economic, social,
universality of biological life - what I have or political role in French society. Conse-
already mentioned as Agamben's "bare life." quently, those who gain entry on the basis of
State officials and doctors confirmed to me chronic illness, such as those who are HIV +
that the space of pure life honored in the illness and who are fully capable of sustaining a full-
clause is conceived of in opposition to political time job, are for the most part not given the
community. [ ... ] Despite increasingly restrict- right to work. Although their papers formally
ive legislation that has managed to alter and allow them to rent apartments, open bank
limit the right to health care, that right remains accounts, and travel on the metro without the
WHERE ETHICS AND POLITICS MEET 253
risk of being arrested and deported, they do not modernity and global capital, in which contra-
have the substantive means to rent apartments, dictory and unexpected diseased and disabled
and they have nothing to put in bank accounts citizens emerge.
and no money to buy metro tickets. Ironically,
in the name of human dignity, the French state
indirectly sanctions work on the black market. Diseased and Disabled Subjects
In this sense, a doctor named Isabelle who
worked at one of the clinics for undocumented I turn in the second half of this article to a
immigrants where I observed suggested that, in discussion of the consequences of humanitar-
her experience, the illness clause was "a curse." ian governance, beginning with the counterin-
It was worse than nothing because it gave tuitive subject positions produced by this shift
people hope, and yet, because work permits to humanitarianism in the politics of immigra-
were not granted with the papers, it paved the tion. Here, political subjects can be found in
way for greater exploitation of their misery, the most "apolitical" of spaces.
making them work in situations of virtual I have been arguing that this shift to seeing
slavery and prostitution. She suggested that the suffering body as more legitimate than the
politicians got rich on the backs of those threatened or deprived person reveals the desire
working on the black market - "Why else are to recognize the universality of biological life
they not deported?" she asked. "It must mean above all else: that is, to find common human-
that it is profitable for the state to keep them." ity in apolitical suffering, a universal humanity
Economic profitability of undocumented that exists beyond the specificities of political
immigrants aside, the illness clause is also pro- and social life. Indeed, according to Agamben,
ductive of a particular moral economy, in which humanitarianism as a practice cannot help but
a new hierarchy of morals takes shape and cer- grasp human life in the figure of "bare life,"
tain ethical configurations gain credence. Here, thereby reproducing the very idea of a form of
humanitarianism functions as politics and has life distinct from political life. Liisa Malkki
inevitably unanticipated consequences. The has ethnographically confirmed this tendency,
threatened body associated with political demonstrating how humanitarian practices
asylum has been recast as suspect, conflated make refugees into "universal man" - how
with that of the economic immigrant - or, in they set up a "bare, naked or minimal human-
the words of former Socialist minister Michel ity" (1996:390). Of course, humanitarianism
Rocard (1996), "the misery of the earth," does work to reduce people to "pure victims''
which, he claimed, France cannot absorb. With (Malkki 1996), making it easier for them to be
humanitarianism as the driving logic, only the configured as objects of charity rather than of
suffering or sick body is seen as a legitimate law. Yet, when one looks closely at this process,
manifestation of a common humanity, worthy one sees that bare life and political life actually
of recognition in the form of rights; this view is combine in new ways as a result of humanitar-
based on a belief in the legitimacy, fixity, and ian practices, particularly when humanitarian-
universality of biology. As just one example of ism takes over the space of political action
this new moral economy, Didier Fassin (2001a, and responsibility. In other words, people elide
2001b) has documented that, as the number of victimhood and reduction to bare life in inter-
permits for medical reasons has increased, the esting, albeit troublesome, ways; political
number granted under the title of refugee has action is constituted as a series of biological
significantly diminished. What are considered compromises. More to the point, however, is
basic human rights are themselves now circum- whether this type of political action can be
scribed to fit the limited understanding of considered desirable or acceptable.
human life. It is in this sense that I speak of Part of the reason for recognizing the uni-
the space of the apolitical suffering body as versality of life involves controlling, managing,
the very center and grounding of the new polit- and cultivating it; this is the biopolitics that
ics of citizenship in France, a humanitarian Foucault (1978} speaks of, making the individ-
space at the intersection of biopolitical ual body and population part of the problem of
254 MIRIAM TICKTIN
sovereign power, in which the power/know- thumbed through the majority of her docu-
ledge of life allows for its transformation. In ments, their attitude suddenly changed from
other words, neither humanitarianism nor the mild annoyance to care and concern. And one
state's support of humanitarianism can be nurse asked her again, "Do you really not
understood outside the context of disciplinary know what you have?" This time, Amina re-
power- the state does not act "altruistically" in sponded that, yes, yes, of course, she did. She
recognizing a common humanity. If life is not left it at that - the illness remained unnamed.
only the object of political struggle but also the The nurses promised her papers and told her to
very grounding of sovereignty, as Agamben take care of herself and the baby. When she left,
suggests - building on Foucault - then the I was told that both Amina and her baby were
power to define bare life, that is, the power to HIV+.
draw the line and decide who and what is This phenomenon was explained to the
included and excluded from the juridical and nurses and me by another woman named
political realms is what actually constitutes Fatoumata, who also opened up exceedingly
sovereign power. Paradoxically, the state's hesitantly when questioned. Fatoumata had
focus on the universality of biological life is recently been released from prison. She had been
turned on its head. [ ... ) Sans papiers demon- arrested on drug-related charges and infected
strate how biology is not the domain of the with HIV through needle use. She told us about
incontestable- biological norms are created. the many infected African women in Paris
Contradictory subject positions emerge who simply reject the opportunity to obtain a
from a politics based on this belief in the uni- visa that would not only grant them basic rights,
versality of life, but only as biological life. On such as the right to housing, but would also
one end of the spectrum is the person who permit and pay for their regimen of triple ther-
infects her- or himself with HIV in an effort to apy- a visa that would literally provide them
be treated like a human being, to be granted with both the right to live and life itself.
legal recognition and, hence, acknowledged as The stigma of HIVIAIDS is so great in their
part of humanity, willfully disabling her- or communities that they would rather comprom-
himself to live more fully. [ ... ] On the other ise their bodily integrity and pay with their
end is the person who refuses the possibility of lives than live ostracized and without dignity.
treatment- purposefully giving up bodily in- Fatoumata had a tough exterior, but when she
tegrity to maintain human dignity in the face of mentioned her inability to trust her closest
the stigma of HIV/AIDS. Here, bodily integrity family or friends with the news that she was
and human dignity are decoupled and differ- HIV+, she began to cry softly.
ently reconfigured. For instance, one day as I In talking to Fatoumata, I became aware of
sat with the state nurses while they attended to the gendered nature of the stigma of HIV/AIDS
undocumented patients requesting papers to among African communities in France. All
stay and receive treatment in France, I watched pregnant women in France must, by law, be
as a woman named Amina refused to even tested for HIV, whereas men are never forced
speak the name of her illness. The nurses ques- to get tested. Thus, more women find out
tioned her many times: "What do you have?" about their illness than do men, leading to an
they asked. "What are your symptoms?" She unequal gender dynamic and a particularly
shook her head and said nothing. Originally gendered stigma in African communities.
from Mali, Amina had come with her baby Indeed, this dynamic has the consequence of
strapped onto her back in a colorful wrap, increasing the numbers of women granted
and she spent her time unraveling herself and papers through the illness clause; it also results
the baby to change his diapers, responding dis- in more women than men having to lead
tractedly to the nurses' questions. She handed double lives, hiding their diagnosis from their
over a slew of documents, both medical and loved ones, or leading lives that define them
legal - the telltale pile of papers that all those solely in terms of their illness, existing outside
who are "paperless" must carry wherever they all community affiliation except for the patient
go - a cruel irony, indeed; after the nurses had groups they may belong to. In other words, this
WHERE ETHICS AND POLITICS MEET 255
stigma creates a subject position for women, in and, thus, had some knowledge of the medical
particular, in which their reason for living be- system. Her illnesses were chronic, however;
comes their illness - it becomes their only she needed both the thyroid medication and
source of social recognition - yet it is also their the skin creams on a constant basis, and neither
death sentence. medication was readily available in Senegal.
[ .•• J The nurses told me about other cases of She left her life and family, ironically, to protect
people purposefully not treating their iJinesses, what the French law calls her right to "private
prolonging them to keep their legal status. [ ... ] and family life"; not only was she not legally
Even something as simple as a cataract can serve permitted to bring her children to France, but
the purpose of prolonging one's stay. Of course, she was also not given papers to work, trans-
it means that the advantages of legality are forming her life into a monotony of shelters in
exchanged for the difficulties of living one's life which she slept at night - shelters force people
partially blind. I say this with an added caveat, out at 8 a.m.- and cafes and parks in which she
in that those who do not treat themselves often sat during the day to pass the time.
have good structural reasons for not doing so, The nurses and doctors at the hospital
such as not having sufficient money to cover the clinic for the disenfranchised where Aicha
costs, or the time, or the means to get to and received treatment were her main source of
from the hospital. The nurses themselves agreed community - and even their friendship and
that a patient's reasons for not pursuing treat- support were contingent. As she stood outside,
ment were not always clear. The point here is they complained to me that they did not need
still valid, however; one must remain diseased to to see her anymore and wished she would leave
remain in France and to eventually claim citi- space for other patients. In their understand-
zenship. Both the medical officials and sans pa- able desire to give others a chance at health and
piers realize this. bodily integrity, the larger structural reality of
Each of the cases mentioned plays on differ- which they are a part dictates that they deprive
ent configurations of bodily integrity and Aicha of her only source of humanity that
human dignity. Along this spectrum are other goes beyond biological life. Occasionally, she
unanticipated subject positions. For instance, wondered aloud to me whether her life was
one of the doctors I worked with treated a worth living - what kind of life was it, she
patient who took on the identity of a person asked, with no family, no work, no money, no
who had AIDS, including taking the person's fulfillment, and nothing to wake up to each
medication- in fact, he literally stole the iden- morning except one's illnesses, the simultan-
tity of a friend of his who died of AIDS. He did eously driving and disabling force of her life?
this to get French papers- to obtain legal rec- She cannot escape her state of injury, which is
ognition that enabled both a life free from daily not only named as such but also embodied. She
violence and a modicum of human dignity. is just one of the new subjects produced by the
Paradoxically, his dignity was not recognized, French nation-state -given life by the conse-
in the sense of his unique, individual self; he quences of ethical regimes such as humanitar-
preferred to give up that identity to get legal ianism that are both created and circumscribed
recognition as someone else, again complicat- by global capitalism.
ing theories of the liberal individual that In the face of what can be called a new space
ground notions of French citizenship. of"biosociality,'' in which biology is remodeled
Finally, the case of a Senegalese woman not only on culture but also on structural need-
named Aicha illustrates the results of a politics in which biological compromises are made as a
of humanitarianism that creates political sub- primary form of political action - the subjects
jects, albeit with limited political choices. Ai- that I have just described are not easily ex-
cha had a thyroid tumor and a serious skin plained by liberal notions of the self, of the
condition aggravated by heat. She left her good life, or of human flourishing (cf. Petryna
family in Senegal, including her five children, 2002:4}. In this emergent ethics, those with
to live in France and treat her condition. Aicha cancer, Hrv, polio, or tuberculosis - and even
had lived in France during her first marriage occasionally those with more explicitly socially
256 MIRIAM TICKTIN
and politically grounded injuries such as rape observing, suggested to me that I might be
or disfigurement- become the most mobile, the interested in a paradox he had witnessed.
most able to travel without hiding themselves He explained to me that several of his HN+
in the cold-storage containers of trucks or patients had stopped taking their medication
making mad dashes through the English Chan- once they had received their papers, despite
nel tunnel or across the straits of Gibraltar. having received papers to gain access to the
[ .•. 1 The emergence of the disabled as the medication. This seemingly incomprehensible
modal subject of political economy [ ... ] thus act reveals the violence at the heart of this
exposes the standard of able-bodiedness [ ... ] story: Without political recognition, undocu-
as fictional, constructed and normativized for a mented immigrants exist as a form of "living
certain type of economic and civic functional- dead" {Mbembe 2003; Petryna 2002:3), in a
ity. Indeed, the assumption that the normative state that, in the immediacy and intensity
human is able-bodied begs redefinition of who of their struggle for survival, is indistinguish-
is included in the category of "human." able from the threat of physical death. 11 The
How can one make sense of these subject difference between the type of future each
positions? In what sense are they the result of a remedy guarantees - papers or medication - is
form of politics based on humanitarianism? elided. In this sense, it is unclear to both
Although the ill and disabled are not entirely doctors and patients which is the more virulent
stripped of their political or social qualities, form of suffering: no papers or no medication.
they exemplify the dangers of humanitarian The conflation of the two reveals a new terri-
government insofar as it limits one's political tory in which the politics of immigration and
and social choices and capacities- it forces one citizenship is at once a politics of life and death.
to conceal one's political self, all the while In this scene, biological life and political life
drawing on that self. In fact, the paradox of have taken on equal significance -life as some-
willed infection or disability suggests that sans one sick is interchangeable with life as a polit-
papiers can act in one of two ways: They can ically recognized subject. Indeed, being sick
choose to suffer from exploitation, exclusion, is what is required to be a political subject
and poverty, or they can suffer from illness. (cf. Petryna, 2002).
But what kind of choice is this, and what kind How did this happen? [ ... ] What I have
of humanity does it sustain? The question be- been articulating so far is the result of the
comes, how have these two options come to be simultaneous institution of a humanitarian ill-
interchangeable, how can they be bartered ness clause and the closing of borders to immi-
against one another - how is it that self-in- grants and refugees. [ ... ] Although one might
flicted violence has come to have the same have imagined that this concept of humanity
value as the violence of being undocumented? based on the universality of biological life
How is a compromised biological life equated would come closer to equality, [ ... 1 in fact,
with a compromised political life? And how this concept has been put into play through a
can one characterize or explain this type of politics of compassion that emphasizes benevo-
ethics and its related politics? I turn now to lence over justice, standards of charity over
the way the politics of humanitarianism actu- those of obligation- one that ultimately pro-
ally works on the ground, helping to answer tects and encourages a limited and limiting
these questions and, ultimately, to contribute notion of humanity.
to understanding what kind of humanity a In shifting the politics of immigration to a
politics of humanitarianism reproduces. politics of humanitarianism, those who enact
the humanitarian clauses suddenly wield great
power - they become the gatekeepers. In this
The New Politics of Compassion: A case, they include the state nurses and doctors
Limited Humanity as well as the medical establishment more
broadly. In the state office where I observed,
Dr. Amara, who worked at the clinic for un- the medical officials [ ... ] explicitly joined
documented immigrants that I had been social and medical, knowing that [ ... ] they
WHERE ETHICS AND POLITICS MEET 257
are inextricably intertwined. Yet the medical the nurses understood that she would return
officials also admitted to being constrained by to a "pitiful" life in Algeria; she would be
their relationship with the prefecture; despite forever shamed because of her rape and,
acting out of a desire to further a notion of hence, unmarriageable. According to them,
social justice, they could not simply let every- her life would be one of ostracization and
one in, because they were being monitored. loneliness. They decided that, in the face of
( ... ]To be kept in the decision-making circles, this reality, they would rather grant her au-
they had to maintain legitimacy - and their thorization to stay in France for treatment for
legitimacy depended on only letting in people an indeterminate period - which means, ef-
who suffer from pathologies that have life- fectively, forever, if she so chooses, renewing
threatening consequences. her illness permit until she can apply for citi-
Yet what qualifies as "life threatening'' zenship. The treatment they prescribed was
when life itself remains undefined? ( ... ] Life psychological - she was considered to be
is ultimately defined quite pragmatically, by suffering from trauma. They were very clear
the particular context in which requests for when talking to me that this decision crossed
papers are received and by those applying the over into the realm of social justice; but they
clause. As noted, this is a relatively arbitrary saw themselves inevitably implicated in moral
process. ( ... ] decision making, which they believe is re-
What this means, of course, is that differ- quired at a fundamental level in caring for
ent understandings of "life" are being played people's health and well-being.
out and that the structure of the particular I deeply respect the medical officials for
state medical office is a major factor in out- allowing their view of health to include the
come. The face-to-face interaction between social and for allowing the disenfranchised to
the nurses and sans papiers largely determined remain when all other doors were and are in-
how "life threatening" was interpreted in the creasingly closed. Clearly, however, the health
particular state office where I observed and, officials' decisions are not based on laws, or
thus, who was granted permits for illness. The rules, or rights. Ultimately, they are within the
personal interaction allowed for compassion discretion of the person who receives the case.
to be evoked - it allowed the sans papiers to The state medical officials' decisions are, thus,
appear as people, not simply as files or path- based at least in part on a notion of humanitar-
ologies. It allowed for their social realities to ianism and compassion or, as it may happen,
be included in the judgment. Yet a face-to-face the lack thereof. I found that the result
encounter allows for performances on both depended on the way the sans papiers'
sides, and if one does not perform in the story was told and on the emotions evoked.
desired manner, one may be penalized and Indeed - perhaps unsurprisingly - I found that
excluded. compassion is elicited differently according to
The dilemmas and the evocation of com- race and gender. Some people's stories of
passion came for nurses and doctors with the suffering do not strike a chord in the nurses
more complicated cases [ ... ]. In the late or doctors.
1990s, for instance, a young Algerian woman Thus, for instance, I sat with the nurses as
named Fatima came to Paris after having been a 25-year-old Algerian man came in one day.
raped and disfigured by her uncle. [ ... ] Both Not long after he entered the office, he
her uncle and aunt blamed her for the rape. started crying. He claimed that he had had
Fatima was therefore sent to France, where a heart attack a few days earlier, which the
her mother was living. The nurses said that nurse, Felicia, pointed out was not true. He
she looked horrible. They decided to give her had a heart murmur, she said, looking down
temporary papers to receive medical care. at his file. He said that he could not go on.
When the treatment was finished and her If he was sent to Algeria, who would take
permit about to expire, Fatima returned to care of his wife and his mother? "Last week I
the state medical office to ask for a renewal was going to commit suicide," he said. "I've
of her papers. As they later explained to me, never done anything to anyone, I haven't
258 MIRIAM TICKTIN
committed a crime and still they do this to The man described above might have had a
us, they break up couples!" I could tell Feli- better chance in an office in which simply his
cia was getting impatient. Her tone of voice file was presented, in which he did not need co
changed. The man told a long story about his appear in person; in other words, face-to-face
mother, who was a healer, and his wife, who interactions are not the answer for everyone.
was sick, and he kept saying how unfair it As critics of the humanitarian movement have
was to have a heart attack at his agel He was noted, for help to be extended, humanitarian-
worked up and kept repeating himself. When ism often requires the suffering person to be
he left, Felicia said "son nez est grand comme represented in the passivity of his or her
un bee" [his nose is as large as a beak], suffering, not in the action he or she rakes to
gesturing toward her own nose, pretending confront and escape it (Boltanski 1999:190;
it was growing, insinuating that the man Malkki 1996). Whether the Algerian man
was lying. She claimed his marriage was one who claimed to have had a heart attack was
of convenience because the wife was 39 and indeed lying or not, his performance was not
he was only 25. Why Felicia was immediately convincing because it was too active, he dem-
so suspicious is hard to say. The man cer- onstrated too much agency- he was perceived
tainly exaggerated, and his story did not as strategic and not as a suffering, passive body.
make complete sense. But, then, he was dis- His personality took up too much room in the
traught and crying. At the time, I was sur- narrative.
prised by Felicia's reaction because she rarely
lost patience, and I concluded that the man
must have elicited a negative feeling in her - Conclusion: An
nothing concrete, because to me, the message Anti-Enlightenment Universality?
he conveyed largely rang true.
As Arendt (1990) notes, compassion is most lv1y ethnographic research demonstrates the
effective in face-to-face interactions, when difference between bare life as conceived and
those who do not suffer come face to face with practiced: Although, in theory, bare life may
those who do. In the state medical offices, be the grounding of humanitarian action
however, the suffering is not always immedi- and the sovereign exception, the concept is
ately apparent - the immigrant has to make a enacted differently in differing places, both
case for it, either in person or in his or her file, creating and requiring new realms of biosoci-
and the emotional commitment involved in ality. The politics of humanitarianism, thus,
compassion is dependent on [ ... ] circulating show how conceptions of bare life blend with
narratives, images, and histories and often on politics and the near impossibility of getting
maintaining an unequal power relation be- beyond socially embedded and mediated inter-
tween nurse and patient and citizen and for- pretations of life. In this particular instance,
eigner - distinctions that are already heavily humanitarianism leads to a politics of life and
gendered and racialized. To be accepted as a death, quite literally, in which one's death
French subject on the basis of compassion, one warrant in the form of AIDS can secure life
must be accepted as plausible; and images of in France, and citizenship is only given to
the Other inform the legitimacy of one's per- those who remain diseased. In this sense, one
formance. Whereas compassion in Fatima's must see the medical realm as an important
case was clearly based on a familiar Orientalist new site of sovereign power, in which doctors,
narrative about pitiful Muslim women, Alger- nurses, and state officials become gatekeepers
ian men are depicted in the French public im- not only co the nation-state but also, more
aginary as violent and deceitful and as importantly, to the very concept of "human-
oppressive to women. These images are the ity," in the sense that humanitarianism pro-
colonial legacy and in some ways have become tects individuals by virtue of their membership
all the more intense since the bitter war of in humanity.
Algerian independence from French colonial [ ... l In this emergent regime of humanitar-
rule. ianism, one must inquire into [he consequences
WHERE ETHICS AND POLITICS MEET 259
of its (often) arbitrary nature, asking what through NGOs, among other institutions);
conditions evoke compassion and why and but it does create and sustain a humanity
what hierarchies are reproduced by it. The that is very limited and forced to make new
ability of such a system to further a more just forms of biological compromise. Ultimately,
world must be seriously interrogated when it sustains a more powerful distinction between
humanitarianism acts as a form of policing, citizen and human while impoverishing
choosing exceptional individuals and exclud- the idea of the human: One can be either a
ing the rest. For instance, although compassion citizen or human but not both - once one is
may abolish the distance between people, affirmed as part of humanity and protected
opening the hearts of sufferers to the suffering by humanitarian clauses, one loses one's polit-
of others, thereby creating an affective public ical and social rights. Here, for instance,
space by its very definition, compassion is the people entering France through the hu-
unable to generalize. In joining people in the manitarian clause come from already margin-
immediacy and intensity of suffering, compas- alized backgrounds, primarily from former
sion abolishes the space between people in colonies; this process, thus, reinforces racial
which political matters are located, shunning hierarchies while casting France as benevolent.
the processes of persuasion, negotiation, and Indeed, the postcolonial space created through
compromise, which are the methods of law this politics of humanitarianism continues
and politics (Arendt 1990:86-7). in the manner of its colonial predecessors,
The citizens produced by the joining of hu- reconfigured for ever-greater forms of
manitarian ethics and politics have inequality exclusion.
literally inscribed on their bodies. They are I want to be clear here: I am not arguing
forever marked and interpellated as sick, as chat the discourse of human rights is in the
already handicapped - they can never realize past [ ... ] but, rather, that an incipient or
equality. This politics of humanitarianism emergent discourse overlaps and coexists with
shows itself to be a politics of universality, but it and is becoming increasingly powerful. Eth-
an anti-Enlightenment universality - one that ical regimes must be understood as always
sets biological life against explicitly rational, contextualized, now as part of larger, trans-
political beings. 12 Immigrants are stripped of national regimes of labor, capital, and govern-
their legal personas when identified solely as ance. [ ... ] It is not accidental that medical
suffering bodies, and, as such, they cannot be humanitarianism is playing an increasingly
protected by law; they are rendered politically important role in both the North and South,
irrelevant. And although they may be liberated intervening in the name of basic human life in
from suffering, they are not liberated into full ways that neither human-rights organizations
citizenship. nor development projects are allowed to do.
To understand the nature of their parti- Rights entail a concept of justice, which in-
cular status, Arendt's ideas are once again cludes standards of obligation and implies
instructive. She argues that being thrown out equality between individuals. Humanitarian-
of one's national community means being ism is about the exception rather than the rule,
thrown out of humanity altogether - being about generosity rather than entitlement. The
stateless deprives one of the essence of human- regime of humanitarianism [ ... ] is an ethics
ity - its political character (Arendt 1951). that, when taken to the extreme, entails selling
Conversely, she suggests that citizenship, as one's suffering, bartering for membership with
membership in a polity, conveys full belonging one's life and body. As the political body loses
in the category "humanity.'' In what I have legitimacy in an increasingly globalized world
described, government by humanitarian dis- in which national sovereignty is at stake and
courses and practices actually does not allow borders of all kinds are zealously guarded,
undocumented immigrants to be expelled the supposedly apolitical suffering body is be-
from humanity altogether, as Arendt believes, coming the most legitimate political vehicle
because it is now instituted and enacted in the fight for a broader concept of social
in a supranational political framework (i.e., justice; our task is not only to understand the
260 MIRIAM TICKTIN
consequences of this shift but also to form a nobyl population has become the grounds for
response to it. social membership and the basis of staking
citizenship claims. As Petryna states, in such
contexts, pain and suffering are made into
social instruments, which does not mean that
NOTES they are any less authentic but that new
1 I am not suggesting that huge numbers of values are being attached to them. I thank
people, if any, are trying to infect themselves. an anonymous reviewer for insight into
And although I cannot offer statistics, I can the ways the situation I am describing
say that the very inclusion of this phenomenon differs from Rabinow's original notion of
as part of the rhetoric of the politics of immi- "biosociality."
gration is indicative of a certain larger quali- 5 I want to be clear that I am concerned pri-
tative political shift. marily with humanitarianism less in its legal
2 I am deeply indebted to Didier Fassin, both form- under the rubric of the laws of war-
medical doctor and anthropologist, for alerting than in its shape as a form of urgent ethical
me to the existence of the illness clause and for action driven by sentiment and need, albeit
helping me to establish contacts in state medical broadly sanctioned by Jaw.
offices and hospital clinics. 6 Although detention centers fall under the
3 The focus on suffering in public and political rubric of the administrative system, not the
life has been mirrored in the discipline of an- judiciary, the treatment of people in these
thropology. For instance, Social Suffering, centers still constitutes violations of basic
edited by Arthur Kleinman, Veena Das, and human rights. Indeed, the phenomenon of
Margaret Lock, came out in 1997 and was detention centers demonstrates how the
followed by two more volumes on the same move from the juridical sphere to an adminis-
theme {Das et al. 2000; Das et al. 2001 ). These trative one (which encompasses humanitar-
volumes group together many types of hith- ianism) allows for new forms of injustice.
erto differently named experiences, such as 7 For a wonderful analysis of the relationship
the pain and trauma of atrocity, poverty, sub- between capitalism and human rights, draw-
stance abuse, street violence, domestic vio- ing on Emile Durkheim, see Collier 2002.
lence, HIV/AIDS, and so on, with the goal of 8 For a discussion of the limits of human rights
drawing attention to the multiple forms of in this context, see Ticktin 2002.
suffering in the current global political econ- 9 To get to a doctor can, in itself, be a trial for
omy. That said, they also point to a tension the undocumented; a whole new set of chal-
between those suggesting that this suffering is lenges are posed for those trying to find a
the result of the current climate and those doctor who will refer patients to the immi-
suggesting that suffering unifies people as gration office (see Ticktin 2002).
human beings across time - that it is the tie 10 I refer here to the Sarkozy laws of 2003.
that binds humanity. 11 Judith Butler provides another way of think-
4 Although I use the term biosocia/ity some- ing about this phenomenon: Those excluded
what differently than Rabinow does, I still from legitimate social and political community
focus on practices of life as important sites are kept "on the far side of being" (2000:81),
of new knowledges and powers and employ not given the type of recognition that allows
the term to indicate the ways that nature the notion of human to come into being.
is known and remade through technique. 12 I would like to thank Nadia Abu EI-Haj for
Instead of the techniques of scientists, how- helping me see this.
ever, I refer to the techniques of "ordinary" Jay
people - such as undocumented immigrants -
who manipulate their biology to the extent REFERENCES
that they overcome the nature-culture spJit.
In this way, what I describe is on a continuum Agamben, Giorgio
with Adriana Petryna's (2002) work on what 1998 Homo Sacer: Sovereign Power and Bare
she calls "biological citizenship" in Ukraine, Life. Daniel Heller-Roazen, trans. Stanford:
in which the damaged biology of a post-Cher Stanford University Press.
WHERE ETHICS AND POLITICS MEET 261
The "biotechnical embrace" and the "medical imaginary," phrases which organize
this set of readings on biomedicines, were introduced by Mary-Jo Good (1995b,
1996, 2001, this volume) to draw analytic attention to the power of contemporary
high technology medicine in the public imagination. Physicians and patients are often
deeply moved by the medical imaginary, energized and embraced intellectually,
emotionally, and physically by medicine's future possibilities and innovative tech-
nologies. The readings in this section demonstrate various ways the wedding of
biotechnology and biomedicine is taken up in the affective domains of illness,
therapeutics and health policies, and the ways it engages the public imagination.
Each reading explores medicine's biotechnical innovations and successes but also the
ironic and dark sides of the marketing of high technology medicine, so widely
desired, sought after, yet restricted.
Beginning in the 1970s, medical anthropologists launched ethnographic investi-
gations of Western or "cosmopolitan" medicine in the societies in which they
worked. In Asian Medical Systems, Charles Leslie and Fredrick Dunn (1976) intro-
duced the term "cosmopolitan" to acknowledge that biomedicine is not merely a
"Western" phenomenon, but that as with Ayurveda or Greek or Chinese medicine,
contemporary biomedicine circulates globally and is adapted to local social and
cultural settings. Anthropologists also turned their ethnographic attention to medical
systems in the diverse societies of North America and Europe. Physicians of Western
Medicine (Hahn and Gaines 1985) heralded this new focus in anthropology and was
soon followed by other collections (Lock and Gordon 1988; Pfleiderer and Bibeau
1991; Lindenbaum and Lock 1993; Berg and Mol 1998).
This new anthropology of biomedicine had several characteristics. First, anthro-
pologists investigated biomedicine as one among many forms of healing and know-
ledge. Ethnographies of "the inner life of medicine" (Good and Good, ms) explored
"how medicine constructs its objects" (B. Good 1994 ), its specialty knowledge and
266 THE BIOTECHNICAL EMBRACE
diagnostic categories (Barrett 1988; Gifford 1988; Young 1994; Martin 2007), and
its reproduction of the profession through performative and narrative actions (M.
Good 1995a). Second, anthropologists focused on the internal worlds of laboratories
and clinics, and the social, legal and ethical structures that constitute medicine as a
complex institutional and ideological phenomenon (Lock et al. 2000). Research
paralleled innovations in bioscience, such as studies of the new genetics related to
reproductive health (Becker 2000; Inborn 1994; Rapp 2000), breast cancer (Koenig
1998), and genomic endeavors (Heath and Rabinow 1993; Taussig 2004); and
ethical dilemmas arising from futile use of technology at the end of life (Good et al.
2004; Ruopp et al. 2005; Kaufman and Morgan 2005). Third, anthropologists
implicitly or explicitly compared biomedical cultures through studies of specialty
knowledge and practice and varied patient experience. Examples include oncology in
the United States, Italy, Japan and Mexico (Good et al. 1990; Good et al. 1994; Good
et al. 1995c; Gordon 1993; Gordon and Paci 1997); pediatric oncology and dying
children {Biuebond-Langner 1978); and gynecology and obstetrics in Japan and the
North America (Lock 1993; Kaufert 1992; Martin 1987).
During the 1990s, anthropologists were particularly drawn to studies of organ
transplantation and brain death, bringing new political, comparative and global
perspectives to a field previously occupied by sociologists and medical ethicists (Ikels
1997; Hagel 1996). Lock followed changing definitions of brain death and trans-
plantation practices in Japan (2002) for over a decade. Scheper-Hughes (2006)
supported young scholars on quests to uncover the dark side of the organ transplant
world through the Berkeley Organwatch project; essays by Cohen and Sanal in this
volume benefitted from that collaboration. Anthropological fascination with the
social meanings of organs and transplantation, "the gift" and kinship donors, con-
tinues the flow of publications (Sharp 2006; Wailoo et al. 2006).
When HIVIAIDS emerged, stunning the newly afflicted and the bioscientists of NIH
and the academy, medical anthropologists swiftly took up research linked to advocacy.
Many critiqued global health policies and postcolonial power relations that dehuman-
ized and marginalized the afflicted poor (Farmer et al. 1993; Farmer 1995; Schoepf
1993). Anthropologists recounted physician colleagues' conversations of being "over-
whelmed by disease entity" and fearing AIDS threatened medicine's "intellectual and
therapeutic enterprise" (Good et al. 1999; Raviola and Good et al. 2002; Eaton 2008).
A sea change in advocacy, intervention, and global policy occurred when anti-retro-
virals became "technically sweet" -imaginable, feasible to manufacture, effective, and
with a soft market price (Kim and Farmer 2006, this volume).
The five essays in this part illustrate diverse ways biomedicine and its techno-
logical interventions live in different social worlds. The first essay, by Mary-Jo
DelVecchio Good, emerged from collaborative research with clinical investigators-
oncologists and internists - and their patients. Observations of clinical interactions,
interviews, and cyberspace communications generated four epistemic terms - the
medical imaginary, the political economy of hope, the biotechnical embrace, and the
clinical narrative. Good analyses experiences of doctors and patients with oncology's
experimental and mundane technologies, the specialty's aesthetics of statistics and
language of odds and chances, and its offering of "choices", manifesting the domin-
ant American thematic of "freedom of choice" even when only momentarily deflect-
ing death (Patterson 2000). Her studies showed that medical technologies are caught
INTRODUCTION 267
The final essay, by Jim Yong Kim and Paul Farmer, physicians-anthropologists and
founders of the NGO Partners-in-Health, is a call for action marking critical historical
developments between 1996 and 2006. It follows Kim's tenure as special assistant to
the director of the World Health Organization (2003-2005). Documented efficacy of
antiretroviral medications, the feasibility of manufacturing dramatically less expensive
generics, and the biotechnical commitments to vaccine development energized Kim
and Farmer's challenge to commonly held views among public health communities
that the poor could not be trusted with the latest HIV anti-retrovirals (due to fear of
promoting drug resistance with erratic compliance and once exorbitant costs). Kim's
WHO project, known as "3 by 5"- 3 million AIDS patients on antiretroviral medica-
tions by 2005 - established a widely accepted global policy goal; and with the vast
increase in global health funding and the availability of technically sweet ARTs at low
cost, Kim and Farmer led the moral fight to make treatment of the poor with the best
innovative antiretrovirals the global norm for public HIV programs. Through the
model programs of Partners in Health and the global policy influences of WHO, Kim
and Farmer brought the fruits of the bench, new biotechnologies, to communities of
poor patients. Research and practice, anthropology and medicine, are wed in the work
of these scholar advocates.
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INTRODUCTION 271
Subjective experiences of clinical scientists (1991) and Marcus (1998) call "multiple
who produce and deliver high-technology regimes of truth" through multisited and com-
medicine and of patients who receive treatment parative ethnographic research in science and
via this technology are fundamental to under- technology. Although acknowledging the im-
standing the political economy and culture of portance of "cultural pasts" and "cultural dif-
hope that underlie bioscience and biomedicine. ferences," Fischer argues that "it is increasingly
In this essay, I examine interpretive concepts artificial to speak of local perspectives in isol-
linking bioscience and biotechnology and their ation from the global system ... the world
societal institutions to subjective experience. historical political economy" and "trans-
These concepts are the medical imaginary, national cultural processes" (1991:526). This
the biotechnical embrace, the political econ- formulation echoes recent trends in anthropo-
omy of hope, and the clinical narrative. Draw- logical studies of biomedicine and biotechnol-
ing on research and observations of the culture ogy and of scientific research and clinical
and political economy of biomedicine in the culture. Such studies highlight the dynamic re-
United States and internationally, I illustrate lationship, tensions, and exchanges between
these interpretive concepts with examples local worlds in which medicine is taught, prac-
from studies of clinical scientists, oncologists ticed, organized, and consumed and global
and their patients, and venture capitalists, as worlds in which knowledge, technologies,
well as observations of public actions and markets, and clinical standards are produced.
discourses. Although we may speak about a plurality of
Cultural and social studies of biomedicine biomedicines that are socially and culturally
and biotechnology lend themselves to examin- situated rather than about a single unified body
ing a concept that anthropologists Fischer of knowledge and practice, such local worlds
Mary-Jo DelVecchio Good, "The Medical Imaginary and the Biotechnical Embrace: Subjective Experiences of
Clinical Scientists and Patients," in j. Biehl, B. Good, and A. Kleinman, eds., Subiectivity; Ethnographic
Investigations. Berkeley: University of California Press, 2007. © 2007 by University of California Press -
Books. Reproduced with permission of University of California Press - Books in the format textbook via
Copyright Clearance Center.
THE MEDICAL IMAGINARY AND THE BIOTECHNICAL EMBRACE 273
financial health of the National Institutes of cialize it and pay you a royalty. So I withstand
Health ($20.5 billion in the 2001 budget, $23.3 the dilution, I start generating revenues from
bHlion in 2002,$27.1 billion in 2003, and $27.9 collaboration, ... and then I hand off the more
billion in 2004), even under a political regime expensive parts of forward integration of
that promotes tax cuts and small government. manufacturing and sales, I don't have to take
Americans invest in the medical imaginary- on those burdens.
the many-possibility enterprise -culturally and . . . So call those your children. Keep the
emotionally as well as financially (Freudeheim family alive by selling your children. The ques-
tion is "is the nature of your platform prolific
2002). Enthusiasm for medicine's possibilities
enough that in having sold off some of your
arises not necessarily from material products
children, you haven't sold off all of your
with therapeutic efficacy but through the pro-
future?" Because if ... at the end of the day,
duction of ideas with potential but as-yet-un-
[you are only] getting some royalties, from the
proven therapeutic efficacy. An officer of one 10% of your efforts that didn't fail, you are
of the most successful biotechnology firms in never going to be a big company. (Holtzman
America has indicated that biotechnology en- 2001)
terprises are in the business of producing ideas
about potential therapeutics, from designer an- Such firms seek to make public the scientific
ticancer therapies to the manipulation of dam- imaginary; until very recently, they have been
aged genes. the darlings of venture capital and continue to
attract considerable investment. (See the busi-
Think about a biotechnology company as a
pharmaceutical company. . .. If you start with ness sections of the New York Times and the
an idea and you are by definition working on Wall Street Journal for analyses of recent
something in the pharmaceutical industry that market trends and for documentation of vola-
is likely to fail 90% of the time .... one of the tility in the financial side of the medical im-
myths of biotech. . . . you are proposing to aginary.) However, companies whose fortunes
start a company in which there is a 90% chance appear bright because of the remarkable scien-
of failure, the cost of product development tific promise of potential and authorized
is $500-$900 million, and from idea to the new pharmaceutical products may find that
time when you have a revenue stream from the questionable long-term efficacy of once-
product development is twelve to fifteen years. promising drugs, such as VIOXX or hormone-
So your question is really, against that funda- replacement therapy (HRT), can threaten fi-
mental absurdity, how do you build a business, nancial futures and disrupt evolving clinical
right? practices. One such example is Johnson and
If you start at that purely abstract level, Johnson's Eprex, an innovative platelet en-
what do you have to sell? You don't have your hancer for treating anemia in cancer patients.
product yet, so what do you have to sell to feed Red-cell aplasia, the inability to produce red
the beast that you are about to build? Well, blood cells, has been associated with this for-
there are only two things that you have to merly billion-dollar product (Pollack 2002;
sell: . . . you can sell things that are or look or
also Tagliabue 2002; Varmus 2002; and on
smell like equity.... What's the problem with
HRT, Kalata 2002).
that? At the end of the day, the pie is so split
At more mundane levels, Americans live in
up, nobody makes any money on their equity,
the dilution is intolerable. So what else do I a world in which the medical imaginary has
have to sell? WeH, instead of selling pieces of star billing in medical journalism, television
the company, an interest in the home, I can sell advertisements, and globally popular television
pieces of pieces, which I call rights - for productions such as ER. (ER is among the most
example, in certain of my discoveries or prod- popular television programs in Indonesia and
ucts - and this is where the pharmaceutical China; the medical imaginary is a global phe-
companies come in . . . They say we will pay nomenon.) The imminent discovery of cancer
for you to do some research on our behalf; we cure, effective genetic therapy, the manufactur-
will take the product that results from it; we, ing of new and better mechanical hearts, the
the pharmaceutical company, will commer- engineering of tissue and the genetic alteration
THE MEDICAL IMAGINARY AND THE BIOTECHNICAL EMBRACE 275
of pig cells to offset organ shortages, the latest high-technology experimental treatments, and
results of clinical trials on AIDS therapies and even salvage therapies. Among my American
reports of their effectiveness, cost, and con- medical colleagues are those who acknowledge
tested patents - all become part of the daily the phenomenon, are energized by enthusiasm
global circulation of popular, business, and albeit tempered with irony, and recognize
medical knowledge. Our vast interests, finan- when patients are embraced. (One pediatrician
cial and certainly emotional, in the political and ethicist has incorporated the term into
economy of hope are evident in daily market lectures on the latest transplant therapeutics.)
reports and public discourses. Recent stories on The specifics of popular and professional en-
the Abiomed mechanical heart illustrate the thusiasm for biomedicine and nascent tech-
more extreme version of the link between prod- nologies may be characteristically American,
uct development and the political economy of as some of my European colleagues suggest,
hope. (See Stolberg 2002 about a patient who but "embracing and being embraced" funda-
lived for nine months with the heart.) mentally link contemporary high-technology
The circulation of knowledge and of the medicine and bioscience to the wider society.
ethereal products of the medical imaginary is Whether this enthusiasm is for new repro-
of course uneven. The robustness of local sci- ductive technologies, effective therapies to
entific and medical communities, NGOs, and treat HIVor MDRTB, innovative organ-trans-
political health activists influence how people plantation procedures, progress in therapeutic
share, access, and use this global knowledge. gene manipulation, or efficacious treatments
(See these recent studies: on Brazil, Bastos for common life-threatening diseases such as
1999; on American research oncology, Cooke cancer and heart disease, it sparks the medical
2001; on French science, Rabinow 1999; and imagination and drives the political economy
on medical missions for high-technology treat- of hope, as well as our society's investment in
ment of multidrug-resistant tuberculosis medical adventures and misadventures.
[MDRTB] and HIV for the poor, Farmer
1999, 2004.) Alternative stories, misuses, and
failures of medicines cultural power and possi- Clinical Narratives and
bilities are also part of the traffic in the medical Ethnographic Frames
imaginary: failures (in genetic therapy leading
to patient death); fraud (in clinical trials in The two worlds of American academic clinical
oncology); discouragement (upon learning that oncology- the therapeutic and the scientific-
promising therapeutics are ineffective); greed provide vivid examples of how patients and
(physicians trafficking in organs or brokering their clinicians embrace, even as they are em-
transfers from the poor to the rich; Cohen braced by, biotechnology and how American
1999; Sanal 2004). Yet these tales are set in medical culture generates enthusiasm for ex-
the larger optimistic story of the hope and the perimental clinical science and "medicine on
many-possibility science of medicine. the edge.'' (The success of Jerome Groopman's
[2000] essays on cancer patients and experi-
mental treatments is evidence of strong interest
The Biotechnical Embrace among certain groups of Americans.) In my
studies of the culture of clinical oncology, I
The image of the biotechnical embrace developed the concept of the "clinical narra-
emerged serendipitously out of studies of the tive" to capture the dynamics of clinical inter-
culture of oncology during the past decade and actions between oncologists and their patients
conversations with my colleagues in medicine, that evolve over time through arduous and
ethics, and social science in the United States, often lengthy therapeutic journeys. (See our
Europe, Asia, and Africa. The concept of "em- work on clinicaJ narratives and oncology stud-
brace" conjured the subjective experiences ies in the reference list; of particular relevance
and affective responses of many clinicians and are M. Good 1995a, 1995b, and M. Good
their patients when using new biotechnologies, et al. 1990, 1994; see Mattingly 1994 and
276 MARY-JO DELVECCHIO GOOD
1998 for her creative work on therapeutic em- chances of particular treatments to patients -
plotment and Mattingly and Garro 2000 for emerge as culturally shaped and institutionally
elaboration.) sanctioned, taking on a centrality in the narra-
tive discourse, even as the narrative skirts ul-
timate questions of death, and addressing the
Narrative Analysis immediacy of therapeutic activities.
Patients' ironic engagement with their clin-
When literary concepts such as narrative are icians, as they negotiate the meanings of these
introduced into observations of everyday clin- clinical narratives, the odds and statistics, and
ical life, new aspects of medical work and the fantastic and questionable, affords a
therapeutic processes become evident. Con- glimpse into how the medical imaginary engen-
cepts drawn from narrative analysis - plot, ders a certain bravado, an experience with
emplotment, and narrative time - illuminate many possibilities, that supports and sustains
how affect and desire play out in clinical nar- the emotional, financial, and cultural invest-
ratives, seducing patients and clinicians and ment in experimental procedures and treat-
enveloping both in a world of the medical im- ments (Gould 1996).
agination, with a many-possibility regime of
truth and with fantastic but apparently pur-
poseful technical acts. This analytic approach Worlds of Oncology
highlights not only how clinical stories arises
and how oncologists develop narrative strat- Case examples from our oncology studies illus-
egies, but it also identifies antinarrative clinical trate how clinical narratives connect the public,
talk, in which events have no meaning, strat- in particuJar patients, to high-technology med-
egies of communication fail, and clinical plots ical science and how patients experience and
fragment or fail to emerge. This type of talk is discuss invitations into a biotechnical embrace.
common to medicine globally. (See B. Good Complementing these clinical examples are il-
1994, B. Good and M. Good 1994, 2000; M. lustrations from a forum created and dominated
Good and B. Good 2000; Mattingly and Garro by patients, BMT-Talk, a cyberspace network
2000; Ricoeur 1981a, 1981b; Brooks 1984; connecting bone-marrow-transplant (BMT} pa-
Iser 1978; and Eco 1994 for references on nar- tients, friends, kin, researchers, and curious clin-
rative analysis.) icians, some of whom dispense second opinions
Narrative analysis enables disaggregation from as far away as Brazil. The global connec-
of specialty power and its economic underpin- tion is evident. In addition, public documents
nings; it leads us to ask how the cultural power from insurance hearings open additional per-
and scientific robustness of clinical medicine at spectives on oncology's multiple "regimes of
the academic medical center where our projects truth."
took place come into play - in "plotting" a In the American culture of high-technology
coherent therapeutic course, structuring clin- medicine, oncologists are expected to invite
ical time, installing desire for treatment, giving patients to enter the world of experimental
hope, and in the case of diseases resistant to therapeutics when cancer is resistant to stand-
standard treatment, inviting patients to open ard treatments. Through this invitation to "sal-
their bodies to experimental treatments that vage therapy" (a clinician's term), a clinical
are often of questionable efficacy. In the Ameri- narrative that weds the experimental to the
can case, oncologists use clinical narratives to therapeutic begins to unfold. Clinical narra-
incorporate evidence-based medicine into clin- tives direct action and technological interven-
ical culture and to introduce therapeutic mean- tions. They inscribe treatment experiences on a
ing through reliance on the findings of clinical patient's psyche and soma, under the guise of
trials and relevant research in the biosciences. multiple plots and subplots that the profes-
And through the clinical narrative, the aesthet- sional subspecialties envision for patient and
ics of statistics -how one conveys the odds and clinicians.
THE MEDICAL IMAGINARY AND THE BIOTECHNICAL EMBRACE 277
"Rules Change": ABMT and ABMT for metastatic breast cancer is a prime
High-Dose Chemotherapies example of enthusiasm based on questionable
clinical science.
The current controversy about autologous
bone-marrow transplants (ABMTs) for meta-
static breast cancer poses an ethical dilemma
Normalizing the Experimental
about societal and individual costs, both finan-
Clinician-scientists such as Dr. William Peters of
cial and personal. As a medical oncologist
Duke University Medical School were among
noted in conversation in 1993, this expensive
the early public promoters of experimental
"salvage therapy" had dubious therapeutic cre-
therapeutics, normalizing the technologies and
dentials; and in clinical trials to that date, pa-
the apparent high-tech oddities, turning the un-
tients who initially responded positively to
usual into an event no more odd than a coffee
transplants "were all relapsing at six or eight
break and adopting the housekeeping meta-
months after the transplant." Yet, in 1994,
phors of daily life. In his persuasive presentation
some patients sued their insurers who refused
at federal government hearings on whether
coverage for these treatments, and many more
Medicare/Medicaid would support coverage of
medical oncologists encouraged their use. (A
ABMT for metastatic disease, Dr. Peters charac-
now-infamous suit brought by a California
terized the procedure as follows:
Kaiser patient who was refused coverage in
1994 helped establish this "experimental treat- As our famous philosopher once said: "the
ment" as a standard of care by 1995-96. "No future just ain't what it used to be" - this is
HMO [health maintenance organization] what most people think of bone marrow trans-
would be able to refuse coverage now because plants as being- a high-technology facility with
of that suit," claimed the chief of surgery at the isolation procedures, use of high-tech equip-
Harvard teaching hospitals in 1996.) ment, multiple supportive care efforts and so
By 1995, clinical studies indicated that mor- on. What is really, happening is that, in the last
tality from the procedure decreased from 30 few years, this is occurring more frequently.
percent to 3 percent, as innovative posttreat- Two women from our institution (post trans-
ment care was introduced and healthier pa- plant day two and day six) - are waiting for
tients were recruited. Although the cost of coffee to be delivered to the hotel where they
are staying during their bone marrow trans-
providing autologous stem-celVbone-marrow
plant. We now essentially do all our bone
transplants declined quickly and dramatically
marrow transplants as outpatient procedures.
(from approximately $150,000 in 1993 to
If one looks at the 100-day mortality in patients
$60,000-$75,000 today), as the technological undergoing transplants, you can see that, back
fix became "technically sweet," increasingly in the mid-1980's, the therapy-related mortality
efficient and standardized, and as treatment in the first hundred days was at over 30%.
locales shifted from lengthy hospitalizations Now, it is in the range of about 3%. In fact, if
to outpatient services, questions continued you look at the 30-day mortality [it has
about long-term therapeutic efficacy. As the dropped] from 15% down to the 3% to 4%
bioscience of the field alters and decisions to realm. This represents massive change in ther-
choose competing therapeutic options (such as apy-related mortality. (Peters 1994)
platelet treatments with new pharmaceuticals)
become ever more complicated, especially
given the uncertain efficacy of many treatments Ironic Humor: The Twilight Zone
and the potential for serious clinical errors, and the Medical Imagination
careful orchestration of the medical imaginary
is necessary. Yet, even with questionable effi- Patients, like clinicians, play the numbers.
cacy, we see padents and physicians captured Ironic humor and an edge of cynicism (hope
by the biotechnical embrace, with enthusiasm against hope?) mix with the medical imagin-
about the possibilities of the experimental. ation and the slightly bizarre imaginary of
278 MARY·JO DELVECCHIO GOOD
what the future might hold. The following Interviewer: It's just a very short growing
comments by patients about the clinical narra- period. Like radishes.
tive created for them are illustrative. Mrs. R: That's right. Like radishes. That's
Mrs. R, a witty fifty-four-year-old educator, right. These little radishes. That's right.
suffers from metastatic disease and is a candi-
Interviewer: So, I have my usual question, how
date for autologous bone-marrow transplant
does all this feel at this point?
and high-dose chemotherapy (Cytoxan). She
Mrs. R: Like a giant mistake. The truth? Like
discusses therapeutic choices with her medical I made a mistake. I shouldn't be doing this ....
oncologist and the transplant surgeon. The ex- I wasn't feeling sick. And, you know, right
cerpts I include here cover several meetings now it's getting toward the big time, and I
over a period of nine months. When we first don't want to do it. I don't want to be here. I
met Mrs. R, she was with the medical oncolo- want to be on with my life. This is inconveni-
gist, who had just informed her that she had encing my life, and I don't like that. Does that
metastatic disease secondary to breast cancer. sound adequate enough? So I am saying why
The first excerpt is from her third visit with the heJI did I decide to do this? This is stupid.
the medical oncologist, with whom she dis- Besides, the whole thing is Twilight Zone.
cusses "choices" and recommendations from
the transplant surgeons, in August. The Transplanter: Good, good, good. Okay. So the
patient's sense of humor is dry; her comments fun part starts.
nevertheless capture the strangeness and uncer~ Mrs. R (to interviewer): He's got this sadistic
tainties of experimental treatments and medi- humor.
cine on the edge.
Interviewer: You know you're in trouble when
he starts rubbing his hands.
Patient (Mrs. R) comments to the interviewer Mrs. R: Oh, that's a sign? Okay. He's kind of
about ABMT: I guess if I had a concern, my got that Frankenstein look. What are we going
concern is - is it going to damage my immune to make today?
system so that it's going to make things worse?
It seems like a very archaic sort of technique. (Aher that day's procedures)
[Speaks about postponing a vacation]. I don't Mrs. R: You know what the hardest part- not
want to jeopardize this great 15 percent to even the hardest part, but- I guess the irony of
20 percent chance. I really don't have a choice, the whole thing is to go through all this and
do I? have absolutely not only no guarantee at the
Medical oncologist: Yes, you do have a choice. end, but not even an indication .... No way to
You don't have a choice if you're only focusing have any idea whether it worked or didn't
on the big picture and ten years down the work. When you think about it, it seems like
road. Then you don't have a choice because at the end they should be able to say, "it looks
these choices can give you a chance. But if you good," or "it doesn't look good."
focus on the next five years- Interviewer: What did they say about that?
Mrs. R: Five years is nothing. Mrs. R: If I'm alive and well in five years
Medical oncologist: So you don't have a they'll call it a success, and I'll follow the 20
choice. It's your choice. percent success rate. It's a hindsight thing. And
Mrs. R: He [the transplant·specialist] said it is it's funny, one of the things that we did do
not a choice. initially that we've gotten off that we have to
get back on, I think, was to go on a diet and
The second encounter, which took place the become vegetarian rreferring to tamoxifen and
following February, begins with an interview the idea that soy is a natural tamoxifen] ....
between the patient and the researcher; it then You listen to the medical profession but you
focuses on the clinical encounter as the phys- must do your own thing. So I'll keep eating
ician removes the stem cells. tofu. So, I'll keep eating tofu. So, I don't know.
Mrs. R~ This is supposed to stimulate the stem It's all so interesting. The teachers gave me a
ce1ls to grow . . . and then they harvest them in huge party. Very nice, a surprise party. And
ten days. It's kind of like gardening. they sent out invitations and they called it a
THE MEDICAL IMAGINARY AND THE BIOTECHNICAL EMBRACE 279
shower. They had a shower for me, a shower chemotherapy to standard treatment proto-
of friendship, they called it. cols. Four of the five studies detected no differ-
ence in longevity, although one study indicated
Five weeks after this interview, the patient a small difference in quality of life (www.
returned for a follow-up treatment just after ASCO). The single trial that reported greater
news articles revealed that a competing insti- effectiveness was discovered to be flawed by
tution, the esteemed Dana Farber Cancer fraudulent research and science. The clinician
Center, had inadvertently overdosed two investigator responsible, Dr. Werner Bezwoda,
\Vomen during high-dose chemotherapy, chair of the oncology and hematology depart-
leading to one patient's death (Boston Globe, ment of the University of Witwatersrand Med-
March 22, 23, 24, 1995). The Joint Commis- ical School in Johannesburg, South Africa,
sion on Accreditation of Hospitals placed the acknowledged he adjusted his data in order to
center on probation. gain fame (Waldholz 2000). Clinical narratives
In April, Mrs. R evaluated for her oncology may inadvertently introduce fraudulent science
nurse her physicians' skill at extracting bone and treatment of questionable efficacy and
marrow (not only for therapeutic purposes high toxicity, even as they offer the power
but for a clinical observation study). She scored of scientific discovery and biotechnical
each of them: "a five, a seven, a three!" innovation.
Nurse: Not a ten?
Mrs. R: Ten does not exist, nobody can get a
ten. Wile E. Coyote: BMT-Talk in
[Just as no ABMT patient can be assured of Cyberspace
a cure.]
Mrs. R: I decided that [cancer) can be a BMT-Talk is filled with the fantastic - with
chronic disease. It doesn't have to be a - I
images of the archaic, the Frankenstein, the
always believed it was a death sentence ....
cyborg, and the bizarre aspects of treatment.
Now my next big decision is, they did the
Below, a young patient writing about a boneM
second bone marrow for their research . . . to
see if there's any breast cancer cells in the bone marrow transplant for his/her multiple mye-
marrow. So do I want to know the answer to loma also draws on American metaphors of
that? the flexible cartoonlike and regenerating body
Nurse: I don't think they can telJ you the (the coyote appears in many forms and, like a
answer to that. cat, has multiple lives).
Mrs. R: Yeah, he said he could.
The thing that is weird to me is that the trans-
Nurse: Right ... and you don't know what to
plant, unlike a liver or kidney or other organ
do with the information ... he shouldn't have
transplant, isn't what's supposed to help
even told you there was an option.
Mrs. R: I'll have to think about that. against the disease [multiple mye]oma].
What's supposed to do the damage to the
The oncology nurse and patient conclude with cancer/tumor ce1ls is the chemotherapy. The
transplant is a rescue technique because with-
additional talk about the 15 percent to 20 per-
out it the chemo would be fatal. Wow. It's a
cent cure rate and about the uncertainty and
really bizarre idea - like if the water in your
ambiguity of what the future holds. aquarium were tainted somehow, you'd put a
Narrative strategies in this type of clinical ton of salt or other medicines in it, then pump
encounter draw heavily on humor, and many it ALL out (leaving the fish inside the aquar-
patients in our study responded in kind. ium), waiting for it to dry out, and then
Humor lends irony to ambiguity. Nevertheless, pumping the water back in and hoping the fish
the clinicians and patient fully experienced could still swim {and not just float upside
the experimental nature of the procedure. down!). Hmmm ... well I just thought up that
Notably, in May 1999, the American Society analogy, and it's not quite right, but it's kind of
for Clinical Oncology released data from five how I feel about it. We'll drop a 16-ton weight
clinical trials comparing ABMT with high-dose on you. That'H kill aH the cancer. Then, you'll
280 MARV·JO DELVECCHIO GOOD
walk along like an accordion, as though you I finished off my responsibility, but the next
were Wile E. Coyote in a Road Runner cartoon, year I did not want to go back to the bone-
until you pump the air back into yourself. In fact, marrow-transplant unit
we'll pump it in for you! ... I know it's the best Bone-marrow transplant is such an odd realm
chance I have, but I can't help feeling that it's of the medical world, and frankly other pro-
going to seem awfully primitive in (hopefully) grams don't even see any of it.
not many years. It feels like with all the techno- And this 35-year-old woman, like all people
logical and medical advances we've made, we're who enter transplant, looked good, then died
not that far removed from bloodletting! of it.
Patients' subjective experiences with BMT Being given high doses of chemotherapy and a
procedures - from enthusiasm to disappoint- bone-marrow transplant is not a natural event.
ment and struggle- contrast with those of phys- Sometimes oncology in general kind of bugs
icians who have cared for BMT patients for me, in that it seems - especially for bone-
whom the procedure has failed. 1 In our recent marrow-transplant patients ... I was feeling,
study of internists' emotional responses to pa- Why are we doing this?
tient deaths (M. Good et al. 2004), we found And, finally, interns:
an alternate and chilling version of the bizarre
"BMT-Talk," as illustrated in the following They come to the ICU and we have to tell
interview excerpts, which I present by clinician them, to tell their families. It's just so frustrat-
rank- faculty physicians (attendings), second- ing that the people don't know [the high rate
to fourth-year residents, and interns. 2 of failure of BMT procedures}.
Attendings commenting on training in I'm on a bone-marrow-transplant team, so
bone-marrow stem-cell transplant: this is like the worst of ... I don't know.
The big hope- there are incredible highs and These excerpts exemplify physicians' in-
lows - the high is when you get the disease to ternal critique of practices they regard as clin-
go away with the transplant and you have ical irrationalities. Their experiences with
done good. patients' deaths rather than recovery convey
Sometimes transplant units are like a morgue; the negative side of the medical imaginary
the transplant people don't see it that way; and the biotechnical embrace.
house staff rotate through and comment about
it all the time.
It's a big risk, an up-front risk, a 20 percent
Metaphors of Entering the Bizarre
mortality rate from the procedure.
Patients in our studies also used metaphors of
Intellectually, bone-marrow transplantation is the bizarre. Even standard chemotherapy feels
a numbers game- I firmly believe in the ability like one is "off to see the wizard." A primary-
to cure the other 60 percent.
school teacher, fifty-three years of age, sang us
We threw everything we could at her and she a little ditty to the tune of "I'm off to see the
died anyway, which is unfortunate, but that Wizard, the wonderful Wizard of Oz," a song
was the standard of care with transplant. she sings with her daughters as they drive to
It was the standard transplant story: go in, get chemotherapy treatment: "Pm off to see the
chemotherapy, radiotherapy, get the trans- wizard, I'm off to chemotherapy."
plant, get sick a couple of weeks later, get Other patients, especially those who seek
sicker, get sicker, get sicker, wind up in the every possible treatment, articulate their am-
ICU, died a week later. bivalence in succumbing to the embrace of on-
I don't expect transplants to work. cology's power:
Although you haven't killed them theoretic-
It makes me wonder what people are willing to
ally, you have at least contributed to their
accept when they think of something, some
death prematurely.
institution or doctor as being the best. Is it
Some comments from residents: how bad you feel? [laughsl Is it how absolutely
THE MEDICAL IMAGINARY AND THE BIOTECHNICAL EMBRACE 281
miserable and sick you are made as a result of particularly high-technology medicine. A global
a treatment they are willing to invite you to moral dilemma arises when the cultural
have? Is that what being a good patient is all traffic from the biosciences and its attendant
about? Not complaining ... I wonder, when marketing of biomedical products influence the
will it be enough? practice of clinical medicine in societies of
Metaphors of living are, of course, equally scarcity. Whereas the world's dominant econ-
central to the way patients address the medical omies invest private and public monies in the
imaginary and the seduction of the biotechni- production of biotechnology and aggressively
cal embrace, the desire for hope. The aesthetics seek to integrate these advances into clinical
of science are wed to art in the poignant recon- practice -thereby reaping financial as well as
figuration of Botticelli's The Birth of Venus in scientific returns on capital investments - all
Art.Rage.Us (Tasch 1998). Venus is refigured societies confront difficult questions about
with a subtle, surgically elegant mastectomy, rationing biomedical interventions that are as-
still beautiful. Thus, as life continues, beauty sumed to be central to competent clinical medi-
too may endure despite the inscriptions on the cine. Local clinicians are thus subject to
body of consequences of clinical narratives, constantly shifting and competing claims and
medicine's technically sweet fixes, and life's regimes of truth from the worlds of scientific
illness traumas. power and transnational biomedicine. (See Bas-
tos 1999 for a discussion of similar issues in
AIDS science.) As metaphors of science and
Concluding Reflections society merge, ethical questions arise about
how best to serve all patients. Integrating cul-
As we deconstruct American clinical culture, tural, ethical, and political-economy analyses of
panicularly the worlds of oncology, we find a contemporary popular and professional bio-
persistent rhetoric of humanism contrasted with medical cultures is critical to unmasking links
that of technology. Such public and professional between interests, be they economic or cultural,
dichotomies may lead us astray, endorsing and policies on "best medical practices" for the
professional power over lay knowledge. And global medical commons. How medicine serves
yet the metaphoric language of many patients humanity in the third millennium may be at least
is profoundly affective, expressing hope and marginally affected by the way in which anthro-
interest in the possibilities of biotechnical innov- pology tackles this interdisciplinary analytic
ations and therapeutics, whether in consultation project.
with their clinicians or in the less structured
interviews with researchers. In BMT-Talk, NOTES
cyberspace connections often appear to heighten
the emotionality of discourses and graphic de- 1 To illustrate, the following describes a bone-
bates with other patients about the limits of marrow transplant for acute lymphocytic leu-
therapeutic options. The affective dimensions kemia: "Treatment begins with chemotherapy
of high-technology medicine are clearly soterio- designed to kill as many cancer cells as pos-
logical (B. Good 1994), reflecting a salvation sible. If the cells have spread to the brain, the
patient will also undergo radiation therapy
ethos that is fundamental to bioscience and bio-
and chemotherapy injected direct1y into the
medicine and to the political economy and cul-
spinal fluid. Generally, 70 to 80 percent of
ture of hope. The biotechnical embrace creates a
the patients achieve remission after chemo-
popular culture that is enamored with the biol- therapy. To reduce the risk of relapse, the
ogy of hope, attracting venture capital that patient is given maintenance chemotherapy
continues even in the face of contemporary con- treatments. Sixty-five percent of the patients
straints to generate new treatment modalities. relapse after remission, and begin aggressive
I began this essay by considering the rela- chemotherapy again. Bone Marrow Trans-
tionship between science and society and plants are usually performed during the
its connection to the relationship between second remission. Studies have found 60
the global and the local in biomedicine, percent long term survival rates (survival
282 MARY-JO DELVECCHIO GOOD
Good, Mary-Jo DelVecchio, Byron J. Good, Cyn- Mattingly, Cheryl, and Linda Garro, eds.
thia Schaffer, and Stuart E. Lind 2000 Narrative and the Cultural Construc-
1990 "American Oncology and the Discourse tion of Illness and Healing. Berkeley: University
on Hope." Culture, Medicine and Psychiatry of California Press.
14:59-79. Peters, William
Good, Mary-Jo DelVecchio, Tsuenetsu Munaka- 1994 Presentation to federal government
ta, Yasuki Kobayashi, Cheryl Mattingly, Byron hearings on Medicare/Medicaid coverage of
Good bone-marrow transplant.
1994 "Oncology and Narrative Time." Social Pollack, Andrew
Science and Medicine 38(6): 855-62. 2002 "U.S. Inquiry and Lawsuit Draw Reac-
Gould, Stephen Jay tion of Drug Maker." New York Times, July 20.
1996 Full House: The Spread of Excellence Rabinow, Paul
from Plato to Darwin. New York: Harmony 1999 French DNA: Trouble in Purgatory.
Books. Chicago: University of Chicago Press.
Groopman, jerome Ricoeur, Paul
2000 Second Opinions: Stories of Intuition 1981a Hermeneutics and the Human Sci-
and Choice in the Changing World of Medicine. ences. Ed. and trans. john B. Thompson. Cam-
New York: Viking. bridge: Cambridge University Press.
Holtzman, Steven Ricoeur, Paul
2001 Interview with Michael M. J. Fischer, 1981b "Narrative Time." In On Narrative,
Byron Good, and Mary-Jo DelVecchio Good. ed. W. J. T. Mitchell (Chicago: University of
january 16. Chicago Press), 165-86.
Iser, Wolfgang Rouse, Joseph
1978 The Act of Reading: A Theory of Aes- 1992 "What Are Cultural Studies of Scientific
thetic Response. Baltimore: Johns Hopkins Knowledge?" Configurations 1(1):1-22.
University Press. Sanal, Aslihan
Kalata, Gina 2004 " 'Robin Hood' ofTechno-Turkey or Organ
2002 "Scientists Debating Future of Hor- Trafficking in the State of Ethical Beings," Culture,
mone Replacement." New York Times, Octo- Medicine and Psychiatry 28(3):281-309.
ber 23. Stolberg, Sheryl Gay
Marcus, George, ed. 2002 "On Medicine's Frontier: The Last Journey
1995 Technoscientific Imaginaries: Conver- of James Quinn." New York Times, October 8.
sations, Profiles and Memoirs. Chicago: Uni- Tagliabue, John
versity of Chicago Press. 2002 "Mystery Effect in Biotech Drug Puts Its
Marcus, George, ed. Maker on Defensive." New York Times Busi-
1998 "Ethnography in/of the World ness section, October 2.
System: The Emergence of Multi-sited Ethnog- Tasch, Jacqueline A., ed.
raphy." In Ethnography through Thick and 1998 Art.Rage. Us: Art and Writing by
Thin (Princeton, NJ: Princeton University Women with Breast Cancer. San Francisco:
Press). Chronicle Books.
Mattingly, Cheryl Varrnus, Harold
1994 "The Concept of Therapeutic 'Emplot- 2002 "The DNA of a New Industry." New
ment.'" Social Science and Medicine 38 York Times Opinion page, September 24.
(6):811-22. Waldholz, Michael
Mattingly, Cheryl 2000 "South African Doctor Admits Falsify-
1998 Healing Dramas and Clinical Plots. ing Data on Treatments for Breast Cancer."
Cambridge: Cambridge University Press. Wall Street journal, February 7.
22
Where It Hurts
Indian Material for an Ethics
of Organ Transplantation
Lawrence Cohen
Lawrence Cohen, "Where It Hurts: Indian Material for an Ethics of Organ Transplantation," Daedalus 128/4
(1999): 135-66. © 1999 by the American Academy of Arts and Sciences.
WHERE IT HURTS 285
had previously been the go-between hooking up unenviable but real conditions. Information
sellers with the clinic and knew where to find brokers joined organ brokers in leading film-
them. We talked for a while: there were not makers and reporters - and, following them,
many patients. The follow-up clinic had closed anthropologists, ethicists, and medical fact-
when Reddy shut down his program in the wake finding teams- along well-rutted paths to pre-
of India's 1994 Transplantation of Human dictable stories. Depending upon the need, ter-
Organs Act, which made the selling of solid rains of violence or of agency and reason
organs unambiguously illegal, authorized the materialized. There was material in the slum
harvesting of organs from the bodies of persons for all manner of social workers.
diagnosed as brain dead, and forbade the gift of ***
an organ from a live donor other than a parent, Few of the growing number of Villivakkam
child, sibling, or spouse. There were exceptions, experts have commented on what is to the out-
approved by Authorization Committees set up sider a pronounced feature of the slum's topog-
in each state that implemented the Act to ensure raphy: it is saturated with pawnshops where
that the donor was some kind of relation or close moneylenders buy and sell gold and other pre-
friend. Frontline, a Chennai-based newsweekly, cious items. Outside many shops in the slum's
had published an article the year before docu- central shopping area are boards noting the
menting how easily these committees were cir- day's buying and selling prices. Women in par-
cumvented. 3 As long as the paperwork was in ticular examine jewelry they are considering
order, the investigative team argued, it was vir- buying to consolidate their earnings or bargain
tually impossible for committee members to over the money and credit earned by pawning
differentiate an altruistic donation from a sale their gold. There are few banks.
masquerading as such. I worried that Villivakkam might not be the
Coutinho and I sat on the verandah and place to begin, given the neighborhood's media
talked about my project. He was interested in glut and my sense of the emergence of infor-
helping out, he said, because he, too, was a social mation brokers offering investigators which-
worker. Later he told me about his project, the ever version of the trade they seem to want to
LOVE Foundation, a home for the destitute eld- find. I asked Coutinho whether there were
erly that he and some friends from his church other neighborhoods, where one might learn
had set up. Would I consider visiting the LOVE something new. We ended up in the Ayanavar-
home and helping it out? We agreed to meet the am municipal projects, in the room with the
next morning to visit Ayanavaram and Ottery political pictures, listening to one woman after
slums, and when I had had enough of kidneys for another recount her story. Similar stories, but
me to talk to the Secretary of LOVE. different in quality from the various public
Many investigators had taken this route accounts, neither tales of graphic exploitation
before, into the Chennai slum: the abject stor- nor heroic agency. There were obvious biases:
ies, the repeated and identical image of a man or Coutinho was identified with Reddy, and his
a woman turning his or her flank to the camera presence might have dampened any accounts
and tracing the line of the scar. The slum of of malpractice or exploitation. Conversely,
choice was Villivakkam, nicknamed "Kidney- I was signifiably well-off - dressed like the
vakkam" because so many of its residents had middle class, foreign, and white - and the
undergone the operation. Raj Chengappa, possibility of future patronage might have
senior deputy editor at the newsmagazine India heightened accounts of poverty and disap-
Today, told me that after breaking the Villivak- pointment. We came in the late morning,
kam story in the early 1990s with an article when many of the women were back from
called "The Great Organs Bazaar," he was del- domestic service but the men were still out
uged with calls from American and European working or looking for day jobs; we may have
based media. 4 Villivakkam gothic became rou- overestimated the proportion of women to men
tinized, as in its wake of scandal and shock did sellers. But the one man we interviewed as well
a counter-narrative in which sellers were as all of the women said that few men in this
informed agents making rational choices under neighborhood had undergone the operation. In
286 LAWRENCE COHEN
each neighborhood, the stories we heard varied What might such a link between gender,
in the details of a body and its particular situ- citizenship, and the possibility of transplant-
ation, but shared several common threads. ation entail? Cecilia Van Hollen has studied
What was common: I sold my kidney for the high usage of reproductive medicine and
32,500 rupees. I had to; we had run out of family planning by poor women in Chennai
credit and could not live. My friend had had and other cities in the state of Tamil Nadu. 5
the operation and told me what to do. I did not The situation differs significantly from much
know what a kidney was; the doctors showed of north India, where women have been less
me a video. It passes water; it cleans the blood. likely to utilize state biomedical interventions
You have two. You can live with one, but you like tubal ligations. 6 Many poor women in
may get sick or die from the operation or from Chennai incorporate surgery and other obstet-
something later. You have to have the family ric and family-planning procedures into their
planning operation because without a kidney lives, frequently electing extensive medical
childbirth is very dangerous. I had already had intervention. Van Hollen's findings suggest
that operation. the ubiquity and intensive character of this
This, too: What choices did I have? Yes, I medicalization as central to any account of
was weak afterwards, sometimes I still am. But agency in women's encounters with the state.
generally I am as I was before. Yes, I would do What they said in Ayanavaram: I already had
it again if I had another to give. I would have that operation. They told me I needed to have it
to. That money is gone, and we are in debt. My before I could have the kidney operation, but
husband needs his strength for work, and could I already had it.
not work if he had the operation. Yes, I also Thus, most women have chosen to undergo
work. tubal ligation before the decision to sell a
*** kidney is imagined. The emergence of Chen-
Around us are several pictures of the husband nai's various "Kidneyvakkams" must be lo-
meeting with the beloved late chief minister of cated in the prior operability of these bodies.
Tamil Nadu, known by his initials: MGR. The The operation here is a central modality of
husband organizes for the All India Anna Dra- citizenship, by which I mean the performance
vida Munnetra Kazhagam party in the housing of agency in relation to the state. It is not just
project. The wife says he had been better con- an example of agency; it is agency's critical
nected with leaders in the days when MGR was ground. In other words, having an operation
alive. She nods toward MGR in the photo: "He for these women has become a dominant and
needed a kidney, too," she says. "He was dying, pervasive means of attempting to secure a cer-
and received one from his niece; they did the tain kind of future, to the extent that means
operation in America. At that time, I did not and ends collapse: to be someone with choices
know about kidneys. If I had, I would have is to be operated upon, to be operated upon is
given him both of mine." to be someone with choices. "Operation" is not
Why Chennai? Deeper poverty and debt are just a procedure with certain risks, benefits,
found elsewhere, but the urban south was the and cultural values; it confers the sort of
first fertile ground for organ harvesting. Part of agency I am calling citizenship.
the answer is not surprising. Both primary Intriguingly, in these interviews the
health care and tertiary medical innovation operation was said to weaken men more than
are more developed in south India, leading women. A prior moment of contest over
not only to some of the earliest transplanta- operability was, of course, the nationwide
tions in India but also to greater access to "Emergency" more than two decades earlier
medical institutions for persons across class with its legacy of coercive family-planning
lines. For the question of contemporary kidney operations, and particularly vasectomies. 7 Cur-
sales in Chennai, additionally relevant is the rent accounts of the operation's greater danger
fact that the relation of medicine to what we to men draw upon memories of that earlier
might term the constitution of the citizen's time, as well as upon a more generalizable
body is gendered. phenomenology of male anxiety in the face of
WHERE IT HURTS 287
imagined female regeneration. 8 In these wo- more and more specific questions, sensing a
men's accounts of their husbands' concerns, symptom.
an operable citizenship came at far higher risk She looks at me, then at Coutinho. She had
to men: it literally "unmanned" them. Regions been talking, before my asking her about this
like the "kidney belts" of rural Tamil Nadu pain, about her husband: a story of sporadic
feeding the Bangalore industry, where more work, frustration, and drinking. Were we
sellers were men than in Chennai, often com- listening? She looks toward her scar again,
prised settlements of mostly male migrant and she says: "That's where he hits me. There.
workers paying off large debts in the wake of When I don't have any more money."
the collapse of the booming power-loom indus- Arthur Kleinman has written of ethno-
try. Women were back in the village, and were graphy as the study of what is at stake, an
less likely than urban women to have been elegant and deceptively transparent formula-
hospitalized in childbirth or to have had pro- tion.10 The stakes in the postoperative scar
cedures like tubal ligations. 9 differ for the women in the room, for the
I would have given him both of mine: if the doctors in Bangalore, for the husband who
gendered terms of citizenship in Chennai are hits, and for me. For the women, the scar has
set in part by one's operability, and if women two moments: a recent past when it marked
here are the primary sites of the operation, then their successful efforts to get out of extreme
this woman's proposed gift of both of her debt and support their households, and an in-
kidneys to MGR can be rethought. Her gesture debted present when it has come to mark the
momentarily seems to redeem the operative limits of that success. A sign of the embodiment
losses of citizenship by framing them as a crit- of the loans one seeks to supplement wages and
ical gift that might have saved the famous give life to one's family, the scar reveals both
leader. Our hostess transforms her second op- the inevitability of one's own body serving as
eration from an abject transaction to an act collateral and the limits to this "collateraliza-
that reconstitutes Tamil Nadu's beloved late tion." One has only one kidney to give, but the
chief minister. A young man, the son of another conditions of indebtedness remain. At some
woman who sold her kidney, complained to us point the money runs out and one needs credit
later that day that other boys ca11 him names: again, and then the scar covers over the wound
"Your mother is a kidney seller!" The current not of a gift but of a debt.
order of the commoditization of everything, in For the doctors, the scar is the sign that
which the operation transforms this mother nephrectomy can and does heal, given their
into a prostitute, is countered here by resusci- knowledge of the operation, skills, and com-
tating MGR as the politician-father and the mitment to what they are doing. Life for life,
idealized order he has come to represent. In another physician had said: the real wound is
invoking MGR's need for a kidney, this seller poverty and the operation provided the money
rescripts her sale into a gift to the Tamil leader to heal it. And yet there is the persistent fear,
that revives the idealized social relations of that the counter-knowledge that things can and do
time and renders all such sales unnecessary. go wrong, not only in the healing of the flesh
but in the healing of the impoverishment the
*** flesh stands for. Doctors know that sellers have
Within the terms of such an imaginable gift, little to no access to hospital care, that they
what language would pain take? One of the often have to work at strenuous labor, that they
women in the room offers the beginning of an are undernourished, and that they live in neigh-
answer. Her operation, she says, caused her borhoods where infectious disease and alcohol
body to hurt. "It still hurts." She points to her are endemic. Thev know that much of the
flank, to the scar. "It hurts there." I ask her, money passes qui~kly through the hands of
through Coutinho, to describe the pain. There sellers and goes to moneylenders and that
is no data in India on the effects of nephrec- many sellers lack bank accounts. In a different
tomy for these very poor sellers, most of whom register, doctors also know the public is con-
lack long-term primary care. I begin to ask her cerned about rumors of organ-thieving gangs,
288 LAWRENCE COHEN
and rival hospitals might foment an accusation country, he said, repeating a frequently heard
against one or another of them: both public claim. The infrastructure is not adequate; the
anxiety and the strategies of rivals can bring mentality will not support it. And even though
the police in at any moment. No matter how in a few years "we will be able to grow fetuses
good the surgery, the scar could still betray like popcorn" - a tantalizing phrase - the use of
them, and sellers have to be kept out of sight. clone technology may have its ethical limits. For
Like de Sade's libertines, the doctors try to the needs of our population, Kishore suggested,
erase all evidence of the cut. we have to reconsider our stance. He turned to a
For me, there was the search for traces of a bit of role-playing: "Look, I'm a man dying of
more accountable medical narrative. Also, and hunger. I ask this one for help, he does nothing.
less credibly, there were the thrill of the chase, That one, nothing. Now I ask you. You say: I'm
the elite pleasures of building theory, and per- also dying. I need an organ. I'll help you if you
haps the premature anxiety over new biosocial help me." Allowing for an exchange of one
arrangements that Paul Rabinow has called man's surplus money for another man's surplus
"purgatorial" driving my attack on medical kidney is not really traffic, Kishore concluded,
practice from a putatively higher ground. 11 but "life for life." Everybody wins.
And for the husband? I never met him, and A more sophisticated version of this case for
for all my easy if persistent repugnance I do not the sale of organs has been made by the British
know how to imagine the pain of the wound he philosopher Janet Radcliffe-Richards and en-
felt on another's body and the absence behind dorsed by her fellow members of the WHO-
the arc of his blows. 12 One is left with an supported International Forum for Transplant
inadequate sense of the deformation of the Ethics in a 1998 article in The Lancet. 13 In
operation's promise, and with it the scar's slow brief, the group has made four points:
slide from a mark of positive exchange to one
of persistent debt. 1 The standard arguments against the sale of
kidneys rely less on logic than emotion, and
require more to justify paternalist refusals
Life for Life to allow people to do as they wish with
their bodies.
Contemporary debate on the ethics of the sale 2 Such arguments make an exceptionalist case
of organs surgically removed from the bodies of for the exploitation, coercion, and risk of
the poor is shifting. Increasingly, philosophers, selling organs while ignoring the myriad
physicians, and social scientists are willing to other exploitative, coercive, and risky things
suspend concern and to consider the case for a poor people do to survive and will have to
market in human organs. In India - the most do more of if organ sales are disallowed.
well known of what is now a large number of 3 The particular forms of exploitation in-
countries supporting an emerging market in volved in the organ trade are in large meas-
kidneys- several prominent opponents of sales ure due to its informality and illegality, and
have reversed their position. One of the most the best response to them may be to cen-
vocal of these is R. R. Kishore, formerly a high- tralize, formalize, and legalize the trade.
ranking medical bureaucrat and currently an 4 The fact that few people with chronic renal
active player in the multilateral conferences failure are able to avail themselves of this
and task forces constituting the global expan- expensive option is no indictment of the
sion of the field of bioethics. An architect in the kidney trade in itself but of the nature of
development of the 1994 Transplantation of private medicine and, more generally, of
Human Organs Act, Kishore, in a 1998 inter- the political economy, and responses
view in Delhi with my colleague Malkeet Gupta should focus there.
and me, concluded that he had made a terrible
mistake. The authors go on to challenge many of
Kishore went through his reasoning carefully. the communitarian, slippery-slope, and denial-
Cadaveric donation will not work in our of-agency arguments made by opponents of a
WHERE IT HURTS 289
regulated market. In a nutshell, the traffic in what I mean by this phrase, my argument will
kidneys, if properly regulated by the state, is a have three parts, which will address "ethics" as
win-win situation. You get a kidney, I get a practice more or less central to all social and
money, and we both therefore survive against human scientists of medicine under the exigen-
all hope. cies of globalization. As such, "ethics" is an
I wish to provide suggestions from field ideal type. If my argument -which in its under-
materials for why neither Kishore's nor the standing of ethics as a central feature of glob-
International Forum's theoretical formulations alization comes out of conversation with the
may be adequate on the ground. These formu- recent work of Rabinow- is reduced only to a
lations are not necessarily the dominant ones, disciplinary attack, then I will have failed. 15
either in India or in the global world of bioethi- First, I will suggest that practices of deferral
cal debate, but they are important because they allow for the reduction of ethical analysis to
challenge an easy paternalism. I take seriously a transactional frame in which all consider-
Radcliffe-Richards's call to go beyond any a ations outside of dyads like buyer-seller,
priori malfeasance of organ sales, reading her donor-recipient, or doctor-patient are reduced
concern in line with Rabinow's criticism of an to secondary processes. Alan Wertheimer's
ethics of suspicion in his work on genomic thoughtful book Exploitation offers an
debate. 14 She asks us at the least to consider example of the value and limits of such a re-
the case for organ sales rather than to jump duction more generally. 16 For the International
into the sort of purgatorial ethics of alarm Forum as for Kishore, the goal seems to be to
and remorse depicted by Rabinow. Fair get to a win-win scenario, achievable as a
enough. But just as the paternalist ethicist matter of life for life. Policy is to be built on
depicted by Radcliffe-Richards presumes "ne- an understanding of social analysis as an aggre-
farious goings on'' prematurely, before the fact, gation of individual transactions.
so she (along with her colleagues in the Lancet Second, the transactional frames - describ-
piece) appears to make several premature able once questions of particular institutional
counter-presumptions of recognizable terrains forms and processes are reduced to secondary
of agency, risk, exchange, and bureaucratic phenomena - are flexible and exportable.
rationality. There is a global audience for The Lancet; but
Thus, our purgatorial paternalist is content even before the report was published almost
to read the wretchedness of selling an organ in every Indian transplant surgeon I interviewed
formalist terms without asking about relative in Bangalore and Chennai was conversant with
risks and benefits for persons whose wretched- the particulars of Radcliffe-Richards's writing.
ness will not disappear with the banning of such Ethics must be able to travel light. Neither the
transactions. But in parallel fashion, Radcliffe- purgatorial visions of religiously based ethics,
Richards's thoughtful rationalist is content to nor social-scientific specificity, nor modes of
presume from scattered news clippings and critical or post-structural analysis serve the
equally wretched stories (for example, of a contemporary moment well: they are not
Turkish man whose sick daughter dies because ecumenical, not economical, and fail to
he cannot sell his kidney to save her) that we valorize the emergent subject of globalization.
can speak with some authority about risks and Radcliffe-Richards's ethics are sensibly con-
benefits in the emerging Kidneyvakkams of the cerned with the small minority of Indians who
world without sustained inquiry. can afford the cost of dialysis or transplant-
The question of authority is critical. Both ation. For the rest, there is no point in worrying
the straw-man paternalist and the rationalist too much about organ sales, as nothing short of
operate through a particular logic of deferral, massive social change would have an impact
what I have framed as a persistent writing on health care anyway. As medical care and
before the fact. This persistence is not inciden- expensive biotechnology become increasingly
tal, I would suggest, but constitutive of our synonymous, less eschatological options for
writing to the extent we occupy what I will the health care of the poor become unima-
term the space of ethical publicity. To get at ginable. Several Bangalore surgeons whose
290 LAWRENCE COHEN
procedures, unlike those of K. C. Reddy, pro- biosociality or a vendor to it. 20 Unlike ethical
vided inadequate to no follow-up care to poor publicity and its realism, scandalous publicity-
sellers were among the most vocal popularizers by which I include the mobilization of purga-
of Radcliffe-Richards's writings and of the sub- torial ethics into public scandal - demands a
sequent Lancet report. Arguments will always single public united in opposition to a piracy
be productively misread, but the point is that that yokes together imaginary and real tissue
certain ethics travel well precisely because of flows.
the flexibility of their reductive transactional
frame. 17 ***
Third, not only flexible but also purgatorial The position of philosophical consideration -
ethics can be mobilized to serve the exigencies the abstract perusal of the case for organ sales-
of the moment. Kidney scandals have erupted is a poor defense against one's misapplication
in Bangalore, Delhi, and many other Indian to the extent one occupies such a position of
cities on a regular basis, with doctors arrested ethical publicity. The challenges that medical
on the grounds of tricking the poor and gullible anthropologists have offered to ethical publi-
into an unnecessary operation during which a city, though partaking {as does this essay) of
kidney was removed. Though such events cer- the same purgatorial much that blurs reasoned
tainly may have occurred on occasion, the apperception, remain critical maneuvers as
scandals I have studied appear to be based on long as the fiction of distanced ethical consider-
trumped-up charges. Accusations are used by ation substitutes flexible transactions for insti-
hospital owners and politicians in league with tutional and local specificity. In particular,
the police to challenge rival combines of medi- Arthur Kleinman's critical engagement with
cine and politics: given widespread public con- bioethics and Nancy Scheper-Hughes's refusal
cern across class about organ theft, kidney to allow us any remove from the bodies and
scandals are devastating for politics and busi- lives of poor donors and sellers map out local-
ness and therefore are an increasingly useful ized responses by ethnographers that must
regulative mechanism. complement critical distance. 21
What is the relation between the flexible The first problem is the dyad. Take, for
ethics of life for life and the purgatorial ethics example, the very real claims of sellers to be
of nefarious goings-on? My sense is that des- able to do as they wish with this unexpected
pite their substantive opposition, these modes resource. Sellers are presented within flexible
of engagement share at least some things, ethics as having a need (for money) and a desire
things I group under the heading of publicity. (to sell an organ for that money). "Yes, I would
Ethics has become the dominant mode of do it again." But listen further in Chennai: " ...
public conversation about emergent biosocial if I had another to give." And further: "I would
situations. 18 I mean "public" conversations in have to." Radcliffe-Richards would question
the double sense that has emerged via Kant and paternalist denials to the poor of their agency,
Habermas, and their critics from Horkheimer an understandable move against a vanguard
and Adorno to Michael Warner: a conversation logic that invokes false consciousness whenever
that not only is located in the public sphere but "the poor" do not tell ethnographers what they
more fundamentally is constitutive of it. 19 want to hear. But the question is not whether
I will term as "ethical publicity" the rational- the statement "I would do it again" is coerced or
ization of emergent biosociality through flex- alienated speech but rather what happens if one
ible logics of win-win, logics that posit an keeps listening: "I would have to." Does the
identity ("life for life") between the life of the opposition of agency and coercion sufficiently
comparatively wealthy person in organ failure account for this "would have to"?
and that of the debtor pressed to sell one of her The problem with an ethical argument of this
organs. As Nancy Scheper-Hughes has noted, sort is the unrelenting presumption that ethics
this public is divided into bodies that can be can be reduced to a primary transaction. 22 This
designated patients and bodies that can be des- reduction frames most relevant considerations
ignated sellers: one is either a client of the new as second-order phenomena and generates a
WHERE IT HURTS 291
utopian formula: if second-order phenomena in Chennai, Bangalore, Delhi, and Mumbai
can be controlled for, then an ethics is possible. (Bombay), and in lieu of a full answer I offer
But in fact the primary transaction is consti- six points as part of a work in progress.
tuted out of the very second-order phenomena
that the analyst would defer: everyday indebt- 1. No data exists on the long-term effects of
nephrectomy to sellers or families.
edness and extraordinary debt bondage in
which money passes from the patient through Many surgeons in these four cities reported
the donor and to the moneylender and other an absence of long-term effects and then went
creditors. If one keeps listening, beyond the on to insist that follow-up research was impos-
desire that sets the market in motion, one sible since they have no way of knowing where
regains the temporal specificity lost in these the itinerant or illiterate sellers have gone. Yet
transactional analyses: "I would have to. That the ability of activist physicians, fact-finding
money is gone and we are in debt., In the Tamil teams of ethicists, and journalists to locate
countryside with its kidney belts, debt is pri- sellers suggests that epidemiological research
mary. But it is not only debt that constitutes the on such long-term effects is eminently possible
frame of the primary transaction and troubles and would seem to predicate any future calcu-
its claim of life for life. In Chennai city, debt lations of risk-benefit ratios.
intersects with operability and the contingent After Reddy, two of the most internation-
logic of biopolitical regulation. Operable ally prominent physicians who are advocates
women are vehicles for debt collateral - and for organ sales are Drs. S. Sundar and A. K.
bear the scar. "My husband needs his strength Huilgol of the Karnataka Nephrology and
for work, and could not work if he had the Transplantation Institute (KANTI), housed in
operation." "Yes, I work too." Bangalore's Lakeside Hospital. All physicians
Against what is heard, the two kinds of in Bangalore and Chennai acknowledged the
publicity constitute alternate public terrains. high standard of care KANTI offers: medically,
For ethical publicity, gender and debt become it is an exemplary site. Like Reddy, Sundar and
second-order phenomena, and ethics is re~ Huilgol make no secret of their commitment to
stored to rational actors pace Adam Smith. organ sales as a win-win scenario in the con-
What happens several months down the line text of local conditions. Like Reddy, they are
is elided. Rational consideration appears not carefully acquainted with Radcliffe-Richards's
only removed from the purgatorial but also work and cite it to challenge opposing pos-
removed from outcomes distant in time from itions as both intellectually unsustainable and
the primary transaction. naive. Unlike Reddy, however, Sundar, in sev-
In scandalous publicity, as manifest in eral 1998 interviews, deflected my question
Indian and international media, images of male each time I asked about meeting his former
victims showing the scar from an involuntary sellers. When pressed, he pleaded the impossi-
nephrectomy are ubiquitous. These are not the bility of finding these people or learning much
bodies of rumor: an operation has occurred, from them.
perhaps involving some measure of coercion. Many of the Bangalore sellers have come
But the point here is that the public scar is from the Salem-Erode kidney belt. According
almost always male: men offer the paradig- to social workers and small-town reporters
matic surfaces bearing scars that in urban areas working in that region, these sellers are primar-
cover operations on female bodies. Scandalous ily men who left unirrigated "dry" farming
publicity reconstitutes the "Emergency., districts for the promise of steady work as
the power-loom industry dispersed from cities
like Chennai to cheaper production sites.
How do we steer between a flexible ethics that Unlike the Ayanavaram and Villivakkam
reduces reality to dyadic transactions and a sellers, these men are more likely to be recent
purgatorial ethics that collapses real and im- migrants who are indeed harder to follow. This
aginary exploitation in the service of complex difficulty has been used to forestall attempts to
interests? I am in the midst of a four-year study generate data.
292 LAWRENCE COHEN
Part of Sundar's cautiousness may arise statistics of donors. The second time I tried to
from the possibility of KANTI's knowing or get Dr. Sundar to talk about a possible follow-
unknowing involvement in the trade. Sundar up study of donors he took out a copy of a
denies awareness of any illegalities: if his Radcliffe-Richards article from his desk and
patients say the donor is a relative or family asked me if I had read her. He read choice
friend, and if the state authorization committee phrases of the article to me, dismissing my
has concurred when necessary, it would be concerns over sellers as paternalist. But where
wrong, he argues, not to go ahead. Sundar is were the donors? If the market structure of
open about patients who seek out the commit- transplantation deflects attention from the
tee. KANTI in fact makes a public display of its actual bodies of sellers onto ideologically con-
transparency. The waiting room is lined with stituted proxies, how complicit are flexible
large wall charts listing the numbers of every ethics in maintaining postoperative inattention
procedure carried out by KANTI and its sister to sellers?
clinics in the state. News clippings attesting to
2. Decisions to sell a kidney appear to have
KANTI's popularity in Bangladesh are hung
less to do with raising cash toward some
along with a computer-generated sign from
current or future goal than with paying off
Bangladeshi patients thanking the clinic.
a high-interest debt to local moneylenders.
Despite this transparent design, three
Sellers are frequently back in debt within
members of the Karnataka State authorization
several years.
committee who were interviewed acknow-
ledged that few of the donors they were asked The Ayanavaram slum dwellers who sold
to consider were relations or friends, from their kidneys described their reasons for sell-
KANTI or most other Bangalore clinics. Why ing and their desire to sell again if biologically
do committee members approve these donors, possible in terms of a transaction not with the
then? The state secretary who runs the commit- present or future - an operation to pay for, a
tee said in an interview with me that patients house to but, a shop to set up, a wedding to
and physicians have political allies who pres- finance - but with the past. They were in
sure the committee to grant approvals. Reddy debt, and could no longer manage their in-
is but the most prominent of several transplant debtedness and still feed and shelter a house-
doctors who specifically accused Sundar and hold. This finding is tentative, for as most of
Huilgol of "going too far" in turning trans- these borrowing and lending transactions are
plants into big business. Reddy claimed that through private moneylenders and small
KANTI has advertised in Sri Lanka and Ban- shopkeepers as opposed to state or private
gladesh for patients and that Sundar and Huil- banks or credit associations, data to confirm
gol had come to the Kidneyvakkams of sellers' and nonsellers' patterns of indebted-
Chennai in search of sellers. Part of Reddy's ness are difficult to generate. But the testa-
concern might have been territorial: the urban ments of sellers do correlate with the work of
Kidneyvakkams had for several years supplied investigative journalists in Chennai. Further-
Chennai clinics, while the rural kidney belts to more, they make sense within the topography
the west had supplied Bangalore. "They have of credit in poor Chennai neighborhoods, in
become greedy," he said - suggesting that, far which moneylenders and pawnbrokers are
from being unable to determine the provenance ubiquitous.
of kidneys, Sundar and Huilgol themselves None of the Chennai sellers interviewed
served as procurers. claimed to have a bank account, and they
Sundar and Huilgol may well be the victims offered the usual reasons: they were illiterate
of false accusations by competitors. But their or poorly literate and of low status, and there-
resistance to follow-up research is striking. fore could not negotiate the language and
The only things missing from the prodigious status practices of the bank bureaucracy with
display of data shown by KANT! on its walls, any certainty. Stories of money lost to bankers
in its publications, on its web site, and through were common. Jewelry offered a seemingly
its dealings with the press are the bodies and more practical locus for saving, though stories
WHERE IT HURTS 293
of gold stolen or appropriated were not un- Debtors' recounting of the process of debt
common. Most of the kidney money went to supports such a process, as does my informal
pay off debt, and the expenses of husbands and observation of moneylenders and discussions
children- education, marriage, medical costs, with Chennai and rural Tamil Nadu journalists
legal fees - took the rest. Several of the women and social workers who cover questions of
interviewed mentioned men who drank up the credit and debt. More analysis of local credit
savings. practices is needed.
Persons sell a kidney to get out of debt, but
3. Few persons in India can afford the cost of
the conditions of indebtedness do not disap-
transplantation or dialysis, so whether or
pear. All of the thirty Chennai sellers with
not organ sales are legalized the majority
whom Coutinho and I spoke were back in
of persons with end-stage renal disease will
debt again. Organs and blood, from the per-
die. Programs to prevent end-stage renal
spective of the debt broker, are but two of the
disease are few, and prevention is not part
multiple sites of the collateralization of the
of the dominant European or American
poor, ranging from patterns of debt peonage
conversations on organ sales, whether pro
with lengthy pedigrees to expanding new
or con.
markets in children for adoption, labor, and
sex work. Technological transformation like The first part of this finding is a commonplace.
that mediated by the emergence of cyclospor- Radcliffe-Richards and her colleagues accept it
ine offers new biosocial strategies for debt but argue that the question of the poor's access
markets seeking under the logic of capital to to medical care is irreducible to their access to
expand. transplant surgery. Purgatorial anxiety over
The argument here is that the decision to organs is a self-serving substitute for concern
sell may be set for debtors by their lenders, who over universal health care.
advance money through an embodied calculus Again, at an imagined distance this logical
of collateral value. In other words, the aggres- maneuver makes sense. But reformulated in
siveness with which moneylenders call in debts terms of ethical publicity, it deforms in a pre-
may correlate with whether a debtor lives in an dictable fashion. At KANTI, when I asked Sun-
area that has become a kidney zone. If so, the dar how he could support a market in kidneys
decision whether or not to sell is a response not given no data on the risks to Indian sellers, he,
simply to some naturalized state of poverty but like Reddy and most other transplant phys-
to a debt crisis that might not have happened if icians interviewed, responded that when a
the option to sell were not present. Based upon person dying from poverty comes to your door
these interviews and discussions with histor- and asks why you will not help him, the situ-
ians, social workers, and journalists in Chen- ation requires action. The scenario of a request
nai, my hypothesis is that kidney zone- the from a dying person is disconcerting and prob-
vakkams and belts of Tamil Nadu - emerge lematic, for the vast majority of persons living
through interactions between surgical entre- with and dying from renal disease could not and
preneurs, persons facing extraordinary debt, would not be attended to, as they lack the funds
and medical brokers. As a region becomes for dialysis or transplantation. Yet the sellers
known to brokers as a kidney zone, their fulfill the terms of the ethical scenario as set by
search for new sellers intensifies. Persons in these doctors: a dying person asks you for help-
debt are approached. In urban areas, more what do you do? Somehow, such a scenario
women than men respond. Creditors, who does not trouble these physicians in the way
must advance and call in loans with an eye to the suffering of the more well-to-do appears to.
interest, collateral, and reproduction -that is, When I asked the KANTI team about
to how much of the debtors' resources to take this apparent inconsistency, they smiled indul-
while keeping them alive and healthy enough gently. We are a poor country, Sundar
to be able to make future payments and take reminded me, and as much as it would improve
out more debt - also respond to these shifting my business to have the government pay for
circumstances. transplantation for the majority of Indians,
294 LAWRENCE COHEN
I do not think it can be a priority for us. Gov- death transplantation and lists are far from
ernment money needs to go to primary care. perfect alternatives to sales, as the work of
The move is impressive, and dizzying. Margaret Lock on the former and Scheper-
Sundar, and the majority of transplant doctors Hughes on the latter have shown. 23 But debate
who concur with him, are masters of ethical on cadavers has not focused on the medical and
publicity. There is no need to worry about ethical limits of brain death as a viable concept.
health risks to the poor seller, because a phys- Rather, lip service under a rhetoric of develop-
ician must always worry about the individual ment is paid to ever-deferred infrastructural
patient: his or her ethical compact is with the and institutional possibilities.
individual sufferer. Yet there is no need to
4. Buyers of kidneys often underestimate the
worry about the majority of individual suffer-
risks and long-term costs of immunosup-
ers, because an Indian physician must always
pressive therapy, leading to dose tapering
think on the societal level, where the money
and organ re;ection after catastrophic ex-
would be better spent on inoculations. What is
penditure.
alarming is the sleight of hand by which indi-
vidualist and communitarian rationales for a Buyers no less than sellers are at risk. Scheper-
medical ethics replace each other in turn to Hughes has documented the predicament of
justify business as usual. poor organ recipients in Brazil who cannot
In this context, the inattention to questions afford to maintain cyclosporine immunosup-
of prevention, to renal medicine that in the pressant therapy and so taper or pool doses.
long term might be both affordable and Members of the Bangalore Kidney Patients'
effective for "a poor country," is particularly Welfare Association, which meets once a month
significant. Communitarian logic serves only to in a city park to distribute low-cost immuno-
justify inattention and to slough off poor pa- suppressant therapy (but not the most expen-
tients to public hospitals. Transplant phys- sive and most necessary drug, cyclosporine),
icians, despite their immersion in bioethics offer similar stories of middle- and working-
and communitarian appeals, are with notable class persons who utilize networks - relatives,
exceptions not involved in campaigns of public job benefits, insurance, and statewide "govern-
education or the development of low-cost al- or's funds" set up for medical emergencies- to
ternatives to current dialysis. Their persistent raise the cash for the operation, for the organ in
resistance to cadaveric donation, which would the case of sales, and for the medication. These
provide an alternative to the use of the organs organ recipients anticipated one to three years
of the poor, is troubling. Most surgeons of diminishing immunosuppressant therapy,
interviewed cited India's "infrastructure" or and thus either were not anticipating the long-
"mentality" as problems, but several pioneer- term costs adequately or simply did not realize
ing cadaveric programs in the country are that therapy might last for many more years.
emerging, and their founders argue that the A monthly dose of cyclosporine costs more
single most significant impediment to success money than many of these famllies bring in
is the unwillingness of most private transplant each month as income. Further ethnographic
clinics to participate. Reliance on cadavers cuts work is needed to study the preoperative inter-
down on a ready supply of organs and dimin- actions between patients and doctors to under-
ishes profits. In Bangalore, John and Rebecca stand what message about long-term costs
Thomas - trained in Pittsburgh, the Mecca of patients are receiving and how they interpret it
transplant surgery -launched an effort to build over time.
an equivalent to the United Network for Organ Part of the problem is that younger nephrol-
Sharing (UNOS), a distribution and informa- ogists are less aggressive in how many tissue
tion network linking brain-dead cadavers to factor "matches" there need to be between
persons on a waiting list. Their efforts, though donor and recipient kidneys in order to go
publicly applauded, have been met with signifi- ahead with the operation. Cyclosporine, in
cant resistance. No hospital wants to give away combination with other drugs, makes a trans-
its own cadavers to a pooled list. Both brain- plantation with fewer matches medically viable
WHERE IT HURTS 295
in certain patients. With the predominance of As the supply of persons who could afford
transplants of kidneys from nonrelatives (now the operation diminished, competition between
disguised under the terms of the 1994 act}, these many programs intensified, and directors
requiring fewer matches means one is more began looking for new markets. With the pas-
likely to find available sellers and conduct more sage of the 1994 act, the number of foreign
procedures. I have witnessed debates between recipients - typically from the Persian Gulf
older and younger physicians over the appro- region, Europe, and Asia -went down sharply.
priate number of matches. As the number of Hospitals were worried about scandals, and it
matches comes to be seen as less important, was harder to pass off a local donor as a friend
the length of time patients will remain on cy- or relation of a foreigner. Clinics like KANTI
closporine increases. Patients and physicians looked to both Sri Lanka and Bangladesh,
reported one to three years as a ballpark figure where recipients without relatives could bring
co me, but the figure may be based on data their own donors or sellers. With the number of
from a different climate of tissue typing and applicants for kidneys in decline, it is possible
matching. that middle- and working-class households
Novartis, the maker of cyclosporine, is ubi- who could afford the operation but not the
quitous in the global transplant world and in immuno-suppression were more aggressively
India. It funds many conferences, not only on approached. This impression is the one offered
organs but on medical ethics more generally, by Welfare Association members, but further
and its representatives attend public gatherings study is needed.
like those of the Welfare Association. At one If clinics face less a shortage in organs than a
such meeting, one recipient's father literally shortage in persons wealthy enough to take
begged the drug representative for a free them, they need to organize their practice
month's supply of the drug as he had no credit around a manageable and relatively low-cost
left. The drug was provided, and apparently source of human material. Recipients can go
this exchange was a repeated scene. Novartis elsewhere, and one must have potential kidneys
becomes the great benefactor for this organiza" ready. The business of these clinics depends on
tion of recipients, and no actions to lower the the market, and would be made far more risky
price are proposed. with a turn to cadaveric donation.
The point here runs against the continual
5. In ma;or urban centersJ the growing
language of shortage that some ethicists take
number of transplant programs led to in-
for granted. Putting aside the vexed issue of
tensified competition in the mid-1990s for
whether one can even speak of a shortage of
recipients who could afford the cost: the
people's organs - an issue drawing on a philo-
ethics of transplantation in India are
sophical analysis of property extending from
driven less by a shortage of donors than
Locke to Marx and seldom engaged within the
by market demands given a shortage of
ethical literature under consideration here -
recipients. one must ask whether the critical shortage is
KANTI is one of eight transplant centers that not of donors but of recipients. The practices
was established in Bangalore within a decade, and the ethics we need to consider are rooted in
in a state where dialysis is almost nonexistent. the economics of this latter shortage.
This rapid expansion was in part a function of
demand, though the supply of persons who 6. The rapid growth of transplant medicine
could afford the triple cost of operation, organ, in the 1990s was part of a larger period
and drugs was quickly exhausted. Beyond of medical institution-building in India
demand, a transplantation ward advertises a in which high-end, privatized medical
new or competitive private hospital as modern care became a major site of investment
and well"equipped: this reputation may be and foreign monetary exchange, and
profitable beyond the income generated by new pt~blic-private assemblages emerged
the ward itself. Transplantation signifies (mar- linking medical institutions and political
ketable) modernity. influence to various sources of capital -
296 LAWRENCE COHEN
liquor, armaments, pharmaceuticals, and scandals (but not all) were socially marginal
"black money., and unlikely to be heard. At present, one must
defer final judgment.
Transplant medicine, as a continual goad to Why, though, in each of these cases do the
public and foreign anxiety, became a strategic police act with such speed on the claims of
site for intervention within and between com- poor and socially marginal accusers? In Naida,
peting assemblages. The frequent manufacture a senior superintendent of the police with a
of scandals in which doctors are accused and medical background was specifically trans-
jailed as kidney thieves appears to be one such ferred in to monitor the case. The accused
intervention. physicians have mobilized their political
One must differentiate kidney panics from connections in an effort to be released, but
kidney scandals. In panics, stories of missing or according to several state medical officials
murdered children circulate and become tied to who spoke with me on the grounds of anonym-
fears over kidney thieves and to the legitim- ity, the word has come down from the chief
ation of state and international involvement. minister's office that the case is not to be
The stories are often based on real disappear- touched.
ances and child loss in the contexts of malnu- The earlier Bangalore scandal was similarly
trition and hunger, of debt bondage and surrounded by hearsay. The YeJlamma Dasap-
child labor. State agencies are challenged or pa Hospital, where the scandal was centered, is
attacked, and state responses focus upon deny- owned by an industrial group that was compet-
ing the stories and providing the materials for ing with another industrial group for a lucra-
renarrativization. 24 tive state contract to supply cheap liquor.
Scandals are not threats to state order but (Most of the city's hospitals are owned by large
forms of publicity collaboratively produced by industrial concerns, several by liquor com-
a mix of state and nongovernmental agencies. panies.) Several hospital administrators, social
The police arrest a group of doctors and workers, and journalists suggested that the
the media are notified. Emerging accounts are contract negotiations lay behind the manufac-
framed not as positings of hidden gangs and tured scandal. The police denied this.
state conspiracies but as stories of greed and "Manufactured" is deceptive here. If most
corruption. Brokers and doctors collude in transplant clinics have violated the letter and
tricking people into having medical tests with spirit of the Indian Penal Code and the later
the promise of a job; people wake up with a 1994 act in using sellers or passing them off as
scar. Such scandals have taken place in Bombay family or friends, and if sellers are provided
(not yet Mumbai} in 1993, Bangalore in 1994, minimal care and shunted back to the villages
jaipur in 1996, and the Delhi suburb of Naida or slums, most clinics are therefore vulnerable
in 1998. Most of these trials are still pending. to accusation- thus KANTI's strategy of per-
It is, of course, possible that the physicians formative transparency. But why police in-
accused are guilty of all charges. Scheper- volvement? Most new clinics and hospitals
Hughes has carefully documented organ theft have had to rely upon extensive political pat-
worldwide, even though she began her research ronage to wade through regulations designed
to show the opposite: that these stories were to promote a public health sector and limit
symptoms of histories of poverty and state vio- private growth. Available urban land often
lence but not necessarily "reaP' thefts. Cer- has squatter colonies, and significant political
tainly worse examples of medical malfeasance capital is needed to move a potential "vote
occur daily. Yet one must exercise caution. bank." Conversely, the new hospitals offer
With a large and growing number of persons a variety of services to politicians and indus-
in debt crises there would seem to be no imme- trialists, ranging from a source of political
diate shortage of sellers, and it is not clear why patronage to a literal tax shelter where indus-
clinics would take the high risk of cheating trialists and others under trial for foreign
someone. Then again, police can be easily exchange and tax violations can be admitted
bought off, and the victims in most of the to defer a court date in perpetuity. Journalists
WHERE IT HURTS 297
and other cosmopolitans in each of the ethnography before distanced consideration
aforementioned cities where kidney scandals can be achieved.
continue offered dozens of accounts of the
nexus between the new medicine, politics, and
industry - some substantiated, many not. Coda: Other Ethics
Transplantation, both because it is a critical
site of publicity around which periodic panics Neither Kishore, Reddy, and Sundar nor the
emerge and because it often involves a nested agents of public scandal currently hold the field
series of illegalities and produces a class of in India, although things change fast. Medical
potentially exploited persons, seems to have activist organizations Like the Voluntary
become a key node around which competition Health Association of India (VHAl) still at-
for control of medical, industrial, and political tract multilateral fiscal support and steer a
resources is negotiated. The paradox is there- course between acknowledging some nefarious
fore created of a politics that tries to quell goings-on and passing over transplantation to
kidney panics while abetting the periodic nego- arrive at more urgent questions of infections,
tiation of scandals. environmental degradation, and access to pri-
What is the relevance of these scandals to mary health and hospital care. The dominant
the sociology and ethics of the market in formation in Indian bioethics is purgatorial,
organs? First, they pusn us to take seriously but with a somewhat different lineage from
the need for an ethnography of the state. Rad- the ethics challenged by Rabinow. Missionary
cliffe-Richards and her colleagues make a clas- discourse and aesthetics predominate, and the
sic transparency argument, parallel to those message of a new science stressing care against
used to defeat prohibition or decriminalize commerce and love against paternalist medi-
prostitution and drugs: if there is exploitation, cine offers the reclamation of society against a
then legalizing and regulating the market sense of loss experienced and inscribed as colo-
cleans it up while allowing sellers their auton- nial. Such missionary ethics form another
omy. But this argument presumes a state struc- public space, one that travels well along certain
ture, one in which increased regulation has routes. At the Fourth World Congress of Bio-
a specified effect and the organization of ethics in Tokyo, Japan, in 1998, one of the
the state can address the organization of the dominant presences was Darryl R. J. Macer,
market. But what if the organization of the the author of Bioethics is Love of Life: An
trade mirrors the organization of the Indian Alternative Textbook. 26 Macer challenged
state in its need for brokers? The presumption most professional ethical stances, but in his
of the ethicists seems to be that once India is repeated "All you need is love" theme what
developed into a certain assemblage of rational really fell out of the equation was politics.
bureaucratic forms, the current abuses will dis- Against flexible ethics, Macer and his followers
appear. This presumption imposes a narrative downplayed any VHAI-rype response and set
of the development of the state with little em- up a global mission, a secretariat of love.
pirical grounding. In consideration of the But if the only alternatives to a world split
recent work of Akhil Gupta on the ethnog- between clients and vendors are reconstitutions
raphy of the Indian state as well as the writing of Christian love, the result seems to be that
of Veena Das, Ravi Rajan, and others on the vendors are authorized to define themselves
bureaucratic management of treatment for the through the gih, with clients remaining the
Bhopal gas disaster victims, what seems more beneficiaries. In Bangalore and Delhi I was told
likely is that any new central bioauthority will stories of persons possessed by a kind of dona-
generate a new class of agents demanding pay- tion madness: a man desperate to give away
ments from sellers. 25 Such "bioethical brokers,, any organ he could; a couple who insisted all
may supplement, rather than eradicate, cur- their wedding guests sign up to donate some-
rently existing tissue brokers and debt brokers thing. But in conversations with recipients, I
in the lives of the poor. At any rate, these are continue to hear love in a different sense:
empirical questions that require ongoing Why should I put a family member I care about
298 LAWRENCE COHEN
Aslihan Sanal, "'RobinHood' of Techno-Turkey or Organ Trafficking in the State of Ethical Beings," Culture,
Medicine and Psychiatry 28/3 (2004): 281-309.
"ROBIN HOOD" OF TECHNO-TURKEY 301
already a few days ago. We filmed the whole because catching an "Organ Mafia doctor"
story. We got you Dr. S. How much did you get "illegally" at work in a prominent private hos-
this time? How much does the Organ Mafia pital threatened the widespread trust in good,
charge for such operations?" Dr. S. does not upscale private medicine. Dr S. transformed
say a word and walks away. (Cut.) the image of high-tech medicine in Turkey,
We are back in the TV studio. "Aaaand . .. where there is not much public awareness of
"says a loud and determined voice, "Dundar scientific malpractice or experimentation on
has perfonned a public service again, and he human subjects.
caught the Organ Mafia as they were abottt to
start a new illegal kidney transplantation.
Dundar will always serve the welfare of the
Turkish people and enlighten you. He will In the Field
serve ;ustice, no matter what/"
In this paper I argue that ethical issues of organ
{from The Arena Show, Winter 1999, trafficking are not limited to marginal private
Channel D, Turkey) clinics and doctors such as Dr S. All living-
related organ transplantations in Turkey involve
The illegal organ trade is a public issue in Turkey. similar ethical dilemmas: according to trans-
In 1997 and 1999, the Arena Team, the produ- plant surgeons, most organ recipients pay their
cers of a TV show on Turkey's Channel D, donors and the demand for living-related trans-
broadcast two cases documenting a Turlcish plantations is increasing every year because of
transplant surgeon, Dr S., 1 conducting illegal the lack of cadavers from which to harvest
kidney transplantations between Turkish lcidneys, and most doctors in Turkey argue that
lcidney sellers and Israeli purchasers. organ trafficlcing is due to this lack. They
The show labeled Dr S. the "Organ Mafia believe there are many religious and cultural
doctor" and helped create the imaginary of a reasons, but the main problem lies in the lack
medical underground community in Turkey of respirators in intensive care units and the
and in international trade networks. The unwillingness of the young doctors to make
narrative was a Faustian one in which the the brain death diagnosis required by law to
actors - patients, doctors, dealers, and donors declare a person dead and available as a poten-
- bargained with evil, dividing this kind-of- tial organ source. Like in Japan, where brain
medical and lcind-of-personal practice into cat- death diagnosis was impossible because of the
egories of the criminal and the innocent. The belief that the soul remained in the body as long
patient who went to a Mafia doctor was still as the heart was beating (see Lock 2002),
considered innocent, as he or she only wanted Turkish doctors have had a hard time believing
to survive. The donor who sold his organ was in the new human invention, made possible by
closer to the evil than the buyer, because he had respirators, of death while the heart still beats.
a pact with the dealer and had violated the Although the transplantation law in Turkey
integrity of his soul by violating the integrity dates back to 1979 (National Newsletter 1979,
of his body. The dealers and "Mafia doctors" as cited in Haberal1993), I have been told that
were shown as the actual criminals. Dr S., with doctors avoided making brain-death diagnoses;
his very short haircut, tiny figure, dark, tanned they are not obligated to do so. The law enables
skin, and frameless eyeglasses, looked more them to make the diagnosis if they act with a
like a scientist figure from an apocalyptic clear conscience. Torn between a law inspired
1930s movie than a transplant surgeon. The by Western models of medicine and traditional
crime setting and the criminals seemed as if practices and beliefs, Turkish doctors are en-
they were marginal to the Turkish transplant- gaged in ethical struggle at every step, balancing
ation community, as if illegal international "ethics~ as defined by law, "ethics" as defined by
kidney transplantation was conducted by their values of saving life, and the "ethics" of
people who had no relationship to legitimate their personal conscience.
transplant practices in Turkey. The scandal I am interested in understanding where
revealed by The Arena Show was intensified judicial, cultural, and social categories of
302 ASLIHAN SANAL
"human rights" and "crime" are constructed, "possibilities" that exist for finding or buying
so I have chosen to write on transplantation a kidney. Doctors operate on patients who they
practices in state and university hospitals and suspect might have paid their donors. Some-
the ethical dilemmas doctors encounter. Fur- times doctors also refuse to care for patients
thermore, I am concerned that critical medical who do not use the dialysis fluids produced by
anthropology displaces widespread ethical the doctor's own facilities. Some doctors in
dilemmas faced by medicine in general onto Turkey advise their wealthy patients to go to
the criminal, marginal characters of media India or Russia to have a transplantation, and
imagery. For this reason, in this paper I draw some take bribes under the name of "charitable
on Agamben's (1988) usage of the threefold donations." In short, if commodification of
corpus (body, state, law) to question medical body parts is illegal, then the path to crime
practice. Only with a better understanding of begins in the hospitals and throughout the
the corpus will we be able to have a better medical community (see FriedHiender 2002).
understanding of what kind of politics creates Many doctors feel the very act of saving lives
bios today. Here I am speaking of the bio- through transplantation is a gray area of crim-
logical corpus on which experiments are done, inality, and that criminality itself is part of the
the legal corpus that expands for its own sake state corpus within which they must work. As
and through its own logic, and the sovereign such, the Organ Mafia is a symptom of ethical
corpus that is viewed as free of crime because disputes within the corpus.
it incorporates the ideals of the state. The Besides doctors' narratives, I looked into
Organ Mafia is symbolically "cast out" from patients' lives. Patients' narratives illuminate
this tripartite corpus. And its creation, in this the experiences of those who, in one way or
context, is a diagnostic symptom of the the other, have become a part of illegal kidney
transition "Turkish medicine as corpus" is ex- transplantation. With their voices, I question a
periencing as transplantation technology turns human condition in which scientific state-
the human body into a means to an end and ments, political experimentation (in the form
not just an end in itself. Today, this corpus of Turkey's two different politics of organ
regenerates and expands through biomedical sharing), and the media shape patients' experi-
technologies and introduces us to a new medi- ences in Turkey. These conditions are such
calized idea of the human created by doctors that patients' and donors' feelings and emo-
who feel they practice in the midst of a criminal tions are expressed only through the political
environment. Here I interpret the corpus and economic conditions they feel a part of.
much like Cassirer (1962) sees the "spirit" in Their speech, which unites their experience
the age of the Enlightenment, but in reverse - and makes it meaningful, is politicized and
the corpus is antithetical to the consciousness mediatized, but at the same time it is distanced
active throughout the Enlightenment. Cassirer's from the realm of crime. People expressed love
vision of the spirit was a soul slowly blossoming and hate, pain and suffering in low tones
through its engagement with life, through the when they narrated the experience of their
experiences of the scientists and the visions of operations. Crime was not something they felt
interpreters. Enlightenment was carried in the they were engaged in, even if they purchased a
spirit of a consciousness that grew with an en- kidney. They felt they were engaged in some-
gaging contribution to human mind, not neces- thing else - some kind of business of life, of
sarily to morality. The corpus, on the contrary, their own lives, and the lives of those who give
is a materialized form: rigid, nontransparent, them life.
and imposed through bureaucracy. Crime and healing, two notions heavily
While the sale of organs is illegal in Turkey, loaded with emotions, are suppressed in the
the definition of crime within the transplant- "rationality" of medical statements in the hos-
ation community is disputable. For example, pitals. There, "money," "statistics," "organ-
any patient who is diagnosed with kidney fail- share databases," "kinship," "ethnicity," "West
ure gets to know at a very early stage of diag- versus Orient," and "corpses versus living
nosis, right in the hemodialysis centers, the bodies" are the main categories physicians use
"ROBIN HOOD" OF TECHNO-TURKEY 303
to talk about the conditions of organ transplant- donor becomes a link in this chain of events,
ation. In physicians' narratives, science, technol- as do the choice of the hospital, the country of
ogy, politics, and economy shape the human transplantation, and the doctor. In the mean-
condition of kidney transplantation. As such, time, a set of underground players becomes
instability in Turkish political life, an authority agents of this, by now, crime. The final section
struggle within the medical system, a transplant- of the article covers how patients talk about
ation law which promotes living donors and their conditional experience of a life of crime.
does not improve the conditions for donations
from cadavers, and the privatization of Turkish
hospitals in the 1990s seem to contribute to the Methods
reasons Turkish people donate, transplant, and
receive organs illegally, and why Turkey has I began doing this fieldwork with the assump-
become a market for organs in the Middle tion that public, state, and medical institutions
East. In this business of life, emotions, feelings, had created a regulated community around
guilt, and anxiety are left unspoken, while tech- formal and informal norms, and thus also
niques on survival create a discourse on life created the "criminal," the Organ Mafia.
strategies. Though the phrase "Organ Mafia" requires
To illuminate the facets of my argument, I clarification here. When I say Organ Mafia, I
first describe the politics of organ share in do not necessarily mean just Dr S., but a busi-
Turkey, which is divided between two organ ness that is structured on trading illegal
transplantation centers, one in Istanbul and the migrant labor, prostitution, and opium, as well
other in Ankara. Then, I explore the privatiza- as organs, throughout eastern Europe and the
tion of Turkish medicine in recent years. After Middle East. In narrating this story of crime
this brief topography on organ transplantation and medicine, I use Dr S.'s case as the doctors
practices and institutional structures, I show were using it: for them, Dr S. was a modality
how media steps in to create the criminal. they talked about in regards to what had to be
Finally, I give diverse accounts of patients who done to improve the conditions of organ trans-
had kidney transplants under various different plantation and prevent the spread of the image
conditions. From a patient's point of view, the of an Organ Mafia. Unlike the public, the med-
set of tyrannical relations in the exchange of ical community totally rejected claims about
organs is shaped by a chain of events the patient the Organ Mafia. They believed that Dr S.
goes through, from the first moment of kidney was an unfortunate case and that there was
failure diagnosis to the end of the kidney trans- no such thing as the Organ Mafia in Turkey. I
plantation. In their book Spare Parts, Fox and use Dr S. 's unfolding character in each narra-
Swazey (1992) argue that living-related dona- tive as a way of exploring the changing and
tions have a tyrannical aspect in their effects on diverse understanding of crime in Turkey
both recipients' and donors' posttransplanta- today. The way the term "mafia" is used in
tion lives. Fox and Swazey adapt Marcel public rhetoric refers to a kind of business
Mauss' concept of gift exchange of the which is not legal, but which in some cases
exchange of body parts, arguing that organs is more people-friendly than state law and
are viewed as spare parts by physicians, and administration. The semantics and pragmatics
when tissue typing matches, members of a of the term "mafia" will become more trans-
family feel obliged to donate. Both recipient parent the more the social structures involved
and donor experience ongoing relations, in organ trade are delineated.
desires, and obligations, and the recipient in This delineation can only be done with
panicular feels she or he must give something in-depth qualitative research methods. Most
in exchange, although nothing is equivalent to interviews were audio- or video tape-recorded.
the gift of life. The nexus of felt obligations Fox In general I interviewed the physicians first,
and Swazey call "the tyranny of the gift. n and then with their permission and introduc-
Organ trafficking, in principle, operates around tions, I spoke to patients at their bedsides. In
this idea of gift exchange. The choice of the this article, peopte•s names - except for those
304 ASLIHAN SANAL
of the heads of the transplantation units - have Istanbul was established by Dr Ulug Eldegez
been changed to pseudonyms. in 1990. He is the founder of the Organ Coord-
Aside from my work in the hospitals, I ination Center in Istanbul and the head of the
spent time with the camera crew who filmed Transplantation Unit at Istanbul University.
Dr S. doing illegal operations. I was allowed to Ankara's database was founded by Professor
use their archives and interview them about Mehmet Haberal, the Rector of Ba~kent Uni-
the programs on organ trafficking they pro- versity, the director of the Ba~ent University
duced from 1997 to 2000. I also collected Hospital, the head of the Transplantation
other material from the media and interviewed Center at Ba~kent University, and the founder
journalists. I was lucky to have a snowball of the Turkish Transplantation Society. Both
effect, a continuum of interviews by storytell- directors are transplant surgeons, but they have
ers who directed me to the people they felt I different politics of organizing their transplant-
should interview next. This gave rise to a ation centers. Eldegez collaborates with inter-
coherent and unfolding story that engaged national organ-sharing groups Eurotrans and
most of the people who were part of this busi- United Network for Organ Sharing (UNOS),
ness of life. I interviewed doctors and patients whereas Haberal has closer contacts with the
at the Organ Transplantation Unit at Istanbul Middle Eastern Society for Organ Transplant-
University Hospital, the Dialysis and Organ ation, although he also works with UNOS and
Transplantation Unit at Haydarpa§a Numune Eurotrans. These centers challenge and com-
Hospital in Istanbul, and the Transplantation pete with one another: according to both dir-
Unit at Ba§kent University Hospital in Ankara. ectors, the criterion for success for a
The following ethnography attempts to map transplantation center is the number of oper-
the complex set of relations within the Turkish ations performed per year. However, the
transplantation community, with its doctors, number of patients waiting for a transplant is
experts, donors, and patients, in an attempt outrageous, physicians suggest, pointing to the
to illuminate the conditions of the making of total number of dialysis patients in the country,
life, crime, and the exchange of body parts. which they estimate is around 30 thousand.
Obviously, patients and doctors look for bodies
that will contribute to the success of the trans-
Transplantation in Turkey plantation center. They need donations. On the
one hand, they have to increase the number of
The organ transplantation community in donations from cadavers; on the other, doctors
Turkey is large; it operates in 28 centers in need to find ways to increase the number of
14 cities. Yet one striking thing about organ transplantations. Hence the divided nature of
transplantation in Turkey is the very low rate the database, the totally different transplant-
of cadaver kidney transplantation (15-20 per- ation politics between Ankara and Istanbul,
cent of all kidney transplantation in Turkey). In and the lack of donations from cadavers
the last decade, most transplantations have become a burden on a transplantation patient's
been made from living-related donors and were life. The struggle between Istanbul and Ankara
regulated by the Organ Transplantation Act of over identifying patients and donors, occupying
1979 and 1982. In the past 25 years of trans- hospitals, and controlling Turkey topographic-
plantation history in Turkey around 1,200 ally causes two different politics of sharing
patients have had cadaver organ transplanta- bodies and also opens up a space for organ
tions (Haberal1993). trafficking.
There are two distinct politics of organ
sharing in Turkey which manifest as two med-
ical authorities over the geographical and infor- Launching Kidney Transplantation
mational distribution of organ sharing. There
are two separate organ-sharing databases, one Dr Haberal, the director of Ba§kent University
in Ankara and one in Istanbul, which do not in Ankara, was the first transplantation sur-
collaborate with each other. The database in geon in Turkey. In 1975, he performed the
"ROBIN HOOD" OF TECHNO-TURKEY 305
first kidney transplantation on a 12-year-old These new categories of kinship were
patient with a kidney from his mother. Three passed into law in 1982, creating a way for
years later, in 1978, he received a kidney kidney patients to bring their donors with them
from Eurotrans and transplanted it into a Turk- when they went to arrange transplant surgery.
ish patient. The same year, he proposed a According to a doctor at Ba~kent University,
law to the parliament on brain death and the unrelated donors were a big issue:
organ transplantation, which was passed in
The whole thing is out of control because
1979 (Haberal1993). With the legalization of
patients bring their donors introducing them
the brain death diagnosis, Haberal had the
as their relatives or they claim the third degree
chance to transplant the first kidney from a
of kinship, the emotional tie ... It is difficult
cadaver in Turkey in 1979, from a patient to tell who is who. Poverty is the main prob-
who had been killed in a traffic accident. lem we are facing in Turkey and under these
In those years, he was working as a surgeon circumstances transplantation regulations are
at Hacettepe University Hospital in Ankara. not ethical enough.
From 1975 to 1992, in transplant centers
across Turkey coordinated from Ankara, Eighty percent of the donations in Ba§kent Uni-
931 kidney transplantations were conducted versity hospital were living related, signifying
with kidneys from both living donors and the nature of transplantation practices in cen-
cadavers. After the political transitions of tral Turkey. According to this same doctor,
the 1990s, Haberal founded the Turkish It would be impossible to control and prove
Organ Transplantation Society in 1991, and the kinship and the kind of voluntary act on
in 1993 he became the President of Ba~kent behalf of the donor. We do not reject a patient
University. who brings his or her own donor. ActuaUy, in
During this time, especially in the late 1970s this hospital there is no other way: either you
and early 1980s, Haberal noticed that the rate find a donor or we put your name on the list
of organ donations from cadavers was very low for cadavers. Dr. Haberal does not take care of
in Turkey. To sustain the improvements in patients who go to Russia or India to have a
Turkish transplantation surgery, he initiated transplant and then come back and want to be
two measures. The first one was the creation taken care of. Due to the low donation rates
of three categories of kinship for living-related from cadavers, most patients have to bring
donations, and the second was developing a their own donors unless they want to be listed
in the organ-sharing database.
medical technique which kept a kidney from
cadaver viable for many hours (111) before it In the early 1980s, Haberal noticed the
was to be transplanted (Haheral et al. 1987). problem of the low donation rate from cada-
The law which defined this kinship was vers and developed a technique that kept a
inspired by regulations in the United States. kidney fresh for 111 hours. This way, the trans-
The first degree of kinship was defined as the plant center could take the kidneys Eurotrans
parents and children of a patient. The second did not want to transplant. They started using
degree of kinship covered the distant relatives, kidneys from old people, or kidneys which
such as uncles and cousins. The third degree of were thought to be no longer viable. However,
kinship defined a group of potential donors Haberal's technique has been highly criticized,
who were emotionally attached to the patient and not without reason, by his European col-
but not necessarily biologically related, such as leagues. Dr iki, a transplant surgeon working
partners, stepchildren, and friends. This new for a private hospital in Istanbul, remembered
group of donors defined through social kinship the debate on the 111-hour kidney during one
actually became the core group who later on of the Eurotrans conferences in Norway. At
started selling their organs to patients. Today, that conference, Haberal was blamed for con·
when I speak of donors as sellers, we are still ducting many operations which risked his
in the realm of legality, not crime, as long patients' lives according to EU criteria. "Most
as these donors have signed papers for their of his patients die," iki told me. "They caU his
voluntary act. list Schindler's Listl The number of operations
306 ASLIHAN SANAL
a doctor makes should not be the criteria of the state, to Haberal, and to the privatization of
success/' he concluded. medicine. Instead of developing techniques and
Statistics and numbers overwhelm the value regulations for pursuing living-related organ
of life in the race toward technological leader- donations, he believes in promoting donations
ship in medicine. The measure of medical ser- from cadavers, reforming the Turkish medical
vice in transplantation surgery was represented system, and improving the conditions of inten-
to me in the statistics about the number of sive care units (ICUs). Eldegez's main concern is
transplantations a center conducts per year. In the attitude of ICU doctors towards organ
the narratives I collected from both Istanbul transplantations. Besides, he believes, ICUs do
University and Ba~kent University, the number not even have enough respirators, which forces
of operations is represented as the measure of doctors to decide which patients have the right
achievement. Since Turkey's rates of trans- to live, so it is very difficult to keep track of
plantation are far behind those of Europe and brain deaths. A 1991 survey of how many
the United States, techniques of organ dona- patients had brain death in Istanbul that year
tion, such as new definitions of kinship and found that the Organ Transplantation Coord-
the 111-hour kidney, became important elem- ination Center had been informed about less
ents in meeting the West's level of surgery. than ten percent of these. The low rate of dona-
Turkish modernity is the cornerstone of the tion from cadavers and the image the media
corpus, which manifests the power of Western created of illegal transplant operations exacer-
morality against the "irrational" ghost of the bated the problem. "All of this news together
Ottomans. This is a moral struggle measured in with conflicts in the medical community dis-
numbers. Biopolitics (Foucault 1980) becomes courages the donation from cadavers. People
the ideal of the Turkish surgeon, who fights not are scared of doctors today. In regard to brain
just for the lives of his or her patients, but also death, they [patients' family members] believe
for the modernity of the state and society. The their patient will be harvested by doctors
ideals of the modern medical corpus mutually and delivered into the hands of Mafia dealers,"
reinforce the Turkish state and society's claim Eldegez told me.
to participate in what Ataturk once called "the According to Eldegez, the organ-sharing
level of Civilizations." network in Turkey should be controlled by
According to Dr Eldegez, in the last 20 years a civic organization coordinated by doctors.
there have been over one thousand kidney Political parties and state interventions should
transplantations from cadavers in Turkey in be separated from this system. The first meas-
total, whereas in Europe the average trans- ure to be taken is the reformation of the in-
plantation rate is 3,500 per year, over 95 per- surance system, which is currently distributed
cent of which are transplantations from among different ministries and controlled by
cadavers. In some years the donation rate from differ~nt political parties. Once all transplant-
cadavers even dropped down to three percent ation patients are insured by a common insur-
in Eldegez's unit. Under these circumstances, ance system (as with Germany's Allgemeine
the 30 thousand dialysis patients and patients Krankenversicherung, for example), patients
listed in organ-sharing databases in Ankara will be able to get the hospitalization they
and Istanbul were urged to find donors. need anywhere in Turkey regardless of their
connections with different political interest
groups. This would eliminate the gap between
Istanbul and Transplantations the transplant choices of the rich and the
from Cadavers poor, bring equality to all citizens, and reform
the health care system overall. With his social-
Since 1991, the main task of Dr Eldegez's ist ideals, Eldegez hopes not only for better
Organ Transplantation Coordination Center health care overall, but for improved condi-
has been to organize organ sharing mainly tions for organ transplantations as a modality
in Istanbul and western Turkey. Politically, of exchange that creates a new social bond
Eldegez is situated in opposition to Ankara, to benveen persons and groups, patients and
"ROBIN HOOD" OF TECHNO-TURKEY 307
donors. "Gift exchange" (Mauss 1990) they come back, he takes care of them at the
applies here to the kind of exchange dominat- transplantation unit at <;apa Medical School.
ing organ donations. Mauss says that a gift Although he is not very supportive of this inter-
carries the personality of the giver, and this mediary system, to him what counts is a
enables social solidarity. This form of ex- patient's life. "Saving a patient's life" and
change is enhanced by the literal donation of "strategies of finding a donor" -two key points
a part of the self through kidney donation in Eldegez's organ transplantation policies -
(Sharp 1995). To Mauss, gift exchange is not are opposite to Haberal's politics. According
based on a voluntary act of giving, even to Eldegez, when a patient brings a donor
though it seems to be. To Eldegez, the tyran- who legally declares his kinship tie to the pa-
nical psychology behind giving a part of one's tient, then there is nothing the doctors can do
self should only be practiced in a socialist except operate on the patient. As long as a
health care system, to prevent the commodifi- doctor is not involved in arranging the donor~
cation of the self through the commodification recipient tie and does not get money for the
of the body. To prevent any sales of body parts operation, he should not be held responsible
and exchange between living bodies - or in for whether the donor was selling his organ
other words what Marx (1990) called com- or not.
modity fetishism, whereby a commodity is de- This was the main cause of controversy
contextualized from the social means of its about Dr S., Eldegez believes. "He was our
production- Eldegez's unit is dedicated to har- friend and he worked here. The only thing I
vesting organs only from cadavers, not living can tell is that he does not respect the norms
bodies. and ethics of being a transplant surgeon too
Eldegez believes that privatization is an- much." In this discourse, when Eldegez speaks
other burden on the medical community. of norms and ethics, he refers to the responsi-
Many doctors choose to work for private hos- bility of a doctor to transplant a kidney in
pitals, and patients who can afford to go to accordance with the law. However, as long as
these hospitals believe that they get the right the doctor is not informed of the patient-donor
treatment. This creates a negative image of deal, he can technically do the operation with~
public hospitals, and patients think doctors out violating the law. In Eldegez's discourse of
perform better in their private office hours conscience, ethics refer to the formal norms
or in private hospitals because they get paid inspired by medical oaths, thus they are total,
right away. they are Ia w. It is the law which has constructed
an untenable definition of ethical behavior, so
Most of our patients are poor. We have that it is difficult for those transplant surgeons
patients who come to us with money and they who do transplants from living donors to avoid
want to have a private operation. I send them being complicit in illegal criminal pacts
to Russia, or they might go wherever they between patients and donors. Besides, know-
want to. We do not do such kind of business ledge of donors' and patients' private lives can
here. But of course in most living related influence a doctor's conscience, which can
donation cases I have the feeling that they eventually affect the doctor's consciousness of
pay for the kidney; or, for example, the father
agency. For this reason, Eldegez's unit at c;apa
is ill, then one of the sons gets an apartment
is dedicated to operating only with organs har-
from his brothers in exchange for his kidney.
Or they promise to take care of him vested from cadavers.
financially. Such internal deals are very Eldegez blames Haberal for making a law
common. This is actually against the organ that opens the way for the commodification
transplantation Jaw. However, we just do what of body parts. Haberal, on the other hand,
we are required, we operate under the law seeks social techniques such as the kinship
Haberal made. definition and medical techniques such as
the 111-hour kidney to be able to integrate
Eldegez encourages patients to go to other more patients and donors into the system.
countries for transplantation and when He pursues this goal by using the means
308 ASLIHAN SANAL
management during his internship at Columbia Dr iki, the head surgeon of the private hos-
University in New York, and then was offered pital Dr Ali works for, also agreed that Dr S.
a job to help establish a big private hospital had been treated unfairly throughout his
in Istanbul. Privatization of medicine is a grow- career, and that was why he was now pursuing
ing business in Turkey. For Dr Ali the job private operations.
offer was worth moving back to Turkey, like He has become the scapegoat of the whole
many Turkish doctors have decided to do in medical community. They exiled him to SSK
recent years. He recruited most of his medical Hospital at Kartal. If you are a doctor in Istan-
staff from this new community of Turkish bul and they appoint you to Kartal SSK, this
doctors. means they are exiling you, and that they want
Dr Ali considers himself a businessman. As to get rid of you. He contradicted the other
we spoke of medicine and business, Ali men- doctors a lot. He was aggressive. But if I were
tioned Dr Yiiksel ~en, who owns more than 50 him, I would be doing the same- I would also
medical institutions in Turkey, more than 20 of be operating in private-. Dr. S. is the best
which are in Istanbul. According to Dr Ali, transplant surgeon in Turkey, and he should
Dr Sen is a conservative traditional business- not stop practicing his job just because of the
man. "He does not know how to do manage- medical community.
ment, he does not like sharing [patients], and
Dr S.'s favorite hospital owner is Dr ~en, and
he does business like in the old days. He is old
Dr S. also views ~en as a successful business-
fashioned. He is the biggest mafia in medicine.
man. "He knows many people, and that is how
He closes some deals through people he knows
he makes his money," Dr. S. told me. This
best and buys hospitals."
"knowing many people" also means DrS. trusts
Dr Ali told me about the profits of
the power of the people he is good friends
investing in medicine. His hospital, he said,
with. "Business is business," and "medicine as
received 30 percent of a surgeon's fee for
business," Dr S. suggested, requires the same
each operation that the surgeon did there.
skills as any other newly opening enterprise in
The hospital also charges patients for accom-
Turkey. Two of the hospitals where DrS. was
modation expenses and gets a share of the
caught performing operations belonged to ~en.
coverage from the insurance company they
The first time, Dr. S. was kicked out of Kartal
have an agreement with - in the end, the
SSK because he was caught by Arena Team
hospital has three sources of income from
preparing for a transplantation from a seller to
each operation. "Organ transplantations are
not pursued in private hospitals yet, and state a buyer that was taking place in one of ~en's
hospitals. Mter this incident, DrS. was kicked
insurance covers all transplantation operation
out of his civil service post for good and banned
costs, but we will try to change this," Dr Ali
from practicing medicine for six months. By the
told me.
end of his ban, he had started working in
What we want is to be able to open private another hospital owned by ~en. He could never
organ and tissue banks and do organ trans- work for a state hospital again, nor could he
plantation in private hospitals like ours. There teach at a medical school. Since a medical
are illegal operations in Turkey, because of the degree can never be rescinded by the state, he
gap between the poor and the rich. The could still operate in private hospitals. So he
wealthy will pay for it by all their means. So could not reject Sen's offer. In the last four
why does the state still insist on such central- years, he told me, he operated on 360 patients,
ized regulations? When we make it private, we and only 2 of them had died.
will be able to control the legal status of the Before DrS. started working as a "criminal"
operations at least. There will be no criminal doctor, he lived in France, where he learned
activity. They put an end to Dr. S. 's medical
transplantation surgery. The Turkish govern-
career. It is the most unfortunate thing. He
ment sent him to Paris's Paul Brousse Hospital.
is the best transplant surgeon in this country,
and of course he will do transplantation. This During his years in France and then in Italy,
is his job. he met many transplantation surgeons from
"ROBIN HOOD" OF TECHNO-TURKEY 311
all over Europe and the Middle East. Eurotrans no choice but to accept when Dr S. told him that
and Middle Eastern Society for Organ Trans- he was going to operate on some patients from
plantation conferences served as platforms for Israel. Moreover, Dr S. had an agreement with
information exchange and meeting sports the owner of the hospital.
where friendships were made. One of the
But Dr. S. felt very guilty, as I was also taken to
friends Dr S. made this way, an Israeli phys-
interrogation with him. He knew I do not like
ician, still sends him many patients from Israel this kind of business. He apologized many
in Turkey. In the meantime, Dr S. also travels times. He is a good guy, and I like the way he
abroad to conduct operations. "I operated in resists the medical community and its estab-
France, Italy, Germany, Ukraine, and Israel," he lished old-fashioned, elitist attitude.
told me.
The relationship between this physician,
Once in Ukraine, I was invited to make a Dr S., and Dr. Sen adds a new level to the
couple of transplantations. I arrived there at complexity of the politics of the transplant-
night, and I went to the hospital to meet the ation community in Turkey. On one side Hab-
doctors and nurses. I had a great team working eral and Eldegez disagree on the politics and
there for me. Anyway, then I went to my hotel.
techniques of organ share, and on the other
In the morning I was driving to the hospital, I
side the Ministry of Health's intervention in
turned on the radio. Of course I did not under-
this situation with a new privatization policy
stand the language; but I heard two words,
"Organ Mafia," which were repeated over gets intertwined with private investors' desires
and over again. First I thought I was dreaming to make a profitable business of body parts,
or mishearing. But then they repeated it so creating a complex set of relations in the defin-
many times, I thought there might be a trouble ition of crime in medicine.
in the hospital. I called them from my cell In the 1980s Turkey was a land of unlimited
phone. They told me that the police were some- possibilities for private investors. Prime minis-
how informed about the operations and they ter and former president Turgut Ozal, from
were looking for me everywhere. I had to go ANAP (the Motherland Party), had taken
back directly to the airport and fly back home. measures to open the Turkish market to foreign
investments. He encouraged Turkish business-
DrS. was very enthusiastic about this story. He men to invest in all kinds of ventures by
was amazed by the fact that they could not exempting them from state taxes. It was in
catch him. Even though this was the only story those years that Haberal started his first hemo-
he told me about his international operations, a dialysis fluid production factory. In the early
friend of Dr S. told me that wealthy patients 1990s private hospitals were founded in the
from all over Europe would send their jet spirit of (hal's privatization policies. Today,
planes to Dr S. for organ transplantations. He there are 137 licensed hospitals in Istanbul,
remembered the last time he received a bottle and 111 of them are private. Sen alone owns
of vodka from Dr S.: more hospitals than the number of all the public
It must have been last January [2000], soon hospitals in Istanbul. The 26 state, social secur-
after he was caught treating Israeli patients. ity, and university hospitals take care of those
He went to Moscow and did ten operations in who cannot afford private insurance. Most of
a row there. He is so talented that they invite their patients are clergy, workers, farmers, and
him everywhere. By the increase in his reputa- small tradesmen.
tion, he also started becoming more profes- "Private practice is a good source of
sionaL Now, he does not find the donors for income," one doctor who just left a state hos-
the patients. He used to do that before. Now, pital in Ankara and moved to Istanbul to work
he is asking patients to find their own donors. in a private clinic told me.
This physician was put in jail with Dr S. after But the main money in medicine goes to hos-
Arena Team caught DrS. in December 1999. He pital owners. Most of the public insurance and
did not approve of these operations, but he had all of the private insurance covers the private
312 ASLIHAN SANAL
treatments. The price range of these oper- contribute to this decision-making. Moreover,
ations has been controlled by the Turkish the choice of the hemodialysis center.:. which is
Medical Association since 1998, because the not optional, but which depends strictly on
private insurance companies have found out the kind of public insurance the patient has -
that many doctors have been writing false pre- becomes central to the creation of the setting in
scriptions for patients - things like declaring which the patient seeks possibilities for a
an operation due to a traffic accident which kidney transplantation.
actually was a cosmetic nose surgery- became The main organ transplantation units and
normal. Fraud had become a part of the rou- hemodialysis centers are located in public hos-
tine in the medical community and the Minis-
pitals which receive patients who have there-
try of Health could not control it. So private
quired state insurance covered by any of the
insurance companies actually have forced the
Turkish Medical Association to set up a price three main types of public insurance. But not
range in U.S. dollars to control fraud because everyone is insured by one of these big insti-
they could not make profits any longer. One tutions. In general, the poor, especially selfem-
could imagine that the increasing number of ployed farmers and peasants in Eastern and
private hospitals would be an even better Northern Turkey and those who have never
damper for the fraud, but it happened just been employed or who cannot pay their own
the opposite way. The private hospital owners insurance taxes, are left out of this system. A
have turned medicine into a business and they public health expert told me that the "green
do not want to share with doctors; nor do they card" regulation launched in the early 1980s
want to be accused of fraud by the insurance was meant to solve this problem. According to
companies. So as they become stronger, they this plan, those who could prove their poverty
are changing the rules of the game. would be given a green card which they could
use to receive treatment in any state hospital.
"Though," she said,
Where to Find a Kidney
just like everything in the Turkish medical
system, this got out of control. People who
The hemodialysis center is the first place kidney
knew people in the bureaucracy received the
patients meet after they are diagnosed with
cards, and people who were really in need of
renal failure. In this period of time the patient's
them could not get any. According to statistics,
daily routines become dependent on the sched-
every town was supposed to distribute a
ule of the hemodialysis center, where a machine number of green cards. Who knows who took
takes control of the body's "cleansing needs" advantage of this distribution.
for four hours three to four times a week. At the
hemodialysis center, the patient meets other Ay~, a patient at Haydarpa§a Numune
patients, learns about the course of kidney fail- Hospital who had had a kidney transplantation
ure from other patients' experiences, shares his a week earlier, was a green card patient. She
or her suffering every day, and gets to know was very happy with the transplantation from
patients who are waiting for kidneys. cadaver she had, which, in her words, "gave an
It is also at this stage of the treatment when end to [my] suffering at the machine in the
the patient starts to understand that he or she dialysis center." The hemodialysis center she
cannot live forever by going to the dialysis was consigned to from Haydarpa~ Numune
center. The blood-cleansing machine becomes Hospital was two hours away from the
a symbol for the beginning of the end of a Sultanbeyli slums, the part of the city where
patient's life with renal failure; as a result, the she lived with her husband and two children.
patient starts considering having a kidney Ay~ was a farmer. She was from a small village
transplantation. The economic status of a in Trabzon, where all of her brothers and
patient has an enormous influence on the kind sisters still lived by farming. After she got ill
of transplantation being considered - from a and could get treatment in Istanbul with her
living-related donor or a cadaver. Other green card, she and her husband and children
patients' opinions, experiences, and advice also decided to move to Istanbul. Today, her
"ROBIN HOOD" OF TECHNO-TURKEY 313
husband works in a factory. Both of her chil- centers. They would advise you to go there,
dren go to school, but her eldest daughter (13 and make your connections with them, if you
years old) also had to take care of the household were willing to have an operation in India or
over the last five years, as Ay¥! was going to Russia. There were two important criterions:
the dialysis center three times a week. Ay¥! used hygiene conditions as well as the reputation
to take the bus to the dialysis center at of the doctors, and the amount of money you
7:00A.M., change three buses, and finally, after had to pay for the best service. My boss
a two-hour bus ride, wait standing in line in helped me out with the money. He was very
front of the hemodialysis center for at least generous.
three hours. Sinan is a 42-year-old IT manager in a travel
Finally at noon I could go inside to have the agency in Istanbul. He underwent transplant-
transfusion. Even though I was already very ation in Moscow five years ago.
tired of a six-hour adventure of getting there,
I was always happy about meeting my other In the early nineties, I started having kidney
family there. We shared the same life, and I problems. One day in 1995 my kidney stopped
would not have recovered and kept my own functioning. My boss flew me to Florida to
family strong if they had not been there for me. West Palm Beach the next day and I went to
The blood transfusion is such a nightmare ex- the JFK Hospital for treatment. They did tests
perience that no one who has not been through and still could not find out why my kidney did
it can understand. We always talked about not function from one day to the other. There,
how it would be if one of us gets an organ. they advised me to do peritoneal dialysis
You know we are all in the same listing [Istan- instead of hemodialysis. Then I came back to
bul University's database]. I will go back to Turkey. Meanwhile, I started looking for a
them as soon as I get out of this hospital. They kidney. I have no relatives; my parents have
need me as well. And my nightmares are over. passed away, and I have no siblings. So the
Every night I dreamt of my gaB bladder and of only solution was to fitzd one.
my kidney. I dreamed that I could pee just like That was the time when I heard that Dr. S.
anyone. I dreamed that I was drinking water, was doing private operations. I met him for
gallons of water. Now, it is over, I am fine. the first time when I was diagnosed in 1995.
He told me that he could do the operation for
Even though Ay'f.! had eight brothers and me. He told me that he could bring a kidney
sisters, she did not want to ask them if they for me from India and do the operation in
could donate a kidney to her. If anything Istanbul. It would cost around $25,000. I did
happened to any one of them, they could not not want such a thing. But in that one meet-
take care of their families, as they were all even ing, he told me the most valuable advice ever,
poorer than her. The physical work on the farm that I should mentally prepare myself for the
was overwhelming, and her family members new kidney. Then I went to Haberal, and he
had not been as lucky as her in getting green told me to leave Istanbul and go to Ba~ent
cards. "So if anything happened because of the University in Ankara where they would put
kidney they donated, no one, no hospital, no me on their list and take care of me there. He
doctor would take care of them," she told me. did not give me any hope or possible dates
Ay~ was one of the lucky ones among the poor,
for the operation, so I was not interested in
his offer. I had visited Dr. S. in his private
getting a kidney from a cadaver after waiting
practice. He was not a public figure back
five years.
then. I guess he was working for Kartal SSK
Those who can afford to buy a kidney or
Hospital. My meeting with Haberal was very
have relatives who donate one to them feel brief. But I was trying to find a solution, so I
even more "fortunate" than Ay~. Sinan was tried everything.
one of these more "fortunate" patients. "In
my time," he told me, So going co Russia, where "dead Russian
it was not hard to find the dealers. The bodies," as Sinan said, "belong to the Russian
doctors knew them in the hemodialysis state," was his only chance. Sinan thought the
314 ASLIHAN SANAL
Russian state "did whatever it wanted" with operation and hospital expenses. It was a pri-
the corpses. vate organization I was sent to by this Turkish
company. The year I had the operation, twelve
In the end, I decided on the Russian solution Turkish patients were sent there by the same
because I also talked to three or four patients company. There were also German patients,
who went through this company to Moscow many of them! And of course Russians from
and they recovered very well. When I went to former Soviet republics were there. I did not
Moscow, I already knew a lot about their see people of any other nationality.
system, such as the food, or life in Moscow.
They were very helpful and informative. . .. [ ... J
At the time, India was very popular, but I was Another patient I met at Istanbul Univer-
told that hygiene there was very bad. One of sity's transplantation unit was Osman Gez.
my colleagues in the company also had a trans- He had had a kidney transplantation ten years
plant a few years ago in Russia. He encour- ago, and he had to be taken care of by the
aged me to think about going there. I looked transplantation unit all his life. He received
into the contact he gave me. It was a small the 13th kidney transplant from a cadaver to
private company in Istanbul which no longer be conducted at the Istanbul University. How-
exists because they had problems with some of ever, initially he had not been planning on
the patients. It was simple, I called them, and having a kidney from a cadaver.
talked to them; and they sent me to Moscow.
They did all the tests at the hospital there as I was at home visiting my village. One day,
well. I was at a state hospital in downtown while farming in the fields, I had an attack
Moscow and there was a large team of frenal failure]. I came to Istanbul, and went to
doctors, who were perfectly equipped. I had Cerrahpa~ Hospital. They told me I should go
the operation a month later. The kidney to a dialysis center. Then at the dialysis center, I
started to work immediately, but I had a small was told to go to Istanbul University's trans-
problem. I had to have another operation, so I plantation center to put my name on the organ
stayed in Moscow for two months. During this waiting list. In the meantime, a friend from our
time, I was required to reside at the hospital in neighborhood here in Istanbul told me that he
case there was an organ available, they could could sell his kidney to me. He was in need of
operate on me immediately. I could not use money. His daughter had a heart problem and
peritoneal dialysis there because their system he needed money to operate on her. So I asked
was unsuitable for this. I switched back to him to come with me to Istanbul University to
hemodialysis again. However, I could leave do the blood tests and tissue typing. He came
the hospital and go sightseeing. One day a with me, had the blood tests, but then disa p-
friend who also was waiting for a kidney and peared. The tissues did not match, but we
I went to dine at a Turkish restaurant in wanted to find him and give him the money
Moscow. When we came back, the hospital he needed for his daughter's operation. My
staff were looking for me everywhere in panic. sons went to the address he gave us, but it
They had a kidney for me. They asked if I had was the wrong address. We could not find
eaten anything. They had to take all the Turk- him anywhere. In the meantime, I started
ish food out of my stomach, and then I had the waiting at the transplantation center with my
operation. wife, and then Eldegez asked me what I was
Sinan thought that the transplantation condi- waiting for. I told him I was waiting for a
tions in Russia might have changed in the last cadaver. He was mad at me. He said there were
five years, just as life in general is changing so no cadavers, and that I should go home. I kept
rapidly there. waiting. He saw me again, and yelled at me
again. He said, "You idiot, how can I find you
I do not know the conditions of transplant- an organ? There are no organs here, go home!,.
ation in Russia now, but back then I stayed at But I still waited. At 7:00 P.M. that night a
a state hospital. The Russians in Moscow or- cadaver came in. So I had my operation. It is
ganized my stay there as well as my operation. God's gift to me. If I had not kept waiting, I
So I paid them, and I imagine they paid for the would not have had the operation.
"ROBIN HOOD" OF TECHNO-TURKEY 315
Since then, Mr Gez has had good fortune. see so many people from so many different
He has not been iii, and his family has taken places, as it had taken her a long time to find
good care of him. Next co his room at Istan- out about it in Istanbul. "But I guess," she said,
bul University's transplantation unit, I met a "once one is in need of a kidney, then one
38-year-old woman, Leyla, with another makes a lot of inquiries about it, and finds the
story. This time it was a kidney operation in people who are involved in this business.''
India. Wherever patients come from, and what-
ever they can afford, they find the way
In April 1992, I went to India. A friend of and the means to have a transplantation.
mine had a transplantation there, and she There is no single pattern or route among
advised me to do the same. It all happened the four examples above, except that these
pretty soon. I was actuaHy planning on individuals were all as mobile as they could
having a cadaver kidney transplantation in afford in their search for a kidney. Almost all
London. But then, as I heard that the organ of the patients whose names are listed in Is-
in India would be from a living donor, I
tanbul University's database are very poor.
preferred that. I arranged all the organiza-
They can neither afford to pay for a kidney,
tional things by myself. I bought my flight
nor can they ask their family or relatives for a
ticket and I got my visa. When I got to the
favor, since they are just as poor. The rest of
airport, the only thing I knew was the name
of the doctor and the name of the hospital in the patient group finds ways- what they call
Bombay. Luckily the plane was full of Turk- companies - co go abroad to have a
ish people who were going there for the same transplantation.
reason. I was very happy to see this, you The transplantations Dr S. performs are
know, because I was al1 by myself. My hus- very expensive. Only very rich people can
band did not want to accompany me. My afford to be his patients. According co his
brothers did not want to go with me either. friend, Dr S. must be receiving around
My mother had to take care of my son. So I $100,000 per operation. Sahin, the editor of
had no one. Anyway, then, we landed in the Arena Show program, believed that the
Bombay. There was a Turkish guy who met money is much more chan chat. The price of a
us there; and before going to the hotel, we kidney was around $40,000 on the illegal
went directly to the hospital to make the market before the Arena Team documentary
tissue-typing test. They then listed us in their was shown on television. The show had a nega-
database, to match us with donors. Usually in tive effect, driving prices higher. One of the
ten days, one gets a kidney in India. cameramen - who filmed Dr S. with a hidden
After I settled down in the hotel, I started camera while they arranged the setup to catch
going to the dialysis. It took them fifteen him - told me that there were Israeli patients
days to find me a suitable donor. In the ready to pay up to $1. million for a kidney and a
meantime I traveled in India, and did some transplant by Dr S., whereas Sinan had paid
sightseeing. Then they called me. They had
$25,000 for his operation in Russia in 1995,
found a donor who was a 20-year-old man.
and it cost Leyla $15,000 to have a kidney
I somehow did not want to meet him, but I
transplantation in India in 1992. The price
am grateful to him. Two weeks after the
operation, I carne directly back to Istanbul range for a kidney varies depending on the
University's transplantation unit where they wealth of the patient and the risks doctors take
took care of me for 15 days. Everything operating on the patient. According to ~ahin,
went smoothly until now. I have some blood the most recent market is Bulgaria, which is
pressure problems recently, and that is why closer to Turkey than India or Russia and has
I am here. enough technology and educated staff to con-
duct transplantations. Iraq has come into play
While Leyla was in Bombay, there were 15 very recently as well- Iraqi soldiers sell kidneys
patients from Antep, Mardin, Van, Ankara, to Turkish recipients in Adana, near Turkey's
and Istanbul there with her, all waiting for border with Syria and Iraq, the Arena Team
kidney transplantations. She was surprised to believes.
316 ASLIHAN SANAL
The organ trade in the Middle East seems alive," "remaining human," and "human
to follow paths similar to trade routes for rights.'' Fischer (2003) describes this condition
opium, prostitution, and illegal migrant labor, in terms of the unstable "ethical plateaus" of
according to the Arena Team. One of the cam- contemporary medical worlds. Ethical plateaus
eraman thought that the dealers engaged in this are strategic terrains on which multiple tech-
business were hired by the Mafia, which has its nologies interact, creating a complex topology
own companies or works for doctors like Dr S. of perception and decision-making (Fischer
This cameraman thought that Dr S. must have 2003). In this paper, I have tried to show how
solid contacts with the dealers, since he finds changes in political economy, technology, legal
the organs for his own patients (as also indi- definitions and regulations, and transnational
cated by Sinan, to whom Dr S. promised to exchange networks, all affect modalities of
bring an organ from India). Another physician ethics. It is in these strategic terrains that whar
was more careful about accusing Dr S. of counts as human rights and innocence and
underground criminal activity. He believed criminality are constructed in an unemotional
that there was a connection between the Euro- language.
pean Mafia and Turkish Mafia, but that Dr S. In an age when medicine has created a
did not belong to either one because he was not worldview which finds its truth in biology
engaged in any criminal activity per se. There (Agamben 1998), Dr 5., in a timely fashion,
was no theft of organs, only the sale of organs has become the "Robin Hood" of Turkey.
by the poor to the rich. Dr 5. was merely doing Patients I have talked to, with a few exceptions,
operations on patients who would otherwise believe that DrS. is a great surgeon who saves
die. patients' lives, regardless of his portrayal in the
[ ... ] media. Patients' health care is always depend-
ent on the mercy of the doctor, in spite of state-
governed institutions, and yet in the negoti-
Conclusion ations between doctor and patient, "morals of
the street" - or as one doctor put it, "the Otto-
[... 1 man moralityn - do not correlate with the
In this paper, I have tried to illustrate the modern ethics doctors learn during internships
nature of kidney transplant patient groups in and fellowships abroad or that they are bound
Turkey with a few examples. While affordabil- by international standards to observe. When
ity is the major motivation influencing the healthcare becomes privately funded, patients
decision a patient makes to purchase a kidney often think they are back in the realm of trad-
from a poor seller, a patient's family structure, itional ethics, where exchange is negotiated as
place of birth, education, sex, income level, part of mutual trust within a network of obli-
profession, and age play a significant role in gations, and where monetary and other means
this decision, and all of these things create com- are part of that nexus of exchange. For doctors
plex reasons why a patient considers buying an the conflict of moralities is no less difficult:
organ. "Ottoman ghosts" or "a feeling for the right
Among doctors, the discourse of ethics and thing" inhibits many doctors from declaring a
legitimacy in Turkey (as elsewhere) must at person brain dead. Conversely, privatization is
least appear to be consistent with the standards a way not just to evade rigid bureaucratic
required by the international community. But ethics, but to pioneer a new modality of ethical
the "spirit" that undermines faith in brain calculation for saving lives in an emerging tech-
death or oversees the selling of organs provides noscientific world, one that is merged with
a window onto a world where patients' (and symbols of modernity and national self·esteem
the public's) wishes and legitimate medical and that operates within a state which uses
worlds pass completely by one another with 'privatization' as a means of justifying what
regards to categories of "the right to stay used to be 'criminal.'
"ROBIN HOOD" OF TECHNO-TURKEY 317
To some anthropologists (Lock 2002; has already established a legitimate space for
Scheper-Hughes 2002), what is of greater con- itself in hospitals, taking organs from the poor
cern in organ transplantations is the human to give to the rich and at the same time
desire to survive at any cost. Dr S. provides a ambiguously making the mafia into heroes.
case study in which such accounting discourses Human rights become an invalid category
are forged and tested. "A patient would pay as patients try to survive their illness.
with all his or her means not to die," said Orner, This new worldview, based on belief in the
who had a kidney transplant from his father a truth of biology and served for public consump-
few years ago. At Orner's dialysis center, DrS. tion through the popularization of science in
was a folk hero. Orner even thought that Dr S. the media, seems to have become the principle
was in prison next to such mafia chiefs as of the corpus, which now teaches us to become
Dtindar Kilic and Alaaddin Cakici. For Orner the right human for its purposes. All personal
and many other patients, Dr S. was the Robin emotions are suppressed in this worldview
Hood of Turkey. Patients' narratives on Dr S.'s except for collective fear, which becomes the
heroism resembled traditional stories such measure of heroism and of oppression. The
as the Koroglu, an epic cycle from the Bolu corpus rhus expands, using privatization in
region of Anatolia that tells of a hero fighting some cases to legitimize the criminal.
the injustices of the Ottoman regime. Dr S.
is believed to fight the injustices of how state
institutions select and treat their patients.
These institutions place patients on death NOTE
watch on waiting lists, whereas Dr S. will 1 A patient - who had never met him - told me
"help" anyone who mobilizes their resources that Dr S. was the "Robin Hood" of kidney
to buy care. That these people might more transplantations: a hero who takes from
often be the wealthy than the poor does not one body to give to another. However, in noir
undo the principle of responding to need techno-Turkey, it is an inversion of the mythic
against bureaucratic inertia and hopelessness. Robin Hood of Sherwood Forest, who takes
I find a striking set of experiential implica- from the rich and gives to the poor. This inver-
tions: given the complexity of issues involved sion is part of the naturalization of a form of
in organ donation and trafficking, patients biosociality in which the poor must struggle
live in a world in which they narrate their against the legalized structures of power that
experiences using partly the rhetoric of phys- would preclude them from the economic and
icians, partly references to the mafia dissemin- biological means of life. On biosociality,
ated by rumor and the media, partly the inverting E. 0. Wilson's sociobiology, and
extending Foucault's biopower, see Rabinow
language of social kinship ties, and partly per-
1996; see also Cohen 2003, Dumit 2000,
sonal assumptions. But only in few cases
Biehl 1999, Fischer 2003, Foucault 1980,
do they express their experiences in relation and Petryna 2002. The biosociality of this
to suffering, pain, or guilt - in short, with "Robin Hood" is a world in which patients
their feelings. In this new ethical terrain can feel that a surgeon doing transplants using
of a second life through the donation of a body purchased body parts is engaging in heroic
part from another person, what seems more acts in a state medical system whose tyran-
artificial and needs explanation are nical definition of morality prevents doctors
the conditions of living in a strange new corpus from saving patients' lives. Figures such as Dr
(law, state, body) which creates an incoherent S. are born not through their eviJ intentions,
understanding of the "human/' the "person," but because of a demand for "life." In such
and "human rights." The media and moments, biosocial relations shape a Weltan-
the politics of organ sharing shape patients' schasmng in which the lives of the poor come
narratives and help create the demand for the to be taken for granted as resources to prolong
economy of the business of life. This economy the lives of the ill.
318 ASLIHAN SANAL
Marcia C. Inborn, "'He Won't Be My Son': Middle Eastern Muslim Men's Discourses of Adoption and
Gamete Donation," Medical Anthropology Quarterly 2011 (2006): 94-120. Reproduced by permission of the
American Anthropological Association from Medical Anthropology Quarterly 2011 (2006), pp. 94-120. Not
for sale or further reproduction
320 MARCIA C. INHORN
However, of all of these concerns, Sa kina's Egyptian women like her - a test-tube baby
financial worries were the most immediate and was, in fact, not in the making by the end of
were the ones that had made her burst into the 1980s.
tears in the doctor's office. When the doctor
told her to purchase the two packets of expen·
sive medicine, she told him that she could not Test-Tube Babies on TV
afford even one packet and would therefore be
unable to undertake IVF therapy. He offered to By the end of 1988, when Sakina ventured to
provide one packet of the drug for free if she Shatby Hospital to earn of her need for IVF, the
would agree to participate as a subject in his subject of IVF was familiar to many urban
clinical study of IVF patients. Furthermore, he Egyptians, who recognized this assisted repro-
told her of a government pharmacy in midtown ductive technology by the name tifll-aniibib,
Alexandria where the drug could be purchased literally, "baby of the tubes." Following an
for only ££ 220 ($88). However, with only announcement in Al·Ahram newspaper in July
£E 100 ($40) to her name, Sakina was still £E 1987 of the first Egyptian "test·tube baby," the
120 ($48) short. Egyptian media began to capitalize on Egypt's
A week after her despairing episode in the newest reproductive technology, in the form of
hospital, Sakina returned to Shatby, smiling, factual discussions of the technique, debates
with a packet of the expensive IVF medication over the religious permissibility of the proced·
in hand. During the ensuing week, she had ure, and melodramatic television dramas about
received zakawiit, or alms, from some upper· infertile women undergoing IVF. In fact, in a
class Egyptians to whom she had told her sad popular televised tamslfiya, a dramatic, fic-
story and who, taking pity on her, gave her the tional soap opera that aired in 1989, the story
remaining £E 120 as a charitable donation. was told of a woman who spent thousands of
However, this did not solve all of Sakina's Egyptian pounds undergoing IVF following
problems. For one, she had no refrigerator in years of hopeless infertility. Unfortunately, the
whlch to store the sensitive drugs, and when protagonist was forced to remain in bed
she told the doctor that she had kept the packet throughout her pregnancy- a false representa-
of drugs at room temperature for several days, tion - and, at four months, she miscarried her
he admonished her for failing to follow hls "baby of the tubes" in a dramatic twist of fate.
instructions. Second, she was told that the This television show served as the primary
drugs she had purchased would be good for means by which the Egyptian public learned
only "one trial" of IVF and that subsequent about IVF, although the information conveyed
attempts to make a "tubes baby" would require about this new reproductive technology was
additional medication. flawed and viewers' understandings were thus
Sakina 's most serious problem, however, in- extremely incomplete. Suddenly, women who
volved delays. Although she and other women had never before heard of "test-tube babies"
with blocked tubes were told that the IVF pro- were instant experts on the subject, having
cedure would begin at the hospital imminently, watched the soap opera and drawn rudimen·
a month of waiting turned into two months, tary information from it. As one woman de·
and then into three, and, eventually, a year. scribed it, "They take the nutfa from him, his
During this interval, Sakina and other women back, and another from her, and they put it in a
like her were advised by their physicians to jar. And they put chemicals in to revive the
resell their expensive medications, lest the dead worms, and the worms start to grow in
drugs lose their therapeutic efficacy and the a jar, and it becomes a child - not a jar like
women lose their money. pickles, [but] like an aquarium where the child
Thus, more than a year after that fateful day grows for seven to nine months, and they put it
in November 1988 when Sakina was told about in a nursery. The woman has to stay on her
her need for IVF, her dreams for a tifll-aniib1b, back all the time."
or a "baby of the tubes," were still not realized. Thus, following the airing of the tams11Iya.
For Sakina - and many other poor infertile "tifl 1-aniiblb" became a household word in
QUEST FOR CONCEPTION 321
Egypt, although, as apparent in this woman's candidates. Most of these women were those
description, few Egyptians understood much with confirmed bilateral tubal obstruction, for
about how "babies of the tubes" were actually whom AIH was not possible and IVF was their
created or how many had been born in Egypt. only real hope for achieving pregnancy.
The misleading rumor that many test-tube
babies had in fact been born in the country
was perpetuated by publicity surrounding the Women's Concerns
eventual birth in Cairo of IVF quadruplets to a
woman who had been infertile for seventeen Yet, for these women, most of whom were
years. poor, their eagerness to undergo IVF was
Although most of the national publicity tempered by numerous practical and moral
about IVF in Egypt emanated from Cairo, concerns, similar to those described for AIH,
where the first private IVF center was estab- but of a slightly different order. Their questions
lished in 1986 (Serour, El Ghar, and Mansour about NF, as we shall see, revolved not only
1990), Alexandria, too, became the site of around its expense and religious permissibility,
major IVF activity, with the emergence of both but around the complicated "mechanics" of a
a private IVF clinic and a public program at the new reproductive technology in which the
government's military hospital. However, both technological imperative of biomedicine is per-
of these IVF pilot programs failed to produce haps quintessentially embodied.
any "babies of the tubes'' and were discon-
tinued almost immediately.
Nevertheless, having begun a successful AIH
What kind of 11tube"?
(artificial insemination by husband) program, Many Egyptians, both men and women alike,
administrators at Shatby Hospital decided to were troubled by NF because of the difficult
continue with plans to expand their assisted re- question of "tubes." As we have seen, many
productive technology program to include IVF. Egyptian women had heard about women's
Laboratory supplies necessary for IVF were "tubes" (that is, fallopian tubes) and realized
ordered from abroad; extra laboratory person- that their blockage constituted a major infer-
nel were hired; research projects involving IVF tility problem. Yet, the structure and function
were designed; and IVF candidates such as Saki- of these tubes and their location in relation
na were selected from the patient population and to other female reproductive organs were
enlisted in the IVF program. Furthermore, as subjects only partially understood by most
noted previously, a widely read national news- women, who viewed the uterus and ovaries
magazine called October - equivalent to Time as the major female reproductive parts. As
or Newsweek in the United States- announced IVF became popularized in Egypt, however,
in a lengthy article that Shatby Hospital had many women came to realize that "babies
begun its own "baby of the tubes" program. of the tubes" were for infertile women with
This article alone brought hundreds of women blocked tubes. But were these "tubes" of the
to the hospital hoping to undergo IVF. Some same kind?
were women who had undergone unsuccessful After seeing the soap opera, many Egyp-
IVF trials in Cairo or Alexandria; some were tians came to surmise that the term "baby of
women who had discovered that they could not the tubes" actually referred to babies conceived
afford the costs associated with IVF in a private and even interned in glass tubes during the
center; and some were simply infertile women course of gestation. Naturally, the thought of
who thought that a "baby of the tubes" might babies "artificially produced" in glass test tubes
provide the long-awaited solution to their in- was one most disturbing to Egyptian men and
fertility problems. women, whose convictions about the necessity
Of the hundreds of infertile women who of natural, God-given conception, childbirth,
came to Shatby seeking IVF, only a small number and parent-child ties were extremely strong.
(including 15 percent of the infertile women in As a result, many Egyptians suspected that
this study), actually entered the IVF program as IVF was most certainly IJ,aram, or forbidden,
322 MARCIA C. INHORN
for IVF had minimal guarantees of success, gynecology professor who had referred the
although most of them did not realize this. case, and members of the Egyptian media, in-
cluding those from the television, radio, news-
papers, and magazines, were received during
How soon, if ever? the delivery by the head of the IVF program,
Given that many women with bilateral fallo- who was also the chairman of the University of
pian tubal blockage came to view IVF as their Alexandria Department of Obstetrics and
last resort- their "only hope" in their quest for Gynaecology.
conception - the realization that the highly In addition, at the time of this writing, there
touted IVF program had yet to become a reality are five or six ongoing IVF pregnancies at Shat-
at the hospital more than a year after irs prom- by Hospital, other than those that have ended
ised inception was also a source of frustration in spontaneous abortion. However, there have
and fear for many women, especially those like been some problems in following the IVF preg-
Sakina who had promptly purchased expensive nancies, because many of the infertile women
IVF drugs in preparation for the procedure. in the program consider it shameful to have
When women who had purchased these drugs become pregnant through IVF and therefore
were told to "sell them back" to pharmacies do not return to the hospital when they dis-
before their expiration dates, IVF candidates cover that they are pregnant with a "baby of
began to panic, criticizing the hospital for false the tubes."
advertising of its program. Questions that had It is important to point out in closing that,
once been framed by IVF candidates as "how even as IVF has successfully unfolded in Alex-
soon?" came to be posed as "will there ever andria, many daunting questions about the im-
be?" Unfortunately, by the end of the 1980s, plementation and future of IVF in Egypt -
IVF had yet to become a reality at Shatby Hos- similar to those raised by concerned feminists
pital, because of numerous political, economic, in the West- remain. For example, will the
and logistical problems beyond the control of focus on IVF divert attention away from the
those who had hoped to make the IVF program primary prevention of infertility in Egypt, es-
a success. pecially among the poor, who are at greatest
risk for infertility but who can least afford
the new reproduction technologies? Will the
Epilogue commercialization of IVF in Egypt lead to the
proliferation of for-profit clinics run by unscru-
After many delays, the long-awaited inception pulous physicians, whose raison d'eltre is finan-
of the IVF program at Shatby Hospital oc- cial gain rather than the reproductive success of
curred in the early months of 1991, almost women? Will success rates be inflated and mas-
two and a half years after the announcement saged in Egypt as they are elsewhere to boost
of the program in October magazine. The the spirits of physicians and to encourage per-
equipment necessary to run an IVF laboratory sistence among patients? Will the choice to
was slow in coming to Alexandria, but by early undergo IVF turn into pressure for Egyptian
1991, it had arrived, and soon thereafter the women, who will be "compelled to try" IVF
IVF laboratory and an accompanying androl- over and over again and hence become trapped
ogy laboratory for high-tech semen analysis in endless infertility careers? Will IVF lead to
were in place. A team of young physicians, the commodification of life in Egypt, with per-
several of whom were trained in IVF in the fect babies being manufactured and purchased
United States and Great Britain, was assembled for a significant price only by the affluent? Will
to run the assisted reproduction program (both IVF reinforce existing patriarchal, pronatalist
AIH and IVF) in the hospital. biases in Egypt, leading to the continuing dis-
The first delivery of an Alexandrian "baby enfranchisement of infertile women who have
of the tubes" occurred in early 1992, only ten failed in their mandate to reproduce? Will IVF
months after the IVF program's inception. The lead to further untoward manipulation of and
baby was delivered by cesarean by the experimentation on Egyptian women's bodies,
QUEST FOR CONCEPTION 325
such that embryos become the "leading actors" hormone (GnRH) agonists; (2) ovulation is
and women mere "living laboratories" for the then induced through the administration of
products of man-made conception? And, fertility drugs for eight to twelve days; (3)
finally, will the effectiveness and safety of IVF ultrasounds and blood tests are performed to
be monitored in Egypt, given the current ab- monitor the development of ovarian foJJicles
sence of professional or consumer bodies con- over a six- to twelve-day period; {4} serum
cerned with technology assessment and progesterone levels are measured to assess
biomedical ethics? the growth of the uterine lining; {5) mature
Although the future of IVF in Egypt is quite eggs (usually at least four) are retrieved from
uncertain, perhaps it is heartening to realize the woman vaginaHy through ultrasound-
guided aspiration of the foUicles; (6) ova and
that ethical debates about research in human
sperm {obtained through the male partner's
reproduction have begun to emerge in Egypt
masturbation) are prepared in the laboratory
and elsewhere in the Muslim world (Anees and then combined for fertilization and cell
1989; Serour 1992), leading to the develop- division over a period of about forty-eight
ment of incipient guidelines and standards for hours; (7) embryos emerging through the fer-
the practice of IVF in both research and clinical tilization process are transferred (injected by a
settings (Serour and Omran 1992). Currently, catheter) into the woman's uterus through the
Egypt leads the way in these efforts to forge a cervix within two days of egg retrieval; (8) the
safe path for IVF and the other NRTs in the woman receives hormonal support, usually
Muslim world and may very well serve as a progesterone, for the first eight to ten weeks
model for other Muslim countries attempting of pregnancy or until menstruation occurs;
to implement these technologies (Serour, El and (9) a pregnancy test is usually performed
Ghar, and Mansour 1991). As Serour and his ten to twelve days after an NF transfer.
Egyptian colleagues note, the total Muslim
population in the world is 1.14 billion (1988
estimate), mostly located in developing coun-
REFERENCES
tries and particularly in Africa and Asia. If one
considers that 24 percent of the population of Aboulghar, M.A., G. I. Serour, and R. Mansour
developing countries consists of women of re- 1990 "Some Ethical and Legal Aspects of
productive age and that 10 percent {on aver- Medically Assisted Reproduction in Egypt."
age) of all married women of reproductive age International journal of Bioethics 1:265-8.
experience infertility, then approximately 27 Anees, Munawar Ahmad
million Muslim women may be currently infer- 1989 Islam and Biological Futures: Ethics,
tile and may either accept or reject IVF treat- Gender and Technology. London: Mansell.
ment services as they become available (Serour, dos Reis, Ana Regina Gomez
El Ghar, and Mansour 1991). 1987 "IVF in Brazil: The Story Told by the
Thus, the experiences of poor infertile Newspapers." In Made to Order: The Myth of
Reproductive and Genetic Progress, ed. Patri-
Egyptian women such as Sakina, as they at-
cia Spallone and Deborah Lynn Steinberg, 120-
tempt to grapple with the complex practical
31. Oxford: Pergamon.
and moral dilemmas posed by IVF, may well El Hak, Gad El Hak AJi Gad
serve as a guide for the therapeutic journeys of 1981 Medically Assisted Reproduction. Fat-
other Muslim women, whose voices and stories wii. Cairo: Al-Azhar University.
have yet to be heard. Harkness, Carla
1992 The Infertility Book: A Comprehensive
Medical & Emotional Guide. Berkeley, CA:
NOTE Calactial Arts.
Jones, Howard W., Jr.
The standard IVF protocol involves nine steps, 1988 "Recent Advances in In Vitro Fertiliza-
occurring over four weeks (Harkness 1992), tion (IVF)." In Human Reproduction: Current
as follows: (1) a woman's current menstrual Status!Futstre Prospect, ed. R. Iizuka and
cycle is halted with gonadotropin-releasing K. Semm, 65-79. Amsterdam: Elsevier.
326 MARCIA C. INHORN
For the past two decades, AIDS experts - emerged from efforts that are well under way
clinicians, epidemiologists, policymakers, in the developing world. During the past
activists, and scientists - have gathered every decade, we have gleaned these lessons from
two years to confer about what is now the our work in setting global AIDS policies at
world's leading infectious cause of death the World Health Organization in Geneva
among young adults. This year, the Inter- and in implementing integrated programs for
national AIDS Society is hosting the meeting AIDS prevention and care in places such as
in Toronto from August 13 through 18. The rural Haiti and Rwanda. As vastly different
last time the conference was held in Canada, as these places may be, they are part of one
in 1996, its theme was "One World, One world, and we believe that ambitious policy
Hope." But it was evident to conferees from goals, adequate funding, and knowledge about
the poorer reaches of the world that the price implementation can move us toward the elu-
tag of the era's great hope - combination sive goal of shared hope.
antiretroviral therapy - rendered it out of The first lesson is that charging for AIDS
their reach. Indeed, some African participants prevention and care will pose insurmountable
that year made a banner reading "One World, problems for people living in poverty, since
No Hope." there will always be those unable to pay even
Today, the global picture is quite different. modest amounts for services or medications,
The claims that have been made for the effi- whether generic or branded. Like efforts to
cacy of antiretroviral therapy have proved to battle airborne tuberculosis, such services
be well founded: in the United States, such should be seen as a public good for public
therapy has prolonged life by an estimated health. Policymakers and public health offi-
13 years 1 - a success rate that would compare cials, especially in heavily burdened regions,
favorably with that of almost any treatment should adopt universal-access plans and waive
for cancer or complications of coronary artery fees for HIV care. Initially, this approach wiiJ
disease. In addition, a number of lessons, require sustained donor contributions, but
with implications for policy and action, have many African countries have recently set
jim Yong Kim and Paul Farmer, Kim," AIDS in 2006: Moving toward One World, One Hope?" New England
journal of Medicine 35517 (2006): 645-7.
328 JIM YONG KIM AND PAUL FARMER
targets for increased national investments in undertaken even in places where physicians
health, a pledge that could render ambitious are abundant, since community-based, closely
programs sustainable in the long run. supervised care represents the highest standard
As local investments increase, the price of of care for chronic disease,3 whether in the
AIDS care is decreasing. The development of First World or the Third. And community
generic medications means that antiretroviral health care workers must be compensated for
therapy can now cost less than 50 cents their labor if these programs are to be
per day, and costs continue to decrease to sustainable.
affordable levels for public health officials Fourth, extreme poverty makes it difficult
in developing countries. All antiretroviral for many patients to comply with antiretrovir-
medications - first-line, second-line, and al therapy. Indeed, poverty is far and away the
third-line - must be made available at such greatest barrier to the scale-up of treatment
prices. Manufacturers of generic drugs in and prevention programs. Our experience in
China, India, and other developing countries Haiti and Rwanda has shown us that it is
stand ready to provide the full range of drugs. possible to remove many of the social and
Whether through negotiated agreements or economic barriers to adherence but only with
use of the full flexibilities of the Agreement what are sometimes termed "wrap-around ser-
on Trade-Related Aspects of Intellectual vices": food supplements for the hungry, help
Property Rights, full access to all available with transportation to clinics, child care, and
antiretroviral drugs must quickly become the housing. In many rural regions of Africa,
standard in all countries. hunger is the major coexisting condition in
Second, the effective scale-up of pilot pro- patients with AIDS or tuberculosis, and these
jects will require the strengthening and consumptive diseases cannot be treated
even rebuilding of health care systems, effectively without food supplementation. 4
including those charged with delivering pri- Coordination among initiatives such as the
mary care. In the past, the lack of a health President's Emergency Plan for AIDS Relief,
care infrastructure has been a barrier to anti- the Global Fund to Fight AIDS, Tuberculosis,
retroviral therapy; we must now marshal and Malaria, and the World Food Program of
AIDS resources, which are at last consider- the United Nations can help in the short term;
able, to rebuild public health systems in sub- fair-trade agreements and support of African
Saharan Africa and other HN-burdened farmers will help in the long run.
regions. These efforts will not weaken efforts Fifth, investments in efforts to combat the
to address other problems - malaria and global epidemics of AIDS and tuberculosis are
other diseases of poverty, maternal mortality, much more generous than they were five years
and insufficient vacination coverage -if they ago, but funding must be increased and sus-
are planned deliberately with the public tained if we are to slow these increasingly com-
sector in mind. 2 Only the public sector, not plex epidemics. One of the most ominous
nongovernmental organizations, can offer recent developments is the advent of highly
health care as a right. drug-resistant strains of both causative patho-
Third, a lack of trained health care person- gens. "Extensively drug-resistant tuberculosis"
nel, most notably doctors, is invoked as a has been reported in the United States, Eastern
reason for the failure to treat AIDS in poor Europe, Asia, South Africa, and elsewhere; in
countries. The lack is real, and the brain drain each of these settings, the copresence of HIV
continues. But one reason doctors flee Mrica is has amplified local epidemics of these almost
that they lack the tools of their trade. AIDS untreatable strains. Drug-resistant malaria is
funding offers us a chance not only to recruit now common world-wide, extensively drug-
physicians and nurses to underserved regions, resistant HIV disease will surely follow, and
but also to train community health care massive efforts to diagnose and treat these dis-
workers to supervise care, for AIDS and many eases ethically and effectively will be needed.
other diseases, within their home villages and We have already learned a great deal about
neighborhoods. Such training should be how best to expand access to second-line
AIDS IN 2006: MOVING TOWARD ONE WORLD, ONE HOPE? 329
antituberculous drugs while increasing control The unglamorous and difficult process of
over their use 5 ; these lessons must be applied in increasing access to prevention and care needs
the struggles against AIDS, malaria, and other to be our primary focus if we are to move
infectious pathogens. toward the lofty goal of equitably distributed
Finally, there is a need for a renewed basic- medical services in a world riven by inequality.
science commitment to vaccine development, Without such goals, the slogan "One World,
more reliable diagnostics (the 100-year-old One Hope" will remain nothing more than a
tests widely used to diagnose tuberculosis are dream.
neither specific nor sensitive), and new classes
of therapeutics. The research-based pharma-
ceutical industry has a critical role to play in NOTES
drug development, even if the overall goal is a
segmented market, with higher prices in de- 1. Walensky RP, Paltiel AD, Losina E, et al.
veloped countries and generic production with The survival benefits of AIDS treatment in
affordable prices in developing countries. the United States. J Infect Dis 2006;194:11-9.
There has been a heartening increase in 2. Walton DA, Farmer PE, Lambert W, Leandre
basic-science investments for tuberculosis and F, Koening SP, Mukherjee JS. Integrated HIV
malaria; funding for HIV research at the Na- prevention and care strengthens primary
health care: lessons from rural Haiti. J Public
tional Institutes of Health remains robust. Yet
Health Policy 2004;25:137-58.
the fruits of such research will not arrive in
3. Behforouz HL, Farmer PE, Mukherjee JS.
time for those now living with, and dying from, From directly observed therapy to accompag-
AIDS and tuberculosis. New tools to prevent, nateurs: enhancing AIDS treatment outcomes
diagnose, and treat the diseases of poverty will in Haiti and in Boston. Clin Infect Dis 2004;
be added to the stockpile of other potentially 38:Suppl 5:5429-5436.
lifesaving products that do not reach the 4. Paton NI, Sangeetha S, Earnest A, Bellamy R.
poorest people, unless we develop an equity The impact of malnutrition on survival and
plan to provide them. Right now, our focus the CD4 count response in HIV-infected pa-
must be on improving access to the therapies tients starting antiretroviral therapy. HIV
that are available in high-income countries. Med 2006;7:323-30.
The past few years have shown us that we can 5. Gupta R, Kim JY, Espinal MA, et al.
make these services available to millions, even Responding to market failures in tuberculosis
in the poorest reaches of the world. control. Science 2001;293:1049-51.
Part V
Biosciences, Biotechnologies
Introduction
The next essay by Joe Dumit explores how knowledge circulates and how it is
transformed as it moves along feedback loops from lab to clinic to media to lay-
people; and also how instruments, visuals, advertisements, and drugs are used as
technologies of what Dumit dubs "objective self fashioning," that is, the use of
objects as templates for stabilizing the self. These core themes frame Joe Dumit's
Picturing Personhood (2005) and Drugs for Life (2010 forthcoming) as well as
Nathan Greenslit's work (2007) on direct to consumer marketing of pharmaceuticals
and Emily Martin's research on the medicalization of women's bodies, immunology,
and bipolar disorders (1987, 1994, 2008). Dumit's essay on the creation of the PET
(positron emission tomography) scan machine provides an exemplar of how differ-
ently its images are interpreted by its designers, radiologists, brain researchers, the
media, families of schizophrenics, and courtroom judges. Images for scientific publi-
cations are selected for the sharpest contrasts, and media tend to mislabel scans as
"pictures" of ill versus normal brains, a mislabeling reinforced by courtroom lawyers
arguing insurance or insanity cases and preferred by families of schizophrenics who
want it to be a biological disease not one of family dynamics, and who in turn were
sources of funding for developing one of the first PET machines. The superimposition
today of CT scans and PET makes slippages between the flow of blood, oxygen use,
and glucose metabolism on the one hand, and anatomical pictures of ill brains on the
other, a little less compelling.
Similar slippages occur when the pharmaceutical industry adjusts the statistics of
genetic predispositions, the thresholds at which drugs are indicated, and the segmen-
tation of markets through advertising, especially in emotionally targeted, intellec-
tually playful, and inclusively "knowing'' infomercials that recruit consumers by
having them take self-diagnostic surveys. We are all "patients in waiting" in a
postgenomic world where we each carry mutations with their profiles of predis-
positions, under unknowable conditions, for risk of illness. "Patients in waiting" are
resources for "surplus health" extraction, analogous to political economy "surplus
value" extraction (Dumit 2010 forthcoming; Petryna 2002, 2005, 2009; Sunder
Rajan 2010 forthcoming).
Increasingly we are dependent upon instruments that see beyond the human eye,
aggregate or package information in non-transparent ways, or deal with massive
amounts of information beyond the processing capacities of the individual human
brain. How databanks are made to interact with one another to generate new
hypotheses about toxicogenomics or other fields of complex interactions and accu-
mulations of effect is a rich arena where epistemic things, modeling, and reality
checks are challenging puzzles for both scientists and ethnographers of scientific
production (Fortun and Fortun 2007; K. Fortun 2001).
Kaushik Sunder Raj an's Biocapital: The Constitution of Postgenomic Life (2006)
and forthcoming edited volume Lively Capital consolidate work in the political
economy of biotechnology (Cooper 2008; Rabinow 1996; Petryna 2005, 2009; K.
Fortun 2004; M. Fortun 2008; Fortun and Fortun 2007, Hayden, 2003; Peterson
2004). Sunder Rajan places these political economy analyses on a global stage, where
populations are being re-stratified in not just biopolitical (national government) or
biosocial (patient groups) ways, but also as global experimental subjects and patients
in waiting, resources for extraction of surplus health.
336 BIOSCIENCES, BIOTECHNOLOGIES
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INTRODUCTION 337
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338 BIOSCIENCES, BIOTECHNOLOGIES
Translation to the clinic proceeds along a pathway strewn with obstacles, and it's
actually harder than making the discovery because it involves other people, and
involves all their different views. (Judah Folkman, 21 September 1999)
In a wonderfully comic but serious account that reason that programs like the Health,
of the changing sites of medical discovery, Science, and Technology Program, the joint
Judah Folkman lays out ten reasons, a deca- MIT-Harvard MD/PhD program, were
logue, that it is nearly impossible to get dis- founded to bring the two cultures of basic
coveries from the lab into the clinic. He science and clinical practice together, to solve
begins with a quick survey of the shift from the problem of the disappearing physician-
discoveries made by physicians at the bedside scientist, and to not leave things to the
in the nineteenth and early twentieth century, pharmaceutical companies without using the
to the need for laboratories and the rise of clinical dues.
the physician-scientist often fostered by Folkman describes a series of different career
training at NIH in the mid twentieth century, paths among his colleagues who maintain both
to today the increasing difficulties of main- labs and clinical practice, and the difficulties they
taining the dual career of physician-scientist, face. Chief among the difficulties is "transla-
and the disjunctures caused by new discover- tion." Indeed, he estimates, some forty percent
ies coming increasingly from basic scientists of the medical school faculty would say their
without much clinical experience and un- obligation is only to do basic work in the labora-
aware of many important clinical clues. It is tory and publish. "They say you have no obliga-
no accident, he suggests, that angiogenesis tion to get into the problems of translating to the
research began in a surgical laboratory (his), clinic because it is a political morass ... the other
not in a molecular laboratory. In a molecular half of the faculty feels that if you find something
laboratory, like that of his good friend that could improve the care of patients, it would
Robert Weinberg, he joked, one thinks of be unethical not to help in some way guiding it
the life of cells that are flat, while surgeons into the clinic." He uses his own experience with
like himself think that cells are crowded a new protein that has anti-cancer activity that
like they are in cancer tumors. It is for his lab published in Science in 1999, a potent
Michael M. J. Fischer, "Lively Biotech and Translational Research." Written especially for this volume.
340 MICHAEL M. J. FISCHER
angiogenesis inhibitor, with no toxicity, many of a scientific paper with the status of in-
animal tests, known genetics, and made as re- ventor. It is a classic transition from gift econ-
combinant in large quantities. Cancer patients omies of affluence to capitalized economies of
are dying at a rate of 1500 a day in the US, one scarcity, the accent being on the ethical tran-
an hour of melanoma, or half a million deaths a sitions. The attorneys are thinking about chal-
year. So what are the obstacles to actually get- lenges to the patents: a patent will always
ting this protein into the clinic? be challenged if it is worth anything. It will
The decalogue of obstacles includes: (1) be infringed upon and the infringers will say
patenting, (2} the break up of collaborations, "sue us." In court tests, patents show their
(3) "their culture has to fit your proteins," weaknesses and can be invalidated. The more
(4) internal company rejection ("it's always in people are named as inventors the easier to
the cafeteria"), (5) transferring skills (the show that some of them had nothing to do
Stradivarius problem), (6) Fridays are cancella- with the idea, even though they may have
tion days, (7) clinical trials, (8) "for your little helped with the chemistry, or done other
protein, change a million dollar manufacturing things. "If you had collegiality, it goes away
process?," (9) physician resistance, (10) stock in one day." Say you had four authors and the
manipulations. lawyers say the first author is not the inventor.
The first author gets upset because although
the inventor did the sequencing, the first
1 Patenting
author thought of it, but the attorneys deter-
mine that it was the sequencing that was the
Idealistic students like to think that patents
first demonstration of principle. The inventor
are unnecessary, everything should be in the
could get all the benefits, even though at this
public domain. We have ten micrograms, the
stage no one knows what they are: someone
gene, the eDNA, all the assays, and we want
licenses the patent and the licensing fee goes
to go to a company to make ten kilos, enough
to the inventor; the drug gets into the clinic,
to treat a hundred patients for one year. No
and milestone fees have to be paid - to the
patent, they will not even talk. That's not the
inventor. Folkman tries to solve the problems
only problem, and it is not merely that an
ahead of time with written agreements that
ethical shift had to occur institutionally and
such fees will be divided between co-authors.
professionally. Before 1974 the Harvard Med-
But he recalls a ten-year merit award shared
ical School and its hospitals did not have a
with a colleague in San Francisco, talking on
patent policy: the policy was to publish, to
the phone, sending things back and forth,
put all research in the public domain. (MIT
publishing together. "And then they sent us
has had a patent policy since 1900.} The view
some of their cells from which we found a
was that it was not ethical to patent because
totally unexpected new protein. Harvard
you should not be making money based on
patented it, and we said co-inventors. The
patients' illnesses. Folkman, deadpans, "Then
attorney said 'nothing doing'; just because
they found out that was actually okay, because
they sent you the cells does not mean they
most of the patents do not make any money.
are inventors. So it made a lot of hard feel-
In fact, nobody makes much money on these
ings, and we wrote out that we just would
kinds of patents. And the reason is . . . by the
equally distribute [whatever proceeds]." It is
time the FDA has approved it, eight years, by
neither that Harvard is playing hardball, nor
the time it has gone into the market and has
that the attorneys are being unmindful of their
been allowed to be used, it is fifteen years, the
clients' egalitarian feelings. Rather if a patent
patents have run out."
is really worth anything, it will be infringed
upon and tested in court. For a research group
2 The Break Up of Collaborations leader, these facts of life mean the need always
to repair relationships. Folkman wryly com-
The second problem comes with the assign- ments, "I just tell you the end result is you
ment by the lawyers of one of the co-authors lose colleagues. You have to get them back. So
DR. JUDAH FOLKMAN'S DECALOGUE AND NETWORK ANALYSIS 341
a lot of my colleagues . . . refuse co patent 'terrific idea, but we are broke.' They are all in
anything." debt. They fear it will take resources away from
their idea. So a company is a zero-sum game."
In the case of angiostatin there was finally one
3 "Their culture has to fit your small company in Maryland, EntreMed, "a tiny
protein." company, about eight people, and they had just
become capitalized, nothing to do yet. So they
Academic scientists need companies to manufac- took on this project . . . and in the bargain we
ture larger quantities than they can produce in got endostatin and a couple of other things that
university laboratories, and to bring it through were discovered because [EntreMed] gave a
the regulatory process. But, says Folkman, "It grant to Children's Hospital."
turns out that big companies prefer to make In the case of anti-angiogenic anti-throm-
small molecules and small companies prefer to bin, the discovery reported in Science, Septem-
make big proteins." In 1991 Michael Roddey in ber 17, 1999, the match with Genzyme came
Folkman's lab discovered angiostatin, one of the about differently. Genzyme was a tiny com-
first angiogenesis inhibitors that could regress a pany at the time, but was one of two that made
tumor. antithrombin which would be an easier source
for the fragment of antithrombin than purify-
Here's what happens when you have a new
ing it from blood (which was how it was dis-
discovery ... and you are funded by National
covered). They made antithrombin-3 for
Cancer Institute grants: you go into debt right
away because it is unscheduled. Suddenly you people with who get blood clots due to a defi-
have to have ... different equipment ... new ciency of the protein. They made it in trans-
mice ... and you have to hire somebody who genic goats. They could get 500 milligrams per
does protein chemistry. So what you do is, you liter from goat milk, much more than the best
take money from all the other grants, and fermenter (75 milligrams, if the E. coli work
immediately you write a grant and hope that properly). They had all the patents for the pro-
in nine months it will be funded and you will cess, and after pasteurizing the milk they had
pay back. So we did that, but the study section 75% active, and threw out the 25% inactive.
said 'you will never be able to purify this' ... Heating it a little longer and adding citrate and
So they turned the grant down. No, now nine from that 25% they could produce the anti-
months down the road we had a $250,000 angiogenic anti-thrombin protein. The presi-
deficit in a big lab, and the hospitals will not dent and founder of the company was
cover that ... what they do is start turning off enthusiastic.
your heat, light, salaries. So what do you do
next? . . . So I wrote to a whole series of
companies, all of whose CEOs had been my 4 Company Cultures ("it's always
students: . . . president of Merck . . . Upjohn in the cafeteria")
. . . Lilly, all Harvard Medical School. And I
got appointments right away ... However
Getting the leadership of a company to adopt
(this is 1991), what would we do with an
the project is not a guarantee that the rest of the
angiogenesis inhibitor? Nobody understood
company will go along. Companies are zero-
it, only the scientists understood it.
sum games, and if the president says we are
So he went to biotech start up companies. There going to work on this new protein, "it is as if
were, he said, 129 biotech companies "hanging he brought home a second wife . . . In his
on for their life in Boston. They have no presence everybody is gung ho. But then comes
income. They have three more years of funding. the undermining. It's extremely subtle. It's
The burn rate is going to close them in two always in the company cafeteria. I hear it's
years." But they understood it right away. not working. That's the rumor. Then they talk
"They have the most advanced, youngest scien- to the press and they say, well it's from a lab,
tists, they are not yet so conservative because you can't reproduce the results. It's incredible.
they have not made any money. So they said, You have tremendous, tremendous rumors.
342 MICHAEL M. J. FISCHER
They are afraid that resources will be siphoned problems turned out to be room temperature.
off." Folkman had such an experience with Mice cannot sweat or shiver. Experiments at
Bristol-Meyers. Some companies have strat- MIT had shown that mice are most comfort-
egies for dealing with this: they spin off a new able at 26• Celsius. Folkman's rooms were thus
company under a young vice-president, and tell set at 26". "One of the [NIH] rooms we went to
him if he succeeds he will be established in the was at 20", and we said we could tell this is not
parent company. right, because in our rooms we sweat when we
are in there for hours." So they did an experi-
ment and found at 20° tumors did not grow on
5 The Stradivarius Problem: the mice. To keep their core temperature at 370,
Transferring Skills the only thing the mice could do to conserve
heat was to close off blood vessels, vasocon-
Next is the classic problem of teaching another strict. This was another proof of the anti-
lab or a company. These are classic problems in angiogenic concept: by vasoconstricting the
science joked over in corridor talk and in such tumors are starved of blood and cannot grow.
terms as having "good hands,, and analyzed
more fully by the chemist Michael Polanyi's 6 Fridays are Cancellation Days:
lectures on Tacit Knowledge (1966), the soci-
Time-investment Gambles
ologist of science, Harry Collins' account of
physics labs (1974), and the historians of sci-
In big companies, with many competing drug
ence Steven Shapin and Simon Shafer's account
candidates, they cannot have more than eight
of Boyle and the Royal Society's experiments in
in the pipeline at a time, so if they suddenly
the seventeenth century (1985). It is a standard
have a new candidate doing well in the clinic
problem in the scaling up from experimental
and closer to market, they shift resources there.
systems to industrial production, from systems
"And suddenly your little project, which is so
that are still returning knowledge through their
fantastic, is stopped for two or three years, and
instability and need for skill to reliable high
there is nothing you can do about it." You have
quality-controlled processes.
to try to write contracts and licensing agree-
"If you are a basic scientist, Ph.D., and you
ments that include every foreseeable possibil-
get a call, 'we cannot reproduce your results,' it
ity. "Suppose they decide to sit on it to keep
is a chilling sleep-losing experience. It implies
competitors out. It is a business decision, not a
you have manipulated the data." Folkman al-
moral or any other kind of decision. Then we
ludes to his headline problems when the NIH
get the right to take it back and there is a
claimed they couldn't reproduce his results.
penalty."
When you see someone who has received such
In the case of EntreMed and angiostatin,
a call,
licensing was in 1991 with only a few micro-
they are pale white the next morning ... grams; it took until 1994 to publish it in Cell;
drained; they cannot do any work, they are until1996 to learn how to make the recombin-
worried that their theory is over. Now, to a ant; and another year to establish what to
surgeon it is a source of pride . . . Surgeons in make it in (yeast, E. coli) in terms of stability,
the locker room refer to this as the Stradivarius cost, and scale-up. By then, endostatin, which
problem. Too bad about surgeon Jones that his had been discovered later (Cell1997) proved to
mortality is twice as high as mine ... They see be easier to be produced and was out by 1999.
it as a skill problem, and most of the time that Folkman says,
is what it is.
People forget. Proscar, Merck's prostate drug,
In the National Cancer Institute case, the prob- took twenty-one years from the time it was
lems were leaked to the press "because nobody discovered in the laboratory to the time they
wants to be at fault." It didn't work at NIH, could figure out how to make a structure that
but when the NIH team came up to Boston was stable in a bottle . . . The AIDS drugs,
with their mice, it worked. One of the which were done at warp speed, were eight
DR. JUDAH FOLKMAN'S DECALOGUE AND NETWORK ANALYSIS 343
years, and they had everybody working on two the pipes had to be curved. Similarly, one of
shifts at Merck. They paid exorbitant fees for Folkman's problems when NIH could not rep-
overtime. And still there is a shortage that is licate his results eventually turned out to be the
massive ... Herceptin, the same way: there's a dry ice on which all proteins and drugs were
lottery, a breast cancer lottery, so you can get shipped in plastic containers. Carbon dioxide
this good drug or not. Genetech is trying to gas goes through plastic and within three hours
build a factory, but they cannot make it fast can agglutinate, unfold, denature, or otherwise
enough. damage proteins. So new packaging needed to
be invented.
7 Clinical Trials
9 Physician Resistance
Clinical trials present a series of complicated
ethical and practical problems: placebos, dose When there is something really new, lt ts
escalation, deployment of hope, selecting who often hard to educate physicians. They are
gets into trials, patient migration to higher dose threatened because it takes so long to learn
trials (so earlier trials cannot be completed) how to do things really well in the clinic. Key
protocol violations, protecting physicians who examples: Semmelweiss trying to teach
decide who gets into the trials, shortages, and people in Prague to wash their hands before
difficulties of timely scaling up as soon as good delivering a baby to prevent the transmission
results are assured. of streptococcus (childbed mortality was
30%), and being kicked out of the hospital
for his efforts; Flory in 1941 unsuccessfully
trying to persuade military physicians in Eng-
8 "For your little protein, change land to use penicillin for soldiers dying of
a multimillion dollar streptococcal septima, and having to come
manufacturing process?" to the U.S. before people would listen; resist-
ance to using Tagamet for bleeding ulcers at
Take the case of a drug that has been proven to MGH in the 1960s (when Folkman was chief
work, tumors regress in animals and people, resident) instead of gastric surgery (a proced-
"and you put it in a patient's intravenous and ure that no one does or knows how to do
it does noc work." It takes awhile to trouble any more); and Proscar, the prostrate drug,
shoot: the problem is that this protein sticks to made by Merck that did the same for
the polyvinyl plastic in the tubing. Change the prostatectomies, but only because Merck
tubing? "Try that: there are only three tubing mounted an ad campaign directly to older
manufacturers in the country. Abbott is the men who insisted they would go to other
biggest. Change our tubing? Are you out of doctors if their physician continued to refuse
your mind? For your little protein, we are prescribing it for them.
going to change a multimillion dollar manufac- A minor problem here is also the insurance
turing process ... it is FDA approved and we companies who can keep saying it is experi-
have not had any problems? We are not mental, and as long as they say that, they do
changing our tubing. Make your own tubing." not pay for it. More insidious is another elem-
So then change the protein so that it does not ent of the market.
stick? If you change the icing, the FDA will say
it is a new protein and you will have to start all
over. The details of manufacturing, packaging 10 Stock Manipulations
and transporting can have unexpected conse-
quences. Monsanto learned an expensive If a small company like EntreMed begins to
lesson that stainless steel pipes for fermenters have some success, there are short sellers.
could not be sterilized with steam if they had Someone puts a rumor on the Internet, or a
angles: viruses could harbor in the bends, and mischievous question: "have you heard that
344 MICHAEL M. J. FISCHER
they are having trouble manufacturing, scaling and Translational Medicine" (in Sunder
up, or whatever. It is not a statement, just a Rajan, ed., 2010).
question. The Securities and Exchange Com-
mission cannot fault you. Others chime in, 'is REFERENCES
that true?' Suddenly the stock is down and the
company has to be sold. And then another Bielenberg, Diane and Patricia A. D' Amore
rumor and the stock rises. 'Have you heard 2008 "Judah Folkman's Contribution to the
Inhibition of Angiogenesis." Lymphatic Re-
about this new publication that says it is
search and Biology 6(3-4):203-7.
okay?'" "It is amazing," Folkman concludes,
Collins, Harry M.
"this goes on all the time. There are a lot of
1974 "The TEA Set: Tacit Knowledge and
greedy people." Scientific Networks." Science Studies 4:165-86.
Fischer, Michael M. J.
2010 "Lively Biotech and Translational
NOTE Medicine." In K. Sunder Rajan, ed., Lively
Capital. Durham, NC: Duke
1 While the terms "decalogue" and "network" O'Reilly M. S., T. Boehm, Y. Shing, N. Fukai,
are mine, in this piece I have tried to capture G. Vasios, W. S. Lane, E. Flynn, J. R. Birkhead,
Folkman's voice. Those, like myself, interested B. R. Olsen, and J. Folkman
in the actual "music" of science, the expres- 1997 "Endostatin: An Endogenous Inhibitor
siveness of how scientists talk, can turn to the of Angiogenesis and Tumor Growth." Ce/188:
longer essay from which this one is condensed, 277-85.
paraphrased and excerpted. Where I have Polanyi, Michael
have used quotation marks, these come from 1966 The Tacit Dimension. Garden City, NY:
my transcriptions of his lectures which he Doubleday.
gave permission to tape. Elsewhere I have Ribatti, Domenico
used his turns of phrase, but it would be tedi- 2008 "Judah Folkman: A Pioneer in the Study of
ous and pointless to mark out each fragment Angiogensis." Angiogenesis (Mar.), 11(1):3-10.
with single and double quotation marks. Shapin, Steven and Simon Schaffer
Those interested can turn to the fuller tran- 1985 Leviathan and the Air-Pump: Hobbes,
scriptions. In the longer essay, I place Folkman Boyle, and the Experimental Life. Princeton:
in a larger global network of "Lively Biotech Princeton University Press.
27
Beyond Nature and Culture
Modes of Reasoning in the
Age of Molecular
Biology and Medicine
Hans-]org Rheinberger
Hans-jorg Rheinberger, "Beyond Nature and Culture: Modes of Reasoning in the Age of Molecular Biology
and Medicine," in M. Lock, A. Young, and A. Cambrosio, eds., Living and Working with the New Medical
Technologies: Intersections of Inquiry. New York: Cambridge University Press, 2000. Reprinted by permission
of the publisher, The University of Chicago Press
346 HANS-J0RG RHEINBERGER
chopped up in pieces and kept in the refriger- Singer and Wells from the California Institute
ators of the research laboratories; on the of Technology in Pasadena traced back to an
other, the competition of the biotechnology electrostatic charge difference in the oxygen-
companies for leadership in molecular engin- transporting molecule haemoglobin, what
eering; and in between, the hospitals, the physicians had long since known under the
health agencies, and the criminologists who phenomenological term of sickle cell anemia.
convert the data of the laboratories into the Pauling accompanied this publication with the
precepts of a molecular medicine and a DNA- publicity-demanding, triumphant accounce-
based recognition of health and treatment of ment that sickle cell anemia was a "molecular
illness. The possibility of the molecular take- disease" (Pauling et al. 1949). The publication
over of medicine is grounded in another date of this article is often quoted as the birth
shared misunderstanding: healthy genes, not date of "molecular medicine." Biomedicine
just cure, for the whole population. Whether promised to open its own, genuine atomic age.
this emerging new misunderstanding delivers A little less than fifty years later, at the time
a realistic picture of the causes and the distri- of this conference, the encompassing project of
bution of diseases in contemporary Western sequencing the whole human genome is well
societies is not a matter of discussion in this under way. Conceived around 1985 in the
chapter. It is clear, however, that the prospect United States, this daunting, molecular genetic
of "molecularizing" diseases and their pos- piece of big science has meanwhile been capil-
sible cure will have a profound impact on larized, has grown into a worldwide network,
what patients expect from medical help, and and has spawned additional genome sequen-
on a new generation of doctors' perception of cing projects. The whole effort has been
illness. Its effects will by far transcend such budgeted to amount to no less than $3 billion.
major transformations in medical practice as In view of the diversification of projects, and
the "Pasteurization" of Europe in the late sources accordingly, that has already taken
nineteenth century, or the "antibiotization '' place, no one will any longer be able to count
of anti-microbial therapy beginning with the how much it will have cost in the end. The
Second World War. At any rate, the identifi- project itself has set in place a mechanism for
cation of a mutated gene such as that thought dissemination and changing its own boundar-
to be responsible for Huntington's disease, on ies. To paraphrase Latour's characterization of
the upper arm of chromosome 4, and other the Pasteurian program, a century earlier, for
comparable genes, have a good chance these fighting against microbial diseases: "It is not a
years of covering the front pages of major question of ideas, theories, opinions. It is a
newspapers. The Huntington disease gene question of ways and means" (Latour 1988
took ten years to be identified. Although the [1984]: 47). Like the Pasteurians, the molecular
search for such a gene started long before the biologists and the project managers of the
genome project took shape, it was quickly National Institutes of Health and the Depart-
perceived as one of the achievements of the ment of Energy, who initiated the program of
project. This is the result of the recursive molecularizing human medicine, "placed
powers of such an endeavour. [their) weak forces in ... places where immense
social movements showed passionate interest
. . . [They] followed the demand that those
forces were making, but imposed on them a
Molecular Biology, Gene way of formulating that demand to which only
Technology, and Molecular [they] possessed the answer, since it required
Medicine [men] of the laboratory to understand its terms"
(Latour 1988[1984]: 71). Those molecular
In 1949, the already world-famous, somewhat biologists engaged in human genetics attempt
eccentric protein chemist and Nobel laureate to precisely localize all human genes and to
Linus Pauling published an article in Science. sequence the three billion or so building blocks
In this article, he and his colleagues Itano, of our genetic heritage in their entirety. One of
BEYOND NATURE AND CULTURE 347
the most outspoken advocates of the project(s), transposttton into biological function. As a
Nobel prize winner and co-discoverer of the result of this process, the proteins (and some
DNA double helix, James Watson, justifies RNAs) govern, either as structural elements or
the venture with the following argument: "For as biocatalysts, that is, enzymes, the life phe-
the genetic dice will continue to inffict cruel nomena of the cell and of whole organisms.
fates on all too many individuals and their fam- The "central dogma" of molecular biology,
ilies who do not deserve this damnation. De- explicitly formulated in 1958 by Francis Crick
cency demands that someone must rescue them (1958), has pervaded all of contemporary bio-
from genetic hells." And he asks: "If we don't physics, biochemistry, cell biology and genetics,
play God, who will?" (Watson 1995: 197). Who and has provided it with a new super-slogan:
is "we"? DNA makes RNA, RNA makes protein. The
Between roughly 1940 and 1970, a new material basis of the genes is DNA which dupli-
paradigm had been established in biology: mo- cates with every cell division, a process called
lecular biology. In 1948, one of the founders of replication. RNA carries the genetic message
cybernetics, Norbert Wiener, in a truly vision- gene from the nucleus to the cytoplasm in a
ary gesture, drew a resume of the history of process called transcription. A very sophisti-
biology in modern times. The organism of the cated molecular machinery with the ribosomes
seventeenth and early eighteenth centuries, he in its center is said to translate the sequential
said, was a mechanical automaton. The organ- information of messenger RNA into molecular
ism of the nineteenth century was a steam prescriptions that are realized through the three-
engine. The organism of the twentieth century, dimensionally folded proteins in metabolism.
however, according to Wiener, had become a The basic insights into these molecular
medium of communication and control, per- processes were gained in the years between
vaded by the crucial concepts of message, 1953 and 1965. The work of Maurice Wilk-
noise, information and coding (1961[1948): ins, Rosalind Franklin, Francis Crick and
62-9). james Watson exposed the double-helical
So far, historians of biology disagree structure of DNA and immediately suggested
whether the development of information a possible mechanism of gene duplication. Paul
theory and cybernetics in the 1940s had a Zamecnik and Mahlon Hoagland, and Jacques
direct influence on the take-off of the "New Monad and Fran~ois Jacob identified the two
Biology" as advocated by Warren Weaver RNA-molecules that mediate between the
(Judson 1979; Kay 2000; Keller 1995). They genes (DNA) and the gene products (proteins),
agree, however, on the basic argument that transfer RNA and messenger RNA, respect-
with molecular biology, a paradigm shift has ively. Monod and jacob also provided a first
occurred that involves the notion of informa- model for gene regulation. Heinrich Matthaei
tion. Indeed, this would be hard to deny, al- and Marshall Nirenberg as well as Severo
though there have been arguments to the Ochoa and his co-workers clarified the relation
contrary (Sarkar 1996). I find it safe to state between these two basic categories of bio-
that biologists and physicians engaged in basic logical macromolecules: the genetic code. (For
medical research have started to view the detailed overviews see Judson 1979; Morange
organism under a new perspective. They have 1994.)
come to envision the fundamental processes of It is extremely compressed but probably fair
life as based on the storage, transmission, to say that the essential epistemic achievements
change, accumulation and expression of gen- of this first phase in the history of molecular
etic information. According to this view, there biology basically rested on two conditions
is a genetic program entrenched in the punctu- which at the same time constituted its early
ated sequence of the DNA building blocks of drive. First, the transition of a small group of
the chromosomes. The development of the researchers to simple, biophysical, biochemical
organism as well as its overall metabolism is and genetic, model systems; and second, the
regulated by means of a differential retrieval of development - by far not all of them in the
this genetically enshrined instruction, that is, its context of molecular biology! - of a series of
348 HANS·JORG RHEINBERGER
biophysical, biochemical and genetic technolo- polymerase chain reaction (PCR). Within a
gies. Examples of the former are bacteria, vir- timespan of less than twenty years, molecular
uses and finally macromolecules. Examples of geneticists have learned not only to understand
the latter are, just to mention a very few of the language of the genes in principle, but to
them, X-ray crystallography, analytical and spell it. In other words, they have learned to
preparative ultracentrifugation, electron mi- read, to write, to copy and to edit that language
croscopy, radioactive tracing, more and more in a goal-directed manner. These are, of course,
sophisticated sorts of chromatography and metaphors. But today, there exist precise and
electrophoresis, as well as the experimental powerful functional equivalents to each of these
tools of phage and bacterial genetics. It goes analogies of language and of writing, and they
without saying that these two series of events have neatly been installed in the form of special
interacted and evolved in interplay by becom- and more and more easily manipulable tech-
ing combined. niques. Those are the procedures of DNA
Indeed, these techniques and their results sequencing (reading) and of DNA synthesis
were crucial for the coming into being of mo- (writing), both automatized in recent years;
lecular biology. But despite much public praise DNA multiplication in the form, for example,
and hope, they were of quite limited immediate of the polymerase chain reaction (copying); and
influence on medicine and its practices. In the arsenal of operations resulting in changes in
many cases, the results, in the form of molecu- the molecular structure of the genes such as site-
lar representation they took on, simply did not directed mutagenesis and refined restriction and
lend themselves to therapeutical application (as ligation, deletion and inversion of bits and
in the case of sickle cell anemia). In other cases, pieces of DNA (editing).
they basically sanctioned a practice that was The emergence of these so-called "recom-
well under way and had developed without the binant DNA technologies,. has created a new
direct impact of molecular biology, as in the situation, and with that, has led back to higher
case of antibiotics, which revolutionized anti- organisms. The central tools of recombinant
bacterial therapy in the late 1940's and early DNA work- such as restricting, transcribing,
1950's. In still other cases, molecular tech- replicating and ligating enzymes; plasmids,
niques expanded diagnostic potentials, but cosmids, artificial chromosomes, and other
did not qualitatively change, much less revolu- molecular transport systems- are not sophisti-
tionize the possibilities of metabolic correc- cated analytical and electronic machinery.
tion. Examples are nuclear medical screening They are themselves macromolecules that
and enzyme tests. work and perform in the wet environment of
The advent of gene technology, genetic en- the cell. With gene technology, the central tech-
gineering or, as some prefer to say, applied nical devices of molecular biological interven-
molecular genetics, since the beginning of the tion have themselves become parts and indeed
1970s has effected a decisive prospective constituents of the metabolic activities with
change in the relation between molecular biol- which, at the same time, they interfere. The
ogy and medicine. Gene technology developed scissors and needles by which the genetic infor-
in three waves. The first was marked by the mation gets tailored and spliced are enzymes.
identification of restriction enzymes and the The carriers by which it is transported into the
construction of recombinant plasmids at the cells are nucleic acid macromolecules. This kit
beginning of the decade. The second was char- of purified enzymes and molecules constitutes
acterized through the development of novel a "soft,. technology that life itself has been
DNA sequencing techniques towards the end evolving over a period of some three billion or
of the 1970s. The third set the stage for the big even more years, according to the recent esti-
genome projects around the middle of the mations of paleobiology. It is able to function
1980s and included pulsed-field electrophoresis, and is adapted to operating within the proper
artificial chromosomes, partially automated confines and in the milieu of the intact living
DNA sequence analysis with fluorescent probes, cell. With gene technology, informational
automated DNA and RNA synthesis, and the molecules are constructed according to an
BEYOND NATURE AND CULTURE 349
extracellular project and are subsequently im- If we are to believe Donald Chambers from
planted into the intracellular environment. The the University of Illinois (Chicago), the editor
organism itself transposes them, reproduces of a recently published Festschrift on the occa-
them, and "tests" their characteristics. With sion of the fortieth anniversary of the DNA
that, the organism as a whole advances to the double helix, the new biology that resulted
status of a locus technicus- that is, to the status from this crucial transformation has effected
of a space of representation in which new geno- "dramatic advances in the biomedical sciences.
typic and phenotypic patterns are becoming Molecular medicine is not a vision for the
probed and articulated. This technique is of future, but is at hand as our intrepid gene
potentially unlimited medical impact. For the hunters identify genetic lesions of disease, de-
first time, it is on the level of instruction that velop new diagnostics, and achieve mechanis-
metabolic processes are becoming susceptible to tic understandings that will yield new, rational,
manipulation. Until that point was reached, molecular therapies" (1995: 413). In the same
medical intervention, even in its most intrusive volume, Sir Walter Bodmer of the Imperial
physical, chemical and pharmacological forms, Cancer Research Fund in London prophesies
was restricted to the level of metabolic that essentially all human genes, estimated to
performance. be in the order of 100,000, will be found, se-
With the possibility of manipulating the quenced and localized on their respective
genetic production program of an organism chromosomes within the next forty, if not the
by its own, unmodified and modified compon- next ten years. This knowledge, he conjectures,
ents, the molecular biologist, as a molecular wiJI be summarized in a "book of man" (1995:
engineer, abandons the working paradigm of 423 ). Others, such as Walter Gilbert, Nobel
the classical biophysicist, biochemist or geneti- laureate and Harvard professor, speak of a
cist. He no longer constructs test tube condi- "vision of the grail" (1992: 83).
tions under which the molecules and reactions Let me just mention a few of Bodmer's
occurring in the organism are analyzed. Just examples that, not to count diagnostic proced-
the ocher way round: he constructs objects, ures such as restriction fragment length poly-
that is, basically, instruction-carrying mol- morphism (RFLP), will be the outcome of
ecules which no longer need to pre-exist within "molecular medicine" within the next four
the organism. In reproducing them, expressing decades: "corrective measures" for the carriers
them, and screening their effects, he uses the of the Huntington gene, Alzheimer,s disease,
milieu of the cell as their proper technical em- and some 5,000 clinically diagnosed diseases
bedding. The intact organism itself is turned with a genetic component; drugs and diets for
into a laboratory. It is no longer the extracellu- the large risk group of people prone to suffer
lar representation of intracellular processes, from heart diseases; preventive measures for
i.e., the "understanding" of life that matters, populations with an elevated risk of genetically
but rather the intracellular representation of an induced cancer; specific forms of immune sup-
extracellular project, i.e., the deliberate "re- pression for patients suffering from genetically
writing" of life. From an epistemic perspective, determined allergies, including hay fever and
this procedure makes the practice of molecular asthma; cures for specific deficiencies in behav-
biology, qua molecular engineering, substan- iour or performance such as dyslexia for which
tially different from traditional intervention in a genetic basis is assumed; an effective vaccin-
the life sciences and in medicine. This interven- ation against HIV; DNA-based cancer therapies
tion aims at re-programming metabolic actions, as well as vaccines against certain forms of
not just interfering with them. As Leroy Hood, cancer. The list could be prolonged. In any case,
one of the leading biotechnologists at Caltech, Bodmer leaves no doubt that the practical med-
has put it: from now on biologists will work on ical benefit of the genome analysis projects for
models whose appropriateness will be "tested efficiently fighting diseases, for which there has
in biological systems or living organisms" been no cure so far, will be enormous and indeed
themselves (1992: 162). unprecedented.
350 HANS-J0RG RHEINBERGER
Moreover, Sir Walter Bodmer is of the opin- genetics is not justified. After all, it is said,
ion that this overall information on the human evolution itself has invented and practiced the
genome "will enable genetic analysis of essen- means of horizontal gene transfer, and the cul-
tially any human difference" (1995: 414). In tivation and breeding of plants and animals by
view of this easy and gliding linguistic transition the enhancement of mechanisms of genetic
to a new genetic determinism, one might ask change goes back to the Neolithic civilizations.
what at all, in the long run, might remain out- I disagree with this view of smooth transition.
side the realm of "molecular medicine.'' We are To this argument, I would like to oppose a
not hearing here the voices of isolated propa- quotation of David Jackson, a former student
gandists of a new eugenics, we are hearing the of James Watson at Harvard and Paul Berg at
virtually unified voice of an international elite of Stanford, who chose a career in industry and
the biomedical complex. None of these experts, became an investigator of the American Pharma
to be sure, is supposed to plead for eugenically Trust DuPont Merck:
motivated measures on the level of the popula-
tion. Since the end of the Second World War, I would argue that the ability to read, to write,
medical genetics in the Western countries has and edit DNA is functionally unprecedented in
increasingly become oriented towards the sick human history. All we have ever been able to do
person, the individual that carries a potential before is to select among the various combin-
ations of genes that the mechanisms of genetics
genetic burden. It is oriented towards individual
have presented to us. And, while we have de-
counselling and bound to respect personal deci-
veloped very powerful and very sophisticated
sions. But precisely here, the dilemma is located.
selection procedures, selecting from among a
Not only diseases are genetically inherited. Es- set of alternatives over which one has almost
sentially normal, as well as very trivial, charac- no control is fundamentally different from
teristics are also genetically inherited. What will being able to write and edit one's own text.
then count as normal? Consequently, Bodmer (Jackson 1995: 364)
asks himself: "Will alterations ever be offered?
Will germline therapy ever be accepted?" {1995: That is, from the point of view of the practi-
424). Just to take a very simple example: shall tioner, what molecular biology and medicine
parents, in the future, have the right ro decide enables us to do. Who is "us"?
what kind of eye colour their child will have? Writing and reading, as forms of calcula-
Bodmer is quite outspoken about the fact that tion, instruction and legislation, have pro-
the decision as to whether to allow such inter- foundly shaped the social body and political
ventions "will become entirely a social and a power structure of Western societies from their
political ... rather than a scientific decision" pre-Greek inception in Mesopotamia through
(1995: 425). But if so, then we urgently need a the Gutenberg galaxy of the Renaissance and
serious discussion about the social and ethical the expansion of printing during the Industrial
dimensions of a molecular or, as Thomas Cas- Revolution to the microchip industry of today,
key from the National Institutes of Health puts with DNA-chips on the horizon. What is new
it, "DNA-based medicine" {1992: 112). To leave about molecular biological writing is that we
such discussion about the scope and limit of now gain access to the texture, and hence the
genetic intervention and action to the biomed- calculation, instruction and legislation of the
ical experts alone will then be plainly counter- human individual's organic existence, that is
indicated. to a script which until now it has been the
Today already, we are witnessing a global, privilege of evolution to write, to rewrite and
irreversible transformation of living beings, to alter. What Darwin called "methodical", or
animals and plants, towards deliberately engin- "artificial selection'' has barely scratched the
eered beings. Future natural evolution will surface of this script within the last 10,000
appear as insignificant in this perspective. The years of human evolution. For artificial selec-
usual objection at this point, especially from tion, in a way, itself still was nothing more than
scientists, is that the adoption of the viewpoint a specific human mode of natural evolution.
of such a radical break produced by molecular This has now gone and with it, natural
BEYOND NATURE AND CULTURE 351
evolution will become marginal. Molecular is not to supersede, but to alter our natural,
biology will arrive at inventing the biological that is, in the present context, our genetic con-
future. Once more Jackson: "The ability to dition. We come to realize that the natural
write and edit DNA is the basis for a synthetic conditio~ of our genetic makeup might turn
and a creative capability in biology that has not into a social construct, with the result that the
previously existed" (1995: 364). Toward the end distinction between the "natural" and the
of this millennium, it has moved a big step to- "social" no longer makes good sense. We could
wards the vision of Robert Sinsheimer some say as well that the future social conditions of
twenty years ago, at the dawn of recombinant man will become based on natural constructs.
DNA technology. "For the first time in all time, a The "nature" and the "social" can no longer be
living crearure understands its origin and can perceived as ontologically different. They are
undertake to design its future" (Sinsheimer no longer useful concepts to describe what is
1969). going on at the frontiers of the present "culture
of biomedicine." We become aware that we
live in a world of hybrids for the characteriza-
Conclusion: Beyond Nature and tion of which we run short of categories. As
Culture Latour says, in claiming that we have never
been modern - at least not in the sense of
The more molecular biology has blurred the successfully separating culture from nature:
contours of what genes might be on a molecu- "Instead of always being explained by a mix-
lar level (Fischer 1995), "genes for such-and- ture of the two "pure" transcendences, the ac-
such," as public icons, have become more tivity of nature/society making becomes the
abundant than ever. What is at stake in the source from which societies and natures origin-
current public discourse of molecular biology, ate" (Latour 1992: 282}.
as Evelyn Fox Keller rightly observed, is a pro-
found "transfiguration" of the longstanding
question of "genetic determinism" (Keller NOTE
1992: 288). An optimistic version of this obser- This paper makes use of two earlier articles:
vation would be that the quest after a "genetic Rheinberger, Hans-Jorg 1995 "Beyond Nature
analysis of essentially any human difference" and Culture: A Note on Medicine in the Age of
will finally result in an inflation of the argu- Molecular Biology." Science in Context 8(1):
ment from genetics. In view of what has been 249-63.
said above, it can at least be stated that the 1996 "Molekulare Medizin als Paradigma?
traditional dichotomy between "nature" and Gentechnologie im Blick von Wissenschaftsthe-
"nurture," between "biology'' and "culture," orie und medizinischer Ethik." In Heinz Schott
is about to collapse. One of the leading narra- (ed.), Meilensteine der Medisin. Dortmund: Har-
tives of Enlightenment philosophy in general enberg Verlag, pp. 555-61.
and of the modern sciences in particular has
been to conceive of the development of human
society as liberating (wo)mankind from the REFERENCES
constraints of nature. It has been trying to
Bodmer, Walter
draw a clear distinction between natural his- 1995 "Where will Genome Analysis Lead Us
tory on the one hand, and social history as Forty Years On?" In Donald A. Chambers (ed.},
superseding and replacing the former, on the DNA: The Double HelixJ Perspective and Pro-
other hand. It is intriguing to argue that mo- spective at Forty Years. New York: New York
lecular biology, as one of the results of this Academy of Sciences, pp. 414-26.
process, definitely subverts the percepcion of Caskey, Thomas C.
history from which it originated. It makes us 1992 "DNA-Based Medicine: Prevention and
realize that the result of its scientific conquest is Therapy." In Daniel J. Kevles and Leroy Hood
not to supersede, but to change our natural (eds.), The Code of Codes. Cambridge, MA:
history, that the very essence of our being social Harvard University Press, pp. 112-35.
352 HANS-JORG RHEINBERGER
In 1951, a piece of cancerous cervical tissue generated such fascinated attention from 1951
was cut from a woman named Henrietta to today. That one party in this relation should
Lacks, Lacks died eight months later of cancer. be alive and the other dead creates a dramatic
Live cells from the biopsy were grown in test tension which continues to generate scientific
tubes, supplied with nutrient medium, and papers, newspaper and magazine articles, and
kept at body temperature in an incubator. television documentaries. The resolution of the
Named HeLa, from the first two letters of paradox in these narratives is always the same:
Lacks's first and last names, and called an im- the woman and the cells are immortal, the
mortal cell line, descendants of these original woman through the cells' life and the cells
cells continue to grow and divide in laborator- through the woman's death. It is a personifica-
ies around the world. Proliferating with these tion of the woman who died that gains immor-
glass-bound populations of cells are narratives tality, while the woman's death is necessary to
of their life and origin. elevate the cells from unremarkable life- main-
The cells live and the woman does not. They tained in laboratories for over forty-six years-
somehow stand for her and she for them; other- to immortal life.
wise, this pair of circumstances would not pre- It is not surprising in itself that HeLa shouJd
sent itself as a paradox, much less one that has be personified. Cell lines are made to stand in
Hannah Landecker, "Immortality, In Vitro: A History of the Hela Cell Line,'' in P. E. Brodwin, ed., Biotech-
nology and Culture: Bodies, Anxieties, Ethics. Bloomington: Indiana University Press, 2000. Reprinted by
permission of Hannah Landecker.
354 HANNAH LANDECKER
for persons in the first place; they function in cultural narratives, from modern medicine's
the laboratory as proxy theaters of experimen- triumph over polio in the 1950s to anxieties
tation for intact living bodies. The visualiza- over race and purity in the 1960s and 1970s to,
tion of cellular processes by placing living cells most recently, a recasting of the story in eco-
under glass, where they are accessible to micro- nomic terms.
scope and camera, has become part of what we In a sense, I mimic the narratives I am ana-
understand to be the "life" of the body. As sites lyzing, by structuring the following history of
of manufacturing - of viruses or proteins or the HeLa cells around the changing definitions
antibodies- cell lines are the tools of the indus- of in vitro immortality over the course of the
try whose product is human health. Their iden- twentieth century. This is meant, in the end, to
tification as "living" and "human" entities serve as a critique rather than a retelling; the
cannot fall from them, because it is this origin final point of this essay is to highlight that the
that gives them commercial and scientific value death of the person who was Henrietta Lacks
as producers of biological substances for use by has been obscured by the personification of her
humans and their validity as research sites of cells as an immortal entity.
human biology.
Given that these living technologies are thus
necessarily understood to be human, I wish to Immortality in the History of
ask more specifically how the material exist- Tissue Culture
ence of the cell line redefines the designations
used to describe that existence. To this end, I HeLa cells were called immortal within a year
trace the history of the cell line and its personi- of their cultivation in vitro. The only way to
fications. Lacks's story is simultaneously what understand what seems a rather rapid jump to
happened to a person and her body and a nar- conclusions is to place the establishment of this
rative vehicle through which journalists and line in the context of the history of tissue cul-
scientists have imagined and witnessed the pos- ture. This essay is not the place to recount the
sibilities for lives and bodies constantly being history of tissue culture; instead, I choose to
changed by the rapid development of these take up a single strand of its development in the
"technologies of living substance'' made from United States. The work of Alexis Carrel at
human tissues. Lacks's photograph graces Rockefeller Institute in New York City from
many of the accounts; the cell line bears frag- 1910 to 1938 is important in the context of
ments of her name; the cells bear various pro- this essay, because it was Carrel who first pro-
portions of the genetic material of which her posed the concept and the supporting technol-
body was composed when it was alive, the ogy of indefinite life of tissues in vitro. He drew
body that was the source of cells whose varied his initial inspiration from Ross G. Harrison,
descendants continue to live and reproduce in an embryologist, who had shown in 1907 that
laboratories all over the world. However, the he could keep a piece of embryonic frog neural
meaning of this material lineage is repeatedly tissue alive long enough to watch a single nerve
being renegotiated in the changing personifica- fiber growing out from it, Harrison thus dem-
tions of the cell line. onstrated how valuable information could be
More than an exercise in cataloguing vari- gleaned from the isolation and maintenance of
ations on a theme, this history demonstrates a living system in which the "behavior of cer·
how the personifications of the cell line shift tain cells could be observed when removed
alongside the development of differing experi- from the bewildering conditions . . . within
mental roles in biology, medicine, and biotech- the embryonic body" (6).
nology, The physical matter, technical practice, However, it was Carrel who first tried to
and economic significance of growing cells in grow human cells in vitro. He did not aim to
vitro - tissue culture - generated new know- keep tissues alive long enough to observe some
ledge about and fresh meanings for the con- aspect of their behavior; rather, his goal was
cepts of human, alive, and immortal. These their "indefinite" or "permanent" life. Drawing
are both shaped by and interact with wider on the philosophy of Henri Bergson, Carrel
IMMORTALITY, IN VITRO: A HISTORY OF THE HELA CELL LINE 355
developed a theory of corporeal life in which From this early history comes not only the
physiological processes were the "substratum sense of a kind of life extracted from the con-
of duration." Time was recorded only when the fines of the animal or human body but an en-
metabolic products of these processes were during connection with magic and sorcery. One
allowed to remain around the tissues being textbook of cell biology states that "until the
grown in vitro: early 1970s, tissue culture was something of a
blend of science and witchcraft," which refers
If these metabolites are removed at short inter- both to the understanding of successful tissue
vals and the composition of the medium is
culture as an "art" that had to be learned in a
kept constant, the cell colonies remain indefin-
hands-on apprenticeship and the aesthetic set-
itely in the same state of activity. They do not
ting of the early tissue culture laboratories
record time qualitatively. In fact, they are im-
mortal. (Carrel, "Physiological Time" 620) (Alberts et al. 161). Carrel and those he trained
staffed their laboratories with technicians
This theory translated into meticulous tech- dressed in black robes and hoods, ostensibly to
nical practices such as washing ("rejuvenat- minimize reflections which might interfere with
ing") the cells every few days, the design of the delicate operations, while the air was kept
special glassware for these procedures, and moist with "witches' cauldrons" of steam
strict protocols to ensure asepsis. By 1912, (Witowski 281). Although contemporaries and
Carrel declared the "permanent life of tissues historians have blamed Carrel for making tissue
outside of the organism'' an issue only of more culture out to be more difficult - and more
perfect technique, and he claimed to have occult - than it really was, thus scaring off
established a culture of embryonic chicken potential practitioners, to my mind there is no
heart fibroblasts. These cells would live in vitro doubt that his sense of the possible was
for thirty-four years, when they were discarded extremely important to the establishment of in
two years after Carrel's death (Carrel, vitro immortality as a desired scientific object.
"Permanent Life"; Ebeling). Getting tissue or cells to live in glass has also
From its beginnings, the living cell in been the venture to get them to live indefinitely
culture - in particular the human cell - has outside of the animal body. What good, after
been an uncanny object. Tissue culture was all, is a technology that only lives for a matter of
developed using living matter cut from fetal days or months? Much better is one that will- if
cadavers and tumors. The living qualities of fed and maintained- reproduce itself and serve
these cells, acted out in isolation from the as a constant medium for repeatable experi-
organism and visible to the observer - con- ments. However, the permanent life of cells
tracting, beating, forming synaptic nets, prolif- outside of the body did not turn out to be an
erating, migrating - are what make them useful easily achievable goal, and HeLa was estab-
for biology. Their isolation gives them the char- lished only after years of effort with other cells,
acter of autonomous life - which is especially animal and human.
evident in the early fascination of Carrel and
other tissue culturists with applying new tech-
niques of timelapse cinematography to the The Establishment of the
study of cells in culture. These silent films of Hela Cell Line
cells enlarged to screen size made visible the
movement and division of entities previously In the laboratory of George Gey and Margaret
seen only in the fixed, stained state of classical Gey, at Johns Hopkins University Hospital, the
histology, and they enhanced the perception of ongoing attempt to establish cell lines from
an autonomous sphere of life. "Tissue and human tissues intersected with another research
blood cells are always in the process of becom- program to determine the relationship between
ing," wrote Carrel. "They do not show their two types of cervical cancer. The first was a non-
true physiognomy . . . under the microscope. invasive form of cancer involving only the epi-
. . . [C]ells appear on the film as mobile as a thelial surface of the cervix. The second was
flame" ("New Cytology" 337). invasive carcinoma involving the deeper basal
356 HANNAH LANDECKER
layers and leading to metastasis. Although it is Indeed, by this time, HeLa cells were being
now understood that the former is a precursor of mass-produced as part of a push for the rapid
the latter, this was still unresolved in 1951. evaluation of the polio vaccine, which Jonas
George Gey had been recruited to the project Salk developed in 1952. HeLa cells were
to grow cervical cancer cells in the hope that chosen as the "host" cell for measuring the
their life under glass would reveal something amounts of antibodies the poliovirus antigen
about their action in the body. It was into this produced. The Tuskegee Institute, a historic-
context that Henrietta Lacks entered when she ally black college in Alabama, was appointed
sought treatment for intermenstrual bleeding. by the National Foundation for Infantile Par-
After initial uncertainty on the part of the Johns alysis to be the locus of production. A labora-
Hopkins' treating physicians as to the nature of tory was committed to the sole purpose of
the lesion they saw on her cervix, they took a producing as many as twenty thousand tube
biopsy of the lesion and made the diagnosis of cultures of HeLa per week (Brown and
cervical cancer. Without her knowledge or per- Henderson}.
mission, Lacks became part of the cervical George Gey had as little control over the
cancer research project when a piece of the story that he released into the public domain
biopsy material was sent to the Gey laboratory. as he had over the cells. Because of intense
In 1951, when it became clear that HeLa national interest in the subject of polio, the
cells were going to continue growing and div- HeLa cell line came quickly to the attention
iding unperturbed by their artificial environ- of journalists. Gey did not want to release
ment, it did not take long before the label of Lacks's name, and so he informed an interested
"immortality" was applied to them and their writer from the National Foundation for
role as a cell line quickly overshadowed any Infantile Paralysis that he could not see fit to
part in the cervical cancer study. George Gey reveal the name of the cells, donor. However, it
distributed samples of HeLa to his colleagues was clear in the reply to this refusal that the
around the world. Because- as one tissue cul- writer had asked Gey's permission only as a
turist put it - "HeLa cells can be grown by formality; he had already learned Lacks's
almost anyone capable of trypsinizing cells name.
and transferring them from one tube to an-
other," their cultivation quickly became a An intrinsic part of this story would be to
widespread practice (Bang 534}. describe how these cells, originally obtained
Gey never attempted to patent or otherwise from Henrietta Lakes [sic], are being grown
limit the distribution of HeLa cells, clearly not and used for the benefit of mankind. Here is a
anticipating the chain letter effect of sending situation where cancer cells - potential des-
out cultures which were then grown up, split troyers of human life- have been channeled
by medical science to a new, beneficent
into parts, and sent on to others. Almost
course ....
immediately, a company called Microbial As-
sociates, Inc., began growing HeLa cells for "Incidentally," the writer smugly concluded,
commercial sale. In 1954, Gey expressed "the identity of the patient is already a matter
dismay over the number of laboratories of public record inasmuch as newspaper
working on HeLa in a letter to a colleague. reports have completely identified the individ-
Gey's correspondent, Charles Pomerat, reacted ual,"2 Another journalist writing for Colliers in
to this statement with some amusement: 1954 was more discreet, referring to "an
unsung heroine of medicine named Helen L.,'
With regard to your statement . . . of disap- (Davidson 79). Helen L. was characterized in
proval for a wide exploration of the HeLa this piece as a young Baltimore housewife
strain, I don't see how you can hope to inhibit whose unfortunate early death turned her into
progress in this direction since you released the an "unsung heroine" because of the HeLa cells'
strain so widely that it now can be purchased research role. Her death and her immortality
commercially. This is a little bit like requesting were uttered in the same sentence: "Mrs. L. has
people not to work on the golden hamster 1 attained a degree of immortality she never
IMMORTALITY, IN VITRO: A HISTORY OF THE HELA CELL LINE 357
dreamed of when she was alive, and her living the slides, Gey's colleagues wrote that what
tissue may yet play a role in conquering many had been originally diagnosed as epidermoid
diseases in addition to the cancer which killed carcinoma of the cervix in its early stages was
her" (Davidson 80). actually an adenocarcinoma, a rarer, more
In this version of immortality, the cells were aggressive form of cancer involving a different
understood to be a piece of Henrietta Lacks kind of cell. While some readers might expect
that went on growing and living, encased in a this admission to cause reconsideration of the
test tube instead of a body. The cells were seen treatment of the patient, who died within eight
as universal human cells. They served as a sub- months of diagnosis - in particular, as one of
strate in the design of a polio vaccine that was the authors was a physician responsible for this
to be applied to millions of people. They were patient's diagnosis and treatment - this is not
used to produce standardized nutrient media the case. They wrote:
for use in culturing all kinds of cells. They were
utilized to figure out methods for growing while it is necessary to record that the first
other cells and how to produce large numbers continuous cell strain is not of epidermoid
of them. They were referred to as the "golden carcinoma of the cervix . . . the exact histo-
pathologic nature of HeLa is but a footnote to
hamster" of cell biologists, and their concomi-
the abiding genius of George Gey. (946)
tant personification was in the form of an
angelic figure, an immortalized young Balti- Thus the woman is paradoxically made immor-
more housewife, thrust into a kind of eternal tal by the engine of her death, in the form of a
life of which such a woman would never dream. biopsy used to diagnose her ailment (inaccur-
To understand how death becomes a foot- ately) that becomes research material without
note to immortality in this narrative, I will do a her permission, to end up as a footnote to the
close reading of one of the retellings of HeLa's abiding genius of the scientist.
origin story. When George Gey died (of cancer) The question of whose immortality is
in 1970, his colleagues wrote a peculiar me- involved in the establishment of cell lines is
morial tribute to him in the journal Obstetrics further accentuated by the predilection some
and Gynecology, entitled "After Office Hours: scientists showed for trying to establish immor-
The HeLa Cell and a Reappraisal of its tal cell lines from pieces of their own bodies or
Origin." They wrote that the original biopsy the bodies of close relatives. In 1961, Leonard
Hayflick of Wistar Institute established a cell
secured for the patient, Henrietta Lacks (fig. 2) line from his newborn daughter's amniotic sac.
as HeLa, an immortality which has now The amnion, which grows from the fetal
reached 20 years. Will she live forever if nur- tissues, was of the same genetic makeup as
tured by the hands of future workers? Even Leonard Hayflick's daughter, and because it
now, Henrietta Lacks, first as Henrietta and carried his genes, it was literally his "daughter
then as HeLa, has a combined age of 51 years.
cell" (Hayflick, "Establishment" 608). He
(H. W.Jones et al. 945)
named the cell line WISH, an acronym which
Beside this statement is figure 2- a photograph stood for Wistar Institute and Susan Hayflick,
of a young woman, smiling into the camera, his daughter.
hands on hips. Underneath the photograph, the In 1966, Monroe Vincent was diagnosed as
caption reads "Henrietta Lacks (HeLa)," as if having a benign tumor of the prostate. He
the photograph of the woman held the image promptly attempted to grow some of the cells
of the incipient cell line, as if the woman was taken from his prostate, and he established the
the cell line, that according to these gynecolo- cell line MA 160, named not after himself but
gists, "if allowed to grow uninhibited under after the biomedical supply company Micro-
optimal cultural conditions, would have taken bial Associates, Inc., in which he was a partner.
over the world by this time." HeLa was itself scientific progeny- letters to
The reappraisal promised by the tribute's George Gey referring to Hela called the cell
I title was another look at the original biopsy line "your precious baby." 3 Gey is fondly
I slides of Henrietta Lacks. Upon reexamining remembered for hand-delivering the cultures
.I
l
358 HANNAH LANDECKER
personally to other scientists: " 'He would put cells (for example, see Harris 45). The cause
his glass tubes containing the cells in his shirt for the famous culture's immortality could not
pocket, use his body heat to keep them warm, be investigated as it was thrown away in 1946.
and then fly to another city and hand them to a More important was the stark distinction
fellow scientist.' , drawn between normal body cells and cancer
cells with this work. Intrinsic to this distinction
was the finite life span of populations of
From Beneficence to Notoriety normal cells, a limit only cancer cells could
break. Normal somatic cells were euploid, that
This benign version of immortality came to an is, contained a normal number of chromo-
abrupt end in the 1960s. First, new scientific somes. Cancer cells were aneuploid, showing
work that studied aging through cell culture abnormal chromosome numbers. Immortality
revealed that only cancerous cells had the abil- was not available to normal, euploid cells
ity to keep dividing indefinitely. This drew a except through freezing. They could be "trans-
sharper line of definition between normal and formed" with a virus or mutagen, but then they
cancerous cells. Carrel's famous immortal became aneuploid and behaved like cancer
chicken heart cell culture had supposedly been cells. Immortality was thus a characteristic
composed of normal cells, in which "perman- solely of cancerous, aneuploid cells, and it
ent life" had been induced by removing them was one of the traits that made cancer a men-
from the body and manipulating their environ- acing and mortal disease of the body.
ment, but in 1961 this was shown to have been Malignancy and cancer were already asso-
something of a fraud, when Hayflick demon- ciated with uncontrolled cell proliferation and
strated that normal somatic cells in culture metasticization, but it was not until after 1966
consistently divide for a set number of gener- that HeLa cells were understood or described
ations and then all die at once. Cells reproduce in these terms. Certainly it was recognized that
by replicating their DNA and dividing into two HeLa cells came from the cancerous tissue that
daughter cells. When a whole population of caused Henrietta Lacks's death, but the em-
cells goes through division, it is said to double. phasis had been on their control by scientists,
Hayflick showed that cells taken from human their harnessing as producers of knowledge in
fetal tissue will always undergo about fifty the victorious battles against polio, and the less
doublings before dying. Even if the culture is successful but still hopeful attempt to under-
frozen, and no matter how long it stays frozen, stand and contain cancer. This sense of control
when thawed it will pick up where it left off came to an abrupt end with the second and
and in total complete approximately fifty dou- more profound disruption of a benign image
blings. Cells taken from adults consistently go of in vitro immortality.
through about thirty doublings (Hayflick, "Biol- This disturbance was the announcement that
ogy") What is more, the finite number of dou- HeLa cells had contaminated and overgrown
blings is species-specific. Chicken cell culture many of the other immortal human ceH cultures
will go through thirty-five doublings at the most, established in the 1950s and 1960s. Because one
not thirty-five years worth of doublings. Thus it human cell looks much like another, only cross-
seemed impossible that Carrel's culture could species contamination - which could be seen
have been composed of normal chicken cells. by counting chromosomes - had up to this time
Hayflick concluded that the chick embryo been identified in cell culture. This changed with
extract preparation used as nutrient medium the introduction of techniques of genetic identi-
for Carrel's cultures provided new viable embry- fication. At the Second Decennial Review
onic cells at each feeding. Others have hypothe- Conference on CeH Tissue and Organ Culture
sized that Carrel's proximity to Peyton Rous at in September 1967, geneticist Stanley Gartier
Rockefeller Institute led to the normal somatic announced that he had profiled eighteen differ-
chicken cells being infected with Rous sarcoma ent human cell lines and judged them all to
virus and thus rendered capable of the same have been contaminated and overtaken by HeLa
kind of unlimited division seen in cancerous cells.
IMMORTALITY, IN VITRO: A HISTORY OF THE HELA CELL LINE 359
Gartler had tested the eighteen lines electro- framed scientific and journalistic accounts of
phoretically for a set of enzymes known to be the cell line.
genetically polymorphous, that is, to differ The following analysis traces this trans-
slightly among different people. All eighteen formation of scientific and popular rhetoric in
cell lines contained exactly the same enzyme detail. It is not sufficient to assert that one
profiles, indicating that they were all the same discourse of contamination merged with one
rather than eighteen distinct human cell types. of miscegenation, as if this were the inevitable
All eighteen had the same profiles as the HeLa course of events. It was by no means inevitable;
cell. The key piece of evidence in this study was I argue that Gartler emphasized the least sound
the profile for a particular enzyme called G6PD piece of his repertoire of evidence of contamin-
(glucose-6-phosphate dehydrogenase), which ation, an error which was then promulgated by
is a factor in red blood cell metabolism. Gartler those who tested, extended, and reported on
stood up in front of an audience of tissue cul- Gart1er's work. This particular course of events
turists and said: reveals much about the functioning of concepts
The G6PD variants that concern us are the A of biological race in American biology in the
(fast) and B (slow) types. The A type has been late 1960s and 1970s.
found only in Negroes.... The results of our First, it is necessary to support my assertion
G6PD analyses of these supposedly 18 inde- that Gartler emphasized the weakest part of his
pendently derived human ceJllines are that all evidence of Hela contamination of other cell
have the A band.... I have not been able lines, keeping empirically stronger arguments
to ascertain the supposed racial origin of all in the background as supporting evidence. Gar-
18 lines; it is known, however, that at least tier did not have to explain his results in the
some of these are from Caucasians, and that manner he did, highlighting the G6PD typing.
at least one, HeLa, is from a Negro. (Gartler, When he tested each of the cell lines for par-
"Genetic" 173) ticular enzymes, he was looking for variations
in structure between the same genes in different
The terminology of cell culture was already
humans. The resulting enzymes differ slightly
dense with the connotations of lineage, culture,
in amino acid sequence, a difference which can
proliferation, population, contamination, and,
then be visualized as lines on a gel. In addition
most recently, malignancy. With the delivery of
to G6PD, Gartler also used three other sets of
this paper, Gartler used these terms in a scien-
tific explanation which marked the contamin- polymorphic electrophoretic variants. Each of
ating cell line as black and the contaminated these three variants occurs in differing propor-
tions across the world's population, much like
lines as white.
blood types, and could not be categorized as
At this moment, the narratives surrounding
being specific to any one population. In Gar-
the HeLa cell changed dramatically. Prior to
tier's own words, the statistical likelihood of all
Gartler's work in 1966, race had not entered
eighteen cell lines carrying the same profiles for
into the discussions of either He La cells or their
donor, Henrietta Lacks. In fact, Gartler had to these systems of polymorphisms was statistic-
ally "absurdly low," regardless of the pur-
write to George Gey early in 1966 to ask about
ported race of the various donors of the cells
Lacks's race.
(Gartler, "Apparent" 750). In other words,
I am interested in the racial origin of the Garder's evidence of contamination would
person from whom your HeLa cell line was have been conclusive even without any refer-
initiated. I have checked a number of the early ence to racial difference.
papers describing the development of the Any eighteen people, in particular eighteen
HeLa ceJI line but have not been able to find unrelated people from the diverse population
any information pertaining to the race of the of the United States, would show different
donor. 4 (Emphasis added)
enough enzyme profiles to be distinct from
Mter 1966, the race of the donor was central to each other. The same enzyme profile for all
the scientific evidence of cell culture contamin- eighteen would be strong evidence of contam-
ation, and metaphors and stereotypes of race ination of all of them by the same cell line.
360 HANNAH LANDECKER
Thus an explanation based on human genetic methods. Their responses gave G6PD type A a
variation, which lurked in the background of simplified, essentialized status as a "black
Gartler's paper as supporting evidence, was gene," as if the register of race went from skin
empirically more sound than that which he to cell to enzyme to gene. This marker, taken
chose to highlight, the G6PD types and their from the context of population genetics and
supposed racial correlations. used as an identifying test for contamination
The presence of G6PD type A or B in a cell in cell culture, lost all the subtleties and com-
culture was correlated in his account with the plications of a gene frequency within a popula-
racial categorization of the patient donor as tion and became, instead, an absolute indicator
black or white, a categorization presumably of difference.
noted by the physicianMscientist on the basis of Once the Jines between cell types were
the patient's selfMdesignation or the physician's demarcated in this fashion, the crossing of
visual assessment. The correlation implied an these boundaries meant that the scientific com-
equivalence of the two kinds of racial categorM munity experienced two simultaneous disrup-
izations - by G6PD variation and visual judgM tions. First was the disruption of a complacent
ment. Gartler suggested that an apparently sense of control. If Gartler was right, these
white donor could not have been the origin of scientists had mistakenly been doing experi-
a cell line expressing G6PD type A, which is not ments on cells that they thought were breast
true at all. This weakness was noticed by the cancer or colon cancer or amnion cells but
founder of one of the cell lines said to be conM were in fact all Hela cells. This was a threat
taminated by Hela. As this was a commercially to the integrity and value of past work, an
marketed cell line, contamination was a threat imputation of carelessness in their technical
to its economic value. Almost immediately, practice, and the sudden switch from Hela as
Monroe Vincent - whose cell line was made a founding success to HeLa as the source of
from his prostate - published a denial that catastrophe. Second, it was the disturbance of a
MA160 was HeLaMcontaminated. He hypotheM previously unarticulated presumption of race.
sized that the G6PD type A in MA160 could be There had been no "information pertaining to
inherited from potential remote "Negro ancesM the race of the donor" to this point, and in its
try" in his lineage (Fraley et al. 541 ). role as a breakthrough, a standard, a universal,
Even with this weakness, G6PD continued Hela and its concomitant personification as an
to be the main marker. in testing for HeLa angelic and immortal Henrietta Lacks were
contamination of cell lines. The consequence unmarked and assumed to be white.
of this emphasis was the essentialization of At the same time, the synecdoche between
cells as "black" or "white" - an error possible cell and person functioned to make the cell
only in the prevailing confusion about concepts populations of petri dishes analogous to popu-
of biological race. An essential black/white difM lations of people. The scientists moved readily
ference was simpler for Gartler to explain and between the language of cells in culture to that
easier for his audience to understand as of people in culture. One respondent to Gar-
"proof" than would an explanation based on tier's paper stood up to remind the audience
human genetic variation. This fact indicates that cross-species contamination occurred
that the concept of population had not yet easily in tissue culture, a statement which ex-
managed to displace the concept of race for emplifies the facile slide from "human cell" to
these biologists. Gartler had been working "human":
since the early 1960s with a cell culture that
carried a mutation at the G6PD locus, and as a We all remember clearly a number of years
geneticist he was well acquainted with the voM ago- maybe 5- when this contamination busi-
luminous literature concerning the incidence of ness began and everybody was very defensive:
G6PD variation in populations around the the L cells contaminating the rabbits, the Hela
world. However, his audience of cell biologists cells contaminating the mouse .... Now, here
was not trained in population genetics, nor comes the HeLa: human contaminating
were these cell biologists familiar with its human. (Hsu 191)
IMMORTALITY, IN VITRO: A HISTORY OF THE HELA CELL LINE 361
Human contaminating human, explained in woman by the black man, and doubt in the
terms of racial difference, meant an immediate genealogy of the scientists thus came to the fore
introduction of the metaphors of miscegen- within minutes of Gartler's conclusions.
ation. The immediacy of this response is better After Gartler made his argument about
understood within the larger context of Ameri- HeLa contamination, the description of what
can history. happened to cells in culture was structured by
The late 1960s saw the arguing of the land- these metaphors of miscegenation. Scientists
mark United States Supreme Court case of passed on this explanation to journalists, who
Loving v. Virginia, ruling in 1967 that the Vir- used this narrative to tell the HeLa story to a
ginia miscegenation law was unconstitutional. larger audience. The scientists also read the
As in science, the validity and utility of racial journalists' accounts, footnoting them in their
categories were being challenged. This ruling scientific papers. The warnings about the
was followed by a general move on the part of danger of HeLa contamination, for example,
most American states to repeal statutes that played up a "one drop of HeLa" theme: "If a
defined racial categories, usually by blood pro- non-HeLa culture is contaminated by even a
portion (Pascoe 67-8). This included the "one single HeLa cell, that cell culture is doomed. In
drop of blood" rule which defined a person as no time at all, usually unnoticed, HeLa cells
black if they had so much as a single drop of will proliferate and take over the culture" (Cul-
black blood. Miscegenation laws, present from liton 1059). One drop was enough.
the 1660s to the 1960s, asserted an absolute The racial metaphors altered but did not
interdiction of sexual or marital crossing of the completely change the way tissue culture had
racial border. However, the existence of the one been understood up to this point. Even with the
drop rule, and its aim to demarcate black from earlier famous chicken heart cell culture, there
white absolutely, admitting no middle ground, was a consistent obsession with hypothetical
indicated that this border was crossed all the calculations of the total volume of cells the im-
time. Originating in American slavery, when mortal culture produced; with HeLa, these were
the mastees rape of the female slave was an calculations of a swamping of a white popula-
"open secret," the one drop of black blood tion by a black one. Ross Harrison had mused in
criterion and miscegenation laws worked to 1927 that had it been possible to allow all of the
deny any kinship across racial boundaries cells in Alexis Carrel's chicken heart culture to
(Jan Mohammed). multiply, it would "now greatly outweigh the
That these boundaries were still anxiously terrestrial globe," while in 1937 P. Lecomte De
regarded - and that kinship across them was Notiy envisioned the same set of cells reaching a
still being denied - is evident in the audience volume "more than thirteen quatrillion times
discussion after Gartler delivered his paper. bigger then the sun" (Harrison 18; De Notiy
There was a great deal of defensive rejection 104). This "mathematical calculation" abruptly
of his conclusion of widespread HeLa contam- became a threat, a literal "fear of a black planet"
ination from these members of the tissue cul- in the case of HeLa. The calculation was of a
ture community, some of whom had founded fleshliness that not only outweighed the globe
the cell lines Gartler was identifying as contam- but threatened to take it over: "HeLa, with a
inated. Leonard Hayflick's WISH- the cell line generation time of about 24 hours, if allowed
made from his daughter's amniotic sac- was to grow under optimal cultural conditions,
one of the cell lines Gartler identified as carry- would have taken over the world by this time"
ing the genetic marker he said was "found only (H. W. Jones et al.947). The calculation of the
in Negroes'' ("Genetic" 173). Hayflick, appar- putative volume of the culture when "allowed"
ently a white man, is reported to have stood up to multiply freely was not just of a cell culture
during the discussion following Gartler's paper but of how much Henrietta Lacks would
and said" 'I have just telephoned my wife, who weigh now, if all her cells were to be put back
assured me that my worst fears are unfounded' " together- an "incredible amount" (Curtis).
(qtd. in Gold 30). Themes of miscegenation and Garcler's findings and methodology were
pollution, the fear of impregnation of the white taken up by Walter Nelson-Rees, director of a cell
362 HANNAH LANDECKER
culture laboratory at the University of California, monster among the Pyrex," "indefatigable,"
Berkeley, who was charged by the National "undeflatable," "renegade," "catastrophic,"
Cancer Institute with keeping stocks of standard and "luxuriant," The narrative of reproduction
reference cells. Starting in 1974, Nelson-Rees out of control was linked with promiscuity
began publishing lists of cell lines he judged to through references to the cell's wild prolifera-
be HeLa-contaminated - an alarmingly high tive tendencies and its "colorful" laboratory
number. Contamination proved to be wide- life. Rogers reported that he first heard about
spread. It is impossible to estimate how much Henrietta Lacks through graffiti on the wall of
research was invalidated by the findings that the the "men's room of a San Francisco medical
researchers were mistakenly working on the school library" (0 1 ). Nelson-Rees, the self-
wrong type of cell. Contaminated cell lines appointed watchdog of Hela contamination
included a set of six cell cultures given to American for the cell culture community, was fond of
scientists by Russian scientists under a biomed- talking about the appearances of "our lady
ical information exchange that Nixon and Brezh- friend." When describing the letters Nelson-
nev negotiated in 1972 (Nelson-Rees et al. 751). Rees wrote to his fellow biologists when he
High profile incidents such as these, the suspected they were working with Hela-con-
emphasis on the "provenance" of cell lines taminated cell lines, another journalist wrote,
(one of Nelson-Rees's favorite terms), the con- "It was like a note from the school nurse
sistent use of the G6PD marker system, and informing the parents that little Darlene had
Nelson-Rees's penchant for personifying HeLa VD," Problems of contamination of cell lines
cells all contributed to a revived interest in the were described as the scientific communitis
figure of Henrietta Lacks in the 1970s and into "dirty little family secret" (Gold 63, 64, 78).
the 1980s. The inability of scientists to explain In the personification of Henrietta Lacks as
why Hela contaminated other cultures, but promiscuous and lascivious, in the character-
rarely the other way around, fed into a charac- ization of HeLa cells as akin to venereal dis-
terization of the cells as voracious, aggressive, ease, in the facile linking of race and
and malicious. contamination, and in what I call the "one
A large number of articles about HeLa and drop of HeLa" narratives of miscegenation
Henrietta Lacks appeared in magazines and and hybridity, I see the long reach of what
newspapers from Science to Rolling Stone be- Hortense Spillers has called the "American
tween 1974 and 1977. Unlike the writers in the grammar" of race, that "the ruling episteme
1950s, these authors were not interested in that releases the dynamics of naming and valu-
the figure of the self-sacrificing housewife. ation remains grounded in the originating
Although cell cultures were being identified metaphors of captivity and mutilation" (68).
by this time by karyological studies - the ap- The distressing literality of the excision, culti-
pearance of their chromosomes- and a number vation, exchange, mutation, and sale of a
of other systems of genetic polymorphism not living, reproducing fragment of a black
characterized as specific to black or white woman's cervix - without her or her family's
populations, cell identity was still being knowledge or permission - evokes Spillers's
explained primarily through the G6PD system. theorization of the "captive body," as that
HeLa cells were depicted as having a distinct, which has been severed from its motive will
identifiable biological race due to their particu- and active desire. The captive body is "cultur-
lar genetic structure. Michael Rogers, reporting ally unmade" by becoming "a thing for" the
in the Detroit Free Press, explained this to his captor, removed and renamed (67).
readers by writing, "In life, the HeLa source I would argue further, that the racialized
had been black and female. Even as a single rhetoric of contamination is not something
layer of cells in a tissue culture laboratory, she apart from the immortality narratives that I
remains so" (D4). discussed earlier. With Gartler's 1967 bomb-
This identity as black and female was com- shell to the tissue culture community, the
bined with a character described variously as desired scientific progen- the immortal cell line-
"vigorous," "aggressive," "surreptitious," "a the "precious baby," exhibited more autonomy
IMMORTALITY, IN VITRO: A HISTORY OF THE HELA CELL LINE 363
than was expected or wanted of it and the personified as the holder of an investment
promise turned to menace. The baby trans- account, where the original capital was those
formed into a monster, supplanting and des- first biopsy cells (for example, see Stepney).
troying more legitimate scientific progeny, These should have had a dollar value from the
such as the tokens of political good will on beginning, because look what they would be
the part of Russian scientists, the WISH line, worth today, after all these years in the invest-
and Monroe Vincent's prostate cells. Because ment account that is the burgeoning biotech-
this transformation was detected and narrated nology industry. Lacks's family is cast into the
in terms of racial difference, the already men- role of the rightful heirs to the proceeds of this
acing aspect of malignant immortality became "investment" who cannot collect, because
inextricably wound with a threat to scientific nobody ever patented the cells and thus it is
order and a set of racial and sexual metaphors difficult to pin down either past or present
of contamination and miscegenation. profit, or any one party who could benefit from
These anxieties provoked by the HeLa cells' the commercial exchange of HeLa cells and all
repetitive appearances are underpinned by the their products and permutations.
more general transgressions of the object of the Race reenters the story here as demarcating
immortal cell line across understandings of the lines of economic power and privilege. As one
life and death of intact bodies. Tissue culture of George Gey's colleagues commented to him
was designed as a microcosm of the human in 1954, it was "out of the goodness" of Gey's
body; it is the double, made for the visualiza- heart that HeLa cells, only three years after
tion of disease processes and as the stuff of their establishment, had become "general sci-
experimental practice. In some cases, it is made entific property." 5 As a black woman from a
from the bodies of the experimenters. This black family, Henrietta Lacks walked into a
double, as Sarah Kofman observes, is "neither clinic at johns Hopkins University Hospital,
living nor dead"; it is "designed to supplement where there was no institutional, ethical, or
the living, to perfect it, to make it immortal'' legal framework to ensure that she or her
(148)-but faced with this double, there is a family was in a position to execute any kind
shock, a lack of recognition. of decision- out of the goodness of their hearts
or otherwise - as to the fate of the cells.
Her family and friends, long left out of the
Conclusion story, are now being interviewed as key players
in a drama where Henrietta Lacks's cells
The two forms of immortality that I have gone became important tools of modern medicine
through here- the beneficent immortal chicken without her or her family's permission. With
heart, wonder fathered by modern science, contemporary awareness that significant tools
cells in a test-tube body form of immortality, of modern medicine are also valuable com-
and the racialized, malignant, out-of-control modities, endless reproduction and worldwide
immortality have both functioned to deflect distribution remain part of a story of Lacks's
attention from what mobilized them in the first immortality, but the metaphors have become
place- Henrietta Lacks's death. This is evident those of the growth of capital and those
in the treatment of her apparent misdiagnosis of miscegenation and contamination have
as a footnote to scientific genius. It is also retreated into the background of the story.
manifest in the volatile, threatening personifica- An analysis of the significance of this story
tion arising from the contamination narrative. to contemporary discussions of the body as
This effacement of death has not dropped property, the implications of laws which allow
away with the 1990s version of the HeLa story. for patenting of living organisms and mater-
Rather, the immortalized Henrietta Lacks has ials, and other cases of immortal cell lines made
taken on a distinctly economic cast. In media from human tissues remains to be written. In
accounts, she has become a figure of economic anticipation of these concerns, this essay has
exploitation, with a contemporary right to sue attempted yet one more return to the origin of
for compensation. Lacks has become the Hela cell line. What this return had
364 HANNAH LANDECKER
indicated is that at the establishment of this cell Immortality, the uncanny double, and the cul-
line exists a moment of irredeemable silence. tural, scientific, and individual effects of ideas of
Lacks's illness and treatment in 1951 at Johns biological race have existed in an intricate reci-
Hopkins took place in an institutional, cul- procity with the matter and practice of the sci-
tural, and scientific setting that had no room ence of tissue culture in this history. The resulting
in it for heroic agency or any other expression personification of HeLa simultaneously captures
of personal will on her part, even the simple act and erases human experience of this twentieth-
of donation. Recognition of this absence places century biomedical reach toward the technical
the establishment of the first immortal human alleviation of aging and death.
cell line and the science of tissue culture within
the long and troubled history of human experi-
mentation (see Lederer). NOTES
The relationship between immortal cell
lines and human experimentation has been 1 Charles Pomerat, letter to George Gey, 5
March 1954, George Gey Papers, Alan Mason
obscured by a "false and misleading plenitude''
Chesney Medical Archives, Baltimore. All
of personification. This functions to animate
letters cited are quoted with permission from
the cells with an autonomous will, as though the George Gey Papers.
they were beneficent or malevolent independ- 2 Ronald H. Berg, letter to George Gey, 24
ent of the scientific apparatus and constant November 1953. Berg was referring to a story
tending that maintains their "life, in the that had appeared in the Minneapolis Star in
laboratory. The narrative of immortality - 1954 and gave Lacks's name, although it is
beneficent, malignant, or monetary - masks unclear who released the name.
the death at its origin. Although it is difficult 3 C. M. Pomerat, letter to George Gey, 19
to say whether an accurate diagnosis of adeno- February 1954. Dr. George Gey, Jr. (qtd. in
carcinoma would have helped in Lacks's treat- Kelly At).
ment, the total absence of questioning of the 4 Stanley Gartler, letter to George Gey, 16
circumstances and adequacy of her medical March 1966.
treatment - even with the clearly stated admis- 5 Charles Pomerat, letter to George Gey, 5
sion of diagnostic error published in 1971 - March 1954.
indicates the power of the concepts of immor-
tality produced by the life of these cells.
The HeLa cell line, even though referred to REFERENCES
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relation to an individual named Henrietta Alberts, Bruce, et al.
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grow and divide, are split up to make new cul- Bang, Frederick
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ther in laboratories around the world. Various Bulletin of the History of Medicine 51 (1977):
516-37.
generations of them remain in stasis, stored in
Brown, Russell, and James Henderson
the freezers of cell culture banks. The original
"The Mass Production and Distribution of
biopsy was a piece of tissue, not a single cell, and HeLa Cells at Tuskegee Institute, 1953-1955."
there exist many subtypes of the HeLa cell line. journal of the History of Medicine 38 (1983):
HeLa cells have been used for years as one part 415-31.
in hybridization procedures which merge two Carrel, Alexis
kinds of cells to make a new and distinct cell "The New Cytology., Science 73 (1931): 331-
line. To speak of the HeLa cell line is to speak of 45.
a distributed, heterogenous thing which is Carrel, Alexis
always growing, multiplying, and changing. "On the Permanent Life of Tissues outside of
HeLa thus serves as its own metaphor. It is the Organism., journal of Experimental Medi-
not a story to which there is a single conclusion. cine 15 (1912): 516-28.
IMMORTALITY, IN VITRO: A HISTORY OF THE HELA CELL LINE 365
Given the explosive rate at which the fields of molecular genetics and neurobiol-
ogy are expanding, it is inevitable that the perception of our own nature, in the
field of sex as in all attributes of our physical and menta/lives, will be increasingly
dominated by concepts derived from the biological sciences. (S. A. LeVay)
come to understand ourselves as subject to the Perhaps one day we wiJ/ speak of an
scientific, medical, and technical discourses of individual's brain chemotype as well as
objectivity, and (2) How these discourses choose his or her genotype and phenotype. (Henry
"us" as their object of study. The difference N. Wagner, Jr., and Linda E. Ketchum)
between the two meanings is a matter of point
of view. On the one hand these cases point to the I am concerned with objective self-fashioning
ways in which we fashion our selves - person, as a result of my work in the field of positron
body, brain, and mind - out of ready-made emission tomography (PET) scanning, a brain-
objective types, and therefore subject ourselves imaging technique that promises to provide
to the disciplines of science and technology, ex- images of the living brain in action as it
pertise and machines. This kind of self encoun- thinks, worries, adds, gets sad, and goes
ters objectivity in the form of resistance; who we mad. I have been examining what might be
are is a product of discourse networks and tech- called, folJowing Stone (1992), the "virtual
nologies over which we have little control {Kit- community" of PET scans - the heterogeneous
tler 1985). On the other hand the practices of community of people who interact with these
science, technology, and medicine fashion selves scans and each other. In addition to fieldwork
as objective facts through scientific experimen- among those who work with the injection and
tation, subject selection, and medical taxonomic imaging of radiopharmaceuticals, I have inter-
exercises. This latter case emphasizes social and viewed graduate students, imaging technolo-
disciplinary production of selves, while the gists, and PET researchers. I have also
former emphasizes cultural presuppositions followed how PET scans have appeared on
built into concepts and practices. TY, in newspapers, and in Hollywood movies.
Attending to the categories of the person In particular, my attention has been drawn to
built into facts and attending to facts-in-the- the use of PET scans as authoritative facts in
world as facts enables us to see more clearly claims about how the world and people ob-
how medical and scientific claims, along with jectively are - that is, what attributes and
our own, are as much about dividing persons as properties our objective bodies have, and
they are about describing them. Here, along what this means for the rest of our persons:
with Emily Martin, I believe we should also our lived bodies, subjective souls, and/or our
"acknowledge the varieties of ways in which selves (see, for example, Begley 1991).
experience resists science and medicine" (Martin The PET scan, produced in university re-
1987). More specifically, the question of object- search laboratories, is one of the iconic center-
ive self-fashioning raises the issue of creativity pieces of the 1990s, "Decade of the Brain."
with regard to facts. Rayna Rapp, for instance, This recent technology produces images of
has followed the different ways in which people living brain and body functions through the
incorporate the possibilities and results of am- use of radioactive tracers. Unlike CT (com-
niocentesis into their lives - for one mother, the puted tomography) and MR (magnetic reson-
fact of a genetic defect means a decision to ance), which provide images of the tissue and
abort, while for another it means preparing to structure of the brain, PET produces high-reso-
take proper care of a challenging baby (Rapp lution, functional images of blood flow and
1990, 1993). Marrin and Rapp are both calling glucose consumption within the brain. Produ-
for a reader-response analysis of our relation to cing PET images is an extremely capital- and
science, medicine, and other facts of life. expertlabor-intensive process. PET requires an
infrastructure- including interdisciplinary per-
sonnel, a cyclotron, a nuclear chemistry lab,
PET Scanning in Courts and at high-speed computers, and a scanner - that
the Movies costs upwards of six million dollars to install
and one to two million dollars a year to oper-
With PET imaging, we can begin to ate. Government fears of high-cost medicine
explore the degree to which biological have contributed to the fact that PET did not
and social factors affect brain chemistry. enter regular clinical medicine as CT and MRI
A DIGITAL IMAGE OF THE CATEGORY OF THE PERSON 369
did, but has remained an experimental science incompetency and insanity as well as neurotoxic
into the 1990s (Dumit 1995). damage and head trauma (see, for example,
After an experiment is designed and repre- Stipp 1992).
sentative subjects selected, a small cyclotron is To begin considering the role these images
used to produce radioactive isotopes. These can play in our own lives, I would like to
isotopes are short-lived, with half-Jives that present an example of PET as depicted in a
range from two minutes to two hours. They popular film about schizophrenia, violence,
are immediately "tagged" or attached onto and insanity. The following is my own tran-
other chemicals to form radio-labeled sub- scription of part of the final four minutes of a
stances, or radiopharmaceuticals. Fl uorine-18, 1989 movie, Rampage, directed by William
for instance, can be tagged onto glucose, and Friedkin. I believe it represents the first use of
Oxygen-15 can be tagged onto water. The PET in a Hollywood movie. At this point in the
radiopharmaceuticals thus formed either script, Charles Reese has committed six grisly
mimic or are analogs of substances regularly murders and is about to be found guilty of
circulating through the brain. them by a jury.
The next step is to set up the experiment,
inject the human subject with the radiophar- In a courtroom.
Defense attorney: [whispering to his client,
maceutical, and place him or her in the scanner.
Charles Reese] We still have a shot to save
While the subject carries out some task (such as
your life. We can still show the jury that you
looking at words) or attempts to maintain weren't responsible.
some state (such as rest or anxiety), his or her
brain is assumed to be using energy differen- Cut to the Judge's chamber.
tially in those regions involved in that activity Defense attorne-y: Your honor, I'm going to
or state. Scans can be taken quickly for a "pic- request that a PET scan be performed as part
ture" of blood flow during a thirty-second of a defense to show the jury that he is men-
period, or they are taken after forty minutes tally ill, during the penalty phase.
for a "picture" of the glucose utilization up to Prosecutor: A PET scan purports to show only
the scan. a patient's brain chemistry at a certain
The scanner depends on the physics and moment of time. In this case it is after the
biophysics of positron emission. As the radio- crime is committed.
pharmaceutical decays in the brain, it emits Judge: A PET scan is a form of medical im-
positrons that travel a short distance, run into aging which is used in the diagnosis of epi-
an electron, and burst into two photons or lepsy, some Alzheimer's, as well as mental
gamma rays that fly off at almost 180 degrees. deficiency. Depriving Mr. Reese of putting this
The scanner consists of a ring of detectors con- in front of the jury ...
Prosecutor: [interrupting] It's only another
nected to a computing system that reacts when
gadget to hide Mr. Reese's responsibility.
two detectors are hit by gamma rays at about Judge: [pausing, contemplating] Well, we're
the same time. The computer then assumes that going to err on the side of caution. I'm going
there was a positron along the line between the to order the test. We'll let the jury evaluate it.
two detectors. Nobody knows what it will show.
After collecting hundreds of thousands of
data points, the computer attempts mathematic- Cut to medical laboratory, Charles Reese is
ally to reconstruct the approximate spatial dens- put in the PET scanner. A computer-gener-
ity of the radiopharmaceutical, a process ated rotating skull is shown, peeled back to
involving many assumptions about brain bio- reveal a rotating brain in red, then green.
chemistry and metabolism. The result is a sim- Two scans come up side by side. One is
ultaneously simple (in the sense of transparent) labeled "Normal Control,'' the other "Reese,
and complex image of a human brain at work. john." The scans look significantly different.
In addition to appearing in popular magazines Medical Doctor: [pointing to Reese's scan)
and newspapers, these images are increasingly These are abnormal patterns, without a doubt.
being used in court cases to argue for Defense Attorney: What does that tell you?
370 JOSEPH OUMIT
Medical Doctor: Well, this yellow-green area of facts. Rampage is an intervention into the
here is consistent with schizophrenia. What facts of PET and the facts of life, presenting as
you are seeing is a computer-enhanced image it does a definition of PET, a set of presump-
of the chemistry of the brain. And what it tions about imaging and mental illness, and a
shows is a picture of madness. possible scenario of PET's use in a court.
Watching the movie, one confronts these facts
Cut to the courtroom again.]ury Foreman: of PET and is drawn into the virtual commu-
Your honor, based on the new scientific evi-
nity of its images
dence, We, the jury, find that the defendant
What is the status of these "facts" pro-
should go to a state mental hospital.
claimed via Hollywood? Are they true? These
At the end of the movie, text: ·~charles Reese
questions trip me up as I watch a world of
has served four years in a state mental facility.
biotechnopower where technology judges
He has had one hearing to determine his eli-
who is responsible/sane/rational and who is
gibility for release. His next hearing is in four
not. This is a "view of the world that might
months."
be different from my current one" (Martin
In the microcosm of this movie, a convicted 1985:195). Like Emily Martin, I often find
brutal murderer is not put into prison but is myself stumbling "over accepting [these] scien-
treated as a mentally diseased subject who may tific medical statements as truth" (1985:10).
be released in the near future. The sole element But Hollywood reframes the question of truth,
presented to account for the jury's decision is a calling for an examination of the ways in which
PET scan. The words of the doctor - "This is new facts, worlds, and persons are produced,
his brain . . . These areas are definitely abnor- distributed, and incorporated. For example,
mal . . . consistent with schizophrenia . . . a Rampage mediates between experts who pre-
picture of madness'' - concatenate a history of sumably provided the details of PET, brains,
struggle and controversy within the medical and schizophrenia, and us lay viewers.
and legal communities regarding a host of rela- Though some might want to claim that
tionships: PET scan to brain, brain to schizo- there is a set of accepted medical truths, the
phrenia, schizophrenia to insanity. In the purpose of this paper is to work with a notion
movie, the PET scan stands as the fact, the of uneven flows of knowledge and contradict-
linchpin referent, which holds the chain of con- ory versions of acceptability and legitimacy.
nections together, convincing a jury that an We don't know how much we don't know
abnormal brain scan is an abnormal brain is about medical truths. Hollywood movies,
an abnormal person who does not bear respon- along with best-selling novels written by phys-
sibility for murder. icians and our own doctors' advice, help to
Not one of these connections, however, is shape our notions of "accepted medical know-
settled in the scientific and medical community, ledge" and thus help shape our categories of
in the legal community, or in my own mind. the person. As part of my ethnography I follow
Medical anthropologist Horacio Fabrega dis- this shaping process, examining how facts
cusses the reluctance of Anglo-American soci- travel in the world, but also how they never
ety to accept a theory of illness-caused travel alone. Instead they are packaged in the
deviance. He suggests that this is primarily form of stories, explanations, and experiences,
due to a need to have the will be socially or as authorized or unauthorized accounts, and
rationally motivated: "In essence, mental ill- they necessarily include definitions of human
ness as a defense of homicide requires a suspen- nature. Faced with novel facts, we may indeed
sion of our attribution of personhood if the stumble over accepting them.
latter is equated with willful symbolic behav- When I have shown the movie clip from
ior" (Fabrega 1989:592). Although I think that Rampage and pictures of PET scans during
this argument makes sense in general when talks, some people with social constructionist
comparing societies, I am interested in the tendencies and some with strong feelings about
ways in which the attributes of personhood in the social or psychodynamic nature of schizo-
the US are continually contested using batteries phrenia have been upset over the biosocial
A DIGITAL IMAGE OF THE CATEGORY OF THE PERSON 371
totalitarian implications of this apparently seam- living brains (Pardes and Pincus 1985). The
less presentation of clear difference between medical imaging advantage was measured in
"them" and "us." I want first to note that despite two ways. First, it allowed correlation between
constant work on PET and schizophrenia over brains and diagnosis among living humans,
the last twenty years, there is still much dis- thus permitting anew the equation of "brain
agreement over whether PET is ready yet for = illness." Second, medical imaging promised
clinical work with mental illness. In addition, to provide early warnings of the onset of
over 90 percent of the PET community furi- mental illness, one of the largest problems in
ously opposes the use of PET for the insanity its treatment and prevention.
defense (Mayberg 1992; Rajas-Burke 1993). In PET in particular was hailed as significant
spite of this unreliability for regular clinical because it promised to provide functional
work, in some places PET has nevertheless been images of the brain in action. Early on, it was
heavily supported, including financially, by realized that many head injuries, strokes, and
mental illness activists, that is, organized fam- epilepsies leave the structure of the brain rela-
ilies of people with mental illness. Here another tively unchanged but show up with different
set of contests emerges. Should researchers look degrees of clarity on PET scans. In biological
for biological correlates of schizophrenia, and psychiatry, such proof of pathology was talked
how should such correlates be interpreted? about as a Holy Grail. One biological psych-
What do the facts mean? Surprisingly, the iatrist, for instance, began a review of PET
meaning of these facts does not emerge solely with the statement, "In the 1970s, the antipsy-
from the research community; the whole virtual chiatry movement almost had us (Szasz 1970),
community must be examined. but now we have proof'' (Kuhar 1989). For
In order to examine this story I have to back this subdiscipline, eager to demonstrate the
up forty years to the beginning of the "biological physiology of mental illness, images of brain
revolution" in psychiatry. During the 1950s and differences between mentally ill patients and
through the early 1960s, new pharmacological non-mentally ill controls were facts that im-
agents- drugs such as thorazine (chlorpromaz- plied that a full biological explanation of
ine), lithium, and valium, which helped reduce mental disease was only a matter of time. This
symptoms in mental patients - were discovered technique thus functioned as a promise that
and allowed many patients to live at home for mental illness was not "in the head" but in
the first time (e.g., Andreassen 1984, 1989). In the brain.
the 1960s and 1970s, however, mental illness
treatment critics organized to reform institu-
tionalization practices. These critics created an
uneasy alliance with psychotherapeutic psych- Patients, Victims: On Seeing
iatrists who were invested in talking cures, and Oneself in a Brain Mirror
together they campaigned heavily for the notion
that schizophrenia and the affective disorders I find a tremendous interest in PET scan-
were psychogenic. These "antipsychiatrists" ning everywhere I go. I do a lot of public
argued that mental illness was socially con- speaking, and I find that people are very
structed and therefore in need of social cures, interested in this. And they are always
not drugs (Laing 1967; Szasz 1970). Their argu- appreciative of the first ten minutes where
ment drew in part on the fact that there were no I go through how positrons decay into
known biological mechanisms for mental ill- gamma rays and the coincidence detec-
ness. Perhaps, the antipsychiatric camp argued, tions. They follow this, they understand
drugs only affected the symptoms, not the cause. it, they have a concept of how they whole
In the late 1970s and 1980s the increasing thing works, and they are terribly fascin-
availability of new diagnostic techniques such ated with the whole idea. People are tre-
as computed tomography (CT) scanning and mendously interested in the brain. You
PET scanning changed this perspective. These know, almost everybody thinks they are
techniques offered different ways of examining going to get Aizheimer's disease. If for no
372 JOSEPH DUMIT
other reason, they want to know what is among their children. As Haier details below,
going on. (Richard Haier) the psychodynamic approach, while support-
ing the social nature of schizophrenia, often
To illustrate the ongoing negotiation of person-
localized this causation into the family and
hood and illness and call attention to the wider
specifically in the mother.
virtual community of objective self-fashioning
around PET, I turn now to one site of my
RH: The Lockhardts contributed $250,000
fieldwork, the Brain Imaging Center at the
to help pay for our scanner ... By that
University of California at Irvine (UCI). This time, the scanner had arrived and we
center was unlike most PET centers in two were making pictures, they had schizo-
important respects. First, it was located in a phrenia in their family, and they were
psychiatry department, not in a chemistry, nu- very interested in it. And they knew our
clear medicine, or radiology department. emphasis was going to be on schizo-
Second, for a PET center, it was extremely phrenia. We always approach it that in
underfunded. Other major PET centers have the long run, the main help will come
received either Department of Energy or Na- through research. Probably not for
tional Institutes of Health program grants to people who currently have it, but be-
support the multimillion-dollar costs of labora- cause there is a genetic component, there
tories in nuclear medicine or radiology. UCI's are still the grandchildren to worry
program was started in a psychiatry depart- about. And families find this compelling.
ment and purchased its scanner and then its Remember, even in the late '80s, the
cyclotron with bank loans. Monthly payments public was just coming out of the idea
were dependent upon an external fee schedule of the schizogenic mother, that schizo-
that dampened free operation. In the words of phrenia was somehow induced because
one researcher. the mother was doing something wrong.
Virtually every set of parents that we talk
YY: We were sort of a shoestring operation. I to now, when schizophrenics are now in
think we were sort of an upstart in some their twenties and their thirties, almost
sense, because other places that have every parent has had the experience of
PET centers are much better endowed going to a psychologist early on and get-
than we were. We were sort of the ting the idea that somehow they were at
scrappy, come-from-behind, shoestring fault. So it is all in their memory. And the
budget kind of guys. And we did things idea that it is biological has caught on
on a budget that is probably one-tenth of real fast over the last five or eight years.
the budget that Hopkins or UCLA has Family groups have organized around
for their PET centers. They are very well this to support biological research, and
endowed and they support their PET imaging is obviously at the heart of that.
centers in a maximum way. I think that So it is kind of a natural sequence of
we have a much more sort of guerrilla- events.
type operation. We are unconventional Supporting PET research became a means for
in that we did so many things on our these families to empower their participation
own, but I think we were fairly product- within science, stay informed, and come to
ive. We've done a fair amount of work understand their role as accountable to, but
even though we are on a shoestring not responsible for, the fact of familial schizo-
budget, relative to a lot of other facilities. phrenia. Along with the National Alliance for
the Mentally Ill {NAMI), these families advo-
This PET center operated from such a pre- cated a biological redefinition of mental illness
carious financial position that its researchers and actively helped to produce facts about the
spent much time doing local community out- nature of personhood and mental illness (OTA
reach. They found a ready alliance with the 1992). Objective self-fashioning is here a strat-
mental illness community in Orange County, egy without which such research might not get
especially with families who had schizophrenia done.
A DIGITAL IMAGE OF THE CATEGORY OF THE PERSON 373
Within the daily practice of clinical psych· Other researchers who have also shown pa-
iatry, these brain·irnaging techniques have also tients their scans have agreed that, especially in
helped sufferers deal with the fact of mental cases of neurological and mental diseases,
illness symptoms. The following excerpt is which are often accompanied with self-disgust
from an interview with Dr. Joseph Wu, a psych· or a sense of failure, both the scan and the
iatrist at UCI. process help legitimate the problem. They
make it something that can at least be ex-
JD: Do you show the patients their PET plored. These patients (and their families) want
scans? schizophrenia and depression to be medica-
JW: Oh yes. We try and show them the PET lized, to have a single cause or explanation,
scans, and then some of these patients will even if there is no solution or cure for them.
refer them out to people. I have a part· Anthropologists of medicine have long ex-
time private practice with some of them,
plored this kind of effect as a crucial aspect of
and they may like to continue with me.
every health care system. Jean jackson discusses
JD: Does it help them overcome part of the
stigma of mental illness? the failure of culture to come to grips with
]W: I think so. I think that definitely. One of chronic pain (Jackson 1994; see also Good et
the intrinsic messages is that the depres- al. 1992). The tension Jackson describes in-
sion isn't something to be ashamed of; it is volves mental versus physical pain. Chronic
an illness which needs to be understood. pain sufferers seek out, even hope for, positive
And it is not something that is their fault. test results, even cancer, because then there
I think that there is a destigmatization would be something to point to and work on
that occurs with the biological emphasis. It to solve the problem. Regarding depression, Dr.
is a fine line, because there are some arenas Wu concurred with this interpretation when I
of personal responsibility that people can asked him about the history of psychiatry.
and should assume for their feelings. But I
think it is a very narrow and tricky bal-
JD: Dr. Wu, Nancy Andreasen has written
ance. It is important not to think that it is
about the biological revolution in psych-
aU biology; that can lead to a certain
iatry. You were in medical school during
eschewing of what is appropriate for one's
this time. Did you also get the other side
own role in understanding one's emotions.
of psychiatry?
On the other hand, I think that people can JW: Oh, very much so. I would say that most of
go overboard, and say, "Gee, I'm entirely the psychiatrists in this department are stiJI
at fault for how I feel." [It is important] to analytically, dynamically focused. I would
try and understand one's role in helping to
say that biologically oriented psychiatrists
monitor one's emotions without being un- still make up a minority of the faculty.
necessarily harshly judgmental of oneself. Maybe 30 to 40 percent, as opposed to
The reconfiguration of mental illness as bio- the psychodynamically oriented people
logical through the use of PET scans becomes fwho] are 50 to 60 percent.
part of a personal reconfiguration of one's own ]D: Do both of these sides come into play in
your work?
category of person. A strict division between
]W: Somewhat. For me, when I do a study of
the biological self and the personal self is not at
depression, there is a part of me, a whole
issue here. Rather, the relations between the
human dimension, that really tugs at my
two selves are redistributed so that, although heart. Part of me feels moved by the pain
the patient must continue to experience the of the patient that we work with. I am
illness and live with it, she or he no longer has also moved by the courage and the will·
to identify with it. The diseased brain, in this ingness that many of these people have
case, becomes a part of a biological body that is to participate in this study, even with the
experienced phenomenologically but is not the depth of their emotional pain and an-
bearer of personhood. Rather, the patient who guish. I think we try to offer to them
looks at his or her PET brain scan is an inno· the gratification that comes with know·
cent sufferer rationally seeking help. ing that they are contributing to the fund
374 JOSEPH DUMIT
of knowledge that will eventually help contestibility of these categories. Patients and
to, we hope, eliminate depression or activists are actively getting together to support
mitigate it. And that is something that and promote research on the shared biological
many of these people find appealing, nature of mental illness because of their desire
because there may be some greater pur- to see the results and their hope for cures. Paul
pose to their suffering. It is a way of Rabinow has called this grouping on the basis
reconnecting in some sense with the of biological commonality "biosociality" (Ra-
broader community. It is a way of binow 1992). A key point to remember here is
making a personal meaning out of the
that the facts of biology around which these
emotional pain that they suffer from.
groups are organizing are not necessarily fully
For me, I see the whole biological aspect
decided within the scientific community. Yet
as not being contradictory or mutually
exclusive from the psychodynamic they provide the means for social action, justi-
aspect. I really see it as complementary fications for support of certain kinds of re-
and synergistic with the dynamic aspect. search, and arguments for a biological
There are some people that see it as understanding of mental illness. The facts
either/or. I see it more as a both/and type enable the groups to further promote a
of proposition. category of the objective person that does not,
in their view, prejudge them and condemn
PET research into mental illness has thus them to blame and guilt. This involves under-
become an area of study worthy of community standing the many very different ways facts
support and patient contribution. The both/ (science, technology, nature) and experience
and approach to psychiatry, popularized by (subjectivity, personality, culture) are con-
writers like Peter Kramer (1993), involves real- stantly shaping and tripping over each other.
izing that the brain can be altered by the social These people are working creatively to refigure
environment and by genetic development and responsibility for mental illness, in this case to
drugs. The kindling theory, for instance, sug- biology, in an attempt to gain control over this
gests that repeated abuse during childhood can part of their world.
build up depressed reactions until the depres- The challenge here isn't just to the social
sion is neurologically self-sustaining (Post and construction of mental illness. This is not a
Ballenger 1984, cited in Kramer 1993:110-18, simple story of the gradual emergence of the
334 ). The brain becomes "rewired" as if the right view of depression, schizophrenia, and
person had been born that way. In the same PET scanning. Biological psychiatry, for in-
vein, both psychodynamic talk therapy and stance, often leads to deinstitutionalization,
psychopharmaceutical drug treatment can which burdens lower-income communities
change brain chemistry and rewire the brain more than upper-income ones. But this story
toward freedom from depression. Note that is not one of victims and blame. By tracing
the brain remains the bearer of mental illness, facts-in-the-world throughout the virtual com-
but has now become an intersection for social munity of PET images, I hope that responsi-
and biological influences. bility for these situations might be multiplied -
Dr. Wu's "both/and" approach to psycho- that accountability might adhere to experts,
dynamic and biological explanations of mental mediators, and laypersons alike for their par-
illness arises, I suspect, from taking patients' ticipation in objective self-fashioning.
perspectives into his account. Pa6ents are able
to participate in social and medical reform by
participating in research th.at might produce Cyborg: Machines My Eyes
facts implying a category of person who suffers and Ears
from a physiological rather than a psycho-
logical disturbance. My present research with PET scanning is
If we see that responsibility and causations concerned with investigating chemical re-
are part of our categories of persons, this actions constantly taking place inside the
example demonstrates the flexibility and human brain, and how these reactions
A DIGITAL IMAGE OF THE CATEGORY OF THE PERSON 375
affect how we think, feel and act . . . how multiple uses and arenas of facts-in-the-world
they affect whether we are afraid, violent but also to their deployment within discourses
or destructive ... Perhaps we will be able of objectivity and to the ways that they have
to learn enough about the brain chemistry built-in, presupposed notions of human nature.
of fear, violence and destructiveness The point is that science and medicine turn out
to save ourselves from the problems of to be our business on a daily basis. We are
interpersonal violence and war. (Henry involved in them, they involve us, and they
N. Wagner) draw upon the ways in which we configure
the person. My hunch is that this process will
When PET researcher Henry Wagner (1986: reveal much about the multiple circuits of
253) says that "In PET, we now have a new set theory transfer from laypersons to experts
of eyes that permits us to examine the chemistry and back again to laypersons via all kinds of
of the human mind," he is pointing to a particu- mediators-movies, magazines, personal phys-
lar kind of humanoid: a cyborg whose experi- icians, and anthropologists. These circuits of
ence of vision includes the physiology of the fact distribution and presupposition are worth
brain as witnessed through PET scanning. Kra- understanding if we want to play a critical role
mer and Sam listen to Prozac to hear Sam,s true in our own understanding of our selves.
self speak. Some of us may shudder at the alien-
ation implied in selves mediated by radiotracers,
new pharmaceuticals, and multimillion-dollar REFERENCES
bioscience. Others may breathe a sigh of relief Andreassen, Nancy.
at not being blamed for personally constructing 1989 Brain Imaging: Applications in
schizophrenic children, at finally being respected Pychiatry. Washington, DC: American Psychi-
as having wonderful children who happen to atric Press.
have a visible and therefore real brain dysfunc- Andreassen, Nancy.
tion. Still others may wonder when and how 1992 "Neuroradiology and Neuropsychiatry:
they will be classed as normal or abnormal, or A New Alliance.,, American]ournal of Neuror-
if the binary categorization will finally prevail. adiology 13:841-3.
In conclusion, I have tried to point out some Begley, Sharon.
of the ways in which contemporary biomedical 1991 "Thinking Looks Like This: PET Scans
and scientific practices are culturally situated. Show the Brain RecaHing and Cogitating.,
These practices are participating in ongoing ne- Newsweek 118 (22):67(1).
gotiations not just of specific brain-behavior- Dumit, Joseph.
mind links but also of the nature of human nature 1995 "Mindful Images: PET Scans and Per-
and the significance of human differences. I have sonhood in Biomedical America." Ph.D. diss.,
tried to show both the complexity of the process History of Consciousness, University of Cali-
of producing contemporary neuroscientific facts fornia-Santa Cruz.
and images as well as the numerous ways in Fabrega, Horacio
which practical considerations often build in as- 1989 "An Ethnomedical Perspective of
Anglo-American Psychiatry." American }attr-
sumptions about human nature with undesirable
nal of Psychiatry 146:588-96.
and socially unequal consequences. My purpose
Good, Mary-Jo, P. Brodwin, Byron J. Good, and
is not to point a finger at any particular sets of
Arthur Kleinman, eds.
people or techniques. I think it is necessary to 1992 Pain as Human Experience: An Anthro-
recognize the social and cognitive benefits of pological Perspective. Berkeley: University of
these practices for many, many people. Rather, I California Press.
am seeking to find a language to talk about mul- jackson, Jean.
tiple accountabilities between the diverse com- 1994 "Chronic Pain and the Tension between
munities engaged with PET. the Body as Subject and Object. In Thomas J.
The challenges of how to understand the Csordas, ed., Embodiment and Experience:
continuing and increasing presence of biotech- The Existential Ground of Culture and Self.
nopower require close attention not only to the Cambridge: Cambridge University Press.
376 JOSEPH DUMIT
Two prominent Indian physicians recently de- a pre-clinical toxicological testing, [ ... ]
scribed the clinical trials of new drugs in India dosage studies, and a three-phase trial in
as a 'new colonialism'. [ ... ] But a moral cri- humans. Phase I trials are conducted on a small
tique of this kind, however legitimate in its own number of healthy volunteers [ ... ] Phase 2,
terms, does not adequately grasp the network [ ... ] involves a few hundred subjects, who
of economic and social relations that the inter- may be either patients or healthy individuals.
national health industry has established on a Phase 3 involves large-scale randomized trials
global scale. Even if all clinical trials conducted on several thousand people, usually patients
in India or other Third World countries adhered suffering from the ailment for which the ther-
to the letter of the law and the spirit of ethical apy has been developed. These trials are fre-
codes, the very structure of this network would quently coordinated across multiple centres,
remain one of exploitation. I shall outline here increasingly on a global scale.
the dynamics of clinical trials in India, focusing The sponsors for trials are generally bio-
especially on the huge capacity currently being technology or pharmaceutical companies
built up in anticipation of the transfer of global [ ... ].Universities and publicly funded labora-
trials to the subcontinent. This will provide a tories play a major role in the early stages of
basis for interpreting the phenomenon in terms discovery - the identification of potential lead
of concepts developed by myself and others molecules and the conduct of pre-clinical tests-
currently researching this field, particularly but the institutional structure of drug develop-
those of biocapital and surplus health. ment is such that they increasingly license
promising molecules to corporations that take
them through clinical trials. This means that
I. The Landscape of Clinical Trials the biomedical and experimental rationales for
clinical trials are completely entwined with the
[ ... ]The clinical-trials procedure is an elabor- market value these companies see in the drugs
ate one, conducted in a num her of stages and [ ... ] According to the Healthcare Financial
contributing to the immense time, risk and Management Association's newsletter, twenty
expense of the drug development process: years ago, 80 per cent of clinical research trials
Kaushik Sunder Rajan, "Experimental Values: Indian Clinical Trials and Surplus Health," New Left Review
45 (2007): 67-88.
378 KAUSHIK SUNDER RAJAN
biotechnology and clinical-research initiatives, that of cost; estimates suggest that overall clin-
especially to open institutes that can perform ical-trial expenses for a multinational company
or facilitate such research around the country. could be reduced by 30 to 50 per cent, thanks
The Department is currently funding several to lower labour and infrastructure costs. There
new clinical research training centres around is also a perceived recruitment advantage - the
India, [ ... ] Building the human-resource cap- assumption being that it is easier to obtain
ability to conduct and monitor trials in India is Indians for such trials, especially 'treatment-
a key challenge, and a number of entrepreneur- nave' subjects. A major problem for drug com-
ial ventures are fully engaged in training the panies conducting trials in the US is that
labour force required. Finally, there are the Americans are therapeutically saturated, al-
physicians who actually conduct the trials, ready taking so many drugs that it is hard to
though in the Indian context they have a rela- determine the efficacy of the molecule being
tively marginal presence compared to the tested without having to confront a whole
CROs in setting the infrastructural and regula- range of interactions that muddy the data
tory agenda for research. considerably.
There is a strong common interest among Other factors come into play when assess-
these actors - though this applies somewhat ing the attractiveness of a country as a clinical-
less to physicians - not just in building up a trial location. The recent report by A. T. Kearney
research infrastructure in India, but also in (2006), which provided an 'attractiveness
promoting the country as a global destination index' for countries as trial destinations, con-
for clinical trials. The experimental potential of sidered - in addition to cost efficiency and
Indian populations as trial subjects melds patient pool- 'regulatory conditions', 'relevant
seamlessly with the market potential that expertise' and 'infrastructure and environ-
Indian CROs perceive from an influx of these ment'. Indian actors are focusing on these three
trials, and this convergence is facilitated by a key areas as part of their capacity-building
larger historical moment that sees the Indian efforts; and indeed, Kearney already ranks
state branding and marketing itself ro investors India as the second most attractive destination,
at global forums. after China, for clinical trials outside the US.
India scored much higher than the US in terms
of patient pool and cost efficiency, but lower on
Economics and ethics the other three counts.
Some of the enthusiasm around clinical trials However, the scenario is more complicated
within India is mirrored in the West by agents than one in which Western multinationals are
who might outsource clinical trials to the coun- tearing down the door to exploit cheap Indian
try. For the most part, however, the anticipated populations. For early-stage trials in particular,
surge in trial contracts to India remains specu- it is uncertain how strong the pressure is for
lative. The infrastructure-building occurring in Western companies to outsource to India.
India is very real; but it is a bet on future There are obvious advantages in terms of cost
outcomes that, like any other speculation, and the ease of volunteer recruitment; but there
may or may not pay off. To understand the is also a downside in terms of the relative diffi-
clinical-trial situation in India, we must con- culty of monitoring trials- very important if
sider both the enthusiasms and the reservations the data generated is to pass muster with the
of Western agents. FDA- and the potential public-relations disas-
The anticipation of global clinical trials ter that could attend an early-stage trial that
coming to India is based on the expectation went disastrously wrong in a Third World con-
that it would serve the interests of Western text. Indeed, the Kearney report points out that
trial sponsors - especially US biotech and in August 2005, the top twelve pharmaceutical
pharmaceutical companies - to outsource these companies were running 175 ongoing trials in
trials to the subcontinent. [ ... ] Germany- attractiveness index 4.69- and 161
The various perceived advantages in taking in the UK - attractiveness index 5.0 - com-
clinical trials to India include, among others, pared to 26 in India, which had an
380 KAUSHIK SUNDER RAJAN
attractiveness index of 5.58. In 2004, Pfizer harmonized with what are known as Inter-
invested roughly $13 million in clinical trials national Conference on Harmonization proto-
in India, but this is put in perspective by the cols. Indian regulators are thus currently
fact that its total global R&D expenditure was involved in a massive standardization process,
$8 billion. Perhaps more than pharmaceutical driven by the Indian CRO industry. As legally
companies themselves, it is Western CROs who embodied, then, Indian ethical guidelines are
see real value in finding new destinations for likely to be at least as stringent as those for the
some of their already outsourced activity. conduct of clinical research in the US, and in
Therefore, while there are convincing market some ways more so.
rationales for taking trials to India, and an Members of India's CRO industry bristle at
already strong flow of trials there through the the suggestion that clinical trials will move to
multinational CRO industry, much of the cap- India because it is possible to cut ethical
acity building in clinical research in India is still corners there. This idea has been part of the
a bet on potential value from trials that could debate around Indian clinical trials, [ •.. J CRO
be outsourced in future. leaders are acutely aware of the need to build a
Capacity building in this context means positive media image for their industry, and
something far more extensive than the experi- place great emphasis on the ways in which
mental infrastructure for conducting clinical Schedule Y exceeds the demands of the
trials, which is perhaps the easiest component International Conference on Harmonization.
in a country like India where material and Specifically, Schedule Y is concerned with en-
financial resources are no longer so limited. suring extra care in gathering informed consent
[ ... ] A more elaborate challenge is building from illiterate subjects and in considering what
an adequate regulatory infrastructure, which might constitute 'ethical' compensation for
needs to be far stronger if India is to host global poor subjects recruited into early-stage trials -
trials. This is especially so for trials outsourced the logic here being that lucrative remuner-
from a US-based sponsor, which needs to meet ation can actually act as a coercive incentive.
the FDA's stringent criteria. Adriana Petryna ...
[ ]
has argued for a state of 'ethical variability,, Outside the enforcement potential of
suggesting that ethical practices for clinical Schedule Y, however, a larger regulatory body
trials vary between First and Third World with the scope of the FDA is still absent. As
locales (2005a, 2005b). While in practice it is mentioned earlier, the Drug Controller-Gen-
quite possible that the implementation of eth- eral of India is the nominal equivalent, but
ical guidelines is ultimately stricter in the First its remit is still basically limited to approving
World, it is important to note the very serious drugs for the market or for import into the
attention now given to ethics by both the country. Part of the regulatory effort currently
Indian regulatory agencies and the CRO indus- under way in India consists in building a more
try there. Of equal importance is what such substantial regulatory body with oversight
ethics comprise, and what is left out. powers that parallel those of the FDA, and
An ethical-trial protocol is primarily con- whose conduct can be harmonized with that
cerned with the question of informed consent. of its US counterpart. This was a central rec-
This includes the entire apparatus surrounding ommendation of the Mashelkar Committee
the consent process, especially an institutional Report of October 2005, which proposed a
review board infrastructure. Ethical practices National Biotechnology Regulatory Authority
in India are enshrined in guidelines that the that would regulate not just pharmaceuticals,
government published in 2001. In 2005, these but also agricultural products, transgenic
guidelines were converted into laws, known as crops, food and feed, and transgenic animals
Schedule Y. Interestingly, India is the only and aquaculture.
country in the world where the violation of Ethics, legally enshrined and contractually
good clinical practice is a criminal rather than enforced, are integral to the capacity-building
a civil offence. At the same time, global trials effort around clinical research in India.
that are valid in the eyes of the FDA need to be Members of the CRO industry are the most
EXPERIMENTAL VALUES 381
good - the development of new therapies. physician told me: 'In the last two trials, the
Those recruited into Phase I trials tend to be companies said they'll try and make the drugs
less well-off in the US as well, so that the social available. We have yet to see if that will
contract can never be a pure liberal one be- happen. If it doesn't happen, then we will only
tween rational individuals. [ ... ] Nonetheless, participate with companies that give an abso-
there is an animating liberal sentiment which lute commitment.'
absolutely presumes that the therapy, if While this physician and the hospitals
developed, will eventually be accessible. And where he works might be willing to take such
even if this is access via the market, for a price, an uncompromising stand on linking clinical
thus raising issues of affordability and distribu- experimentation with therapeutic access and
tive justice, these issues can in principle be pastoral care, such a linkage is less likely to
addressed through liberal welfare-state mech- figure in the calculations of the CROs, espe-
anisms. In the Indian context, by contrast, cially those focused on early-stage trials, since
there is no guarantee that an experimental drug their source of values lies directly in increasing
tested on a local population will necessarily be the number of trials they can conduct, rather
marketed there after approval - let alone be than in providing tangible therapeutic benefits
made available at an affordable cost. The to patients. As suggested earlier, it is the CRO
Indian state has made no moves to ensure this, industry rather than physicians that is currently
for example through such mechanisms as com- driving the establishment of regulatory infra-
pulsory licensing regulations. The likely out- structure in India. The Delhi-based psychiatrist
come is therefore a situation where Indian told me that while there is intense debate
populations are used purely as experimental within the psychiatric community in India over
subjects without the implicit social contract of the relationship of clinical trials to drug access,
eventual therapeutic access. physician investigators are involved only to a
The question of access to drugs is certainly a very limited extent in efforts to streamline the
live one in the Indian medical community. regulatory process.
[ ... ] A leading Delhi-based psychiatrist in a This subjection of patients to experimental
prominent private hospital - who preferred to regimes without an insistence on concomitant
remain anonymous - told me that 'while we therapeutic access does not seem to arise pri-
understand the need for conducting trials, there marily from any reluctance of Western pharma-
is need for more uniform regulatory control'. ceutical companies to market drugs in India. It
This is not someone outside the circuit of clin- is true that 85 per cent of all global drug sales
ical research; he is himself engaged in testing a are currently accounted for by US, European
number of psychiatric drugs. Most of the trials and Japanese markets, though the burgeoning
such prominent physicians conduct, however, middle class in India may be a factor in the
are categorized as Phase 3, and involve patients companies' future planning. At the present
they are treating, which puts their practice time, however, the only real avenue for any sort
under a different ethical calculus - having to of therapeutic access to experimental drugs is
do with pastoral care - from that of CROs through the 'compassionate use' programmes
looking to increase Phase I trials on healthy of a number of pharmaceutical companies,
volunteers, where the issue is simply one of which make the drugs tested in Phase 3 trials
experimental subjectivity. The relationship of available to the sick volunteers for a fixed
such trials to drug access is an acute question period of time after completion of the triaL
for this physician, especially as regards subjects No one in the Indian CRO industry whom I
who may need to continue taking the experi- talked to, and no one who is actively involved
mental medication that is tested upon them if it in developing clinical-practice guidelines, felt it
is shown to have positive effects. The only was necessary to insist that drugs tested in India
mechanisms that exist to provide such access, should be marketed there, in contrast to the
however, arise from the policies of the com- vigorous discussion among physicians of the
panies sponsoring the trials, or the concerns relationship between clinical trials and access
of the centre conducting the trial. The same to drugs. 'Ethics', therefore, are provisional and
EXPERIMENTAL VALUES 383
partial, bearing primarily at this point on con- few biotech companies that have managed to
cerns about informed consent. grow sufficiently to join the marketing effort.
The uncoupling of experimental subjectiv- Upstream companies conduct more basic
ity from therapeutic access, which - through research, focusing on informatics, the develop-
acts of omission- occurs at a legal and regula- ment of diagnostic kits or the provision of re-
tory level, enrols Indian experimental subjects search tools to other companies. Clinical-
in the cause of health, but locates them outside research organizations fit into this model as
a regime of pastoral care. In other words, these downstream facilitators to large pharmaceut-
experimental subjects contribute in some nebu- ical companies. There are particular risks in
lous sense to health by making themselves this marketplace, in view of the enormous time
available as experimental subjects, but this is spent on drug development (roughly fifteen
in no way necessarily linked to their own years), the cost ($800 million per drug,
healthiness, or that of other Indians who might according to the industry, though that is most
obtain access to new medication as a conse- certainly inflated) and the risk (only one in five
quence of the risks to which the volunteers drugs makes it through clinical trials). And
are exposed. The nature of these risks was there are particular power hierarchies within
brought home to me during my tour of Vimta, it, such as the hugely powerful position of big
when I was shown a room, at the time dark and pharmaceutical companies in the value chain
secluded, with just four beds in it. This, I was relative to smaller biotech companies.
told, is the intensive care unit where trial sub- The second layer of specificity is epistemic.
jects are admitted and ministered to in case of For instance, emergent life sciences such as
adverse effects. It looked like a medical emer- genomics have the potential to radically recon-
gency room of the kind used to attend to acci- figure our understanding of life in ways that
dents on the factory floor. It re-emphasized not parallel the fashion in which neo-liberallogics
just the high-risk nature of experimental sub- of capital are reconfiguring our understanding
jectivity, but that being a trial subject is, specif- of value. While I do not elaborate on this point
ically, high-risk labour. here, I believe that to describe the institutional
arrangements of the life sciences is not a suffi-
cient basis for comprehending biocapital in all
3. Expropriation, Exploitation, its complexity; emergent epistemologies are
Violence also crucial.
These first two layers of specificity are in-
A theoretical critique of the global biomedical ternal to biocapital. The third has to do with
economy, situating the latter in relation to the the larger epochal transformations in capital-
logics of expropriation and exploitation, re- ism as a whole, which preface some of bioca-
quires the introduction of the key concepts of pital's structural logics. The transformation
biocapital and surplus health. By biocapital, I that is pertinent to understanding biocapital is
refer to the simultaneous systemic and emer- what Joseph Dumit (2005a, 2005b, 2006)
gent production of the life sciences, especially identifies as the change in the logic of the bio-
biomedicine, alongside the frameworks of cap- medical industry, shifting away from being
ital and the market within which such tech- 'an arm of capital' to becoming 'an industry
noscience increasingly operates. There are in itself'. At an earlier stage of capitalist
three layers of specificity to biocapital: insti- development, medicine was integral to repro-
tutional, epistemic and structural/epochal. ducing the conditions under which industrial
First, the biomedical industry, like any production was made possible. Capital needed
other, has its specific institutional terrain. In healthy workers. But just as the logic of com-
the US, this terrain is seen as partitioned into modity production became self-perpetuating
'upstream' and 'downstream'. Downstream lie and self-sustaining, to the point where commer-
big multinational pharmaceutical companies, cial activity became an end in itself, so too has
with the human and capital resources to bring the logic of the production of health for work
drugs to market. These are supplemented by a become self-perpetuating and self-sustaining,
384 KAUSHIK SUNDER RAJAN
turning into an industry that produces health disease risk provided by diagnostic-testing cap-
not for work's sake, but for health's sake. In abilities, and calibrated through these thresh-
biocapital, health operates directly as an index olds, enables the marketing of drugs for
of value, unmediated through the labour-power diseases that are increasingly reframed as
of the worker. In Foucauldian terms, it is not 'chronic'. just as much of the manufacturing
labour but life itself which becomes the locus of labour previously performed by the working
value in biocapital, with health becoming the class in the First World was later exported to
index of life, rather than the facilitator of Third World peripheries, so much of the Phase
labour. I experimentation, initially performed on mar-
Crucial to this transformation is the emer- ginal populations in the US, is now being
gence of the value-form of surplus health. Du- exported to Third World sites such as India.
mit defines surplus health as 'the capacity to The experimental subjects there, outside the cir-
add medications to our life through lowering cuits of pastoral care and therapeutic consump-
the level of risk required to be "at risk" . This tion, come to be merely risked. But these very
occurs by setting biomedical risk thresholds. circuits rely for their constitution on the exist-
Clinical trials become a part of the apparatus ence of such 'merely risked' subjects. These
through which such a lowering of the risk level experimental subjects provide the conditions
takes place. An analogy might be made with of possibility for the nco-liberal consumer sub-
the way in which machinery, in Marx's analysis jects for whom surplus health is generated.
in Volume One of Capital, operates not to
reduce work, but to increase surplus labour
by widening the gap between waged work
The context of consent
and the potential productivity of the worker. The 'merely risked' volunteer is subjected to a
Surplus health refers to the market value logic of expropriation integral to the structural
that pharmaceutical companies gain from the logic of biocapital that I am trying to trace.
potential for future illness of chose who might Bodies are made available to the global ma-
one day consume their drugs- which includes chinery of experimentation, machinery driven
anyone with the buying power to constitute a by the value logic of pharmaceutical capital.
market for therapeutics. As with surplus-value Indeed, the global scale of these circuits is
in the Marxian sense, surplus health is an ani- precisely a function of capital's value consider-
mating abstraction, in this case of the logic of ations. Without the cost rationales for outsour-
pharmaceutical risk. Just as the setting of wage cing clinical trials to the Third World, their
rates is the material calculus for the unfolding globalization would not have become such a
of surplus-value, so the setting of biomedical dynamic imperative - such trials had, after all,
risk thresholds is the material calculus upon been an important part of the American drug
which surplus health unfolds. And as machin- development landscape for nearly half a cen-
ery serves to increase surplus-value by increas- tury before moves to take them abroad began
ing the potential for labour over and above that in the mid 1990s. And without the property
remunerated by wages - through an increase in mechanisms, harmonized and enforced glob-
the efficiency of Ia hour - so too can clinical ally through the WTO, that provide patent
trials serve to increase surplus health by dem- protection to multinational pharmaceutical
onstrating therapeutic efficacy. interests, globalizing capital would not have
Similarly, just as machinery requires labour had the security to realize its aspirations. Simi-
to operate it- which, during the era of industrial larly, capital considerations drive the Indian
capital, was high-risk work - so clinical trials CRO industry to a vigorous build-up of infra-
require experimental subjects as their high-risk structure to attract clinical trials, increase trial
labour. Dumit suggests that biomedical markets recruitment, and uncouple these considerations
in advanced liberal societies - especially the from any serious concern with therapeutic
United States - depend on the generation of access.
surplus health, which in turn operates through In this situation, the partial ethic enshrined
the setting of risk thresholds. The knowledge of in 'good clinical practice', far from mitigating
EXPERIMENTAL VALUES 385
the structural violence of capital, serves instead Marx in his analysis of capital, and pertains to
to facilitate it. The instrument through which the conditions of possibility that ensure the
this takes place is the liberal contract embodied availability of workers for capital - or in this
in the informed consent form. Just as the wage case, of experimental subjects for clinical trials
is the materialized contractual form through - in the first place. In 'The So-Called Primitive
which individuals are 'freed' from serfdom Accumulation', Marx shows that this availabil-
and converted into workers for industrial cap- ity is generated by pre-existing acts of violence
ital, so the informed consent document 'frees' that created a property-less proletariat. Such
experimental subjects from being coerced processes are historically specific, but they do
guinea-pigs by providing them with the au- show a consistency of form. Thus, for instance,
tonomous agency such a contract signifies. subject recruitment into Phase I clinical trials in
The concerns raised over ethical variability in India occurs, on the face of it, through news-
global clinical trials are often premised on the paper advertisements. The public face of trial
notion that ethical enforcement is likely to be recruitment does not, however, reveal the con-
looser in the Third World than in the First. My ditions that make it financially attractive for
attempt here has been to show that, on the individuals to risk themselves as experimental
contrary, it is precisely the global harmoniza- subjects.
tion of ethical standards that provides the con- I have written elsewhere, for example,
ditions of possibility for the experimental about Wellquest, which is located in the mill
subjection of the 'merely risked' Third World districts of Mumbai (Sunder Raj an 2005, 2006).
subject; and further, that this harmonization of I learned from scientists there that most of the
ethics goes hand-in-hand with the global har- trial subjects recruited by this CRO happened
monization of property regimes. These two to be unemployed mill workers who had lost
parallel movements - the contractual codifica- their jobs due to the progressive evisceration of
tion of ethics and the exclusionary instruments the Mumbai textile industry over the last thirty
of property - together provide global capital years. The number of unemployed is over two
with the security to turn healthy Indian popu- hundred thousand, many of whom are
lations into experimental subjects, who are still waiting for the payment of back wages.
both merely risked and free to choose to be so. They are already, therefore, subjected to the
The structural violence of clinical experi- violence of de-proletarianization that occurred
mentation starts with the fact that it is a pro- following the demise of a sector of manufac-
cedure that can only be set in motion by the turing capital. This violence is exacerbated by
risking of healthy subjects. Indeed, the very the fact that the textile mills are situated on
epistemology of clinical trials is risk-laden - prime land for property development, with
both for the subjects experimented upon, and former mill owners themselves turning to
for the companies who invest huge amounts of real-estate speculation as a far more lucrative
money in a therapeutic molecule that may or source of capital investment. This means that
may not eventually come to market. The struc- the workers' tenements or chawls, mainly lo-
tural violence of experimentation is then cated close to the mills, are under threat of
exacerbated by pre-existing global inequalities, demolition, so that in addition to losing wage
which result in more bodies available for less and livelihood, these workers are now in
cost in Third World locales. If the former vio- danger of losing their shelter as well. Demoli-
lence is epistemic, the latter is historical. A tion of the chawls was temporarily halted by a
third layer of structural violence is imposed in 2005 Bombay High Court verdict that stayed
the form of the liberal contract, which frees the real-estate development in the mill districts,
experimental subject to make his body avail- but this was overturned by the Indian Supreme
able not just for experimentation, but for ex- Court in March 2006, making it legal to tear
ploitation, since the clinical trial becomes a down the mills and chaw/s and build middle-
locus of surplus-health generation. class housing instead.
The question raised by this third layer of The violence of de-proletarianization and
structural violence is one that was central for dispossession is a function of the dominance
386 KAUSHIK SUNDER RAJAN
of speculative real estate, which has replaced that those for which the drug was initially ap-
textile manufacturing as a source of value-gen- proved- or by increasing the timespan of the
eration for capital. A number of unemployed prescription, justified by reframing diseases as
mill workers have turned into street hawkers in chronic staces rather than events. Dumit ob-
order to earn a living, but there is an organized serves that currently 'the average American is
state and middle-class campaign against the prescribed and purchases somewhere between
hawkers, who are deemed noisy and polluting, nine and thirteen different prescription-only
and perhaps most importantly, accused of drugs per year.' He continues:
taking up valuable parking space. There is no
According to the pharmacy benefits com-
way to understand the dynamics of clinical
panies and insurance companies, such as Ex-
experimentation in the mill districts of Mum- press Scripts, sampling 3 million unique
bai without taking into account all these prior individuals in their plans, 11 per cent of
moments of violence that provide the induce- Americans were prescribed cholesterol-
ment to sign an informed consent form. First lowering drugs last year, 40 per cent of
the mill workers are removed from their factor- all those over 50. More than 20 per cent
ies. Then they are removed from their dwell- of women over 40 were prescribed anti-
ings. Then they are removed from the streets. depressants in 2002, almost 10 per cent of
Only thus do they acquire the freedom to boys 10-14 were prescribed attention-deficit
become autonomous trial 'volunteers'. disorder drugs . . . The growth rates for
almost all classes of drugs have been in the
low double digits for a decade, with prescrip-
Global connections tion rates for children growing upwards of 30
One way of understanding the situation of ex- per cent per year. Similarly, both the preva-
propriation that I have described is in terms of lence (the number of people on each drug)
neo-colonialism. [ ... ] a deep historical and and the intensity (the size of the yearly pre-
continuing inequality, whereby rich/First scription) are projected to continue to grow in
World/white subjects enrich their health- and all drug categories for the foreseeable future.
often wealth- through the corporeal disposses- The figures do match the fears, and according
sion of subalternffhird World/racially marked to many surveys, Americans are spending
more time, more energy, more attention, and
subjects. While sympathetic to the inequalities
money on health. Health clearly is not simply
that such accounts describe, the accumulation
a cost to the nation to be reduced; it is also a
by dispossession, [ ... ]that I am trying to trace market to be grown.
here is not agential but structural, where the
one thing that accumulates as a consequence of Marx's analysis in Volume One of Capital is
'merely risking' experimental subjects is not two-fold. First, the contemporary conditions of
health- not even that of the advanced liberal industrial capital that he traces are marked by
subject - but value. exploitation materialized through surplus-
For this, it is important to turn to Dumit's value, a function of labour-power being always
(2006) account of surplus health in the United already greater than the labour remunerated by
States. The therapeutic economy that Dumit wage. Analogously to this, surplus health is a
traces in the US context is also not one of function of potential therapeutic consumption
pastoral care, but rather therapeutic satur- that is always already greater than that re-
ation. Dumit and I have indeed suggested that, quired to maintain healthiness. This excess
considered from the perspective of pharma- therapeutic consumption is not harmless -
ceutical company logic, health in the US is not indeed, it involves ever-greater medication of
about healthiness either, but about expanding the American population, and has produced
the market for therapeutics. Rising therapeutic catastrophic and fatal side-effects such as those
consumption can be achieved either by increas- associated with the cox-2 inhibitor Vioxx. This
ing the number of people who take a particular therapeutic saturation also leads directly to
drug- most effectively achieved by 'off-label biomedical rationalizations for the outsourcing
use', i.e. prescribing drugs for treatments other of clinical trials, as it becomes increasingly
EXPERIMENTAL VALUES 387
difficult to test the effects of experimental generation both structures and overdetermines
drugs in populations who tend to be on many an allegedly benign enterprise in terms of ex-
other drugs that interact with the molecules propriation and exploitation. Other competing
being tested. logics of capital also naturally come into play,
But the conditions of possibility for most notably a logic of insurance that is par-
exploitation through surplus-value generation ticularly salient in the American context of
are, as Marx shows, dependent on a prior managed care. It is also relevant to the Euro-
expropriation, achieved through a form of pean public-health context, where paying for
violent accumulation that forces people into increased therapeutic consumption is a burden,
becoming workers for industrial capital in the and the logic of value dictates an accent on
first place. The two-fold movement of capital- disease prevention that is not mediated by
violent dispossession followed by exploitation therapeutic saturation.
-is a temporal one in Marx's analysis. In the It is important in every case to privilege the
case of clinical trials, however, the violence analysis of value, rather than assuming from
is spatial, with Third World experimental sub- the outset that the issue is one of biopolitics or
jects expropriated not so that First World pastoral care. At the same time there are many
consumer subjects become healthy, but so that incongruities that are vital to note, not least the
they can be exploited. In both cases, the only Indian state's hyper-attentiveness to ethics and
value that is constantly preserved and its regulation of clinical practice. The struc-
increased is value itself. tural violence of global clinical trials on the
Much of my argument rests on the fact that subcontinent is not due to a lack of ethics, but
clinical experimentation in the Indian context to the fact that value, captured by the logic of
is not linked to therapeutic access. It is, how- capital and mediated through the pharmaceut-
ever, certainly possible to imagine such a situ- ical and CRO industries, overdetermines the
ation; and if this linkage is not created either by practices that emerge.
the intervention of advocacy groups fighting
for access to drugs, or by the state's insistence
on a biopolitical rationale of public good and REFERENCES
public health, it is most likely to be brought
about by market mechanisms once India is Dum it, Joseph
perceived as a potential market for therapeutic 2006a "Drugs, Algorithms, Markets and
consumption. In such a scenario, one can quite Surplus Health." Presented at the Lively
easily envisage the continued expropriation of Capital workshop. University of California,
experimental subjects- those who fall out of Irvine.
the market because they lack the purchasing Dumit, joseph
power to buy drugs- side by side with exploit- 2006b "Living in the Aggregate: Accumulat-
ation of therapeutic consumers within India ing Prognoses, Growing Markets, Experimen-
itself. Stefan Ecks has been studying psychiatric tal Subjects." Presented at the American
drug marketing by companies like Pfizer in Anthropological Association Annual Meetings.
San Jose, CA.
India, and observed strategies not dissimilar
Ecks, Stefan
to those employed in the US.
2006 "Global Citizenship Inc.: Big Pharma
H we are to understand bioca pi tal from the and 'Depression Awareness' in Urban India."
perspective of the pharmaceutical companies' Presented at the Asian Biotechnologies Work-
logic, then what is at stake is not therapeutic shop. Honolulu, HI.
access in the cause of health, but increasing Grace, Patricia
therapeutic consumption in the cause of value. 1998 Baby No-Eyes. Honolulu.
In parallel, from the perspective of CROs, the Harvey, David
issue is not clinical trials in the cause of thera- 2003 The New Imperialism. Oxford.
peutic access, but rather clinical trials in the Jones, Jennifer and Alan Zuckerman
cause of value. The global articulation of "Clinical Research Trials: Creating Com-
pharmaceutical and CRO logics of value- petitive and Financial Advantages." Managing
388 KAUSHIK SUNDER RAJAN
For over half a century, anthropologists have been engaged in international health,
becoming increasingly influential as scientific advisors, researchers and advocates in
the modernist projects of public health and medicine, as well as scholars of these
endeavors and of the social lives of the diseases that produced them. In the late
twentieth century, HIV/AIDS and its global threat revolutionized the institutional,
financial and political architecture of international health (Brown et al. 2006),
culminating in a robust global health movement led in part by anthropologists who
are also physician-activists. Essays in this part span nearly a half century; read
together they represent diverse lineages, historical threads, and ethnographic engage-
ments which have made the anthropology of global health one of the most vital
empirical and theoretical domains in anthropology today.
Speaking in 1976 at a USAID workshop on international health planning, George
Foster, then a leading anthropologist of international health at the University of
California Berkeley, debunked simplistic notions that the cultures of "traditional
peoples" are barriers to use of scientific medicine, arguing instead that "economic
and social costs" and the cultures and interests of those responsible for delivering
care are the greatest barriers. Foster's stance with the people to be served is a
recognizable common thread evident in Paul Farmer's work and that of a great many
anthropologists (cf. Nguyen 2005; Hyde 2007; Biehl 2008).
Craig Janes and Kitty Corbett's essay, originally published in the 2009 Annual
Review of Anthropology, is a gift of references and a masterful tour through the vast
riches of anthropological research in international health and recent writings on
anthropology and global health (Adams et al. 2008; Nichter 2008). Although intro-
ducing an array of definitional components for global health, they argue that the
anthropology of global health is constituted by health actions aimed at reducing
global health inequalities and developing "salutogenic sociocultural, political, and
economic systems." Four broad topics are discussed: {1) explaining health inequities;
392 GLOBAL HEALTH, GLOBAL MEDICINE
REFERENCES
Adams, Vincanne, Thomas Novotny, and Hannah Leslie
2008 "Global Health Diplomacy." Medical Anthropology Quarterly 27:315-23.
Biehl, Joao
2008 Will to Live. Princeton: Princeton University Press.
Brown, T. M., M., Cueto, and E. Fee.
2006 "The World Health Organization and the Transition form International to Global
Public Health." American Journal of Public Health 96(1): 62-72.
Hyde, Sandra T.
2007 Eating Spring Rice: The Cultural Politics of AIDS in Southwest China. Berkeley:
University of California Press.
Nichter, Mark
2008 Global Health. Tucson: University of Arizona Press.
Nguyen Vinh-Kim
2005 "Antiretroviral Globalism, Biopolitics, and Therapeutic Citizenship." In Aihwa Ong
and Stephen J. Collier, eds., Global Assemblages. Oxford: Blackwell Publishers, pp. 124-44.
31
Medical Anthropology and
International Health Planning
George M. Foster
Nevertheless, I am increasingly struck by the evil eye) - illnesses marked by vague and
the fact that many of the apparent resistances shifting symptoms - tended to remain the pro-
to acceptance of health services commonly venience of the traditional curer. The task of the
attributed to villagers' apathy and their anthropologist was to help medical personnel
cultural barriers, are, in fact, the result of find ways to demonstrate the superiority of
administrative and professional inadequacies. scientific medicine, which little by little would
International health programs made significant move the illnesses in this second category into
strides when the importance of social, cultural the first one, the illnesses routinely brought to
and psychological factors in target group cul- the medical doctor.
tures was recognized. The next opportunity for This model is not without merit: independ-
comparable progress lies, first, in recognizing ently it has been worked out in Latin America,
(or admitting) the limitations in present bur- South and southeast Asia, and other places as
eaucratic forms, and in many professional and well. It was through this model that we learned
individual assumptions found in all health pro- the pragmatic quality of traditional reasoning
grams; and second, in being willing to face up processes, that if peasant and tribal peoples
to these problems, even at the cost of profes- could perceive advantages resulting from
sional discomfort. changed behavior, they were willing to drop
old and cherished beliefs and practices by the
wayside. This dichotomous model - illnesses
Innovation in Health Behavior medical doctors can cure, and those they
cannot cure - has proven to be simplistic, as
Let us now ask a pair of questions that stem will be pointed out a little farther along.
from premises two and three: (1) What have we Obviously there are social, cultural, and
learned about the sociocultural and psycho- psychological barriers to the full acceptance
logical factors in traditional populations that of modern medicine that are found in every
enable us better to understand the process of traditional community. It would be foolish to
accepting scientific medicine, and that suggest deny the importance of these factors, examples
leads in future program planning? and (2) What of which are known to all of us. In parts of
do we know about health bureaucracies and Latin America there is great resistance to with-
health personnel, or what must be learned drawal of blood for laboratory analyses, or for
about them, in order to design and carry out blood transfusions, because of the belief that
more effective health programs? blood is a non-renewable substance, and that a
In early analyses of the sociocultural factors person is weakened permanently by such with-
that seemed to inhibit acceptance of scientific drawals (Adams 1955:446-7). In Africa where
medicine by traditional peoples, anthropo- the belief in witchcraft is strong, resistance to
logists developed an "adversary'' model to the use of sanitary latrines has been noted.
explain the resistances that occurred. It was People are reluctant to concentrate their feces
postulated that scientific and traditional medi- for the convenience of witches who may wish
cine were locked in battle, each trying to win (or to work their magic on them {Kark 1962:26).
hold on to) the allegiance of the community. In India it has often been reported that villa-
The model postulated that traditional peoples gers are reluctant to vaccinate against small-
divided illness into two categories: those that pox because of the belief that this is a "sacred"
medical doctors understood and could cure; disease sent by a Mother Goddess whose will
and those medical doctors did not know about, should not be contravened. In other countries,
much less understand, and which therefore they pregnant women have given as their reason
could not treat. Acute, infectious diseases - for refusing hospital delivery the fear that the
those yielding to antibiotics - quickly fell into placenta will not be given to the family for
the first category; the medical doctor's compe- ritual disposal. All of these, and countless
tence here was easily demonstrated. Chronic more examples, can be given of real "barriers"
illnesses, those with major psychological com- to full acceptance of available medical
ponents, and those "magical,. in nature (e.g., services.
MEDICAL ANTHROPOLOGY AND INTERNATIONAL HEALTH PLANNING 397
Yet I am increasingly convinced that eco- Among those who suffer from major illness,
nomic and social costs are more important in only a very tiny fraction preferentially adopt
determining the use or nonuse of scientific these practices by positively rejecting facilities
medicine than is the belief-conflict between of the western system of medicine which are
traditional and modern medicine. I now believe more efficacious and which are easily avail-
that the adversary model is appropriate for the able and accessible to them (1974:7)
initial contact period when traditional peoples The picture is the same in Thailand where,
for the first time have the alternative of con- in a major study of doctor-patient relation-
sulting medical doctors. But the evidence is ships, it was found that "The decision to go to
overwhelming that in countries where trad- a hospital depends less on the gravity of the
itional peoples have had access to modern disease than on financial resources" (Hinder-
medicine for a generation or longer, and where ling 1973:74). The same study revealed that,
this medicine has been of reasonably good while in rural areas far from hospitals phy-
quality, the battle has been won, and scientific sicians are sometimes seen as a last resort,
medicine is the victor. in cities the order is reversed: "The modern
The first decision-making model to account doctor is the first to be consulted, and [only]
for choice of medical help, worked out by an- if he is not successful, one of the quite fashion-
thropologists for developing countries, was a able [traditional] healers will be called upon"
three-stage sequence: (1) home remedies, (2) {Boesch 1972:34).
indigenous curer, and (3) the medical doctor,
but only after the first two choices failed to
produce results. In 1945, this was true in Tzint-
The Basis for Acceptance of
zuntzan, Mexico, a peasant community I have Scientific Medicine
studied since that date. Today, however, the
sequence is the same as that followed by many We now turn to the motivations and processes
Americans: (1) home remedy, (2) medical underlying innovation in medical practice. The
doctor, and (3) indigenous curer (or faith healer first thing we note is that they are essentially
in the United States) only after the first two the same as those that underlie innovation in
choices fail to produce results. all areas. I suggest that people will change
It may be argued that relatively few coun- traditional behavior, i.e., innovate:
tries in the developing world have the resources
of Mexico, and that general acceptance of sci- 1 if they perceive personal economic, social,
entific medicine will not come so readily in the psychological, health, or other advantages
rest of the world. Yet the evidence suggests the in so doing;
contrary. In India, Banerji and his colleagues 2 if they perceive change as a realistic possi-
have carried out studies that show the same bility for them;
trend. In a fairly extensive study they were 3 if the economic costs are within their capa-
surprised to find bilities;
4 if the social costs do not outweigh the per-
that the response to the major medical care ceived advantage.
problems is very much in favour of the west-
ern . . . system of medicine, irrespective of In other words, people are remarkably
social, economic, occupational and regional pragmatic in evaluating and testing new alter-
considerations. Availability of such services natives, including health services. One can
a11d capacity of patients to meet the expenses almost speak of a cost-benefit mode of analy-
are the two maior constraining factors (Banerji
sis. When, on the basis of empirical evidence,
1974:6; emphasis added).
traditional peoples see that scientific medicine
Further, while Banerji found numerous examples is more effective than their own, and when
of consulting practitioners of indigenous or they can have scientific medicine on terms
homeopathic medicine, they deem acceptable, they happily tum to it.
398 GEORGE M. FOSTER
Speaking of the acceptance of curative medi· one or combination of reasons a person feels
cine in Ecuador, Erasmus, many years ago the goal is unrealistic, change motivation will
pointed out that, as far as tradition was be lacking.
concerned, "folk beliefs in themselves are
offering no resistance to modern medical prac·
rices in so far as those practices may be judged "Free" Services
by the folk on an empirical basis,'
(Erasmus 1952:418; emphasis added). In When traditional peoples attempt to determine
contrast Erasmus found that preventive medi- whether contemplated changes in their health
cine was resisted because its comprehension is practices are in fact realistic, economic factors
essentially theoretical, not lending itself to easy appear to be the most important of all vari-
empirical verification. ables. While on the one hand token fees for
The evidence clearly indicates that, as far as medical services have often been reported to
individual decision making is concerned, cura· confer value on these services, and hence may
tive medical services are embraced much more be desirable policy in some situations (e.g.,
readily than preventive services. The reason is Foster 1973:136-8), most improved medical
obvious: the results of scientific curative medi- services for village peoples will have to be pro-
cine are much more easily demonstrated than vided by the state, at little or no cost to the
the results of preventive medicine. Few people consumers. Increasingly this is recognized, and
suffering from yaws or other dangerous infec- more and more "free, services are offered.
tions which have been cut short by an injection "Free" services, unfortunately, are often expen-
of an antibiotic question that this is indeed sive by village standards. Ndeti, for example, in
a miracle medicine much superior to any a study of tuberculosis control in Kenya found
they have previously known. Cause and effect that the bus fare kept a large number of patients
are easily comprehended when serious illness from coming to the clinic (Ndeti 1972:408).
gives way to no illness in a few hours or days. In Indonesia, family planning services,
Cause and effect are less easily seen when, as in "free" in the strict sense of the word, are some-
the case of immunization and environmental times underutilized because of social customs
sanitation programs, no disease is followed by requiring expenditures. Most mothers are
no disease. The implications that must be interested in birth control only after they have
drawn from this evidence is that the traditional had four or five children. Often they have no
American separation of most clinical from one with whom to leave these children so that
most preventive medical measures is, in other when, in response to the urging of a family
parts of the world, counter-productive. Ex- planning worker, they decide to visit a clinic,
perience suggests that preventive measures at least the younger children must trail along.
are more apt to be accepted if they are "blan- This usually means a bus fare for all. But a trip
keted in" with, or sold as a part of a "package on a bus is, by definition, an "outing," and on
deaP, along with curative medicine, whose ad- such occasions people buy food snacks, to
vantages are so much more easily demon- which Indonesians are much addicted. So a
strated. mother with three or four small children may
But, however pragmatic people may be, this well spend a day's income on a simple visit to
quality is of little value unless innovation is the "free" family planning clinic.
seen as a realistic aspiration for the individual. Other kinds of costs may also make "free"
A peasant farmer may be persuaded that family planning services prohibitively expen·
hybrid rice sown on a heavily fertilized irri- sive. In a village near Bandung, in western java,
gated field is agriculturally advantageous, but at the bottom of a steep valley reached only by
if his marginal lands do not lend themselves to a poor dirt road, a woman seeking family plan·
this intensive approach, or if credit facilities are ning help has to ascend to the health center in a
inadequate, his planting practices are unlikely truck or old bus that requires nearly an hour
to change. Similarly, changing health practices for the five·mile trip, paying 100 rupiahs fare
may be perceived to be desirable but if for any each way. There she finds that, prior to being
MEDICAL ANTHROPOLOGY AND INTERNATIONAL HEALTH PLANNING 399
given pills or fitted with an IUD she must take a much a bureaucrat as is a medical adviser sent
pregnancy test, which carries a laboratory fee abroad by AID. My manifest function is to
of 150 rupiahs. The woman is asked to return contribute to higher education and research,
three days later- again at a cost of 200 rupiahs formally-defined as a societal need.
for transportation - to learn the laboratory My argument here is that if we are fully to
results. If the 200 rupiahs lost by absence from appreciate the dynamics of the planned change
work for two days are added in, it costs process, in health practices and in all other
a woman 750 rupiahs -more than a week's fields, it is essential to study administrators,
income - simply to find out if she is eligible planners, and professional specialists as indi-
for family planning. Small wonder that few of viduals and as members of professions and
these women are interested in this kind of ser- bureaucracies, in the same ways and for the
vice (author's field notes). same reasons that we study traditional societies
or any other client group - for bureaucracies
and their personnel can be studied in essentially
the same fashion as a peasant village or the
Social Costs urban neighborhood served by a public health
center. A bureaucracy, in its structural and
Finally, we must take note of the "social" costs
dynamic aspects, is very much like a "natural"
often involved in changing health behavior. A
community such as, for example, a peasant
young woman may be convinced that the gov-
village, in that it is a real society with a real
ernment health center in or near her village that
culture. And, like a peasant village, most bur-
offers pre- and post-natal care, and delivery
eaucracies include members of both sexes of
services by a doctor and nurse-midwife team,
widely varying ages, organized in a hierarchy
is a more desirable alternative than is delivery
of authority, responsibility, obligations, and
with the aid of a village midwife. But if the
functional tasks. Bureaucracies have social
midwife is her mother's sister, failure to turn
structures that define the role relationships
to the aunt may be seen as a personal rejection,
and statuses of their members, and they have
an act that may cause major family rifts. This
devices to change these relationships, through
kind of a "social" cost is sometimes seen by
promotion, horizontal shifts, by-passing
traditional peoples as too high a price to pay
manoeuvers and - rarely - demotion. Like aU
for perceived advantage. Major behavioral
people in social units, the personnel of bureau-
changes almost always produce, or require,
cracies, and the bureaucracies themselves,
major restructuring of traditional and valued
operate on the basis of implicit and explicit
social relationships. When the "social'' costs of
assumptions which can be analyzed just as
this restructuring - the conflict potential - are
can those assumptions found in natural soci-
seen as outweighing the potential advantage,
eties. Many of these assumptions are influential
the decision will be against change.
in the planning of developmental programs, as
the following examples will show.
A bureaucracy, as we have seen, ostensibly
Bureaucracies in Relation exists to fulfill a need or needs in society; the
to Health Innovation manifest functions of bureaucracies are ex-
pressed in their charters or enabling legislation,
We now turn to the (frequently) unrecognized and it is expected that they will fulfill these
barriers to the best possible health services that functions, normally defined in terms of a client
are inherent in bureaucratic structures and in group. Yet we aU know that, in practice, the
the premises of their personnel. The term "Bur- primary concern of every bureaucracy and of
eaucracy" is used here, not in a pejorative its personnel is the corporate survival and, if
sense, but rather to refer to an organization, possible, the growth of the organization, and
an administrative structure, whose manifest the simultaneous protection of the position
functions are to meet formally-defined societal of staff members. Only when these concerns
needs. As a university professor, I see myself as are taken care of can a bureaucracy turn fuiJ
400 GEORGE M. FOSTER
attention to its client group; and on those time they change and evolve. Innovative pro-
occasions when corporate or individual sur- grams and pilot projects designed to meet these
vival are threatened, this group may receive changing definitions of purpose and need re-
short shrift. quire that new skills and professional specialties
A second premise characterizing most bur- be brought into the organization. Simultan-
eaucracies is that the convenience of personnel, eously the talents of some staff members which
their likes and dislikes, has priority over the were of critical importance during an earlier
convenience of clients. This is seen particularly period, or in the context of projects now closed
clearly in hours of service. I speak from experi- out, may become less essential. To put it briefly,
ence: in setting my major university lectures at new priorities mean that new roles must be
eight o'clock in the morning I have uppermost created, and some old roles given added import-
in mind my own convenience. I realize this ance, while other old roles diminish in import-
hour is not the choice of most members of my ance, with loss of relative rank, authority, and
client group, the students, whose needs I am privilege to the incumbents occupying these
supposed to serve. They would prefer the more latter roles. But, just as the first concern of a
popular hour of ten o'clock; and were I to bureaucracy is to ensure its survival and to pro-
lecture at that time my client group would tect itself against inroads from competing
double. Similarly, hours of service of govern- organizations, so is the first priority of the pro-
ment offices, including health departments, in fessional to protect his or her position within the
this country and in developing countries, are organization. Like people in "natural" commu-
set for the convenience of personnel and not for nities, we professionals jealously guard our trad-
clients. We have all observed instances where itional perquisites and privileges; we do not
the services of government clinics have been willingly surrender something except in
badly underutilized, largely because official exchange for something as good or better. All of
hours from eight in the morning until two in us, as bureaucrats, rationalize our resistance to
the afternoon are the least convenient time for change that may leave us in a less desirable
village women. Moreover, frequent failure of position by arguing - and usually genuinely be-
health personnel to be available at these stipu- lieving- that what is good for us is also best for
lated times means that long and expensive trips our institution, and for its clients. Consequently,
by patients may be in vain. Such casual atten- we may go to extreme lengths, including
tion to the needs and feelings of patients is at back-biting, in-fighting, and bickering in
least as much a "barrier'' to adoption of better effort to protect ourselves. The resulting social
health practices as are beliefs in the efficacy of costs -lowered morale and intra-organizational
traditional medicine, or the fear of disrupting friction - often seem to outweigh the advantages
family relationships by adopting new health of greater responsiveness to new needs, and con-
customs. sequently most bureaucracies change very slowly.
was assumed in early programs to be the "norm" must admit that we crave recognition. Conse-
for overseas development. The Rockefeller anti- quently, our ego-needs not in-frequently motiv-
hookworm campaign in Ceylon was very strictly ate us to search out and concentrate on special
a preventive program, and field personnel re- problems that are important, not so much to
peatedly were cautioned not to become involved our client group as to ourselves, because of the
in curative services. Yet one reason the project opportunity they offer to demonstrate to our
failed to eradicate hookworm was that to the peers our exceptional capacities. All too often
Ceylonese the rationale of environmental sanita- we confuse our psychological needs with the
tion to the exclusion of their health priorities needs of our clients, and we assume that our
made little sense. personal priorities must also be those of the
people we serve. In the planning and operation
Some villagers were irritated by the concen-
of health programs we must acknowledge that
tration on hookworm disease in view of their
personal interests - even research hobbies -
other overwhelming medical needs. . . . The
play an enormously important role in the final
villagers were more interested in having their
form of a service.
wounds and abscesses dressed and their mis-
Finally, we must note an assumption of
cellaneous acute illnesses attended than con-
many medical doctors that is crucial to one of
tinuing in the duB routines of anti-hookworm
the main themes of this workshop, the possible
work (Phillips 1955:289).
role as sub-professional workers of indigenous
Despite the home-office warnings not to scatter medical personnel. John Bryant, in Health and
their energies by engaging in curative activities, the Developing World, has put the matter suc-
field directors found they had to treat all kinds cinctly and sympathetically. A part of the great-
of complaints in order to gain support for the ness of the good physician, he says, is his
hookworm work. acceptance of responsibility to give unstint-
Institute of Inter-American Affairs pro- ingly of himself to those who need his help.
grams in Latin America in the 1940s also em- But this is also the basis for his traditional
phasized prevention rather than curing. This reluctance to share his activities with others,
medical assumption has, in the past, proven to relinquish some of his tasks to less thor-
to be one of the most serious of all barriers in oughly trained personnel. To admit that many
building better health services in developing of the professional tasks he has been trained to
countries. Fortunately, few if any such coun- perform can be carried out equally well by less
tries today are planning their health services on well trained people apparently threatens the
other than a combined basis. ego of many medical practitioners.
The mode of definition of health problems
A curious side of this concept [that only the
frequently limits medical organizations in
physician can provide quality care] is the value
searching for the most efficient ways of meet- the physician places on the particular acts of
ing health needs. As John Bryant has pointed diagnosis and prescription of treatment. Phys-
out, a health problem is what is defined by the icians are anxious to use every level of health
medical establishment (headed by medical worker in furthering a health program . . . but
doctors) as a health problem; consequently the words "diagnose" and "prescribe" evoke
health priorities set by "medically qualified" the strongest feelings of professional posses-
people are the appropriate priorities. In explor- siveness (Bryant 1969:141-2).
ing this phenomenon, we find that we are deal-
ing not alone with the traditional wisdom of The concept that the physician must attend
personally to his patients actually determines
the medical profession, but also - frequently -
the form of most health services, says Bryant,
with the ego structure of individual specialists.
As professionals we are proud of our skills, and and it can obstruct efforts to change the design
we derive satisfaction in demonstrating our of health systems.
competences to ourselves and our colleagues, Thus while logic tells us that the physician's
and in having these competences acknow- role should be determined by the health needs
ledged. If we are honest with ourselves, we of the entire population, implementation of
402 GEORGE M. FOSTER
this logic is obstructed by the insistence of the the development of national health programs
medical profession that only physicians can based on Western medicine official attitudes
evaluate and treat the sick. This stand of the toward traditional healers have ranged from
medical profession has a paralyzing effect on neglect to outright opposition: they have been
the design and implementation of health ser- looked upon by most medical doctors as un-
vices and is one of the most serious obstacles desirable competitors, if not outright enemies
co the effective use of limited health resources" to be vanquished. Only occasionally, as with
(1969:143). Ayurvedic medicine in India, has an indigenous
Bryant's warning leads to my final point: pos- medical system and its practitioners been for-
sible roles for traditional healers in national mally encouraged by government. Even in
health services. India the vast substratum of "folk" medicine
not recognized as Ayurvedic is ignored by the
government.
Possible Roles for Traditional The question of recognition of traditional
Healers healers is important because, in addition to the
manpower problem, the fact remains that no
Paradoxically, the growing acceptance of West- scientific medical system completely satisfies
ern medicine is creating a crisis in most develop- all health needs of a nation. Even in countries
ing countries. There are not now, nor will there with highly developed health care systems
be in the foreseeable future, sufficient fully- many people, under certain conditions, will
trained health personnel to meet all health turn to non-establishment forms of medical
needs. Auxiliary health workers have been and help such as faith healers, herbal doctors and
will continue to be used in almost all countries. the like. "Alternate" forms of medical care fill
In the former British and French colonies, local social, psychological, and perhaps organic
men were trained as "dressers'' or "infirmier health needs which, at least for some people,
auxiliaires" to staff rural clinics and, depending remain unmet by physicians and associated
on level of training, to perform a variety of care services. With respect to a formal policy,
therapeutic duties including simple laboratory the answers are not easy. Viewing particularly
analyses. Among the Navaho Indians the the supportive sociopsychological functions
"health visitor" works under the supervision of the indigenous curer, anthropologists have
of the public health nurse, significantly exten- been impressed with the positive aspects of
ding her capacity to fulfill her role. In contem- non-Western medicine. Medical doctors, on
porary China, rural "barefoot doctors" offer a the other hand, point out that some traditional
primary level of treatment in a referral system remedies are definitely dangerous, and that at
which sends seriously ill patients to more the very least treatment by traditional curers
highly trained health personnel. may delay referral to medical doctors until
In these, and in other comparable instances, routine treatment such as an appendectomy
the sub-professional worker is (or was) a becomes vastly more complicated.
member of the formal health establishment, Harrison, in discussing the possible role
trained by qualified teachers, and paid by, and of non-Western medical personnel in Nigeria
formally incorporated into colonial, tribal, or found that most government personnel were
national health services. Because of the relative skeptical of their value.
success of this approach in helping to solve One government official told me that they are
health problems, and in the face of (almost untrainable because of their superstitious
certainly) permanent shortages of highly beJiefs and because their practice is secret and
trained personnel, the question periodically difficult to evaluate. They view the delivery of
is asked, should indigenous healers also be babies as a supernatural process. Mothers are
recognized as having something important to discouraged from using traditional healers
offer? Should they, in some way, be incorpo- because there are so many quacks among them
rated into the health services of a country? In (Harrison 1974-5:12).
MEDICAL ANTHROPOLOGY AND INTERNATIONAL HEALTH PLANNING 403
This negative evaluation is reflected in most role, while the latter has the priest's assurance
other countries. that he can be counted on to carry on with his
In spite of this prevailing view, successful normal activities. This is in striking contrast,
efforts have been made to incorporate indigen- says Maclean, to Western society where a
ous midwives into formal medical services. former mental patient leaves the hospital with
Since most births are "normal," it is reasoned, a stigma which may never disappear (Maclean
the primary problem is (1) to encourage the 1971:79-80).
midwife to practice hygienic methods and (2) Whatever the potential merit of making
to refer difficult cases to government health formal use of the medical talents of indigenous
services. Since at least the early 1950s village curers, the idea has made little progress in
midwives in El Salvador have been recognized practice. Perhaps the question will never need
and trained by government personnel, and to be resolved, for it erroneously assumes that
among the Navajo Indians similar training traditional healers will continue to be pro-
has reduced infant and maternal mortality. duced in the same numbers and with the same
More recently there are reports of this kind skills as in the past. But social, economic, and
of training for indigenous midwives in Tanza- educational change is coming with such speed
nia (Dunlop 1974-5:138) and Liberia (Dennis in all the world that most of tomorrow's trad-
1974-5:23). itional healers probably will have been trained
Mental illness is a second area in which in medical schools, schools of nursing, and
formal recognition of traditional healers seems other government health institutions. Conse-
potentially promising. Since patient expectation quently, I suspect that any increase in the
is an important element in therapy, it seems formal use of traditional healers in the context
reasonable to expect that in the absence of or- of national health services will be at best no
ganic dysfunction mental stress and illness can more than a transitional step, and that after
be alleviated by curers whose treatments have relatively few years, the question of their pos-
been seen to be successful in the past. Torrey sible utility will be moot.
believes that, in spite of the anecdotal nature of
the evidence on the efficacy of therapists in other REFERENCES
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The former patient now dresses in new Community Health.
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sembled for a feast in honor of his newly- 1972 Communication Between Doctors and
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404 GEORGE M. FOSTER
Defining Global Health not typically invoked the term global health
as a referent for a subdisciplinary domain of
Defining global health in relation to anthropo- research or practice or in description of their
logical research and practice is a challenge. own identity as scholars. Although a recent
Although in common use in a variety of discip- upsurge in publications and several recent edi-
lines, the term defies simple delineation. It fre- torials suggest that global health may at last be
quently serves as a gloss signaling complexities finding a home in anthropology, definitional
inherent in linking health and accelerating and clarity is needed (Adams et al. 2008; Erickson
intensifying global processes, although it some- 2003; lnhorn 2007a; Nichter 2008; Pfeiffer &
times simply refers to work that has an inter- Nichter 2008; Whiteford & Manderson 2000).
national (read: poor country) dimension. In his As noted, global health is used to either
recent book on the subject, Nichter (2008) supplant or mirror the longstanding concep-
suggests that anthropology intersects global tual domain of international health. This dis-
health along a number of dimensions, ranging tinction is complicated by the fact that
from the study of popular health culture and international health references a better-defined
local perceptions as a way to both critique and set of research and applied skills, many of
improve international public health, to the which are derived from the disciplines that
study of ethics, governance, and emergent constitute public health and development stud-
forms of biological citizenship. Cast in such a ies (including anthropology; compare Nichter
broad framework, though, these intersections 2008 ). In contrast, global health remains a
could characterize much of the development of diffuse and highly diverse arena of scholarship
medical anthropology to the present, includ- and practice (lnst. Med. 2009; Macfarlane
ing, especially, much of the ethnographic ap- et al. 2008). The political scientist Kelley Lee,
plied research on local social and cultural a prolific writer on global health, distinguishes
factors linked to improving community health the two by highlighting the construct of trans-
in developing countries (Foster 1976; Hahn & nationalism. Lee argues that global health, as
Inhorn 2009; Inhorn & Janes 2007; Nichter opposed to international health, should be a
1989, 1991; Paul1955). To further complicate field of scholarship and practice that focuses
matters, until recently anthropologists have on health issues that transcend the territorial
Craig R.janes and Kitty K. Corbett, "Anthropology and Global Health," Annual Review of Anthropology 38
(2009): 167-83.
406 CRAIG R. JANES AND KITTY K. CORBETT
boundaries of states (Lee 2003c). International 2001; Ong & Collier 2005a). Although the
health becomes global health when the causes concept of locality is worthy of extended
or consequences of ill health "circumvent, analysis, we take a pragmatic approach: As
undermine, or are oblivious to the territorial ethnographers we study people-in-places or
boundaries of states, and thus beyond the cap- people-in-contexts. We thus prefer the definition
acity of states to address effectively through advanced by Ginsburg & Rapp (1995b}: "[T]he
state institutions alone•' (Lee et al. 2002, p. 5). local is not defined by geographical boundaries
Lee (2003a,c) argues for a model that spe- but is understood as any small-scale arena in
cifically positions health as an outcome of pro- which social meanings are informed and
cesses that have intensified human interaction, adjusted', (p. 8).
given that previous boundaries separating indi- What does this mean for understanding
viduals and population groups "have become health? Both theoretically and methodologic-
increasingly eroded and redefined, resulting in ally the task is to understand how various as-
new forms of social organization and inter- semblages of global, national, and subnational
action across them" (Lee 2003a, p. 21). She factors converge on a health issue, problem, or
identifies three such boundaries or dimensions outcome in a particular local context. Ong &
of globalization: the spatial, the temporal, and Collier (2005a) refer to these processes collect-
the cognitive. As she and others note, in this ively as the "actual global," and they prefer the
sense global health has come to occupy a new more fluid, irreducible, and emergent concept
and different kind of political space that of the "global assemblage" to "the global": An
demands the study of population health in the assemblage "does not always involve new
context of power relations in a world system forms, but forms that are shifting, in forma-
(Brown et al. 2006; Kickbush 2003; Lee tion, or at stake" (p. 12). These heterogeneous
2003c). global assemblages interact with local institu-
Lee's model merges with writing in anthro- tions, social worlds, and cultural identities
pology and sociology that looks at globaliza- through unpredictable and uncertain processes
tion from the perspective of local, though not (Whiteford & Manderson 2000). Consistent
necessarily spatially bound, social contexts. with Burawoy's (2000) approach to grounded
Appadurai (1991, 1996), for example, has in- globalization, anthropological work in global
voked the idea of "scapes" that have come to health thus requires a focus on the instantiation
stand in place of older place-based divisions. of global assemblages in local social arenas,
Burawoy (2000), who with his graduate stu- however defined. Methodologically, Burawoy
dents developed a theoretical and methodo- (2000) argues for the grounding of globaliza-
logical program to "ground globalization," tion through what he identifies as the extended
observes that the "mishmash of migrations, case method: "extending from observer to
capital flows, hostilities, and opportunities participant, extending observations over time
jostling within the hot signifier of globaliza- and place, extending from process to external
tion" (p. ix} can be sorted along three axes. forces, and extending theory, (p. 28). In so
These axes are global forces, including global doing, the ethnographer is positioned to "con-
economic and political processes as mediated struct perspectives on globalization from
by agents, institutions, and ideas; global con- below" (p. 341 ).
nections, referring to the underlying social With this information as a brief back-
grids, networks, flows, and new forms of soci- ground, and for purposes of this exercise, we
ality; and the global imagination, which ad- offer the following definition of global health
dresses the adoption of values and images that as it pertains to anthropology: Global health is
circulate globally. an area of research and practice that endeav~
Burawoy takes these abstractions of glob- ours to link health, broadly conceived as a
alization and applies them to understand dynamic state that is an essential resource for
something local. Yet what constitutes the life and well-being, to assemblages of global
"local, in the context of globalization is con- processes, recognizing that these assemblages
tested (Ferguson 2005; Janes 2004; Morgan are complex, diverse, temporally unstable,
ANTHROPOLOGY AND GLOBAL HEALTH 407
contingent, and often contested or resisted at Pfeiffer & Nichter 2008; Scheper-Hughes
different social scales. This includes work that 1993). This research encompasses different
focuses on health inequities; the distribution of registers, mainly in the depth of engagement
resources intended to produce health and well- with local materials, the care by which the
being, including science and technology; social local is nested within higher-level social struc-
identities related to health and biology; the tures, and the degree to which the analysis is
development and local consequences of global used as a platform for public health advocacy.
health policy; the organization of health ser- However, this work tends to share a common,
vices; and the relationship of anthropogenic critical theoretical perspective that focuses on
transformations of the biosphere to health. explicating or grounding health inequities in
The ultimate goal of anthropological work in reference to upstream constellations of inter-
and of global health is to reduce global health national political economy, regional history,
inequities and contribute to the development of and development ideology. It is closely linked
sustainable and salutogenic sociocultural, pol- with critical medical anthropology, a research
itical, and economic systems. tradition that seeks to identify the social origins
Although global health conceptually includes of distress and disease, recognizing that these
all peoples regardless of social, economic, and origins are ultimately located within the pro-
political contexts, its ethical and moral commit- cesses and contradictions inherent in the capit-
ment is to the most vulnerable. However, and alist world system (Baer et al. 2003; Singer &
given the impending and hitheno unprecedented Baer 1995). Farmer (2004) has used the con-
scale of global catastrophe that environmental cept of "structural violence" to explain this
destruction, mass species extinction, and anthro- impact of political-economic regimes of op-
pogenic climate change presage, global health pression on the health of the poor.
might benefit from redefining the vulnerable Such work has contributed to redefining the
to include all of us (McMichael & Beaglehole concept of risk in epidemiology by redirecting
2003). attention from risky behaviors to structural
So defined, the anthropological project in factors that constrain or determine behavior.
global health can be arranged along several axes. For example, early reports on the epidemiology
Here we review what we consider key arenas of of HIV/AIDS tended to focus on individual
research and practice: ethnographic studies of behaviors rather than on the impact of poverty
health inequities in political and economic con- and marginality that differentially affected
texts; analysis of the impact on local worlds of men and women within particular populations
the assemblages of science and technology that and communities (Farmer et al. 1996, 2001;
circulate globally; interrogation, analysis, and Simmons et al. 1996). Pointing to the tendency
critique of international health programs and of some public health researchers to conflate
policies; and analysis of the health consequences poverty and cultural difference, Farmer and
of the reconfiguration of the social relations of colleagues argued against "immodest claims
international health development. of causality" and for a focus on, and mitigation
of, the structural violence that produces ill
being on a massive scale among the poor
Explaining Health Inequities (Farmer 2003; Farmer et al. 2001; Simmons
et al. 1996; Singer 1997). In similar fashion,
The anthropological contribution to the study anthropological research on infectious dis-
of health inequities has primarily been to eases, particularly HIV/AIDS, TB, and cholera,
ground globalization (as anticipated by Buro- have contributed significantly to moving global
woy 2000 and Nichter 2008) through exposing public health away from a narrow focus on risk
processes by which people are constrained or groups (Baer et al. 2003; Trostle 2005).
victimized or resisting external forces in the The social origins of infection with HIV are
context of local social worlds (Baer et al. often bound up with or linked to a number of
2003; Farmer 1997, 2003, 2004; Farmer et al. other threats to health and well-being, and in
1996; Kim et al. 2005; Maternowska 2006; turn, the coexistence of two or more diseases
408 CRAIG R. JANES AND KITTY K. CORBETT
may synergistically interact to produce a higher body of scholarly work in anthropology seeks
degree of pathogenesis (an example would be to link wider social, economic, and political
HIV and TB coinfection). Termed syndemics, forces to local experiences of sickness and
these synergistic processes suggest a biosocial suffering. We believe that this work is an im-
model of disease (Nichter 2008; Singer 2009; portant adjunct to the emerging scholarship on
Singer & Clair 2003) that conceives "of disease the social determinants of health that tends to
both in terms of its interrelationships with nox- focus more on patterns evident at population
ious social conditions and social relationships, levels (Comm. Soc. Determinants Health
and as one form of expression of social 2008). A few examples include studies of
suffering ... it would make us more alert, as extreme hunger and scarcity in northeastern
well, to the likelihood of multiple, interacting Brazil {Scheper-Hughes 1993); the global cir-
deleterious conditions among populations pro- culation of tobacco and its impacts (Nichter &
duced by the structural violence of social Cartwright 1991; Stebbins 1991); parasitic and
inequality" (Singer & Clair 2003, p. 434). infectious diseases (Briggs & Mantini-Briggs
Many researchers experience a tension be- 2003; Farmer 1999; Feldman 2008; Ferguson
tween a close rendering of the local and effect- 2005; Inhorn & Brown 1997; Kendall 2005;
ive engagement with the global. Analytically Manderson & Huang 2005; Whiteford & Hill
and methodologically, how does one extend 2005); reproductive health, fertility, and infer-
ethnographic work to incorporate globaliza- tility (lnhorn 2003, 2007b; Janes & Chuluun-
tion while portraying faithfully the rich dorj 2004; Maternowska 2006; Morsy 1995};
human stories that bring voice to the poor mental ill health (Desjarlais et al. 1995; Klein-
and suffering, without conceptually flattening, man 1988); alcohol and drug use (Singer
simplifying, or objectifying one or the other 2008); and life style transitions and noncom-
(Butt 2002)? Farmer and his colleagues often municable diseases (Dressler & Bindon 2000,
juxtapose stories of individual suffering with Evans et al. 2001, McElroy 2005).
political-economic givens, offering sometimes Although anthropologists have engaged
thin analyses of intervening processes and with many of the core themes of health equity
structures. Some have observed that the con- studies in global public health, they lag in
cept of structural violence is a black box, taking up some emerging concerns. Gaps are
rarely unpacked (Bourgois & Scheper-Hughes apparent in the domain of environmental
2004; Wacquant 2004). Future work on change affecting and affected by global pro-
global health inequities might thus profitably cesses. Examples range from climate change
employ ecosocial epidemiology (Krieger 2001) broadly (Baer & Singer 2009; Guest 2005;
by addressing, for instance, the interplay McMichael & Beaglehole 2003; Patz et al.
among exposure, susceptibility, and adapta- 2005) to specific problems such as microbial
tion at meso- and macroscales across the life resistance (Orzech & Nichter 2008). Many of
course (Nichter 2008). Application within the models of human impacts of climate
global health contexts of the construct of "in- change point to the need for more research to
tersectionality" also provides a way to unpack identify factors that affect the vulnerabilities of
the concept of structural violence. Derived local populations in the context of political
primarily from feminist studies, this theoret- economy (Intergov. Panel Climate Change
ical and methodological perspective empha- 2007}. We anticipate that in the next decade
sizes the importance of simultaneously medical anthropology will begin to investigate
considering how different aspects of social more systematically the relationship of global
location (e.g., gender, ethnicity, class, age, environmental transformations to health.
geography, sexual identity) interlock and the
impact of systems and processes of oppression
and domination (Hankivsky & Cormier 2009; Global Technoscapes
Hulko 2009).
Whether explicitly identified as critical Invoking the term technoscape, Appadurai
medical anthropology or not, a substantial {1996) refers to the "global configuration ...
ANTHROPOLOGY AND GLOBAL HEALTH 409
of technology, and the fact that technology, practices, medicalization, and the politics of
both high and low, both mechanical and infor- biomedical knowledge through the interwoven
mation, now moves at high speeds across dynamics of drug production, marketing, and
various kinds of previously impervious bound- sales practices, the classification of disease, and
aries'' (p. 34). The global technoscape as it patterns of clinical practice (Applbaum 2006;
pertains to health is comprised of an inextric- Hayden 2007; Singer & Baer 2008).
able mix of things (e.g., medicines, medical A particularly robust area of research has
devices, machines), techniques (e.g., medical focused on the globalization of reproductive
procedures), and bundles of shared under- and prenatal diagnostic technologies (Browner
standings and epistemological practices that & Sargent 2009; Erikson 2003; Ginsburg &
together constitute science in the global north. Rapp 1995a; Inhorn 2003, 2005, 2007b; Ong
Far from being a homogenizing influence, the & Collier 2005b). Writing of the globalization
global circulation of science and technology of treatments for infertility, Inhorn (2003) ob-
engages various localities as one component serves that "[l[ocal considerations, be they cul-
of a global assemblage (Ong & Collier tural, social, economic, or political, shape and
2005a). This assemblage of things, ideologies, sometimes curtail the way in which these West-
and representations interacts with commu- ern-generated technologies are both offered
nities in diverse ways, both shaping and being to and received by non-Western subjects"
transformed by local beliefs and practices. (p. 1844 ). Cultural or religious proscription
Questions central to investigation of global of procedures such as donor insemination has
science concern how paradigms, practices, led to increased global demand and rapid
and results are negotiated and unfold far from circulation of more expensive technologies
their places of origin (Adams et al. 2005). As such as in-vitro fertilization (lnhorn 2003}.
many scholars have noted, the products and In Egypt, for example, men and women con-
purported benefits of science and technology tending with infertility are confronted by con-
are unevenly distributed; some sites and groups straints that are deeply embedded in local
have greater access than others do (Ginsburg social and cultural contexts. These arenas of
and Rapp 1995b; Inhorn 2003). constraint include local understandings of re-
Examples of key works in this area include productive biology, social and economic bar-
the local impact of biomedical research prac- riers to access, gender dynamics within
tices, such as those involving translation of the marriage, and local understandings of Islam
ethical principles of scientific research, espe- (lnhorn 2003, p. 1844, 2005, 2007b).
cially clinical trials, in specific cultural contexts Globalization also sets into motion people,
(Adams et al. 2005; Petryna 2005); the circula- for example, the export of physicians and
tion of medicalized objectifications of body nurses (the "brain drain") from low-income
and behavior, such as those having to do with countries to rich countries (Pfeiffer & Nichter
sexuality in this era of HN (Parker 2000; 2008), and "medical tourists" and others who
Pigg & Adams 2005); the transformations of travel to places where desired technologies
local beliefs and understandings about the exist or are affordable (Kangas 2002). As noted
body, life, and death that are entailed by the above, it also enables the flow of organs,
globalization of human organ replacement tissues, and genetic materials (Marshall &
therapies (Lock 2001; Marshall & Daar Daar 2000; Scheper-Hughes 2005). Described
2000); local acceptances of and resistance to as an artifact of "second coming" capitalism,
contraceptive technologies (Maternowska the worldwide spread of medical procedures
2006; Rak & Janes 2004); the complex local/ and technologies has produced "strange
global dynamics of organ transplantation and markets and 'occult' economies" (Comaroff &
medical tourism (Cohen 2005; Scheper-Hughes Comaroff2001, cited in Scheper-Hughes 2005,
2000, 2005), including the definitional exer- p. 149).
cises needed to create harvestable tissues and Bioscience is not the only set of ideas about
organs (Lock 2001; Marshall & Daar 2000); bodies, physiology, and health that circulate
and cases illustrating complexities of corporate globally. Countervailing creativities also exist,
410 CRAIG R. JANES AND KITTY K. CORBETT
whereby what were formerly "locaP' and "non- they increasingly situate these practices within
western" engage both the imagination and the global institutional and perceptual systems
markets at the center of the world system. This (Nichter 2008). Medicines, whether originat-
is the case for Asian medicines, both brought ing in local traditions or developed through the
by immigrants and practiced by immigrant pharmaceutical pipeline, are global citizens.
communities, but also adopted by New Agers One dimension of the global circulation of
and others challenging the hegemony of con- expert, biomedical knowledge on disease,
ventional biomedicine. In their places of origin therapeutic regimes, and prevention is the cre-
and their global circulation, the content and ation of novel social forms (Biehl 2007; Lee
practice of these medical traditions are trans- 2003a; Nguyen 2005; Rose & Novas 2005).
formed (Alter 2005; Hag & Hsu 2002; Janes In the context of HN, notes Nguyen (2005),
2002). In many cases these processes of trans- these groups are "more than social movements
formation involve at their core the commoditi- articulated around objectives" and are a
zation of medicinal substances, which is in tum "complex biopolitical assemblage, cobbled
based on the reduction of complex systems of together from global flows of organisms, drugs,
diagnosis, explanation, and healing to the discourses, and technologies of all kinds"
exchange and consumption of medicinal sub- (p. 125). Nguyen is interested particularly in
stances (Janes 1999}. how the constellations of technoscientific
Medicines - materia medica - are at the understandings of prevention and treatment
heart of much of what we might define as that together constitute the global AIDS indus-
"medical technologies." Although medicines, try are translated locally by groups and organ-
especially pharmaceuticals, were ignored as a izations to mobilize a response to the epidemic.
focal topic more often than not by medical Similarly, Petryna (2002) shows how the Cher-
anthropologists in the first decades of the dis- nobyl disaster and its impacts on health pro-
cipline, work by van der Geest and other an- vided an avenue for affected individuals, joined
thropologists in the 1980s and 1990s initiated by a biologically mediated identity, to make
a florescence of research on their uses in the claims on the state for resources. The develop-
context of global influences and on factors ment of therapeutic groups is increasingly
affecting their production, distribution, entangled with the industry of health develop-
demand, and consumption (Trostle 1996; van ment (Nguyen 2005, p. 125). This form of
der Geest et al. 1988, 1996). This trend con- citizenship represents evolving subjectivities,
tinues, spurred in part by the ethical and prac- politics, and ethics that result from the global-
tical challenges represented by the need for ization of biomedical developments and dis-
people everywhere who live with HIV/AIDS coveries (Ecks 2005; Rose & Novas 2005}.
to receive treatment (Farmer et al. 2001;
Robins 2009; Whyte et al. 2006). Addressing
access needs requires investigation into Interrogating Health Policy
pharmaceutical governance, trade practices,
patent protection, distribution channels, and Analysis of the formation, dissemination, and
alternative industries and markets, as well as local consequences of expert knowledge forms
local organizations and the cultural and ritual the core of the anthropological critique of
properties of medicines. Approaches to under- global public health policy (Castro & Singer
standing how medicines function in society 2004; Whiteford & Manderson 2000). This
increasingly include attention to the context critique focuses on both the process and conse-
of global assemblages, including greater atten- quences of policymaking: ideological and
tion to formal and institutional sectors (Hayden political-economic relations that influence
2007; Kim 2009; Mather 2006; Oldani 2004 ). decision makers and the policymaking process
As anthropologists reflect on medication and the impacts, intended or otherwise, of spe-
use, including not just underuse but also cific policies on the health and well-being of
overuse, inappropriate use, and errors in the intended beneficiaries. In regard to the
delivering appropriate medications to patients, latter, it is common for observers to report on
ANTHROPOLOGY AND GLOBAL HEALTH 411
the problems inherent in localizing global produce planning reports and documents (e.g.,
health policies (Whiteford & Manderson about essential medicines, their distribution,
2000). Central to the interrogation of health etc.) but who are not invested in program im-
policy, an area only a few anthropologists have plementation. Whyte & Birungi (2000) found
explored in any depth (e.g., Justice 1986), that World Health Organization (WHO)-
are the processes by and through which the sub- inspired model policies were ineffective in
stances of international health policymaking- changing local-level and lay practices around
knowledge, ideology, politics of representation, inappropriate prescription and use of pharma-
competing vested interests, processes of persua- ceutical medicines. Hardon (2005), also crit-
sion and advocacy, etc.- come to constitute it. In ical of policymakers, asserts that their work
a pure and perhaps idealized form, policy repre- often entails a focus on "magic bullets." She
sents translating knowledge into action. What notes that recent policy shifts reflect a growing
are these processes of translation? Is it possible, acknowledgment in the policy sectors that
thinking here in ethnographic terms, to expose people without economic resources or literacy
these processes through careful analysis of can and do use HIV/AIDS treatments appropri-
global policymaking communities? And how ately. Yet although many more people now
might anthropologists proactively affect these have access to previously far too expensive
translational processes? treatments, the policies have had side effects.
Nichter (2008) suggests that policymakers The prices of pharmaceuticals are still ex-
tend to simplify and frame problems in ways tremely high for people on the margins of the
that limit the thinking about possible solutions; economy, and entire family networks may ex-
these "key social representations" dominate perience cash depletion and food insecurity as
health and development discourse as "master they shift the household economy to procure
narratives" (p. 2). Lee & Goodman (2002) medicines for a family member who is ill
argue that the networks of so-called experts in (Whyte et al. 2006).
global health tend to be fairly small but are The global circulation of expert knowledge
positioned strategically to create and success- produces particular relations of power be-
fully advocate for solutions to key inter- tween policy makers and policy subjects. The
national agencies. Such networks comprise collapse of the primary care initiatives fostered
what are in international relations and global- at Alma Ata in 1978, the resurgence of select-
ization literatures termed epistemic commu- ive forms of primary care and vertical public
nities (Adler & Haas 1992), loose networks health programs, and the ascendency of the
of actors that develop common frameworks \Vorld Bank as the principal health policymak-
of knowledge, values, and beliefs that underlie ing institution provide a glimpse of how these
configurations of public health policy and processes work themselves out (Janes 2004,
action. Although presumably oriented to tech- 2009; Janes et al. 2005; Lee & Goodman
nical matters, these epistemic communities are 2002; Paluzzi 2004 ). Deploying a set of strat-
powerful because they, as representatives at egies to reframe health and health care in
least implicitly of the global capitalist class narrow technical terms (i.e., the development
(Singer & Castro 2004), can set agendas, frame of the disability adjusted life year, or DALY)
issues, identify problems, and propose solu- subject to the principles of classical economics,
tions. These networks extend into major uni- a relatively small group of individuals crafted
versities, especially in the fields of economics an approach to health care that removed it
and public health (Lee & Goodman 2002) and from public governance and placed it largely
are now at the core of global health governance in the hands of the market, complementing
(Adams et al. 2008). and bolstering processes of structural adjust-
VanderGeest (2006), in commenting about ment begun in the 1980s (Farmer 2003;
pharmaceutical matters, critiques an over- Farmer & Castro 2004; Janes 2004; World
emphasis in global health on policies as a solu- Bank 1993). The result has been increasing
tion, commenting about the lip service and inequities and contradictions at local levels,
culture of policy makers whose mandate is to for example reforms that mandate selling
412 CRAIG R. JANES AND KITTY K. CORBEIT
medicines to poor people who cannot afford those arising in the context of organ trans-
them (Keshavjee 2004). Although it is remark- plantation and drug development (Marshall
able that the WHO is currently attempting to 2005; Marshall & Koenig 2004; Petryna
reclaim the discourse on health reform and 2005); the local impact of the global extension
reassert the principles of primary care (World of regimes of monitoring and evaluation of
Health Organ. 2008), it remains to be seen public health programs, a variant of "audit
whether rights-based approaches will be able cultures" (Nichter 2008; Strathern 2000);
to trump the neoliberal orthodoxy that domin- ideologies of community participation and pol-
ates health sector policy. itical will in international health program plan-
Population and reproductive policy is a sig- ning (Janes 2004; Morgan 1989, 1997, 2001};
nificant area in which deeply held beliefs about and HIV/AIDS treatment and prevention pol-
the causes and consequences of poverty, and icies (Bastos 1999; Biehl 2007; Desclaux 2004;
the role of scientific development and expert Farmer 1999; Farmer et al. 2001).
knowledge of demographic processes in reme-
diating poverty, have come to drive health and
social policy (Escobar 1995; Maternowska An Unruly Melange
2006). For example, in a series of works focus-
ing on population policy in China, Greenhalgh Neoliberal development strategies initiated in
(2005) has shown how the development of the health sector since the 1980s have system-
coercive family planning practices linked a atically reduced the size, scope, and reach of
version of Western population science with public health services. As a result, a number of
socialist planning and party-led community private organizations, grouped collectively
mobilization in order to achieve demographic under the general heading of civil society, have
modernity. Although the International Confer- become a cornerstone to health development.
ence on Population Development held in Cairo These include everything from smaH, local pri-
in 1994 urged countries to move away from a vate organizations, to faith-based charities, to
narrow focus on fertility targets and to respect local offices of large international philanthro-
and protect women's rights to make an pies. Favored as implementing agents by bilat-
informed choice about their reproduction, in eral and international donors, including the
many contexts oppressive and coercive regimes major foundations and development banks,
of family planning have continued, directed these agents of civil society have in many
primarily at poor women (Castro 2004; Green- locales effectively supplanted government in
halgh 2005; Maternowska 2006; Morsy 1995). the provision of primary health care. Often
Other important works also focus on the prob- uncoordinated, competing with one another
lematic disjuncture between global reproduct- for donor and ministerial attention, duplicat-
ive health policy and the lived experiences of ing efforts, and distorting local economies
local women and men (Berry 2009; Browner & through the demands for food, housing, trans-
Sargent 2010; Castro 2004; Ginsburg & Rapp portation, and entertainment by their expatri-
1995a; Rak & Janes 2004; Towghi 2004). ate staffs they comprise, as Buse & Walt (1997)
The anthropological literature documenting note, an unruly melange (Adams et al. 2008;
the problematic implementation of internatio- Pfeiffer 2003, 2004),
nal health development policy is vast. Other Despite their prominence in health develop-
examples include, in addition to the above, ment, nongovernmental organizations (NGOs)
work on child immunization (Justice 2000; have received relatively little attention as social
Nichter 1995); implementation of therapeutic and cultural phenomena in their own right
regimes for tuberculosis (DOTS) and treatment (though see Abramson 1999; Markowitz
of multiple-drug-resistant forms of the disease 2001; Pfeiffer 2003, 2004; Redfield 2005).
(Farmer 2003; Kim et al. 2005; Nichter 2008); Pfeiffer (2003, 2004) has documented how in
disaster management and resettlement (White- Mozambique the operation of NGOs, instead
ford & Tobin 2004); the globalization of bio- of strengthening health services, may have in
ethics and ethical issues, including especially fact had the opposite effect, undermining local
ANTHROPOLOGY AND GLOBAL HEALTH 413
control of health programs and contributing to Citing his colleague, Jim Kim, Farmer (1999)
the health human resource crisis by recruiting has wryly observed that we are now in the
public-sector employees from public health ser- midst of a global "Tuskegee experiment." We
vice. Pfeiffer also gives us a glimpse of the are mindful of the fact that global health, a
social dynamics of NGOs, observing that in field of exploding popularity largely in Europe
the interaction between the elite, educated and North America, is deeply involved in this
technicians from the rich countries and com- manner of knowledge creation, exploitation,
munity members living in extreme poverty, the and exchange.
exercise of power is laid bare: international We argue that a central ethical problem for
NGOs intensify unequal social relations at the anthropologists, as for scholars of global health
local level. more generally, is consideration of the fairness of
The expansion of NGOs is but one example the terms of this exchange and whether their
of a growing number of transnational institu- work contributes to social justice and the reme-
tions that have become active in global health. diation of structural violence where it is the most
Along with existing bilateral donors, intergov- severe. This problem provokes two questions:
ernmental institutions, and public private part- Are the products of anthropological scholarship
nerships, these include economic interest in global health - conceptually, theoretically,
groups, large philanthropic organizations, and methodologically, and pragmatically - relevant
multinational pharmaceutical companies. The to those broadly interdisciplinary efforts to
effective practice of global health regardless of improve health and well-being? And, is anth-
disciplinary background increasingly requires ropology, principally an academic discipline,
not just understanding of how to work effect- prepared in the context of global health to
ively at a local level to improve health and engage in what we refer to here as principled
well-being, but also skills to work across these engagement and intervention?
many, and often competing, interest groups Pardy in response to these questions, it is
(Adams et al. 2008). useful to reflect on anthropology's relevance to
global health, which we have encapsulated into
four main areas of research and practice. In the
first of these, through ethnographic analysis of
Conclusion: Reflections on the health inequities, anthropologists have added
Economy of Knowledge in Global considerable depth to the project of identifying
Health the social determinants of health (Comm.
Soc. Determinants Health 2008). By specifying
A colleague of ours, reflecting on the virtual links among local life worlds and the global
invasion of Africa by international researchers, forces of neoliberal development, anthropolo-
suggested that the continent's new export was gists have laid bare the lines of power, exploit-
information for university-based researchers ation, and structural violence. Although more
and pharmaceutical companies. In addition, conceptual development is needed, this work
academic programs in global health (like our has pointed to inherent flaws in health devel-
own), located primarily in schools of public opment programs that do not take poverty and
health in North America, send thousands of environmental degradation, their root causes
students abroad each year to complete global and consequences, as primary problems.
health practice placements. Presumably these Second, and what now currently seems to be
students gain through these experiences the a popular avenue of research, is the study of
knowledge and skills they need to "do'' global global technoscience. Here anthropologists
health. This experience raises the spectre of a focus on the global circulation of technology
new form of colonialism: extending uses of and the bundles of meanings, representations,
sites in the global south to study their disease and understandings that together constitute bio-
burdens to satisfy the needs of science (parti- medical science in the global north. The intent
cularly, these days, the AIDS industry) to here is twofold: to unpack and explicate the
find new subjects and explore new problems. cultural context of science and its products,
414 CRAIG R. JANES AND KITTY K. CORBETT
and then to understand how science, as a social change, habitat destruction, and mass species
and cultural product, interacts with the local, extinction, as well as the global economic
where it is transformed and transforms, through crisis? Here we are less sanguine. We have
being adopted, used, and resisted. Theoretically promising examples, and the work that many
complex, this research area nevertheless has researchers have done lends itself clearly to
simple, direct, and profound implications for concrete, appropriate policies, programs, and
global health problems related to access to interventions. Like many, we are buoyed by the
medicine and technology, the impact of western work of Farmer and his colleagues at Partners
bioscience on conceptions of the body, ethical in Health in a variety of country and commu-
issues related to experimentation, the commo- nity settings, from poverty-stricken neighbour-
ditization of body parts, identity and citizen- hoods in the United States to postgenocide
ship, and emerging processes of governance. Rwanda. We are also mindful of the several
Third, an investigation of the globalization generations of anthropologists who, largely
of western bioscience facilitates interrogation of external to the academy, through hard work
entailed policies. How are policies made? Who at community to policy levels, through clear
makes these policies, and what ideologies, dis- and principled commitment to socially and
courses, representations, and systems of know- culturally relevant public health efforts, have
ledge do they draw on to craft decisions? How made a difference. These efforts are, in many
are policies made by global communities imple- ways, both the foundation and the backbone of
mented, and to what effect, in highly variable current medical anthropology and constitute in
local settings and contexts? Here, as with the large measure the substance of promise and
study of the global technoscape, the focus is on hope that we hold out to our students. Never-
examining the unintended consequences of theless, we also recognize that many anthro-
policy for locals, reflecting on the fact that for pologists continue co be reluctant to do work
the poor and vulnerable it is an unlevel playing identified as "applied" or "public health," or,
field (Whiteford & Manderson 2000). perhaps perceived as worse, glossed as "devel-
Fourth, it is clear from the analysis of global opment" (Escobar 1995; Ferguson 1997).
health policymaking that the institutional land- Although writing of current work in
scape in health development has been trans- pharmaceutical anthropology, van der Geest
formed. The proliferation of nonstate actors and (2006) offers an opinion that is a cautionary
neoliberal development practices that both con- note co other anthropologists working in
stitute an engage civil society has produced a global health:
complex mix of groups and organizations at state
and community levels. Successful health develop- Overcoming the "temptation" of just writing
ment entails both coordinating across this unruly about the intriguing [pharmaceutical] nexus
melange and understanding the social and cul- should be a first concern of medical anthro-
tural effects of their various operations. Yet there pologists. We owe it to our informants to
is much we do not understand about how civil contribute to the actual improvement of dis-
tribution and use of pharmaceuticals. Ironic-
society operates in global health. The principal
alJy, however, that imperative of turning our
questions appear to be when and how private
paper medicines into medicines that cure and
organizations operating in parallel to the state protect people is not exactly what main-
foster, or compromise, positive health outcomes, stream anthropology encourages us to do.
and whether they in fact contribute to reducing, Applied medical anthropology is somewhat
or increasing, health inequities. slighted as diluted anthropology and as too
Although clearly relevant, we have to ask subservient to policy and medical science.
whether anthropology has contributed, or is My view, however, is that uncommitted eth-
capable of contributing, in substantive ways nographers lack reflexivity and fail to see
to the kinds of engagement and interventions themselves in the nexus of pharmaceuticals
that promise to reduce health inequities, foster and of culture in general. Their methodo-
social justice, and address the challenges to logical innocence gives way to epistemo-
global health presaged by global climate logical nai'vete. (pp. 313-14)
ANTHROPOLOGY AND GLOBAL HEALTH 415
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ANTHROPOLOGY AND GLOBAL HEALTH 421
Pimpawun Boonmongkon, Mark Nichter, and Jen Pylypa, "Mot Lzmk Problems in Northeast Thailand:
Why Women's Own Health Concerns Matter as Much as Disease Rates," Social Science Medicine 53
(2004): 1095-112. © 2004 by Elsevier Science & Technology journals. Reproduced with permission of
Elsevier Science & Technology Journals in the format Textbook via Copyright Clearance Center.
MOT LUUK PROBLEMS IN NORTHEAST THAILAND 423
from abdominal and lower back pain to symptoms because the disease or germs remain
vaginal discharge, itching, odor and rash using in their bodies and only manifest themselves at
the phrase pen mot luuk (literally: 'it's the certain times, or because an 'ulcer' or 'wound'
uterus'). Pains, infections, or other health prob- that exists inside the uterus persists without
lems associated with the abdominal and pelvic ever entirely healing. Hard work was the most
regions that reference the mot luuk include commonly cited trigger that causes symptoms
pains associated with occupational health to reemerge; symptom recurrence is also asso-
problems, such as muscle strains resulting from ciated with menstruation, tiredness, poor
agricultural labor or weaving. Examples of hygiene, or the sexual transmission of germs.
such local illness terms include jep mot luuk [ ... J
('pain in the uterus'), which is used to refer to Many women feared that if their symptoms
abdominal pain of various etiologies, mot luuk were not treated or if they persisted for a long
ak seep ('inflammation/infection of the period of time, they would transform into a
uterus'), an ambiguous term for mot luuk more severe illness. They engaged in a great
problems that is sometimes described as simply deal of 'what if' speculation- what will happen
a more 'medical' term for jep mot luuk, and if my symptoms persist, or if they get worse?
mot luuk boo dii [mot luuk mai dii ('bad Am I destined for a more severe or chronic
uterus'), which refers to chronic uterine abnor- illness? Some women [ ... ] feared that their
malities with multiple possible causes. symptoms might turn into [ ... ] a prolapsed
Mot luuk problems are believed to have a uterus, a tumor, kidney stones, dysuria, or
wide range of causes [ ... ) including many that AIDS, while others expressed a non-specific
Western medicine would not consider to be concern that their illness could become 'some-
related to reproductive physiology. Many thing worse'. However, women's greatest con-
women with recurrent symptoms see their cern by far (49 out of 50) was that their
problems as ultimately resulting from some symptoms would 'become' cervical cancer
event earlier in life that either caused their (ma/eng paak mot luuk, or simply maleng
ongoing symptoms or made them vulnerable [mareng]). [ ... J This perception was reiterated
to problems that emerged at a later point in in interviews with health providers. [ ... ]
time. Failing to follow the traditional postpar- Health staff talked a bout women's infections
tum practice of 'staying by the fire' (yuu fai) for transforming into 'pelvic inflammatory dis-
a number of days following childbirth is one ease', a term they used very loosely during
such past event; others include an injury or interviews with us and on patient records.
working very hard in youth, a complication Curiously, this term was not used in communi-
or problem during a past pregnancy or abor- cations with patients and local women
tion, pushing too hard during childbirth, and expressed no familiarity with it. [ ... ] A few
sterilization. [ , . , l More than a quarter of the women imagined that gynecological com-
women interviewed who suffered from chronic plaints or sexually transmitted diseases might
or recurrent symptoms felt that their current ultimately transform into AIDS, as has been
problems were the result of an inadequate reported elsewhere in Southeast Asia, such as
period of staying by the fire following child- in the Philippines (Nichter, 1996).
birth, a practice that is believed to dry out the The connection that women draw benveen
uterus and return it to its normal pre-preg- a wide range of abdominal and reproductive
nancy state. The increasing prevalence of hos- tract symptoms and cervical cancer can be ex-
pital births has interfered with this custom, plained by looking at their ethnomedical model
such that women are increasingly concerned of what is happening inside their bodies. From
about the ill health effects that its omission a biomedical perspective, women's complaints
may cause (see also Mougne, 1978; Whittaker, of mot /uuk problems may include fungal, viral
1995, 1996). or bacterial infections that may be sexually
A number of women with recurrent or transmitted as well as endogenous or iatro-
chronic symptoms see their illness as latent, genic in origin and muscle strain associated
that is, they feel that they experience recurrent with hard manual labor. Each problem is
MOT LUUK PROBLEMS IN NORTHEAST THAILAND 427
different and requires specific treatment. khaaw/tok khaaw); in some cases, these prob-
Women in Northeast Thailand see things dif· lems lead directly to cancer, whereas in others
ferendy. They place a wide range of mot luuk they first cause a secondary set of symptoms,
problems on the same illness continuum as including discharge, fungus, itching, an ulcer
cervical cancer (see also Whittaker, 1996). or tumor, or infection, which then becomes
The visual images of mot luuk problems that cancer. [ ... ] Similar variability in the per-
most women describe include the presence of a ceived causes of cervical cancer has also been
large ulcer, fungus, or collection of pus inside found to exist among Latina immigrants in
the uterus. They have a macroscopic, rather the United States, one of the few populations
than microscopic image of the problem; that for which such data exist (see Chavez, Hubbell,
is, they imagine a large uterine anomaly that McMullin, Martinez, & Mishra, 1995;
would be visible to the naked eye upon inspec· Hubbell, Chavez, Mishra, & Valdez, 1996).
tion during an internal exam. Cervical cancer is Seven major pathways of illness transform-
imagined as an extreme, life-threatening stage ation leading from other gynecological com-
in the development of this uterine anomaly - plaints to cervical cancer, identified during
the final common outcome of all untreated mot our ethnographic fieldwork, were presented
luuk problems. Ideas presented in health edu- to 10 women informants in villages and 10 in
cation materials distributed as part of a cer- a nearby town who had not previously been
vical cancer screening campaign in Khon interviewed, to see which of these models they
Kaen Province have been appropriated by recognized as common (see Table 33.1). These
women and incorporated into these preexist- pathways were seen as possible ways in which
ing, ethnogynecological perceptions, and have illness could progress, not definitive routes of
thus come to inadvertently reinforce such local transformation. [ ... ] Women suffering from
models (cf. Gregg 2000). One educational chronic or recurrent mot luuk problems often
poster showing an enlarged photograph of ad- maintained more than one explanatory model
vanced cervical cancer provides women with a of illness causality and imagined multiple ill-
macro-image of a microscopic anomaly; with ness scenarios. Regardless of the particular
no indication as to the scale of the photograph, series of intermediate stages, cervical cancer
the picture bears a striking resemblance to a was recognized by all informants as the final
large ulcer, fungus, or accumulation of pus. common outcome.
This image thus serves to reinforce the existing
visual image of cervical cancer and perpetuates
the link between cancer and the imagined Implications for Women's
manifestations of mot luuk problems (see Suffering
Boonmongkon, Nichter, Pylypa, & Chantapa-
sa, 1998). Women who experience persistent or recurrent
Although it is clear that there are many mot luuk problems, regardless of etiology, are
different, and often ambiguous, ideas about often subject to both physical pain and psycho-
how mot luuk symptoms can progress through logical suffering. Many of the 50 women inter-
subsequent stages and eventually become cer- viewed in-depth who suffer from chronic or
vical cancer, the image of an ulcer, fungus/ recurrent mot luuk problems described the se-
germ, pus, or 'infection' inside the uterus is a verity of their symptoms in functional terms.
common theme. The specific pathways leading They often said that pain prevented them from
from women's own symptoms to cancer vary sitting, walking, sleeping, or working. When
from woman to woman, but include certain asked how their symptoms affected their work,
common ideas. The initial symptoms are often 60% of these 50 women stated that they had to
described as 'pain in the uterus' (jep mot luuk), alter their work activities significantly because
lower abdominal pain (iep thoong nooi), 'in- of their illnesses. Some women spoke of their
flammation/ infection' of the uterus (mot luuk physical pain as intolerable and of vaginal itch-
ak seep), a 'bad uterus' (mot luuk boo dii [mot ing severe enough to make them scratch until
luuk mai dii]), or vaginal discharge (maat they bled or their skin burned. Many women
428 PIMPAWUN BOONMONGKON, MARK NICHTER, & JEN PYLYPA
Table 33.1 Explanatory models for maleng fmarengJ paak mot luuk (cervical cancer): How mmzy women
recognize each pathway as common
Village Town
Model (n = 10) (n = 10)
Ulcer model: An ulcer inside of the mot luuk gets infected and full of pus, fungus/ 10 8
germs make the ulcer worse, discharge often occurs and the woman gets cancer.
Husband infects wife model: The husband has extramarital sex with a woman who 7 8
is not clean and transfers fungus or germs to his wife who gets a mot luuk problem;
discharge with bad odor occurs and sometimes itching. The woman develops mot
luuk ak seep ('inflammation/infection of the uterus') and an ulcer and gets cancer.
Poor hygiene model: The mot luuk becomes infected from a woman working in a 8 7
dirty place, dirt entering her body from a rice field or fish pond, not being able to
wash after urination while working, or dirt transferred to her sexually from a man
with poor hygiene. Fungus/germs cause itching and bad odor and discharge occurs.
Cancer develops.
Hard work model: Hard work leads to lower abdominal pain; the woman gets jep 5 5
mot luuk ('pain in the uterus') and/ or mot luuk ak seep ('inflammation/ infection of
the uterus') which can become cancer.
IUD model: An IUD left inside for a long time causes an ulcer which becomes 4 3
infected; discharge increases and the woman gets cancer.
Yrm fai model: After delivery of a child a woman does not stay by the fire ()•uu fai) to 3 3
dry out her mot luuk; discharge increases, fungus/germs develop and she can get
cancer.
Sterilization model: Sterilization causes a woman to develop mot luuk boo dii {mot 1 3
luuk mai dii] (a 'bad uterus'), which leads to cancer.
reported that they had suffered from chronic cancer has resulted from a combination of wo-
symptoms for years. One woman complained men's pre-existing, ethnogynecological models
of having abnormally colored discharge, and the added effect of an intensive cervical
vaginal itching, and abdominal pain for 12 cancer education and screening campaign con-
years; another woman suffered from discharge, ducted in the region. An unfortunate by-product
itching, dysuria, and painful intercourse on an of this well-intentioned campaign has been a
almost daily basis for 20 years. A local gyne- situation in which women are convinced that
cologist who runs a private clinic reported that cervical cancer is far more common than it
most of her patients had suffered from symp- really is. Enhanced awareness about cervical
toms for at least 2 to 3 years. A review of cancer has resulted in both higher Pap smear
patient histories kept by four privace practi- rates and a significant rise in women's anxiety
tioners confirmed her impression. and suffering related to fears of illness progres-
Psychologically, the concerns about illness sion. Yet the great majority of these women
progression discussed above result in a great most likely suffer from non-life threatening con-
deal of worry and fear. First and foremost, ditions such as recurrent bacterial or fungal
women experiencing chronic or recurrent infections that might be easily managed, if not
symptoms are concerned that their illness cured.
will culminate in cancer and death. The actual The impact of educational activities was
incidence of cervical cancer in Thailand is 28 evident in in-depth interviews conducted with
cases per 100,000 women, but women in our women who suffered from recurrent symp-
study perceived the disease to be far more toms. One woman stated that from the health
common. [ ... ] This heightened fear of cervical education messages dispersed over the village
MOT LUUK PROBLEMS IN NORTHEAST THAILAND 429
loudspeaker she learned how common cervical at increased risk to cancer, or suspend sexual
cancer is among women her age, and it made relations and risk losing their husbands to
her so afraid of cancer that she suffers from other women? In some instances wives did
insomnia. Several women reported going to the not have a choice, given the sexual demands
local health station to request sleeping pills of husbands and their own social powerless-
because worrying about cancer kept them ness. In other cases, wives did suspend sexual
awake at night. One woman explicitly stated relations with their husbands' consent, but
that her symptoms were not serious enough to worried that their husbands would eventually
prevent her from working as usual, but that she engage in extramarital relations. They feared
was still worried about them turning into cer- that this would expose their husbands and
vical cancer because they conducted a health themselves to sexually transmitted diseases
education campaign in her village. Another and HIV/AIDS. In still other instances, wives
woman commented that "years ago people with prolonged illnesses who maintained close
did not know about cervical cancer. Women relationships with their husbands suggested to
had [vaginal] discharge and thought they had their spouses that they take up sexual relations
syphilis or gonorrhea. Now we think, cancer". with local women who were sexually available,
In contrast to diseases such as syphilis and in lieu of visiting prostitutes. In three out of the
gonorrhea for which medications can be pre- fifty in-depth case histories we conducted with
scribed, cervical cancer is thought by many women experiencing chronic or recurrent mot
women to be incurable and is strongly associ- luuk problems, wives sanctioned their hus-
ated with death. bands' extramarital sex in this manner, stating
The fear of cervical cancer among women that it was too difficult for men to live without
suffering from recurrent mot /uuk problems sex for more than a few months. [ ... ] Our
has reached extreme proportions. Many research suggests that in addition to general
women spontaneously mentioned a fear of promiscuity, peer influence, and migration for
cancer and even a fear of dying when asked a work, mot luuk problems should be considered
general question about how their experience of as a potentially significant influence on male
mot luuk problems had affected their lives. extramarital relations.
One informant reported that when she saw
two members of our research team coming to
interview her, she feared that they were coming Mot Luuk Problems as Idioms
to tell her that she had cancer. In another vil- of Distress
lage, a woman was diagnosed with cervical
cancer after suffering from vaginal itching for Do women in Northeast Thailand commonly
a long time; now if women in this village employ mot luuk complaints as "idioms of dis-
experience vaginal itching for awhile, they tress" (Nichter, 1981) and a means of securing
worry about cancer. Psychological suffering secondary gain in the form of time off from
from such worry and fear manifests itself as work, social attention, or an acceptable excuse
anxiety, insomnia, worry about chronic illness for refusing unwanted sexual relations? It may
or death in the future, and concern over who be recalled that this was an explanation offered
will take care of children when chronic illness by some outspoken clinicians and epidemiolo-
prevents the woman from fulfilling this role. gists in Thailand for high rates of self-reported
Sex is thought to hasten the onset of cer- gynecological complaints. When investigating
vical cancer when one is suffering from mot whether or not somatic complaints are being
Juuk problems. Some women perceived sex to used as a means of articulating personal
aggravate existing problems and others sus- discontent, it is important to recognize when,
pected that their husbands were in some way in what contexts, and to whom such communi-
contaminating them with germs or impurities cation is being directed and whether feelings
related to poor hygiene or extramarital sex. of discontent are recognized or acknowledged.
Wives thus faced a predicament: Should they It is also important to consider the ramifica-
continue sexual relations and place themselves tions of such communication and response to
430 PIMPAWUN BOONMONGKON, MARK NICHTER, & JEN PYLYPA
somatic complaints by others in both the short assistance with work if requested. Some hus-
and long term. bands requested that their wives not engage in
Bearing in mind these issues: What is at strenuous work, but in most cases women
stake for women in impoverished Northeast attempted to return to work of their own
Thailand if they complain about gynecological accord. When impoverished women had to
problems as an 'idiom of distress'? In our study, reduce or alter their work routines because of
we found that married women tended to illness, they generally bemoaned the fact that
inform both their close female friends and hus- they had less income and yet had to spend
bands about mot luuk problems, but did not scarce resources on medical expenses. They
wish others to learn about their symptoms. saw no secondary gain from being able to earn
Gynecological problems are a source of gossip, less and eat less! Being able to relax and recu-
especially when experienced by a woman perate from an illness (secondary gain) was an
whose husband has been absent or recently upper class behavioral pattern that they were
returned from migrant work. Knowledge of clearly not in a position to emulate. 'Cure me
another's gynecological problems can be used or give me better pain medication so I can work
against her to call into question the woman's or hard like before', one woman requested of a
her husband's moral identity. These symptoms doctor. A cursory medical exam turned up
are associated with sexual impropriety and nothing unusual and she was sent home with
poor hygiene, in addition to a wide range of paracetamol. Later she complained to an inter-
other causes. While women actively seek viewer, 'How can my family's welfare be good
advice from close female friends and relatives when I cannot work hard and there is less
about what kinds of medicine are effective for money? You ask me if my husband supports
different mot luuk complaints and where they me and is sympathetic. How long can he afford
should go for treatment, confidentiality is to do so if work remains undone and his needs
important to them when they attend health are unmet? When there is less money in the
stations and district hospitals. house there are more quarrels. When the chil-
Interviews with 10 husbands revealed that dren demand snacks, or items for school, I do
they acknowledged their wives' mot luuk com- not have money and I end up scolding them. Of
plaints as both a consequence of hard work and course it is better to work!'
a sign of women's vulnerability. However, they Women interviewed spoke of their power-
considered mot luuk complaints to be women's lessness, need for money, and the ramifications
business and played little if any role in deci- of chronic mot luuk problems in terms of social
sion-making about treatment, aside from risk {i.e., risk to valued social relationships).
encouraging their wives to seek medical When we raised the possibility of amplifying
attention. Women reported that when medical (not inventing) mot luuk complaints as a means
attention was sought, they rarely requested of communicating personal discontent, women
their husbands' attendance at local clinics, spoke of having too much at stake to do such a
and clinic staff complained that it is difficult thing. Complaining a lot about one's repro-
to get husbands to take treatment along with ductive health and pain during sexual inter-
their wives when it is suspected that the hus- course might lead a husband to take a minor
band is the source of his wife's infection and re- wife (and feel he had a right to do so). Taking a
infection. Health staff reported that if a hus- minor wife (i.e., an established mistress) con-
band is not presently experiencing symptoms, stitutes a threat not only to a woman, but also
he is reluctant to engage in treatment, since his to her children, due to the economic ramifica-
participation has the effect of fostering specu- tions of a husband spending family funds on
lation about his responsibility for his wife's his mistress. This is not to discount the possi-
illness. bility of individual women using mot luuk
Women spoke of informing their husbands complaints as a means of avoiding sexual rela-
about the mot luuk pain they experienced, but tions when social relations are strained, but to
they did not expect their husbands to pay suggest that it is unlikely that this accounts for
special attention to them beyond offering the vast majority of mot luuk complaints. Our
MOT LUUK PROBLEMS IN NORTHEAST THAILAND 431
research suggests that far more women suffer the mot luuk, such as muscle pain and fungal
in silence by bearing physical pain during infections. Fungal infections are in fact exacer-
sexual relations, than complain of mot luuk bated by the use of antibiotics. However, popu-
problems to avoid sex. lar brands of tetracycline are widely believed to
During group discussions, women did occa- be 'good for mot luuk problems' in general and
sionally speak of mot luuk pains in terms of also capable of improving the condition of a
women's difficult lot in life. At times it appeared 'bad uterus' (mot luuk boo dii [mot luuk
that the experience of pain was linked to a mai diij). These drugs were readily available
woman's moral identity. Women who worked in all villages surveyed, and were easily pur-
hard and sacrificed for the welfare of their fam- chased without a medical prescription (see also
ilies suffered pain, mok medications, and kept Whittaker, 1996).
on working. Could an association between being The idea of taking tetracycline for mot luuk
a virtuous woman, working hard, and bearing problems is not merely a 'folk medical belief',
pain bias women's responses to survey questions for these medicines are marketed through
about mot luuk complaints? Given that the poster and radio advertising as drugs to treat
symptoms in question are associated with hard the uterus (see Boonmongkon, Nichter, Pylypa,
work (lower back and abdominal pain), this & Chantapasa, 1998; Whittaker, 1996}. Gov-
possibility cannot be discounted. However, to ernment bans on other drugs previously avail-
argue that the majority of mot luuk complaints able in local provision shops have also likely
are related to identity management would be as contributed to the popularity of tetracycline.
misleading as to label such complaints as Self-medication is extremely common in both
'merely psychological' or a means to secondary rural and urban Thailand - through the use of
gain. Little evidence supports this conclusion. both brand name drugs, and unlabelled packets
On the contrary, there is compelling evidence of a mixture of drugs assembled by drugstore
to suggest that this is not the case. staff according to non-standardized recipes
(yaa sut [yaa chutj) that are commonly sold
for particular complaints (Chantapasa &
Self-Treatment Nichter, 2001}. The government has recently
initiated campaigns against the sale of yaa sut
How do Isa an women attempt to manage mot drug packets at local grocery shops (but not at
luuk complaints? What types of self-care and drug stores), and in the last few years fewer
health care seeking are common, and how ef- village grocery shops in the Northeast have
fective are they likely to be? When women been carrying yaa sut packets for women's
initiate treatment, most engage in self-medica- problems. This has left a market niche open
tion. Eighty percent of all women surveyed that companies selling tetracycline have been
(n = 1028) reported self-medicating the last all too happy to exploit further through decep-
time they experienced a mot luuk problem. tive or ambiguous marketing.
Three-quarters of these women purchased their What are women hoping to accomplish
medicines at village grocery shops, and almost when they self-treat mot luuk problems with
two-thirds of them bought antibiotics. In our antibiotics? Some women interviewed about
50 in-depth case studies, women overwhelm- Kaanoo and Hero spoke of these drugs as a
ingly reported treating their mot luuk problems cure for common mot luuk problems, others
-regardless of perceived etiology- with two as a means of preventing mot luuk problems
popular brands of tetracycline (Kaanoo 1\l and from becoming worse, others as a prophylactic
Hero·lJ:). Less commonly, they purchased peni- against the recurrence of problems they had
cillin. Case study interviews revealed that most experienced in the past, and still others as a
women used inadequate doses of these antibi- pain killer for mot luuk problems. [ ... ] Some
otics, taking between one and three pills only. women explicitly mentioned taking antibiotics
Tetracycline, even when taken in the correct so that they could continue to work, believing
dosage, is medically inappropriate for many that Kaanoo would either reduce pain or pre-
problems women classify as associated with vent their problem from becoming worse. For
432 PIMPAWUN BOONMONGKON, MARK NICHTER, & JEN PYLYPA
many women, taking these medicines was no Most of the women we interviewed spoke of
more noteworthy than taking stimulants or visiting the health station primarily because it
pain medications, drugs commonly consumed was convenient and inexpensive (particularly if
in rural Thailand to permit people to work they had government health cards), but
longer hours (Sringernyuang, Hongvivatava, expressed doubt that medicines obtained at
& Meeporn, 1991; Sringernyuang, Hongviva- the health station would cure their mot luuk
tava, & Pradabmuk, 1996). [ ... ] Five of the problems. They went to the health station to
50 women [ ... ] interviewed used some form get temporary relief from symptoms that they
of medication on an ongoing basis (daily, anticipated would return.
weekly, or monthly) in an attempt to either During the health service component of our
control or cure their illness. research we documented that the vast majority
of treatments offered to women at health sta-
tions for mot luuk problems were medically
Health Care Seeking inappropriate (Chantapasa & Nichter, 2001).
In one of the first clinic interactions we ob-
When self-medication fails to decrease the se- served, a woman came and complained of
verity of mot luuk problems or a woman begins pelvic and lower abdominal pain and
to worry that her symptoms are advancing to demanded an injection so that she could return
maleng [mareng] (cervical cancer), there are to work. She was given pills she recognized as
several sources of health care she may consult common painkillers and was dissatisfied. She
in both the public and private sector. Govern- again requested an injection and was given a
ment health stations (sathaanii anaamai) muscle relaxant in tablet form instead. "These
staffed by nurses and/or midwives are found types of demands are common," reported the
in most larger villages and within clusters of nurse in charge, "We give them something to
smaller adjoining villages. Their range and make them happy." A follow-up interview with
quality of services vary significantly by loca- the woman revealed that she and her neighbors
tion. District hospitals are found in towns, and commonly received injections for ;ep mot luuk
Khon Kaen city supports a regional hospital, a ('pain in the uterus') at this health station. It
maternal and child health center, a university appears that our presence had altered the treat-
hospital, and a government clinic for the treat- ment normally administered. In another health
ment sexually transmitted disease. Many gov- station, diazepam was administered for vague
ernment nurses and doctors [ ... ] have private mot luuk complaints without any physical
practices after hours, and in larger towns one examination being performed or history taken.
finds other doctors in private practice as well as It was assumed that such complaints were psy-
several drugstores that compete for clientele. chological or work-related. In yet another
Most women in Northeast Thailand have health station, a woman complaining of
contact with government health facilities. vaginal itching and lower abdominal pain was
Nursing staff at local health stations and dis- given a painkiller and an antihistamine for her
trict hospitals see approximately three-quarters complaints of pelvic pain and excessive dis-
of all women in their service areas at least once charge. This was not her first time visiting the
per year. During our initial survey, 52% of health station with this complaint. During an
informants reported visiting a local health sta- exit interview she spoke of her symptoms as
tion in the last six months and 37% had visited annoying, but generally bearable, and the
a district hospital. In the past year, 47% of medicines she received as helping, but not
women had visited a government health facility curing her problem. She worried about cervical
for some service related to obstetrics and gyne- cancer because her problem did not seem to go
cology (family planning, pre- or postnatal care, away, and she wanted a physical examination
Pap smears, or mot luuk problems). When and some reassurance that it was not trans-
women seek out health services specifically forming into a more serious condition.
for mot luuk problems, the vast majority of Staff in health stations overwhelmingly
them consult government facilities first. [ ... ] reported feeling poorly trained and ill equipped
MOT LUUK PROBLEMS IN NORTHEAST THAILAND 433
co diagnose and treat patients with gyneco- is a procedure that identifies any gynecological
logical complaints. [ ... ] During health staff disease. As they understand it, a Pap smear is a
training, far more emphasis is placed on the diagnostic procedure for all mot luuk problems
treatment of major STis than on RTis such as (the worst of which is cancer), not a screening
bacterial vaginosis and candidiasis, which procedure for precursors of cervical cancer.
health providers more commonly encounter. In Since many women think of cervical cancer as
the absence of clear treatment guidelines, the a large ulcer, fungus, or accumulation of pus
treatment offered to women presenting common that would be visible to the naked eye upon
gynecological symptoms was found to be incon- inspection, they expect to be immediately diag-
sistent across health stations and often nosed when examined. However, instead of
'irrational' by biomedical criteria. [ ... } The being informed by nursing staff about what
limited set of drugs supplied to health stations they have seen, they are told to wait for labora-
by the provincial health service and the need to tory results that often take up to 3 months to
ration available drugs significantly influenced process. Thus, women's expectations for diag-
the treatment prescribed. Often, 3-5 days worth nosis and treatment are not met, and they go
of an inappropriate antibiotic [ ... ] is prescribed away worried, unsatisfied, and untreated.
(Chantapasa & Nichter, forthcoming), and con- The number of women attending Pap smear
sultations are characterized by ad hoc 'diagnosis clinics in Northeast Thailand is at once a testi-
by response to treatment' in which diagnosis is mony to the success of this screening campaign,
retrospective, based on the efficacy, or lack and a barometer for women's anxiety about
thereof, of the treatment prescribed. mot luuk problems turning into cervical cancer.
Women are generally referred from health [ ... ] Estimates by two nurses who routinely
stations to the district hospital when treat- conduct Pap smears and data from exit inter-
ments are ineffective and ailments do not sub- views with dozens of women indicate that the
side, or when the resident midwife or nurse vast majority of women who get Pap smears
does not feel comfortable treating them or has (over and above those recruited by health staff
inadequate medicines to do so. Several women postpartum as a condition for receiving contra-
we interviewed took referrals to mean that they ceptives) do so because they have vaginal dis-
had a serious illness (such as cancer), when in charge and fear cancer. These women want
fact they could just as easily have had a fungal both treatment for their symptoms, and for
infection treatable with appropriate medica- the doctor 'to check and see if they have
tions. Other women (23 out of 50) traveled to cancer'. [ ... ]
district hospitals because they wanted an in- Women visiting district hospitals for mot
ternal exam to set their minds at ease. [ ... ] luuk problems by and large do not feel they
An aggressive Pap smear campaign has been receive enough information about their prob-
established in Northeast Thailand for the early lems from staff. Exit interviews following Pap
detection of cervical cancer. District hospitals smears revealed that patients had several ques-
offer weekly Pap smear clinics. [ ... ] Pap tions they wished to ask, but dared not for fear
smears are generally conducted by nursing staff of being scolded or angering busy staff. Aside
in the health promotion section of the hospital from wanting to be reassured that they did not
and in two out of three hospitals studied, have cancer, women wanted to know more
reproductive tract infections are not treated about their health problems. Could their illness
by nursing staff conducting these exams. Thus, be cured or only managed? Why did the illness
women experiencing symptoms are often return, did it remain in the body, and what
recruited for cervical cancer screening but made it flare up? While patients had a lot to
their immediate symptoms are not addressed. say to researchers about their mot luuk prob-
Furthermore, these women are poorly lems during exit interviews at hospitals, they
informed about the purpose of a Pap smear. were observed to volunteer little information
Since women perceive of cancer as the most to health staff and ask few questions. They
extreme manifestation on a continuum of mot provided only short answers to direct questions.
luuk problems, they imagine that a Pap smear Given the suffering that occurs as a result of
434 PIMPAWUN BOONMONGKON, MARK NICHTER, & JEN PYLYPA
Hubbell, R A., Chavez, L. R., Mishra, S. I., & (1998) The prevalence of reproductive tract
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34
The New Malaise
Medical Ethics and Social Rights
in the Global Era
Paul Farmer
First, to what level of quality can medical ethics aspire, if it ignores callous
discrimination in medical practice against large populations of the innocent
poor? Second, how effective can such theories be in addressing the critical issues
of medical and clinical ethics if they are unable to contribute to the closing of the
gap of socio-medical disparity? (Marcia Fabri dos Anjos, ''Medical Ethics in the
Developing World: A Liberation Theology Perspective")
Far be it from me to make ethics tremble. I tremble even at the prospect that I will
be found guilty of spreading the word that the pants of the great man are split.
For that I have already prepared a defense aimed at exonerating me of all
responsibility . ... The result is that it will be very hard to identify the guilty party,
to find anyone who is singularly responsible, if we are all rounded up by the
police and charged with inciting a riot against ethics. (John Caputo, Against
Ethics)
Paul Farmer, "The New Malaise: Medical Ethics and Social Rights in the Global Era," in Pathologies of
Power. Berkeley: University of California Press, 2003. © 2003 by University of California Press - Books.
Reproduced with permission of University of California Press- Books in the format Textbook via Copyright
Clearance Center.
438 PAUL FARMER
Tuskegee ended in 1972 amid public outrage partner. The researchers then tracked these
when the Atlanta Constitution and the New serodiscordant couples for thirty months,
York Times ran front-page stories on the study. following the viral load of the infected partner
In a critical reassessment ofTuskegee, historian and the rate of seroconversion among the pre-
Allan Brandt notes, "The entire study had been viously uninfected partners. The study con-
predicated on nontreatment. Provision of ef- cludes that "viral load is the chief predictor
fective medication would have violated the ra- of the risk of heterosexual transmission of
tionale of the experiment - to study the natural HIV-1." Such a finding "raises the possibility
course of the disease until death. " 2 It took the that reductions in viral load brought about by
US government decades to acknowledge its the use of antiretroviral drugs could poten-
wrongdoing; President Clinton's public apol- tially reduce the rate of transmission." Quinn
ogy came in 1997. and colleagues called for more research "to
My student's e-mail message contained a develop and evaluate cost-effective methods,
Reuters story about a paper published the day such as effective and inexpensive antiretroviral
before in the New Englmtd Journal of Medi- therapy or vaccines, for reducing viral load in
cine. Under his terse subject heading, he for- HIV-infected persons. " 4
warded the story, without commentary: Already, the Ugandan study has occasioned
a good deal of comment. Some of it appeared
Boston, March 29 - A study of more than
15,000 people in Uganda that has raised eth- in the same issue of the New England Journal
ical questions about AIDS research in poor of Medicitle: "Tragically," noted a researcher
countries concluded that the risk of spreading from another U.S. university, "results such as
AIDS through heterosexual sex rose and fell these could be obtained only in places with a
with the amount of virus in the blood. very high incidence and prevalence of the virus
The study, in Thursday's issue of the New and few practical or affordable means of pre-
England ]ottmal of Medicine, also confirmed venting transmission .... The challenge now is
earlier research suggesting that circumcision to use these results to develop prevention strat-
guarded against the spread of HIV, the virus egies that can benefit everyone, especially those
that causes AIDS. who participated in the research. " 5
The research was controversial, not because Develop prevention strategies. This sounds
of its conclusions, but because of its method- eminently reasonable at first blush. But were
ology. Unlike studies of H.I.V. in developed more research and the development of preven-
countries, the volunteers in the Uganda study tion strategies the only real challenges
were not offered treatment, nor did doctors emerging from this and other studies? I had
inform the healthy spouse of an infected just participated in a conference in rural Haiti
person that his or her partner harbored the - a conference attended mostly by women
virus. living in poverty, several of them also living
Instead, the team led by Dr. Thomas Quinn with HIV - and the "challenge'' as outlined in
of the National Institute of Allergy and Infec-
the paper or the accompanying commentary
tious Diseases, tested the volunteers and
did not ring true to me. Prevention strategies
tracked the spread of their illness. 3
had already failed those infected during the
In brief, the randomized-control trial con- course of the Ugandan study; prevention strat-
ducted between November 1994 and October egies were hardly the "challenge" at hand for
1998 examined the relationship between "those who participated in the research." The
serum viral load, concurrent sexually transmit- women at the meeting in rural Haiti had raised
ted diseases, and other known and putative a very different set of challenges. As one asked,
HIV risk factors (for example, male circumci- "What about those of us who already have
sion and several sociodemographic and behav- HN? Are we merely to wait for death?" An-
ioral factors). The research team screened other participant said simply, "Treatment is
15,127 individuals in a rural district of important for sick people."
Uganda, of whom 415 were identified as Commenting on the Ugandan study, ochers
HIV-positive with an initially HIV-negative echoed my student. In the electronic magazine
THE NEW MALAISE 439
Slate, one writer asked: "The 15,000 Ugandan A 1997 article by Peter Lurie and Sidney
volunteers in the sample were not offered treat- Wolfe triggered what have become increasingly
ment nor were their healthy sex partners vocal attacks on the AIDS clinical trials being
informed that the research subjects were HIV conducted in developing countries - studies
positive. Excuse please, but why isn't this like involving, for example, what many argue are
the [New England Journal of Medicine] sup- unethical placebo controls in AZT trials at-
porting the Tuskegee experiments?" 6 tempting to develop a cheaper drug regimen
Let us leave aside the fact that there were to prevent mother-child transmission of HIV,
415 serodiscordant couples in the study, not Udo Schiiklenk cast this argument in a different
15,000, and the facts that the Journal pub- light:
lished rather than conducted the research and
that its editor wrote a highly critical commen- In the real world there is no such thing as a
tary. 7 The point here is that even though we fixed local standard of care. Rather, the local
might dismiss comments from outside the standard of care in, for example, India, is a
standard of care determined by the prices set
research community as inaccurate or tendentious
by Western pharmaceutical multinationals.
or worse, an understanding of the social field
The only reason why the [AZT placebo] trials
that generates such commentary reminds us
took place at all is the pricing schedule set by
that we live in a peculiar age. Although histor- the manufacturer of the drug. Glaxo-Well-
ians and economists warn against simplistic use come therefore, more than anything else, de-
of the term "globalization," rapid develop- termines what is described by bioethicists and
ments in communications clearly are changing clinical researchers as the "local standard of
the way we understand, experience, and care.'' 10
manage social inequality. 8 Surely it is a novel
development that research published one day What does medical ethics have to say about
in the New England Journal of Medicine can, such transnational research? The short answer:
within twenty-four hours, trigger heated very little, so far. This in spite of the demands
responses from around the globe. contained in the International Code of Medical
These and other developments in communi- Ethics, first drafted in Geneva in 1949, that
cations are reminders that, increasingly, epi- physicians not only place the well-being of
demics of disease are transnational ones. 9 research subjects above the supposed benefits to
Research universities and development agen- science and society but also that they declare,
cies now also have global reach, and, just as "I will not permit considerations of religion,
epidemics are transnational, so too, increas- nationality, race, party politics or social standing
ingly, is research. But although pathogens read- to intervene between my duty and my patient." 11
ily cross borders, the fruits of research are often But is it not precisely "social standing" and
delayed in customs. For example, it seems to be "nationality" that place Ugandans at risk for
easy enough to use First World diagnostics - in becoming AIDS research subjects and for
the Ugandan study, sophisticated assays of receiving substandard medical care? By sub-
viral load were available - even though antire- standard, I mean lower chan the care that the
troviral therapy is deemed unfeasible, too diffi- researchers would expect for themselves in the
cult, or "cost-ineffective.'' The most commonly unlikely event that they were to contract HIV.
encountered justification, though, is that anti- It is not my intention here to focus over-
retroviral therapy does not reflect "local stand- much on one particular study. Indeed, Quinn
ards of care." The devastation wrought by HIV and colleagues are likely not guilty of violating
in sub-Saharan Africa - AIDS is now far and the ethical codes established by their university
away the leading cause of adult death across and by their Ugandan counterparts, as they
the continent and has already orphaned were quick to protest. They pointed out that
fourteen million children there - has brought four institutional review boards in the United
the local-standard-of-care argument to the States and Uganda had approved the study and
forefront of medical and public debate in the that a data safety and monitoring board from
past few years. the National Institutes of Health, composed of
440 PAUL FARMER
of professional ethics? Writing about codes of virtue of their very reality, constitute the most
medical ethics, Soh] and Bassford offer a polite radical question of the truth of this world, as
definition that would be challenged by few: well as the most correct response to this ques-
tion."17 As a physician-anthropologist who
While it is undeniable that a major motivation serves the poor in Haiti, Boston, Peru, and
for desiring self-regulation is the pursuit of Russia, I have no reason to back away from
professional power, self-regulation carries this stance in contemplating medical ethics,
with it an ethical component, and involves a and every reason to cling to it ever more tightly.
moral commitment on the part of the profes-
Our work -analysis and praxis- takes place at
sion. To see this one need only think of any of
an invigorating intersection of medicine, social
the occupational groups currently trying to be
theory, philosophy, and political analysis. And
recognized as having professional status. One
of their first acts is to formulate and publicize these disciplines help us to see why it is so
a code of ethics for their members. 16 important to socialize ethics. As humans, we
are all vulnerable to sickness; as physicians, we
Codes of medical ethics exist in profusion, and care for the vulnerable. But some groups are far
though some are less self-serving than others, more vulnerable than others, as every serious
most have, as their implicit or avowed focus, epidemiological study has shown. For the poor
the protection of the professionals. In the Tavi- in affluent countries, it is possible to document
stock document, we have something more the impact of services that are inferior to those
novel: a code crafted by professionals that offered the nonpoor. In many resource~poor
starts by asserting that health care is a human countries, it is often possible to document a
right. complete absence of modern medical care. 18
In subsequent discussions, some have As other chapters in this book show, current
pushed this assertion even further, to argue that trends are far from heartening.
quality health care is a fundamental human A few decades ago, the impact of this injust-
right. In a very real way, such a redefinition ice would have been significant, but not invari-
would bring all those who comfortably agree ably a matter of life and death. That is, people
with the Tavistock principles to the brink of the lived and died, many of them unjustly, but even
abyss. They would have to look down at the the well-to-do lived in fear of microbes that
squalid misery endured by much of humanity, could kill them, as Nancy Tomes reminds us
with its Sisyphean burden of readily treatable in her book about infectious diseases at the
pathology, and ask how a decent physician or turn of the nineteenth century. 19 And although
nurse (or other health professional) should the nonpoor always did better than the poor,
act ethically. More specifically, what would pneumococcal pneumonia and tuberculosis
the world's destitute sick, wherever they lan- came with a high case~fatality rate, regardless
guish, have to say about the key tenets of the of social station.
statement? And one could ask still harder Everything is different now, in large part
questions: Do the invisible poor come into because medicine is indeed becoming the
view only when they become research subjects "youngest science," as Lewis Thomas has writ-
or immigrants, or is the next step the inclusion ten. 20 Using the basic sciences to develop new
of everyone under the rubric "everybody"? therapies and the scientific method to evaluate
The inclusion of all humans under the their efficacy reminds us that the fight over
rubric "human"? The inclusion of social and equal access to leeches is certainly no longer
economic rights under the rubric "human one worth wasting time on. If the medical
rights"? interventions in question are ineffective, or
I pose these questions with trepidation. But only marginally effective, lack of access to
they are, in my view, far and away the most these interventions, though unfair, is of limited
important questions for medical ethics. I agree importance. But biomedicine can at last offer
with Jon Sobrino and others who believe that the sick truly revolutionary new therapies. In
"the poor and impoverished of the world, in my own field, infectious disease, we have
442 PAUL FARMER
certainly seen a revolution. Antibiotics and a curious, at times almost silly, tenor, as Larry
vaccines can, for the fortunate few, virtually Churchill has noted:
erase the risk of mortality from polio, tetanus,
measles, pneumonia, staphylococcal and other Bioethical disputes - as measured by the de-
bacterial infections, diarrheal disease, malaria, bates in journals and conferences in the United
tuberculosis. Even HIV disease, the latest States - often seem to be remote from the
rebuke to undue optimism, has been rendered, values of ordinary people and largely irrele-
for those with access to therapy, a readily treat- vant to the decisions they encounter in health
able disease. care. In this sense, philosophical theorizing
Then comes the obvious irony. In the areas might be considered harmless entertainment,
which if taken too seriously would look ridicu-
where I work, most premature deaths are
lous, as several Monty Python skits have suc-
caused by precisely these pathologies. 21
cessfully demonstrated. 22
There have been few attempts to ground
The Leading Ethical Question of medical ethics in political economy, history,
Our Times anthropology, sociology, and the other con-
textualizing disciplines (although each of these
Into this irony comes bioethics. I have served would have no doubt lent its own native
on the ethics service of the Boston teaching silliness). 23
hospital with which I am affiliated, and of Second, medical ethics has been to a large
course take each consult seriously. These con- extent a phenomenon of industrialized nations.
sults are often enough about too much medical This has facilitated the process of erasing the
care. That is, we are called to explore cases in poor, since most of them live elsewhere. Thus,
which care is painful, expensive, and pro- the great majority of the world's ethical
longed well beyond the point of efficacy. This dilemmas - and, to my mind, the most serious
is termed "medical futility." But being a clin- ones - are not discussed by the very discipline
ician who works in both a Harvard teaching claiming expertise in such matters. The third
hospital and rural Haiti, I can't help but make reason that medical ethics and bioethics have
connections between the surfeit on one side - been mum on the leading ethical dilemma of
too much care- and the paucity on the other. our times is that experts have dominated public
As an infectious-disease consultant, I feel that discourse on these matters, drowning out the
my job in Haiti is to say, "Quickly, start the voices of those who have far more direct
antibiotics," whereas my job in Boston often experience. To again cite Churchill:
comes down to saying, "Stop the antibiotics."
Ethics, understood as the capacity to think
In Haiti I am called to explain, to those who
critically about moral values and direct our
come begging for assistance, that effective
actions in terms of such values, is a generic
treatments for HIV are not "cost-effective," human capacity. Except for sociopaths, it is
whereas in Boston I spend much of my time common to all of us, and ski]) in ethics does
begging patients with AIDS - some of them not lend itself easily to encapsulation in theor-
originally from Haiti - to take these same etical categories, core competencies, or a pro-
medications. In Boston I might be alone in fessional speciality. 24
witnessing this painful irony, if not for the
transnational Haitian janitors who keep the A fourth reason, in part an unavoidable one, is
hospital clean. that in the hospital we are asked to address the
What does bioethics have to say about this, "quandary ethics" of individual patients. In the
the leading ethical question of our times? affluent countries where bioethics has blos-
Almost nothing. Conventional medical ethics somed, these have often been elderly patients
does a good job of erasing such obscene dispar- for whom further care is deemed futile, even
ities, for at least four reasons. First, ethics though the machine of "care" grinds on, leav-
draws strength from experience-distant discip- ing family and providers feeling a bit ground
lines such as philosophy, lending ethics debates up themse]ves.
THE NEW MALAISE 443
As the Tavistock statement notes, "The per- own checks and balances. A principle such
sonal experience of illness is generally the prin- as this would lead us to push for public health
cipal concern of individual patients; therefore, but at the same time resist the prevailing
the principal focus of the health care delivery conditions - conditions in which it is possible,
system must be individual patients and their indeed deemed reasonable, for physicians
families or support groups. " 25 This priority is to contemplate the results of a study con-
altogether appropriate and should not be ducted among the destitute sick of Uganda
changed. What should be changed, rather, is and feel that the only challenge is "prevention."
that millions are denied the chance to become As the women participating in our conference
patients and to have an "individual focus" in Haiti observed, prevention comes too
trained on them. Beyond the administrative late for people who are already sick and
borders erected around catchment areas or immiserated.
states or nations, legions die - not of too much The self-appointed guardians of inter-
care or inappropriate care but rather of no national health cannot ethically erase the tens
care at all. One gets the sense, in attending of millions already sick with HIV disease. Even
ethics rounds and reading the now-copious using their own, often punitive, analytic tools
ethics literature, that these have-nots are (for example, cost-effectiveness analysis),
an embarrassment to the ethicists, for the prob- treatment of HIV should surely have its role
lems of poverty and racism and a lack of among the destitute sick of southern Africa.
national health insurance figure only rarely in As Evan Wood and colleagues argue, even
a literature dominated by endless discussions of "limited use of antiretrovirals could have an
brain death, organ transplantation, xeno- immediate and substantial impact on South
transplantation, and care at the end of life. Africa's AIDS epidemic." 27 Their assessment
When the end of life comes early - from death projected that the use of short-course prophy-
in childbirth, say, or from tuberculosis or in- laxis would reduce perinatal transmission by
fantile diarrhea - the scandal is immeasurably 40 percent, preventing 110,000 infant HIV
greater, but silence reigns in the medical ethics infections by 2005 - at a cost of less than
literature. 0.001 percent of the national per-person health
In an era of globalization and increased com- expenditure. In a more costly scenario, triple-
munication, this selective attention can become combination treatment for only 25 percent of
absurd. The world's poor already seem to have the HIV-infected population would prevent
noticed that ethicists are capable of endlessly both 430,000 incident AIDS cases and a 3.1-
rehashing the perils of too much care, while year decline in life expectancy. 28 Thus even
each year millions die what the Haitians call without recourse to ethical reasoning- which
"stupid deaths." The erasures are expedient would lead us to ask not "if" but rather "how"
for some, certainly, but the effaced are less -we find the world revealed to us as it really is:
easy to silence these days. One reason is that a place in which the absolute majority of med-
communications are different- and by and large ical ethics violations go unremarked by experts
better- in the global era. Another reason is the in this field.
sheer burden of unnecessary suffering and pre- The millions already dying during child-
mature death. A third is that the current trend is birth or from diseases such as HIV and drug-
coward even further entrenchment of social resistant malaria and tuberculosis face other
inequality. challenges beyond prevention. 29 If "the care
In the midst of all of this comes the second of individuals is at the center of health care
principle of the Tavistock document: "The care delivery," as the Tavistock statement argues,
of individuals is at the center of health care then concerns over equity won't simply go
delivery but must be viewed and practiced away. In the global era, global health equity,
within the overall context of continuing work more than ever before, must be a goal of any
to generate the greatest possible health gains serious ethical charter. Questions regarding
for groups and populations. " 26 Here is a social and economic rights are at the heart of
principle suited to our times. It contains its what must become a new medical ethics.
444 PAUL FARMER
and human rights. Although disciplinary spe- A charter such as the one proposed in Tavi-
cialization has yielded great insights, the argu- stock would mean that we would no longer be
ments in this book have tried to emphasize the more comfortable talking about "patient au-
cost of desocializing the concept of rights. tonomy" than about the right to receive care
Whether we consider Russian prisoners with when sick. Such a charter would have a great
drug-resistant tuberculosis, HIV-infected deal to say about medical research conducted
Cubans living within sanatoriums, Bostonians by First World universities in settings of Third
with AIDS living on the streets, or Haitians World poverty. It's naive to pretend that there
with AIDS detained on a US military base, the are no competing agendas here. At the same
story is the same: a failure to understand social time, the first half of the second principle
process leads to analytic failures, with signifi- reminds me to be focused on the individual
cant implications for policy and practice. patient. And it does not exhort me to treat only
patients of a certain nationality.
from exploiting some public-entitlement pro- Brandt 1978 and Jones 1993. Rothman 1984
gram in an affluent industrialized nation. But if and Reverby 2000.
Haiti and Uganda and Russia and Harlem are 2 Brandt 1978, p. 27.
part of the same world, we could argue just as 3 "Criticized Research Quantifies the Risk of
easily that conducting research in settings of AIDS Infection" 2000.
great privation and excess burden of disease 4 Quinn, Wawer, Sewankambo, et al. 2000,
also runs the risk of "manipulating the pp. 921, 927, 928.
system," with the system in question being the 5 Cohen 2000, p. 972; emphasis added.
global web of connections that is increasingly 6 Shuger 2000.
7 Angell 2000b.
visible to all of us. Much of this research would
8 Yach and Bettcher 1998b; Navarro 1998;
never be considered ethical within the country
and Kim, MiUen, Irwin, and Gershman
sponsoring the research; its approval by insti- 2000.
tutional review boards relies on the argument 9 See Farmer 1996c; Farmer 1999b; Farmer,
that the local standard of care - in the poor Bayona, Becerra, et al. 1998; and Garrett
communities where the research subjects live 2000. For details on transnational cases of
and die-is no care at all. So too can we drug-resistant tuberculosis, for example, see
wonder, as the Financial Times estimates cap- Becerra, Farmer, and Kim 1999.
ital flight out of Russia at greater than $130 10 Schuklenk 2000, p. 973. Morsy 1993,
billion in seven years, if our failure to fight Mintzes, Hardon, and Hanhart 1993.
hard enough for food for prisoners with tuber- 11 World Medical Association 1983.
culosis is merely a concession to far more 12 Gray, Quinn, Serwadda, et al. 2000.
powerful forces who are only too happy to 13 Angell 1997a, p. 849.
"manipulate the system" to the substantial dis- 14 The official title of the document, published
advantage of the poor. simultaneously in several journals in early
The concept of human rights may at times 1999, is "A Shared Statement of Ethical Prin-
be brandished as an all-purpose and "univer- ciples for Those Who Shape and Give Health
sal" tonic, but it was developed to protect the Care" (Benatar, Berwick, Bisognano, et al.
vulnerable. The true value of the human 1999; Smith, Hiatt, and Berwick 1999a and
rights movement's central documents is 1999b). I had the good fortune to be in-
revealed only when they serve to protect the volved in some of the follow-up discussions
of the Tavistock Group, held in April2000 at
rights of those who are most likely to have
the American Academy of Arts and Sciences
their rights violated. The proper beneficiaries
in Cambridge, Massachusetts. This meeting
of the Universal Declaration of Human
led to further clarification and expansion of
Rights - however inexpedient this point the initial five principles into the following
might be in our age of individualism and seven Tavistock principles:
affluence and relativism - are the poor and Rights: People have a right to health
otherwise disempowered. The true value of and health care
the Tavistock statement is that it attempts to Balance: Care of individual patients is
restore the language of rights to the arena of central, but the health of popu-
health care. Since the burden of disease is lations is also our concern
borne by the poor and otherwise marginal- Comprehensiveness: In addition to
ized, we are offered a chance, once again, to treating illness,
contemplate the lot of most of humanity and we have an obli-
to ask, simply enough, if by "everybody" we gation to ease
truly mean everybody. suffering, minim-
ise disability, pre-
vent disease, and
NOTES promote health
Cooperation: Health care succeeds only
1 For more on the Tuskegee study, including the if we cooperate with
role that racism played in its continuation, see those we serve, each
448 PAUL FARMER
Finally, this idea of man's sacredness gives grounds for reflection that what is here
pronounced sacred was, according to ancient mythical thought, the marked
bearer of guilt: life itself. (Walter Benjamin, "Critique of Violence")
On March 28, 2003, as on the last Friday of foundations and public partners, a program of
every month, the board of administrators of research and development similar to that of
Medecins sans frontieres (MSF; Doctors with- the pharmaceutical industry but dedicated to
out Borders) met between five and eleven treatments deemed unprofitable because of
o'clock in the organization's head office on the poverty of the Third World patients who
the first floor of a building in the eleventh need them.
arrondissement of Paris. On that particular The meeting of the board of administrators
evening a peculiar atmosphere of expectation is open to the public. All members of the asso-
and excitement reigned. There was of course ciation have the right to participate, as do the
the customary rapid overview of the situation employees who carry out the organization's
in a number of "missions" in various parts of bureaucratic and technical functions. In gen-
the world where the organization intervenes, eral, attendance gradually thins out as the
followed by a more in-depth examination, with evening wears on. But that evening many
discussion of various specific topics concerning stayed, waiting for the last item on the agenda.
the running of the association and its humani- The subject was the state of operations in Iraq.
tarian activities. The construction of the "inter- Eight days earlier, American and British troops
national movemenrt' was also raised: it referred had begun their bombardment of the country,
to the network of sections in twenty countries, ending the long run-up to a war that had been
of which six are actually in a position to con- declared in a climate of growing international
duct operations, and which strives to ensure a tension and division. MSF has a complex his-
coherence of identity and policy in the work of tory with the Iraqi state, having refused to
each national body beyond the details of local intervene during the period of the embargo so
history and culture. The DNDi (Drugs for as not to succumb to what it considered to be
Neglected Diseases Initiative) program was the manipulation of international humanitar-
another issue addressed: this is an original ian sentiment by the criminal Baathist regime:
project that the organization had instigated bringing aid to the Iraqi population would
two years earlier in order to establish, in inter- have meant comforting Saddam Hussein's
national collaboration with private charitable power. Nevertheless, the organization had
Didier Fassin, "Humanitarianism as a Politics of Life," Public Culture 1913 (2007): 499-520.
HUMANITARIANISM AS A POLITICS OF LIFE 453
recently changed its position and had started save (e.g., by selecting AIDS patients to be
negotiating its presence with the Iraqi Ministry given antiretroviral drugs for lack of resources,
of Health, as the prospect of war was getting or deciding whether to provide assistance to
more and more obvious: a medical team of six people who have participated in massacres).
was therefore present in Baghdad and, after And humanitarian intervention is also a polit-
long and difficult discussions in its executive ics of life in that it takes as its object the defense
committee, MSF had decided to stay. of causes, which presupposes not only leaving
The debate was now taking place publicly other causes aside but also producing public
within the board of administrators. Should the representations of the human beings to be
medical team remain in Baghdad, given the defended (e.g., by showing them as victims
danger it would face both from the cornered rather than combatants and by displaying their
military of the Iraqi regime and from the pre- condition in terms of suffering rather than the
dictable rain of American bombs, on the one geopolitical situation). What sort of life is im-
hand, and given the likely limited efficacy of its plicitly or explicitly taken into account in the
presence, since the team was so small com- political work of humanitarian intervention?
pared with the extensive health-care facilities This is the question that interests me.
and professionals available in Baghdad, on the In the first part, I differentiate lives to be
other hand? Should the lives of aid workers be saved and lives to be risked as a fundamental
risked to save other lives among local popula- distinction between the mere physical and the
tions? The discussion that arose around the fundamentally political dimensions of life, that
presence of these members in Iraq was by aJI based on the possibility of the subject to decide
accounts the most intense debate the associ- about it. This is what underlies the debate in
ation has seen in the past few years. However, MSF on whether or not to stay in Baghdad. In
it avoided the most painful truth - the radical the second part, I discuss saving and risking the
inequality that underlies this transaction in lives of others as a basic opposition between
human lives. humanitarian and military politics of interven-
I take this scene as a starting point for rais- tion in a supposedly clear separation of victims
ing the question of humanitarian action as it and enemies. This is what is meant by MSF
constitutes one of the paradigmatic forms of a team members who expose their own lives
politics of life, by introducing this dialectic and the soldiers who expose the civil popula-
between lives to be saved and lives to be risked. tions' lives. In the third part, I blur these lines
What I call "politics of life" here are politics by introducing a series of concrete situations
that give specific value and meaning to human unveiling more complex realities of the politics
life. They differ analytically from Foucauldian of life, revealing the aporia of risk taking,
biopolitics, defined as "the regulation of popu- discriminating expatriates and nationals, and
lation," in that they relate not to the technolo- displacing lines from biological to biographical
gies of power and the way populations are existences. This is what is implied by the final
governed but to the evaluation of human failure of MSF's mission in Baghdad with the
beings and the meaning of their existence. 1 abduction of its members and the departure
Humanitarian intervention is a biopolitics from Iraq. The three configurations have a
insofar as it sets up and manages refugee camps, common moral background in which the
establishes protected corridors in order to gain sacred, as Walter Benjamin puts it, resides no
access to war casualties, develops statistical longer in man as master of his existence but in
tools to measure malnutrition, and makes use "life itself. "2 However, the series of distinctions
of communication media to bear witness to implied by the differentiation of lives on the
injustice in the world. But humanitarian inter- battlefield indicates radical inequalities in the
vention is also a politics of life, as I suggest to human condition.
phrase it, in that it takes as its object the saving To display these humanitarian politics of
of individuals, which presupposes not only life I have thus chosen a classical dramaturgy
risking others but also making a selection of with its unity of place, time, and action,
which existences it is possible or legitimate to because the social drama of the decision to stay
454 DIDIER FASSIN
seemed to me so emblematic of the tensions Baghdad and taking responsibility for the care
and contradictions within these politics. But of a potential20 million displaced people. But
there is another reason for me to concentrate in the days following the signing of that agree-
on this episode: my personal implication in it, ment, the Iraqi authorities proved unwilling to
as I further discuss. In fact, I do not intend to keep their side of the bargain, forbidding the
present a detached examination, "to unveil and volunteers from entering hospitals to evaluate
denounce truths and violations," 3 but rather the health situation, on pain of expulsion: in
aim to enter, as it were, into the heart of hu- this tense context, the humanitarian new-
manitarian activity, to analyze the conse- comers seemed suspect allies.
quences of choices made and practices On March 18, George Bush issued a solemn
implemented- in short, to follow humanitar- appeal to Saddam Hussein, calling on him to
ianism to its logical conclusion. I do it here on leave Iraq within forty-eight hours. As the last
the basis of my experience and research primar- flights evacuating expatriate staff of inter-
ily with MSF: experience as a member of the national and nongovernmental organizations
board of administrators for four years and re- were leaving Baghdad, and with three hundred
search through a series of interviews with its of their members stationed in the country
personnel in Paris. The choice of studying this awaiting the strike from the Western armies,
sole organization and moreover this specific six members of MSF- including a surgeon, an
event may seem to limit the scope, whereas anaesthesiologist, and a medical doctor - de-
humanitarianism increasingly appears as alan- cided to stay despite the evident danger of the
guage for states and international agencies as coming situation. They included one of MSF's
well. But although MSF is a unique organiza- most public figures, the president of the inter-
tion, to which the award of the Nobel Peace national movement. Other organizations made
Prize in 1999 nevertheless offered a certain the same choice; in addition to the Inter-
exemplary value, I believe that the lessons from national Committee of the Red Cross, Premiere
this case study can be applied much more Urgence and Caritas maintained a skeleton
widely, throwing light beyond the work of this presence. On March 20 the Americans and
particular organization onto the profound British launched their attack and the bombard-
meaning and aporia of humanitarian politics ment of the Iraqi capital began. Intense and
of life. intermittent, it lasted several days, during
which the MSF team in Baghdad had very little
chance of leaving its hotel. Several bombs fell
Where It Hurts nearby, a brutal reminder of how close the
danger was. However, team members knew
During the months preceding the American that the hospital where they had begun to work
invasion of Iraq, MSF, like many other aid had received only a handful of patients with
organizations, undertook exploratory missions minor injuries, for which they supplied some
in Iraq and neighboring countries with the aim surgical equipment. "At the moment the team
of predicting the consequences of military feels that it is not very useful, but it is preparing
intervention, in terms both of injured and sick for what may come," the desk officer in Paris
within Iraq and of refugees outside the coun- commented. 5
try.4 In particular, delicate negotiations were This period of looming danger and uncer-
conducted with the Iraqi Ministry of Health tainty formed the context for what the minutes
and the Red Crescent in order to establish an of the administration board of March 28 call a
official framework for the mission, so as to "debate on the controversial decision to install
obtain the necessary residence permits and a team in Baghdad." 6 There was lively discus-
ensure independent operation. A memo of sion around the issue of the team's safety, as
March 11, 2003, makes reference to two pro- there had been a few days earlier, at the meet-
posals that were agreed on by both sides, that ing of the executive committee that made the
is, the Iraqi regime and MSF: providing med- decision to stay in Iraq despite the imminence
ical assistance in a hospital in the south of of the American intervention. Conflicting
HUMANITARIANISM AS A POLITICS OF LIFE 455
op1mons were expressed and deep divisions director: "We had no visibility, but we were
emerged around whether it was justified to aware that spaces could open if we were there."
maintain a humanitarian presence in this con- Some were not completely convinced by these
text: the issues raised concerned both the evalu- responses, particularly given the small number
ation of the danger and the anticipated efficacy of staff - six people, with only two possibly
of the team. As the president of the organiza- active in the operating room - relative to the
tion, who was himself in favor of the team's Iraqi casualties that everyone anticipated. The
staying, remarked, the stake is the same in vice president mused: "I have no view on
every situation involving humanitarian inter- whether it was right or not for the team to
vention: for those who are in the locality, once remain, but I nevertheless wonder why they
the conflict is under way, "there is no guaran- decided to stay. It must be for some other
teed emergency exit,'' and this was a question reason than saving lives; it's not for their effi-
of "the occupational hazards of our profes- cacy in terms of number of lives saved. I think
sion.'' Staying in a country at war, he sug- we are not following the analysis through
gested, always has a cost, if not in actual fully." One of the organization's founding
human losses, then at least in terms of the members offered his own interpretation on this
possibility of casualties. Nevertheless, he con- point: "It is part of our charter to be present in
cluded that "the level of risk we run in Baghdad war zones- although we know that war sur-
does nor seem any greater than in other places gery is inefficient because it saves only 10 per-
where we operate" and that "we have many cent more people than if there were no
teams in danger zones." 7 In the debate the issue intervention. The question therefore is, to be
of security was, however, overshadowed by there or not? If MSF was not there, I would ask
another: what reasons were there for the team why." An administrator retorted: "That's the
to remain? If the risks were high, what justified whole point: the constant dialogue between the
raking them? What use was a team on the spot, principles in our charter and genuine efficacy.
within the confined and endangered space Some people put more emphasis on the prin-
where it found itself? It was the question of ciples, some on efficacy; you often find that in
the usefulness of the mission that generated teams." But the president insisted: "We send
the most heated exchanges, but arguments on people when we think we can provide concrete
this point were quite contradictory. assistance, not just in the name of an ideal!
Some believed, in effect, that wherever in That should be really clear, unambiguous. " 8
the world MSF volunteers expose themselves Finally, as the atmosphere of the discussion
to objective danger they do it to bring "real, became increasingly tense, a young member
concrete assistance," as one desk officer put it. of the Fundation Medecins sans frontieres, the
In the case of Iraq, then, the potential contri- intellectual branch of the organization,
bution of a team of three health professionals attempted a synthesis between the logics of
was obviously modest compared with the hun- efficacy and principles: "It seems to me," he said,
dreds of doctors, surgeons, and anaesthesiolo- "that what Medecins sans frontieres represents
gists working in the thirty-five hospitals in is an ethics in action; it's impossible to dissoci-
Baghdad, or even, within the specific context ate the two, and we are always aware of the
of the team's intervention, compared with the limits of our activity. What is part of our prin-
sixty doctors, surgeons, and anaesthesiologists, ciples is that each life saved counts, and that
with seventeen operating theaters, in the sole some actions save lives. I think that in Baghdad
hospital where MSF workers aimed to offer that space will be there very soon. " 9 His analy-
their assistance. Nevertheless, efficacy was the sis might have been correct, but unfortunately
officially accepted justification for the decision not his prediction: actually, events were to
to stay. According to the organization's presi- prove him wrong.
dent, "The reason we have representatives in Four days after this meeting at MSF's Paris
Baghdad is so that they can provide assistance. office, two members of the team that had
That is the criterion on which we based out remained in Baghdad were abducted. For over
decision." He was echoed by the executive a week there was no news of them; the
456 DIDIER FASSIN
organization refrained from describing them as justify its surprising decision, MSF had to ex-
hostages or releasing their names, in order to plain that its presence was henceforth unneces-
avoid any additional risk. Anxiety mounted as sary. At the end of this operation, although it
Western troops approached. Conditions in the conformed to both the spirit and the letter of
capital grew increasingly unsafe, and finally the organization's charter, according to which
the hospital where the team had hoped to pro- members "bring aid to populations in distress"
vide assistance was looted, leaving the four and "assess the risks and dangers of missions
volunteers who were still free with no work. they carry out," MSF had certainly not shown
The desk officer for Iraq in Paris deplored the the efficacy that had been the directors' justifi-
absurdity of the situation in a memo dated cation for maintaining a team in Iraq, notably
April 10: "Medecins sans frontieres has had failing to "save lives" as they had hoped. 13 But
to suspend its activities at the very moment what merits attention here, more than this fail-
when Baghdad's hospitals are overrun with ure, which was after all easily understood in
casualties." 10 After being held for nine days, the uncertain context of the war, is the strength
the two members of the association were of emotions aroused by this mission among the
finally freed. They revealed that they had been executive committee and the board of
taken by agents of the Iraqi intelligence service. administrators. 14
Seventy-two hours later U.S. and British troops If one starts from the hypothesis that crisis
arrived in the center of Baghdad. For the team in an institution arises when a situation touches
on the spot, which was now able to reach its directly on its core issues, then one needs to
hospital and get to work there, it seemed that examine what underlies the conflict around the
the time had finally come when it could pro- decision to stay in Iraq. The discussion among
vide real assistance to the victims of the war. the board of administrators may be seen, in
Moreover, aid was flooding in, especially from Weberian terms, as a confrontation between
humanitarian organizations that had accumu- an ethics of conviction, represented by adher-
lated staff and equipment on the other side of ence to principles (to assist populations)
the border in the expectation of refugees who regardless ofthe cost (to endanger aid workers),
never arrived, since the anticipated massive and an ethics of responsibility, identified with
population movements had not occurred. careful assessment of risk (if staying) in relation
However, two weeks later, on April 28, the to the anticipated efficacy (by saving lives). The
decision was made to interrupt the mission. clash of ethics seems to be resolved in the final
The team was thus leaving Iraq before it had formulation of an "ethics in action" differenti-
even started its aid operation. Having come to ating two constructions of life: the life that is
render assistance to "populations in danger," at saved, that of the victims, and the life that is
a time when many had decided to leave a coun- risked, that of those intervening. Physically,
try deemed much too risky, MSF was therefore there is no difference between them; philosoph-
getting out of the country without having been ically, they are worlds apart. They illustrate the
able to intervene, just when most others, dualism that Giorgio Agamben derives from
including the Belgian and Dutch sections of Aristotle's Politics, between the bare life that
the association, were choosing to return or to is to be assisted and the political life that is
stay. The team left a little disillusioned, not freely risked, between the zoe of "populations,'
without criticism of the latecomers among hu- who can only passively await the bombs and
manitarian organizations who, it claimed, had the aid workers and the bios of the "citizens of
been too ready to exaggerate the seriousness of the world," the humanitarians who come to
the situation in order to sensitize their donors. render them assistance. 15 Recognizing the in-
"Desperately seeking humanitarian crisis," one equality between these lives at the level of their
former president of the association and the meaning - even more than in terms of the
desk officer commented ironically, in a text threats they objectively face- is not to question
published a few months later. 11 "No humani- either the justification for a specific humanitar-
tarian crisis in Iraq," declared the current presi- ian action undertaken in the name of the
dent in a French daily newspaper. 12 In order to victims, rights or the good faith of individual
HUMANITARIANISM AS A POLITICS OF LIFE 457
humanitarian actors who defend those rights; it had several ministers for humanitarian aid) or
is rather to attempt to understand the anthro- because they delegate it to paragovernmental
pological configuration in which the two are agencies (such as the Oxford Committee for
located. Humanitarian workers have the free- Famine Relief [Oxfam] in the United King-
dom to sacrifice themselves for a good cause, dom). Whatever form it takes, what appears
whereas the Iraqi population shares the condi- to be emerging is a humanitarian government
tion of those who can be sacrificed in a dirty at both the global and the local level, in the
war. In contemporary society this inequality is camps for displaced persons there and in the
perhaps both the most ethically intolerable, in social services for illegal immigrants and
that it concerns the meaning of life itself, and asylum seekers here. 18 This is a government
the most morally tolerated, since it forms the that defines itself through the introduction of
basis for the principle of altruism. 16 And it is morality into politics, in a so-called New
this truth that humanitarianism reveals. World Order that appears to have succeeded
The scene I describe above therefore has a the Realpolitik of the Cold War.
general relevance. For me it also has a more A common interpretation of this new situ-
personal resonance. As vice president of MSF ation tends to distinguish and to contrast polit-
at the time, I was one of the principal actors ics and humanitarianism, declaring that the
involved. And no doubt it holds a truth for me, latter is gradually replacing the former or even
too, since it was the last board of administra- announcing the advent of humanitarianism
tors meeting I attended. To understand the and the end of politics. "Humanitarianism is
issues related to this tense discussion, one has not a political issue and it should remain separ-
to be reminded that in the humanitarian ethics ate from political maneuvering,'' asserts Rony
the potential sacrifice of one's life reasserts the Brauman, a former president of MSF. Pointing
sacredness of others' lives, which is precisely to the renaissance of nongovernmental hu-
denied by the military necessities. This is what I manitarianism during the 1970s and 1980s, at
now explore. a time when communism's star was waning, he
even sees in this new configuration a sort of
historical fluid mechanics based on the
Sacred Lives. Sacrificed Lives principle of the communicating vessels: "It is
as if, during these periods when the ideological
Humanitarian intervention has become an tide is going out, humanitarian action comes to
important mode and even a dominant frame occupy the space left vacant by politics." 19
of reference for Western political interven- Agamben offers a more radical version of this
tion in global scenes of misfortune, both in thesis, suggesting that "the separation of polit-
cases of armed conflict and natural disasters ics and humanitarianism that we are witness-
and around their more or less direct conse- ing today represents the last phase of the
quences in the form of epidemics, famine, separation of human rights from civil right."
physical injury, and emotional trauma. No For the Italian philosopher, the image of the
war is now without its humanitarian corri- refugee becomes "the most significant sign of
dors and its humanitarian workers. And no bare life in our era," and he sees the refugee
Western military intervention into another camp as the "biopolitical paradigm." This
country is now without its justification on being the case, humanitarianism, insofar as it
humanitarian grounds. 17 Previously the pro- distances itself from the figure of the nation-
vince of nongovernmental organizations like state, abandons the political field. 20 However,
the Red Cross, MSF, and many others in their I believe that the contemporary world does not
wake and intergovernmental bodies, notably become more intelligible viewed in these terms,
the United Nations High Commission for and one may doubt whether there exists, in
Refugees, humanitarian intervention has one,s own society or in any society, a space
become a policy of nation-states, whether be- empty of politics or even a space outside polit-
cause governments are developing their own ics - all the more given that these interpret-
activity in the field (France, for example, has ations relegate the dominated and the
458 01 DIER FASSIN
excluded to this depoliticized space, leaving the is increasingly a merging of politics and
political space to the dominant and the in- humanitarianism.
cluded. They are thus doubly problematic - But what sort of humanitarian politics is
first empirically, for all investigations show being promoted? Bradol, president of MSF
that on the contrary, forms of political life since June 2000, is probably the organization
continue to arise even in the camps, and second representative who expresses with the greatest
ethically, since this reading appears to reinforce force the founding ethic of humanitarian inter-
the domination and exclusion by denying the vention- saving lives. 23 "By resisting the elim-
possibility of a political life to those who are ination of a particular sector of humanity,
subjected to them in practice. 21 Other avenues humanitarianism can create a way of life based
therefore need to be explored. on the satisfaction of offering unconditionally,
In fact everything suggests that rather than to a person in danger of dying, the aid which
become separate, humanitarianism and politics enables him to survive," he writes. "It is on this
are tending to merge - in governmental, inter- condition that victories - always by definition
governmental, and nongovernmental spheres. provisional and partial - over this politics of the
In France at least three former presidents or worst are possible." His moral geography of the
vice presidents of MSF have become ministers; world draws two opposing continents: that of
some have been elected to political office, the "established political powers" whose "role is
others have entered the civil service at high to decide on human sacrifice, to divide the
levels - not only in the traditional aid sector, governed into those who must live and those
but also in health and social welfare. Con- who may die," and that of the "humanitarian
versely, former ministers of social affairs or of project," which has "taken the arbitrary and
health have become presidents of Action contre radical stand of attempting to aid those sacri-
Ia faim (Action Against Hunger) and the ficed by society." The former relates to the "can-
French Red Cross. Thus one is seeing a huma- nibal ideal" since "building the international
nitarianization of national health and social order always requires its quota of victims." The
policy and a politicization of humanitarian or- latter derives from a "subversive dimension"
ganizations. At the international level the pro- since "humanitarian aid is offered as a priority
cess is even more marked, and one sees how, to those whose need to live is threatened by
particularly since the Rwandan genocide, with the indifference or the overt hostility of others."
the French army's belated Operation Tur- Thus this binary world opposes a politics of
quoise, Western military action in arenas of death, that of the criminal states, to a politics
disaster or conflict is conducted under the of life, that of the humanitarian agents. 24 Polit-
banner of humanitarianism, and increasingly ics is defined in moral terms: it consists of a
insistent attempts are made to bring non- new war of an axis of good against an axis of
governmental organizations on board. 22 When evil. By an astonishing paradox, at the very
they intervened in Kosovo and Iraq, the gov- momem when some countries are throwing
ernments allied to the North Atlantic Treaty themselves into a moral crusade against their
Organization (NATO) and to the United demonized enemies and appropriating the
States, respectively, spoke of the humanitarian vocabulary and symbolism of humanitarian-
imperative, thus confirming that the legitimacy ism, nongovernmental organizations are dis-
of interventions was being displaced from the tancing themselves while nevertheless casting
legal sphere (since they did not have the sup- their discourse in the same rhetorical mold.
port of the United Nations) to the moral sphere This remarkable mimetism - which operates
(the defense of human rights and even, more in both directions- should nevertheless not lead
restrictively and more specifically, the humani- one into a form of relativism that would set
tarian right). Thus one can speak both of the warmongers and humanitarians on the same
humanitarianization of international crisis level. The fact that the rhetoric is reproduced
management and of the politicization of the does not mean that the politics are equivalent.
nongovernmental humanitarian field. Rather While it may be fallacious to reduce the
than a dissociation, what one is actually seeing war makers to a consistently barbaric
HUMANITARIANISM AS A POLITICS OF liFE 459
"necropolitics'' and humanitarians to a purely also still informs the thinking of some of its
altruistic "biopolitics," it is much more interest- members, there is no greater gift than that of
ing to compare them in terms of the politics of one's own life. It is easy then to understand to
life they effectively engender. 25 what extent MSF's decision to go to Iraq plays
The humanitarian politics of life is based on on this ontology of inequality, by distinguish-
an entrenched standpoint in favor of the "side ing those whose life is passively exposed, be-
of the victims. "26 The world order, it supposes, cause they are at the mercy of the bombs, and
is made up of the powerful and the weak. those whose life can be freely sacrificed,
Humanitarian action takes place in the space because they have decided to stay.
between the two, being deployed among the This courageous decision - all the more
weak as it denounces the powerful. It therefore courageous given that it was, as could be pre-
relates to only one part of humanity - the one dicted from the moment it was made, of hardly
on the wrong side of life. It intervenes "in any use- should moreover be understood from
places where life is not worth a dollar." 27 It is the point of view of the armed forces that
aimed at those who are considered at risk of intervene in present-day conflicts. In this
physical disappearance and incapable of main- respect, the ethical norms of the Western
taining their own existence. Admittedly, not all military establishment, clearly influenced by the
"survival" situations, as the humanitarian general evolution of the value attached to human
agents readily term them, are so dramatic; nor life, underwent a profound change over the
do they involve the same risks to life, but the course of the twentieth century: from the carnage
scene is very much that of life under threat. The of the World War I battlefields, the move was to a
lives in question are those of refugees and dis- maximum avoidance of military losses among
placed persons in camps (over there), and the Western troops after the collective traumas of
homeless and asylum seekers at accommoda- the Algerian war, for France, and above all of
tion centers {over here), and it is largely the the Vietnam war, for the United States.
same organizations - like MSF and Medecins The corollary of the "zero death" doctrine,
du monde - that look after them in an effort to however, is the rhetoric of "collateral damage."
challenge the boundaries between poor and Reducing the risks on one's own side implies
rich countries, preferring to acknowledge the increasing them on the enemy's side, including-
existence of "victims" in both. in conflicts officially launched to "liberate" or
This process essentializes the victims: "protect" populations -among civilians. When
against the thickness of biographies and the NATO intervened in Kosovo in 1999, not only
complexity of history, it draws a figure to did the strategic choice of an aerial operation
which humanitarian aid is directed. 28 This con- make it possible to limit losses among the Allied
struction is certainly necessary to justify hu- forces, at the expense of the human casualties
manitarianism, and it is also sufficient to it in that a bombardment inevitably involves, but
that it has no need for the point of view of the the tactical decision to have the planes fly at a
persons in question. Moreover, in the configur- high altitude in order to make them inaccessible
ation thus defined, these persons often will- to Serb weapons also necessarily brought with
ingly submit to the category assigned to them: it a reduced level of ballistic precision: more
they understand the logic of this construction, than five hundred civilians were killed, but not
and they anticipate its potential benefits. The one pilot. 29 When the United States invaded
ontological principle of inequality finds its con- Iraq in 2003, in addition to the fact that there
crete manifestation in the act of assistance too the massive bombardment that had pre-
through which individuals identified as victims ceded and prepared the invasion had generated
are established. They are those for whom the large numbers of casualties, including many
gift cannot imply a counter-gift, since it is civilians, the subsequent measures to ensure
assumed that they can only receive. They are the security of American and British troops
the indebted of the world. In the system of resulted in widespread preventive use of fire-
Christian values that not only forms part of arms, again in order to reduce the risk of sol-
the history of the humanitarian movement but diers being killed themselves. A year after
460 DIDIER FASSIN
military operations began, the army of occupa- to harsh reality. The abduction of two team
tion had suffered about a hundred deaths, com- members paralyzed not only their four col-
pared to the one hundred thousand estimated leagues bur also the entire organization,
by a British epidemiological investigation which initially halted all activity and then
among the Iraqi population. 30 In both cases, resolved to withdraw the mission. 31 On the
the marked difference between the number of Iraqi side, no life was saved; not one injured
deaths on the two sides of the intervention person was treated. Above all, it became clear
offers an a posteriori measure of the implicit that the organization itself could not counten-
politics of an a priori differential evaluation of ance risking lives: when the danger shifted
human beings: in Kosovo, sacrificing the life of from the hypothetical to the real, the interven-
several hundred is the condition of preserving tion was suspended in order to avoid risk to the
the life of one individual; in Iraq, the life of one staff abducted, and when the two members
Western soldier is worth one thousand times were released by their abductors, at a time
the life of the inhabitants of a country in which when other aid organizations were setting to
the soldiers are intervening to "liberate" or work in the vast arena of a far from pacified
"protect" them. One could however consider country, the French section of MSF left Iraq,
it moral progress that such a calculation is even arguing that the health situation did not after
possible: at the time of the first Gulf War, esti- all give cause for concern and that conditions
mates of Iraqi deaths varied from a few thou- of operation could in no way be considered
sand to several hundred thousand, but no secure. The trauma of the abduction effectively
attempt was made to count them either by the highlighted the contradictions inherent in a
Allied troops or by the defeated regime. When declared politics of risking lives that did not
no one counts deaths, it means that lives barely hold up in the face of real danger. The case of
count. Iraq is exemplary. Each time a member of a
In these conditions, the spectacular and humanitarian organization has been taken hos-
controversial gesture of MSF members who tage in recent years, in Colombia or the Cau-
decided to stay in Baghdad when the bom- casus, the mission in question has been wholly
bardment was about to begin issues a chal- diverted from its initial goals and has concen-
lenge to this politics of lives that do not trated on a single aim - saving the abducted
count. By exposing themselves to danger, they companion. Moreover the protagonists in con-
opened up the question of the equality of flicts are well aware of the Western world's
lives in a concrete, immediate way: all lives sensitivity to hostage taking and in some
become equal again, as vulnerable for Iraqis regions of the world take cynical advantage of
as for the humanitarian agents who are it, unconcerned about the difference between
assisting them. The sacrifice to which they soldiers and aid workers, private security
consented {risking being killed) shifted the guards and foreign journalists, and forcing
radical inequality between the sacred life on states and nongovernmental organizations into
one side (Western soldiers) and the sacrificed protracted and difficult negotiations in which
life on the other side (local civilians). By this the value of the lives of those who have been
heroic act long debated and weighed, the abducted is assessed and translated into cash
humanitarian politics of life offers a striking terms, often very specifically and precisely. 32
counterpoint to the military politics of life. At But even within this context, even among the
least it appears to. members of humanitarian organizations, not
all lives have the same value.
The most common distinction MSF makes
Lives Valued, Lives Told in its missions (like all foreign organizations,
whether involved in aid or development) is
In effect this equality does not long with- between "expatriates" and "nationals." Ex-
stand the test of the facts. The hostage patriates who come almost exclusively from
taking during the first days of the U.S. inter- Western countries are volunteers of the organ-
vention brought the humanitarian ideal back ization. Nationals are local agents who are
HUMANITARIANISM AS A POLITICS OF LIFE 461
considered as mere paid employees. This dis- the case in August 2006 for seventeen Sri Lan-
tinction, which is seen as simply an operational kan Action contre la faim humanitarian
matter, not only involves huge differences in workers killed by military forces.
salary (and also contractual terms, since many But the Iraq case unveils another truth.
local agents are recruited for limited periods, Until now, the hypothetical framework for
sometimes paid by the day} and in rights (par- analysis of humanitarianism has been that lives
ticularly in decision and voting processes) but are saved by its intervention. This was of
also has consequences regarding social and pol- course the official reason given for maintaining
itical protection. On the one hand, in the case a team in Baghdad. In actual fact the abduc-
of serious illness the medical coverage for ex- tion, followed by the hasty withdrawal, meant
patriates is equivalent to that of the French that no Iraqi life was saved. This case is much
system, while for nationals there is usually less exceptional than has been suggested.
limited or no health insurance. Even when Teams may arrive too late at disaster sites
MSF was involved in an ambitious inter- (where the civil security agents of large coun-
national program to promote antiretroviral tries often arrive more quickly); they may not
drugs, irs own local agents suffering from have the space to intervene with enough free-
AIDS, particularly in Africa, were not receiving dom and security (which the parties to conflict
treatment. 33 On the other hand, when violent often refuse them); or local actors may take
disturbances arose, while expatriates were usu- responsibility themselves for the injured and
ally spared, nationals enjoyed no institutional sick (when their health provision structures
immunity. One inquiry reveals that almost six allow them to do so). This is where the second
of every ten deaths among aid workers over the dimension of humanitarian action comes into
past twenty years were of local agents, but this play: providing assistance is of course import-
is certainly a substantial underestimate, par- ant, but so is bearing witness. 35 Although testi-
ticularly with regard to Rwanda, as many of mony is an integral part of any humanitarian
the locally employed staff did not appear on intervention, it takes on an even greater
aid organizations' staff lists. 34 In other words, importance when the offer of assistance is late,
even within these institutions - as in develop- impossible, or pointless - not only because it
ment and cooperative organizations, too- dis- becomes the main focus of intervention, but
tinctions are set up between foreign staff, also because it is then the only justification that
almost always Western and white, and local can be given for it, either by agents or by popu-
employees. These distinctions, in addition to lations. In Chechnya, where it is considered
the material advantages conferred on foreign dangerous for humanitarian organizations to
staff, are augmented by much more serious be present because of the abductions and
disadvantages that for the local staff, concern murders, as in Palestine, where it seems point-
their very survival, whether they are endan- less given the medical and surgical treatment
gered by illness or war. The AIDS epidemic on available through local structures, bearing wit-
the one hand, and the Rwandan genocide on ness is a crucial activity. In the first case it is
the other, cruelly exposed the workings of this based on remotely controlled structures (from
process of exclusive categorization. Thus, Moscow, where a number of missions have
within the humanitarian arena itself hierarch- been established}; in the second it uses the
ies of humanity are passively established but resources of psychiatry and psychology (making
rarely identified for what they are - politics of it possible to document the reality of trauma
life that at moments of crisis, result in the caused by the conflict). 36 And humanitarian
formation of two groups, those whose status testimony takes a particular form. Since, as
protects their sacred character and those whom has been seen, the organizations place them-
the institutions may sacrifice against their will. selves "on the side of the victims," provide
The protagonists in conflict are well aware of assistance to them, and defend their cause, they
this distinction when they abduct people. They produce one truth: that of the "victims.,
know that only foreigners have market value. By becoming their spokespersons, human-
Their compatriots are usually executed, as was itarian organizations introduce another
462 DIDIER FASSIN
distinction into the public arena - the distinc- of humanity and two sorts of life in the public
tion between those who are subjects (the wit- space: there are those who can tell stories
nesses who testify to the misfortunes of the and those whose stories can be told only by
world) and those who can exist only as objects others. 37 With this new dividing line, life is no
(the unfortunate whose suffering is testified to longer, as it was before, biological (the life that
in front of the world). Of course, the humani- is risked or sacrificed); it is henceforth
tarian agents who collect accounts or carry out biographical (the life that is lived but that
inquiries to reveal the violence or injustice others narrate). More tenuous and less visible,
suffered by oppressed or displaced or bombed it is nevertheless essential to what constitutes
populations base their testimony partly on beings insofar as they are human. At the very
what the victims of this violence or these injust- time when humanitarian action is shifting from
ices say about them. Their third-person testi- bare life to qualified life, from physical survival
mony is grounded on first-person testimonies. to social existence, a new inequality is insinu-
However, the requirements of defending causes ating itself into humanitarian politics of life.
and the logic of their intervention lead them to
what might be termed a humanitarian reduc-
tion of the victim. On the one hand, all that is Humanitarian action by nongovernmental or-
retained of people's words is what contributes ganizations, from the birth of the International
to a telling image in the public space: both the Committee of the Red Cross to the emergence of
Chechen fighter and the Palestinian stone the movement inaugurated by MSF, has histor-
thrower become suffering beings who can only ically been constructed in response to the in-
be described in terms of their physical injuries humanity of war, a way of restoring the basic
and psychological trauma. On the other hand, principles of humanity. Whether their origins are
the individuals in question tend to conform to Christian, as among the charitable religious
this portrait, knowing that it will have an orders, or secular, with philanthropic societies,
impact on public opinion, and thus offer to these principles have two aspects that refer back
the humanitarian agents the part of their ex- to the two senses of the word humanity itself.
perience that feeds the construction of them as On the one hand, it is a concept that suggests
human beings crushed by fate. that humanity, as a collective of human beings,
Of course, there is no single truth of their is one and indivisible - a concept that, as one
condition, and the narrative offered by victims knows, is both recent and fragile. On the other
to the exclusion of any other reality is just one hand, it is a sentiment that manifests an indi-
of the possible truths through which their ex- vidual's gesture of humanity toward fellow
perience can be rendered intelligible, particu- humans who are suffering or in danger - a senti-
larly given that by dint of being presented ment that gives a concrete sense of belonging
under this light of suffering, they end up per- to the human species. This paradigm has been
ceiving themselves, too, at least in part, as established in contrast to others that either imply
victims. However, from the perspective of a distinctions among human beings (through the
politics of life and an ontology of inequality, idea of race, for example) or promote indifference
the issue is not that the historical context and to distant others (particularly by whipping up
geopolitical dimensions of conflicts, the stra- nationalist sentiment).
tegic games and contradictory interests, are In contemporary conflicts the soldiers who
erased by the representation of war situations intervene, in the name of either their country
given by those whose only interest is in the or higher concerns (leaving aside the question
"insulted and humiliated,, to use Brauman's of whether this often largely rhetorical dis-
formula. It is rather that if one believes that tinction is genuine), do not in theory negate
what distinguishes humans from other living the idea and sentiment of humanity; however,
beings is language and meaning and that what their practice calls it into question. The dis-
makes human life unique is therefore that it can course of their governments and their officers
be recounted, as Hannah Arendt asserts, then generally leads them to construct the enemy as
humanitarian testimony establishes two forms a category of humanity sufficiently distant to
HUMANITARIANISM AS A POLITICS OF LIFE 463
be killed in large numbers and without com- project and effectively insurmountable within
passion. The inhumanity of contemporary the value systems of Western societies, particu-
war resides no longer in carnage shared larly when considering the tension that exists
roughly equally between the opposing sides between the claimed sacredness of life (which is
but, rather, in the unequal value accorded to no more viable in the context of wartime vio-
lives on the battlefield: the sacred life of the lence than in conditions of structural violence)
Western armies of intervention, in which each and the expressed force of compassion (which
life lost is counted and honored, versus the makes it possible to maintain up to a certain
expendable life of not only the enemy troops point the thread of solidarity, even at the price
but also their civilian populations, whose of ontological inequality). Far from the ideo-
losses are only roughly numbered and whose logical criticisms traditionally aimed at hu-
corpses end up in mass graves. In the face of manitarian organizations- which their agents
these politics of life, both inhuman and inhu- in any case readily take up themselves - this
mane, humanitarian organizations call for a critical perspective stresses the contradictions
politics of life that could reestablish solidarity that exist in contemporary moral economies,
among human beings and give equal value to well beyond the sphere of intervention of hu-
all lives. manitarian organizations themselves, in what
But neither the actors involved nor their characterizes the political disorder of the
usual commentators are sufficiently aware of world: the inequality of lives.
the triple problematic of the humanitarian pol-
itics of life. First, it distinguishes lives that may
be risked (humanitarian agents) from lives that
can only be sacrificed (the populations among NOTES
whom they intervene): this is illustrated by the Translated by Rachel Gomme
Iraqi case. Second, within the movement itself 1 On the distinction between politics of life and
it separates lives into those with higher value biopolitics, see Didier Fassin, "La biopolitique
(expatriate humanitarian workers) and those n'est pas une politique de la vie'' ("Biopolitics
that are accorded only limited protection (na- Is Not a Politics of Life"), Sociologies et soci-
tional staff): this is what the abductions starkly etes 38 (2006): 35-48. For Michel Foucault,
reveal. Third, it establishes a distinction be- biopolitics correspond to the technologies de-
tween lives that can be narrated in the first fining, studying, counting, controlling, and,
person (those who intervene) and lives that more generally, "normalizing" populations.
are recounted only in the third person (the See Michel Foucault, The History of Sexual-
voiceless in the name of whom intervention is ity: An Introduction (New York: Vintage
done): testimony, operating as an autobio- Books, 1990).
graphical account for the former and the con- 2 See Walter Benjamin, "Critique of Violence,"
struction of a cause for the latter, reveals this in Selected Writings, vol. 1, 1913-1926
split. Thus as one gets deeper into humanitar- (1921: repr., Cambridge, Mass.: Harvard Uni-
ianism a series of dimensions of what may be versity Press, Belknap, 1996).
called a complex ontology of inequality 3 As formulated by Peter Redfield, "Doctors,
Borders, and Life in Crisis," Current
unfolds that differentiates in a hierarchical
Anthropology 20 (2005): 328-61. Redfield's
manner the values of human lives. What I have
aim is rather to consider humanitarianism as
shown here in relation to MSF holds in general
"an array of particular embodied, situated
for all humanitarian organizations, whether practices emanating from the humanitarian
nongovernmental or supranational, whatever desire to alleviate suffering of others" (330).
their different orientations, when one considers I, however, think that critical thinking can
their ethics not through theoretical principles and must emerge from within the analysis
but in practical operations. of these practices and this desire.
By describing these problems as an aporia, I 4 See, for instance, "Reflections on the U.S.
intend to demonstrate that these contradictions Military's Provision of Assistance during
are both constitutive of the humanitarian and Immediately after Conflict with Iraq"
464 DIDIER FASSIN
(draft internal paper, MSF, February 18, 15 See Giorgio Agamben, Homo sacer: Le pou-
2003). voir souverain et Ia vie nue, trans. Marilene
5 From the minutes of the meeting of the ad- Raiola (Paris: Seuil, 1997); published in Eng-
ministration board of the MSF, March 28, lish as Homo Sacer: Sovereign Power and
2003 (hereafter cited as MSF minutes). These Bare Life, trans. Daniel Heller-Roazen (Stan-
sessions are always recorded and afterward ford, CaJif.: Stanford University Press,
transcribed and summarized. 1998).
6 MSF minutes. 16 See Didier Fassin, "L'ordre moral du monde:
7 MSF minutes. Essai d'anthropologie de l'intolerable" ("The
8 MSF minutes. Subsequently, however, in a Moral Order of the World: Toward an An-
retrospective evaluation of his organization's thropology of the Intolerables"), in Les con-
activity during this period, jean-Herve Bra- structions de /'intolerable (The Construction
dol, president of MSF, was to comment: "On of the Intolerable), ed. Didier Passin and
the whole, Iraq has been a small emergency Patrice Bourdelais (Paris: La Decouverte,
for us" (Bradol's internal report: MSF, "Rap- 2005), 17-50.
port moral 2003"). 17 Note the evolution from Michael Pugh,
9 MSF minutes. "Military Intervention and Humanitarian
10 MSF, Messages: Journal interne de Medecins Action: Trends and Issues," Disasters 22
sans frontieres, no. 124 (May 2003): 2. (1998): 339-51 (on the war in Bosnia), to
11 Rony Brauman and Pierre Salignon, "lrak: Susan Woodward, "Humanitarian War: A
La posture du missionnaire" ("Iraq: The New Consensus," Disasters 25 (2001 ):
Missionary Position"), in A l'ombre des 331-44 (on the bombing of Kosovo).
guerres justes (In the Shadow of Just Wars), 18 On the notion of humanitarian government,
ed. Fabrice Weissman (Paris: Flammarion, see Didier Fassin, "Humanitarianism, a
2003), 287. Non-governmental Government," in Non-
12 References are taken from Brauman and Sal- governmental Politics, ed. Michel Feher
ignon, "Irak: La posture du missionnaire," (New York: Zone Books, 2007), 149-59.
275-91; and from an interview with Brado) 19 See Rony Brauman, L'action humanitaire
in Le Figaro on March 24, 2004. These com- (Humanitarian Action) (Paris: Flammarion,
ments may be contrasted with the analysis of 2000), 61. He recognizes, however, that
the postwar situation by Medecins du monde "humanitarianism cannot be considered
(Doctors of the World), in "L'lrak en plein apolitical" (61).
chaos" ("Iraq in Full Chaos"), Medecins du 20 See Agamben, Homo sacer: Le pouvoir sou-
monde: Le journal destine aux donateurs verain et Ia vie nue, 145.
(September 2003): "Despite the end of the 21 See Liisa Malkki, Purity and Exile: Violence,
military conflict, Iraq finds itself in an Memory, and National Cosmology among
alarming situation. The consequences of Hutu Refugees in Tanzania (Chicago: Chi-
war are numerous: insecurity, shortages, risk cago University Press, 1995); and Michel
of epidemics, technological backwardness. Agier, Aux bords du monde, les refugies
The international network of Medecins du (Refugees at the Margins of the World)
monde has massively responded to the Iraqi (Paris: Flammarion, 2002).
emergency" (2). 22 See the testimony of Bernard Granjon, then
13 MSF, "La charte de Medecins sans frontieres" in charge of Medecins du monde's mission in
("Charter of Medecins sans frontieres"), Rwanda, about his discussion with Fran~ois
www. paris.msf.org/site/site.nsf/pages/charte Mitterrand, "Quatre-vingt minutes avec
(accessed June 14, 2007). Fran~ois Mitterand" ("Eighty Minutes with
14 The assessment of failure comes from the desk Fran~ois Mitterand"), in "Le genocide des
officer in charge of the program, Pierre Sal- Tutsis du Rwanda: Une abjection pour l'hu-
ignon, in an interview in Le Monde on May 8, manite, un echec pour les humanitaires"
2003: "For those who have tried to achieve ("The Tutsi Genocide in Rwanda: Abjection
an independent humanitarian action, diffi- for Humanity, Failure for Humanitarian-
culties have been overwhelming and, in the ism"), special issue, Humanitaire: Enieux,
end, we have failed." pratiques, debats, no. 10(2004): 37-42.
HUMANITARIANISM AS A POLITICS OF LIFE 465
23 See Jean-Herve Bradol, "L'ordre inter- circle and because we failed to anticipate
national cannibale et ]'action humanitaire" events, haste prevailed from beginning to
("The Sacrificial International Order and end of our imervention."
Humanitarian Action"), in Weissman, A 32 The financial conditions of Arjan Erkel's re-
l'ombre des guerres justes, 32. lease in Dagestan in 2004 have been publicly
24 This dichotomy is of course destabilized exposed, with the Dutch government
when military and humanitarian agents claiming 1 million from the Swiss section of
become one, as described by Sherene Ra- MSF to reimburse the ransom it paid to the
zack, Dark Threats a11d White K11ights: The kidnappers. See PhiJippe Ryfman, "Humani-
Somalia Affair: Peacekeeping a11d the New tarian Action on Trial," Messages: Journal
Imperialism (Toronto: University of Toronto interne de Medecins sans frontieres, no. 137
Press, 2004). (2005): 16.
25 "Necropolitics" is a concept proposed by 33 The decision to give free antiretroviral drugs
Achille Mbembe as a corollary to Foucault's to national staff was finally reached by the
biopolitics; see Achille Mbembe, "Necropo- board of directors in 2003. Nevertheless,
litics," Public Culture 15 (2003 ): 11-40. Bradol notes that during his field visits, local
26 See jean-Herve Bradol, "Le camp des vic- staff members "were not usually aware of this
times" ("The Side of the Victims") in decision." See MSF, "Rapport moral2003."
"1971-2001: 30 ans d'action humanitaire" 34 The epidemiological study is Mani Sheik,
("1971-2001: Thirty Years of Humanitarian Maria Isabel Gutierrez, Paul Bolton, Paul
Action"), special issue, Infos Medecins sans Spiegel, Michel Thieren, and Gilbert Bum-
frontieres 89 (2001): 2. ham, "Deaths among Humanitarian
27 See Laurence Hugues, "Liberia, Ia ou Ja vie Workers," British Medical Journal 321
ne vaut pas une guinee" ("Liberia: Where (2000): 166-8. Between 1985 and 1998,
Life Is Not Worth a Guinea"), Messages: 382 deaths were reported among staff of
Journal interne de Medecins sam frontieres, United Nations and nongovernmental
no. 124 (2003): 3-4. bodies, of which almost a third occurred
28 On the process of constructing victims, see during the genocide in Rwanda. However,
Didier Fassin, "La cause des victimes" ("The Bradol, who conducted a mission for MSF
Cause of the Victims"), Les temps modernes, in 1994, comments: "If we asked humanitar-
no. 627 (2004): 73-91. ian organizations for the list of their employ-
29 See the analysis proposed by Michael Igna- ees who died during the genocide, 90%
tieff, "The New American Way of War," would be unable to give it. And this gives
New York Review of Books 47, no. 12 an indication of what has or has not been
(2000). done to help people when they really needed
30 See the estimate suggested in Les Roberts, help." See Bradol, "La commemoration
Riyadh Lafta, Richard Garfield, Jamal amnesique des humanitaires" ("The Amnesic
Khudhairi, and Gilbert Burnham, "Mortality Commemoration of Humanitarian Actors"),
before and after the 2003 Invasion of Iraq: Humanitaire: Enieux, pratiques, debats, no.
Cluster Sample Survey," Lancet 364 (2004): 10 (2004): 12.
1857-64. 35 Historically, the emergence of the second age
31 In the organization's internal critical journal, of humanitarianism, with the "French
significantly called DazibAG (no. 125 doctors" returning from the war in Biafra,
[2003): 27), Fran~ois Calas, the head of the was a reaction to the silence of the Red Cross,
MSF team in Iraq and one of those who had wedded to its principle of neutrality. Testi-
been abducted by the Iraqi police, publicly mony in favor of the victims becomes, for
expressed his frustration as the organization MSF and even more for Medecins du monde,
left the country: "The decision taken by the a key dimension of their action. See the six
French section to leave Baghdad seemed to volumes of the series Prises de parole publi-
me very precipitate and has been justified ques de MSF (Pttblic Positions), ed. Laurence
after the fact on fallacious grounds. Rather Binet (Paris: MSF, 2003-7), on Ethiopia
than qualifying the crisis, we disqualified it. 1984, El Salvador 1988, Rwanda 1994 and
Ironically, one could say that we've come full 1995, and refugees from Rwanda 1994-97.
466 DIDIER FASSIN
36 On the testimony of MSF and Medecins du condition de victime (The Empire ofTramna:
monde, compared with that of the local organi- Inquiry on the Condition of Victims)
zations Gaza Community Mental Health (Paris: Flammarion, 2007), 281-319.
Programme (GC.NIHP) and Natal, the Israel 37 On life as "a story with enough coherence to
Trauma Center for Victims of Terror and be told," see Hannah Arendt, The Hmnmr
War, see Didier Fassin and Richard Rechnnan, Condition (Chicago: University of Chicago
L'empire du traumatisme: Enquete sur Ia Press, 1958), 85.
Part VII
Postcolonial Disorders
Introduction
The final part of this reader groups a set of recent essays under the heading "Post-
colonial Disorders." This phrase, taken from an edited collection by this title
(M.-J. Good et al. 2008), refers both to emergent realities that have come increas-
ingly to occupy medical anthropologists and to theoretical concerns and an emerging
framework for writing about subjectivity in the early twenty-first century. These
essays thus point to one of the possible futures for medical anthropology.
Postcolonial Disorders was conceived as an effort to re-think the nature of
subjectivity- "everyday modes of experience, the social and psychological dimen-
sions of individual lives, the psychological qualities of social life, the constitution of
the subject, and forms of subjection" (B. Good et al. 2008:1)- found in the diverse
places where anthropologists work today. At the beginning of a year long seminar
which had long focused on "culture and mental health," we invited speakers to
rethink some aspect of their work on subjectivity by replacing the common anthro-
pological trope "culture" with the analytic category "postcoloniality" or "the post-
colonial." What emerged from that project was a set of reflections on "disordered
states," on political violence and the way it shapes individual lives (Aretxaga 2005);
on labor migration and social displacement and the nature of subjectivity of those on
the margins or borderlands; on the close linking of international health and political
efforts to control pandemic infectious diseases and the resistances these efforts have
produced in many postcolonial societies; on the complex space occupied by psych-
iatry in such settings; and on the haunting presence of colonial trauma and colonial
memories associated with eruptions of social and psychological "disorders" and the
diverse forms of humanitarian and medical responses. These are precisely the issues
being addressed today by many medical anthropologists.
"Postcolonialism" was read broadly by many who presented to that Harvard
seminar, suggesting relations between powerful political, economic, and state entities
and those that are marginalized; recognition that anthropological knowledge
470 POSTCOLONIAL DISORDERS
categories are often resisted by those who experience research as reproducing colo-
nial relations; and a critique of classic understandings of culture that allow the
ghostly phantoms of colonial experience to remain beyond the reach of analysis.
The book called for a broad project of investigating and theorizing subjects in
postcolonial societies and situations, addressing "disorders" while taking seriously
the special complexity of investigating social "pathologies" and "social suffering"
(Kleinman et al. 1997; Das 2007). And it argued that medical and psychological
anthropologists today carry out their work precisely among the dilemmas
represented by this framing of the field. The essays in this final part of the reader,
as well as a number of those in earlier sections of the book, can be read as contrib-
uting to this project, suggesting the benefits of conversations between medical
anthropologists and those exploring postcolonial or political subjectivity and dis-
ordered states.
The section begins with a short essay by Byron and Mary-jo Good that takes up
"amok," an old category within medical anthropology, studies of "culture bound
disorders" (e.g. Simons et al. 1985) and comparative psychiatry (e.g. Yap 1974). The
Goods discovered that while most anthropological and psychiatric discussions of
"amok" have focused on individual, dissociative violence, the Indonesian term
mengamuk, to run amok, was often used by journalists during the repressive New
Order regime of Indonesian president Suharto to describe unrest and threats of
violence by Indonesian crowds, particularly during political campaigns. Analyzing
sources for this use of amuk takes the reader back to British and Dutch colonial
psychiatry with unexpected results. This reading opens a space for analyzing the
political and psychological origins of the divide between "order" and "disorder" as
deriving from Indonesia's terrifying "year of living dangerously," 1965-66, when
between 600,000 and a million citizens were identified as Communists and killed.
The second essay, by Erica James, explores the political economy of "trauma"
among Haitian women and men seeking restitution for the terrible violence enacted
against them during the reign of terror following the ouster of legally elected
President Jean-Bertrand Aristide. James analyzes the United States' perception of
Haitians as threatening to "security" at precisely the time citizens were living the
experience of insecurity. She introduces an analysis of the "occult economies of
trauma" that led the humanitarian apparatus to "generate new forms of victimiza-
tion" in the name of documenting and verifying human rights violations deserving of
recompense, exploring the subjective effects of the production of "traumatic citizen-
ship." And she argues that responses to Haitian politics cannot be understood outside
of the historic imagination generated by an independence movement at the heart of
New World slavery, and goes on to analyze how American foreign aid and humani-
tarian organizations reproduce colonial violence in the aftermath of recognized states
of emergency.
These themes are picked up and extended in Mariella Pandolfi's analysis of the
humanitarian apparatus in Albania and Kosovo. Pandolfi is one of a group of
anthropologists developing critical analyses of the convergences between military
and humanitarian forms of intervention, and the role of international organizations
as "operators of a new military-humanitarian form of governance" (cf. Redfield
2005; Malkki 1996; Nordstrom 2005; Passin and Rechtman 2009). Pandolfi draws
together Foucault's analytics of biopolitics with Agamben's (1988) challenging
INTRODUCTION 471
REFERENCES
Agamben, Giorgio
1988 Homo Sacer: Sovereign Power and Bare Life. Stanford University Press.
Aretxaga, Begona
2005 States of Terror: Begona Aretxaga's Essays. Reno: Center for Basque Studies, Uni-
versity of Nevada.
Das, Veena
2007 Life and Words. Violence and the Descent into the Ordinary. Berkeley: University of
California Press.
Fassin, Didier and Richard Rechtman
2009 The Empire of Trauma: An Inquiry into the Condition of Victimhood. Princeton
University Press.
472 POSTCOLONIAL DISORDERS
Good, Byron, Mary-Jo DelVecchio Good, Sandra Teresa Hyde, and Sarah Pinto
2008 Postcolonial Disorders: Reflection on Subjectivity in the Contemporary World. In
M. Good, S. Hyde, S. Pinto, and B. Good, eds. Postcolonial Disorders. Berkeley: University
of California Press.
Good, Mary-Jo DelVecchio, Sandra Teresa Hyde, Sarah Pinto, and Byron Good, eds.
2008 Postcolonial Disorders. Berkeley: University of California Press.
Kennedy, David
2004 The Dark Side of Virtue: Reassessing International Humanitarianism. Princeton
University Press.
Kleinman, Arthur, Veena Das, and Margaret Lock, eds.
1997 Social Suffering. Berkeley: University of California Press.
Malkki, Lisa
1996 Speechless Emissaries: Refugees, Humanitarianism, and Dehistoricization. Cultural
Anthropology 11: 377-404.
Nordstrom, Carolyn
2005 Shadows of War: Violence, Power, and International Profiteering in the Twenty-First
Century. Berkeley: University of California Press.
Redfield, Peter
2005 Doctors, Borders, and Life in Crisis. Cultural Anthropology 20: 328-61.
Simons, Ronald C., and Charles C. Hughes, eds.
1985 The Culture-Bound Syndromes: Folk Illnesses of Psychiatric and Anthropological
Interest. Dordrecht: D. Reidel Publishing Co.
Yap,P. M.
1974 Comparative Psychiatry: A Comparative Framework. Toronto: University of
Toronto Press.
36
Amuk in Java
Madness and Violence in
Indonesian Politics
Byron f. Good and Mary-Jo DelVecchio Good
It was 1997, and we were living in Yogyakarta, invited to Yogyakarta's Institute for Journalism
teaching at Gadjah Mada University with support (LPPPY) to discuss how her reporting on polit-
from senior Fulbright lectureships and the Ameri- ical campaigns in the United States compared
can Indonesian Exchange Foundation. Although with that in Indonesia. At the end of the talk,
we were teaching and carrying out research on the moderator of the discussion asked for our
how culture shapes mental illness and its treat- observations. We commented simply that we
ment, it was impossible not to attend to the polit- were surprised by the near exclusive focus on
ical campaign that was underway. In April and campaign violence in the papers. We were sur-
May, "konvois" of youth on motorcycles or in prised not that the violence would be reponed,
trucks and automobiles, elaborately decorated but that little else, including policy issues, was
in party colors and carrying banners, engines even mentioned in most news accounts. Every
roaring and horns blaring rhythmically, took event seemed to be judged solely on where it lay
over urban streets throughout Indonesia, as along a continuum from order to disorder. The
part of the campaign leading up to what turned moderator asked whether we thought this was a
out to be the final national election before "cultural" matter. We replied that it might have
President Suharto was forced from office in a cultural element, given Javanese values of
May 1998. Although little real expression of polite comportment. But we suggested that this
opposition was allowed in Suharto's New focus on order also seemed to have a "hege-
Order elections, the konvois of kampong (local monic" element, a quality of naturalizing order,
neighborhood) youth represented a substantial treating nearly all mass political activity as dis-
form of protest and class resistance, with the order and potentially anarchic.
threat of violence always present. News reports As we thought later about our spontaneous
of the campaign and of the rioting in several comments, we began to reflect on how political
cities earlier in the year characterized the elec- violence was often described in official dis-
tion as the most violent in Indonesian history. course as a kind of madness and on the role
Near the end of the campaign, an American of such language in pathologizing political pro-
journalist, another Fulbright scholar, was test. An experience of a tragedy involving a
474 BYRON J. GOOD AND MARY-JO DELVECCHIO GOOD
mentally ill man focused our attention on one And then on a day in July he had become
aspect of this language. violent again, attacking another villager's tree
We found a Javanese friend, a woman from a with his machete. When the owner tried to stop
poor village outside Yogya who worked on the him, the old man threatened him. The owner
university staff, in tears one afternoon. The called a friend, but they were unable to subdue
story was not yet clear, but a man from her him. The two ran for help, found a group of
village had gone mad, had been attacked by a forty village men working on a voluntary labor
group of village men who attempted to subdue project, repairing a road, calling out "menga-
him, and had been killed. Members of her muk, mengamuk., The whole group came run-
family had been taken by the police for ques- ning to stop him. When he threatened them,
tioning. Over the next several days, the story they picked up sticks and began beating him.
began to emerge, as she and others in our neigh- When the incident was over, the old man was
borhood traveled back and forth to the village dead.
some two hours outside of Yogya. The man We were caught up in the affair, helping
who had been killed was a man we had seen support our friend whose family members
and caught on video several months earlier were being held for questioning, knowing that
when we had visited an annual slametan (a the family would have to pay the police to
communal feast involving the sharing of food) gain their release. The incident was reported
in our friend's village. He had participated in in the local newspapers, and our attention
the dancing that day - which is why we had was drawn to the wording of the news stories.
videotaped him- in a way we later learned was One report included the sentence, "Da/am
considered highly inappropriate. The whole keadaan emosinya memuncak itu Pawiro Rejo
village knew he had been mentally ill, though ngamuk dan mengancam penduduk yang ber-
on that day he had been relatively healthy. usaha mendekat." "At the culmination or
It turned out that this man had been period- peak of his emotional condition, Pawiro Rejo
ically mad since the time, several years before, ngamuk (ran amok) and threatened those who
when he sold his house and land to the govern- tried to approach him." Each news report
ment as a site for a television relay station. As used the Javanese verbal form ngamuk or the
they began work on the station, tearing his Indonesian form mengamuk to describe his
house down, he had begun to go crazy. People behavior.
speculated about the cause. Perhaps the These terms, more commonly in the noun
"stress" of selling his land and seeing his house form amuk (or "amok" as it is usually spelled in
torn down had been too much and he had English), are well known to cultural psych-
become crazy. Perhaps the spirits of the land, iatrists- and have, of course, entered common
who had long gathered at this place, had been parlance globally. Amok is a classic in the
angered and had possessed him. Or perhaps the literature on "culture-bound syndromes," psy-
45 million rupiah which he had received from chiatric conditions which seem to be unique
selling his land had attracted jealousy and to a particular culture or region of the world
made him a target of black magic. Whatever (Simons and Hughes 1985). Amok (Carr 1985)
the reason, this vigorous man in his 50s had denotes an episode of dissociative violence, a
begun, for the first time in his life, to suffer behavioral syndrome of an individual, often
bouts of madness. He would become violent, from a Malay culture, who suddenly goes ber-
threaten other villagers, chop down their trees serk, becomes wild and violent, attacking
and attack their agricultural plants, and resist others and threatening to kill them, until he is
their efforts to stop him. His family had sent subdued or killed by those he is threatening.
him to a mental hospital for treatment several Survivors are left with amnesia for their behav-
times. Each time he would return, suffer a iors. The psychiatric literature treats amok as
relapse, and become violent again. Villagers individual pathology, never as a form of mob
were fed up; his family seemed helpless to violence by a group - the madness of the old
control him, and the police had stopped man, not of the group who killed him. From
responding to their complaints. the perspective of cultural psychiatry, the case
AMUK IN JAVA 475
of this villager was interesting because the term of this behavior. Explanations ranged from
mengamuk was used for an individual with a accounts of Malay culture and personality, to
much more chronic or persistent mental illness suggestions that such acute violence might
than usually described in this literature. result from infectious disease or the use of
However, the case also drew our attention opium, to attempts to understand these cases
to the use of the term mengamuk in other news as a specific form of mental illness or a distinct-
articles, particularly the newspaper stories and ive form of committing suicide. For example,
official pronouncements about campaign vio- D.j. Galloway, a British psychiatrist who read
lence and riots that had been occurring earlier a paper at the Fifth Congress of the Far Eastern
in 1997. "Kenapa Massa Gampang Menga- Association of Tropical Medicine in Singapore
muk?" - "Why do the masses so easily run in 1923, distinguished cases representing
amok?" - the cover of a special issue of a known forms of insanity from those he termed
weekly news magazine Gatra (31 Mei 1997), "true amoks." These included cases in which
devoted entirely to this topic, read. "Massa an individual was publicly shamed or humili-
Mengamuk di Pekalongan" - "The Masses ated, and after brooding retaliated, escalating
Run Amok in Pekalongan"- was a headline to a rampage that ended in the death of the
in the national newspaper Kompas. And so it pengamuk, the person who had run amok.
went: analyses of episodes of political violence "The impress of the primitive mind lies brood
were framed as the masses running amok, as over the whole series of events; the inflated self-
kerusuhan, riots, as anarkis or kebrutalan - esteem, the proportionate resentment at the
anarchy or brutality - of the masses. It was this wounding of it, the tendency of the resentment
conjunction that set us to thinking, and that to pass uninhibited into action against the of-
suggests the value of reading these two litera- fender, the necessity of re-establishing his pres-
tures- the historical writing on amok (usually of tige . . . the appeal to arms" - all of these
individuals) and the news reports and analyses explain the tendency for Malay natives to run
of mass political violence - against one another amok (Galloway 1923:168, in Winzeler 1990:
(cf. B. Good, Subandi, and M. Good 2007). 109).
A few examples will indicate what a close In another example, Van Loon, a Dutch
reading of the historical writings might yield. psychiatrist in charge of the Batavia Hospital
Amok, in its restricted meaning as a psychiatric (outside present-day Jakarta), writing in the
syndrome, was defined in 1951 by Dr. P. M. British journal of Medical Psychology in
Yap, a leading cultural psychiatrist, as 1928, combined a cultural and developmental
view:
an acute outburst of unrestrained violence,
associated with homicidal attacks preceded in the malu feeling (unbearable shame and
by a period of brooding and ending with embarrassment, especially when made ridicu-
exhaustion and amnesia. (1951:41) lous in public), in mata gelap (blind rage) and
This view of amok as a culture-bound syn- in the bingung reaction (losing one's head),
etc., the Malay shows the same characteristic
drome was based on widespread reports by
weakness, a lack of resistance against sudden
travelers, colonial administrators, judges, and
emotion.
colonial psychiatrists, dating in particular from
the nineteenth century, and is echoed by more Following this reading over into the writ-
recent accounts of anthropologists and psych- ing on political violence, it is easy to find
ologists. Case reports- from Malaysia, Singa- similarities in the grammar of the discourse.
pore, Java, and Sumatra- of persons who "run Amok, in colonial psychiatry, is pathological,
amok," persons who would become depressed, impulsive or instinctual, and developmentally
brooding, and suddenly go on a homicidal primitive, a form of wild, uncontrolled - and
rampage, ending only when they were subdued exotic - antisocial behavior. And it is often
or were killed, but leaving the survivors with seen to be caused by an overwhelming emo-
amnesia for the events, fascinated colonial tional response to frustration and humiliation.
observers and led to speculations on the causes Analyses of the sources of mass violence in the
476 BYRON J. GOOD AND MARY-JO DELVECCHIO GOOD
news in 1997 often drew on a similar logic. into a ditch or scattered upon the ground"
Mass violence indexes lack of social, political, (Norris 1849: 462-3, quoted in Winzeler
and intellectual development, a sign that the 1990: 101-2). This contrasted with the case
masses are not yet ready for democracy. It of Bugis, a sailor on board ship in Singapore
represents pathological, impulsive reactions who had "suddenly picked up a dagger and
to emotionally frustrating social conditions. slain a relative who was visiting him, then
The presence of the term amuk or mengamuk rushed on deck and began attacking and killing
in the popular press reports on the violence everyone in his vicinity," who was acquitted by
associated with the campaign thus served reason of insanity (Earl1837: 377-8, quoted in
to naturalize a reading of mass violence as Winzeler 1990: 101). Psychiatrists' efforts to
pathology. describe amok as a culture-bound psychiatric
Although there are adequate data of this disorder were thus aimed less at portraying the
kind to support our hypothesis about how exotic than at defending the pengamuk on
the term amuk functions in such reports, it grounds of madness, to build the case for an
would be a mistake to end the analysis at insanity plea based on a distinctive form of
this point. As we have gone on to read the illness.
historical works, it is clear that the literature This debate opened onto a more general
on amuk is a more complex resource for read- question of how the pengamz1k, the person
ings of commentaries on political violence in who runs amok, should be punished, and the
Indonesia. linked speculation on its cause. As early as the
The term amok in the colonial literature end of the eighteenth century, William Mars-
does not begin as a psychiatric term. The term den, in The History of Sumatra (1811 edn.),
apparently enters European languages in the rejected the notion that opium caused the
mid-sixteenth century, referring to "groups of behavior, reporting that it is more likely caused
exceptionally courageous men who had taken by mistreatment of slaves or servants by colo-
a vow to sacrifice themselves in battle against nialists. He reponed a case he had personally
an enemy" (Murphy 1973: 34). In the nine- observed of a slave, who "being treated by his
teenth century, use of the term amuk to refer mistress with extreme severity, for a trifling
to heroic acts of bravery on the part of war- offence, vowed he would have revenge if she
riors, keris (sacred dagger) in hand, was known attempted to strike him again; and ran down
but was said to be largely archaic, replaced by the steps of the house, with a knife in each
reports of individual pathological violence as hand." When she cried out "mengamokl", the
the primary referent of the term. The attempt civil guard came and fired upon him. Marsden
to define the "true amok," such as that we reports that in Batavia, where such persons
quoted from Galloway, was not however "are broken on the wheel, with every aggrava-
simply an attempt to distinguish heroic acts tion of punishment that the most rigorous just-
from pathology. It was roared in a set of ice can inflict, the mucks happen in great
debates in colonial Malaysia and the Dutch frequency," proving the inefficacy of harsh
Indies. First, it was rooted in legal debates punishment, in contrast to the "influence that
about whether a person who committed mild government has upon the manners of
murder while "running amok" should be held people." Thus, Marsden contrasted detrimen-
legally responsible for his acts. In a widely tal responses to Dutch rule with the beneficial
quoted ruling in 1846, Judge William Norris effects of English rule.
ruled that a man in Penang captured after Our point is that while there were specula-
killing eight persons was guilty, despite the tions about the causes of amok - whether it
defense that he had been grieving for his child reflected Malay or Javanese character, whether
who had died recently, had killed indiscrimin- it was linked to Islamic fanaticism, resulted
ately, and claimed he had no memory of killing from a constitution weakened by disease or
anyone. judge Norris found him guilty, sen- from opium use, or represented a culturally
tenced him to be hanged and then to have his distinctive form of suicide- these debates were
body "cut into pieces and cast into the sea or formulated in the larger context of discussions
AMUK IN JAVA 477
of native violence in response to colonial rule. tolerance" and the increasing place of violence
As with the colonial responses to cases of in the language of politics, particularly in re-
worker violence on the plantations of Sumatra sponse to the growing role of the military in
{Stoler 1985, 1992), discussions of amok politics. "People have learned that if you want
reflected concerns of order and disorder under to play politics/' he wrote Uakarta Post May
the colonial regime, and included clear 15, 1997), "you have to use power and vio-
examples of resistance to harsh rule, even of lence, not intellectual arguments." Berhanud-
the use of amok as an "instrument of social din, writing in Kompas (January 9, 1997),
protest by individuals against rulers who analyzed the growing differentiation of Indo-
abused their power" (Carr 1985: 202). The nesian society that has accompanied modern-
rejection of the psychiatrists' claim that amok ization, the loss of social and moral coherence,
was a local form of insanity, excusing the indi- and the replacement of religious leaders with a
vidual from punishment, and the vicious sen- background in the pesantren (Islamic boarding
tences given out suggest that in the colonial schools) and a closeness to the people with
context some judges saw the act of running kiyai or religious leaders who are part of the
amok as heinous precisely because it was a alienated political elite. And so it goes: vio-
form of violent protest against colonial rule, lence, described as masses running amok,
requiring extraordinary public displays of served as a source for a critical reading of
punishment. Indonesian society and politics and a site of at
Analyses by Indonesian intellectuals at the least covert contestation, and commentaries
end of the New Order of why the masses of combine subscribing rational motives to the
this period were "running amok" seemed to actors with a reading of violence as mad, mob
reflect a similar underlying logic. Intellectuals action.
and journalists writing on outbreaks of vio- We have not attempted here to trace a direct
lence associated with the run-up to the 1997 historical linkage between colonial debates
election often described these "riots" as about amok and contemporary uses of amuk
resulting from frustration (frustrasi), "dis- or mengamuk. However, our "reading
placed aggression,, "emotional illiteracy/' together" of contemporary and historical uses
"jealousy" associated with the gap between of these terms suggests a strong resonance,
rich and poor, or the suggestibility of the indicating that the colonial, as well as
masses. However, in what was often a remark- resistance to the colonial, remain alive in the
ably open critique of the growing gap between structure of contemporary discourses on both
rich and poor, corruption of the elite, and arro- madness and violence.
gance of government officials, writers in the In Java, the term amuk still has its primary
Indonesian press of the mid-1990s, still under grounding in psychopathology. Today there is
the censureship of the Suharto regime, carved little evidence of the kinds of dissociative epi-
out a space for social reflection and social cri- sodes described by colonial psychiatrists. How-
tique. The special issue of Gatra, entitled Ke- ever, the term is used, primarily in verbal form,
napa Massa Gampang Mengamt~k?, described to describe the behavior of an individual
a poll they had undertaken of 787 university suffering from schizophrenia or another psych-
students and recent graduates; 57% of otic illness who goes out of control, screaming
respondents agreed with the statement "riots or crying out, perhaps becoming violent or
can't be avoided in the process of democratiza- suddenly running out of the house into public
tion''; 49% agreed that "riots are important to spaces. Mengamuk thus references the loss of
stimulate change"; 93% agreed that violence self-control and the concomitant breaking of
reflects the growing social and economic gap, social decorum, bringing madness into the
and 82% the ineffectiveness of political public in a way that embarrasses families as
channels. well as the sufferer.
Intellectuals were often asked to write com- If amuk makes initial reference to the char-
mentaries on the sources of violence. Arief Bu- acteristics of an individual suffering mental
diman criticized the lack of a "culture of illness, the broader uses of the term to stake a
478 BYRON J. GOOD AND MARY-JO DELVECCHIO GOOD
position on political violence open onto a long The placing of political activities during the
history of discussions of order, disorder, and 1997 elections on a continuum from order to
resistance to colonial rule and oppression. Mi- disorder, with which we began this essay, also
khail Bakhtin, Russian literary critic under the reflected a deeper grammar of New Order
Stalinist regime, wrote: politics. Suharto's New Order regime was
born in a wave of violence unleashed by the
For the consciousness that lives in it, lan- military following the attempted coup of 30
guage is not an abstract system of norma- September 1965. Supported by a virulent anti-
tive forms but a concrete heterological Communist propaganda operation (Goodfel-
opinion on the world. Every word gives off low 1995), over 500,000 Indonesians, only
the scent of a profession, a genre, a current,
some of whom were formally associated
a party, a particular work, a particular man,
with the Indonesian Communist Party (PKI),
a generation, an era, a day, and an hour.
Every word smells of the context and were arrested and imprisoned or summarily
contexts in which it has lived its intense killed. During the 33 years of the New Order,
social life; all words and all forms are in- Suharto's counter-coup was represented as the
habited by intentions. (quoted in Todorov originating event that saved Indonesia from a
1984: 56-7) Communist takeover, separating order and the
New Order's authoritarian rule from disorder,
The word amuk reflects, even today, the associated with the "Communist menace,"
"intense social life" of colonial psychiatry and with nearly all forms of progressive political
colonial discussions of Malay peoples as im- activities, and with hidden subversive forces.
pulsive, prone to violence, and subject to In this grammar, amok stands on the side of
primitive emotions and rage. These figures disorder. A wide range of explicit political
have been taken up internally to offer "con- activities, as well as occasional mob violence,
crete heterological opinions" on contemporary were thus associated in New Order symbolic
political acts. Lt. Gen. Prabowo Subianto, structures with subversion and the social evil
who gained notoriety for human rights viola- to which Suharto's military authoritarianism
tions during the immediate post-Suharto was antidote.
reformasi times but has been rehabilitated as At the same time, as we have suggested, the
candidate for Vice President, running with term amuk has had an alternative social life
Megawati Sukarnoputri in the 2009 elections, associated with colonial resistance and revolu-
was reported in 2001 as acknowledging army tionary violence, providing symbolic resources
excesses in East Timor, but as going on to for a more complex and critical analysis of
defend the military, saying, "We do have a politics and modernity. Thus even official
culture of violence, the tribes, the ethnic readings of history by New Order historio-
groups in Indonesia, the Indonesians will go graphy represented heroic struggles against
very fast to violence. The word amok comes the Dutch - for example, a Balinese uprising
from the lingua franca of this archipelago, led by the slave Untung Surapati (Ricklefs
something we are aware of and that we do 1993: 82)- as resulting from the Balinese ten-
not like" (April 20, 2001, AFP). Gen. Zacky dency to run amok (Degung Santikarma, per-
Anwar Makarim, who helped lead the Indo- sonal communication). Amok also had the
nesian army in East Timor, said simply, "The potential to describe violence as a powerful
character of the Indonesian people is indeed force for positive transformation, as when Su-
one that likes to go amuk" (Robinson 2001: karno was reported to say that "the Revolution
224). Such statements are classically hege- runs amuck, rampages, sweeps people along
monic; they naturalize violence, obscure like a tidal wave." During the first half of
social and political responsibility by claiming 1997, activists and intellectuals drew on these
violence to be in the character structure of readings of amuk as resistance and sources of
Indonesians, and thus reflect the colonial revolutionary change to provide analyses that
(and now postcolonial) life of the term subtly countered the official representations
"amok." of mass violence as subversive disorder,
AMUK IN JAVA 479
Where is the line between drawing attention to international system, promoting the security
the suffering of others in order to assist them of groups and individuals, and concerns for
and appropriating the suffering of others for the protection of the physical environment
institutional or personal gain? This thorny (Rothschild 1995: 55). As the definition of
question is emerging as the humanitarian assist- security has expanded, the imperative has
ance apparatus- assemblages (Deleuze 1988) been to determine the ways in which political,
of governmental and nongovernmental agen- economic, social, or environmental factors
cies - intervenes across and within national impact "human security." In addition to this
borders to assist traumatized "victims, of pol- there has been an expansion of the locus of
itically motivated and interpersonal violence, responsibility for promoting and protecting
disasters, and the conflicts that arise within "human security'' at a policy level. The insti-
failed or failing states. As much as governmen- tutions that adopt this humanitarian impera-
tal and nongovernmental humanitarian inter- tive include multilateral (international),
ventions are motivated by compassion, they national, and local governmental and non-
are also motivated by concerns for security: governmental institutions (among others)
global political and economic security, as well (Rothschild 1995: 55-56). In practice, how-
as national, institutional, and "human, or ever, both the conventional and expanded
"common" security- "the security of individ- forms of security may be present within for-
uals [or groups] as an object of international eign policy initiatives of both governmental
policy" (Rothschild 1995: 54). and nongovernmental institutions. One of
The definition of security has been extended the ways in which both traditional and
in the post-Cold War era. From an initial, expanded concerns for security have mani-
militaristic focus upon protecting the nation- fested, particularly since the reputed end of
state against other polities, current concep- the Cold War, has been in international dis-
tions of security have shifted to encompass courses of 'trauma' within the humanitarian
concerns for maintaining the integrity of the assistance apparatus.
Erica james, "The PoJitical Economy of 'Trauma' in Haiti in the Democratic Era of Insecurity," Culture,
Medicine and Psychiatry 28 (2004): 127-49. With kind permission from Springer Science & Business Media:
Culture, Medicine and Psychiatry 28 (2004), pp. 127-49.
482 ERICA JAMES
In this article I explore the relationship engenders different linkages of power relations
between discourses of security - so prevalent in or forces from the local to international realms
the West after the September 11, 2001, attacks- of social and political action (James 2003). At
and discourses of 'trauma' or posttraumatic the same time I sought to understand and alle-
stress disorder (PTSD). Trauma and security viate in some small measure the embodied
issues intersected in fieldwork that I conducted suffering of my Haitian physical therapy clients
with victims of organized violence over more at the clinic, and to witness how Haitian
than 2 7 months of residence in Haiti between viktim articulated their trauma in therapy
1995 and 2000. I worked at three institutions groups that I cofacilitated in the rehabilitation
during this period in my capacity as an ethnog- program. Despite the manifest struggle to cope
rapher, activist, and physical therapist: between with everyday ensekirite and the ongoing
1996 and 1999 I worked at a privately funded experience of "traumatic stress," a peculiar
women's clinic in Martissant - an urban area transformation of viktim's subjective and
just southwest of the capital that was heavily intersubjective pain and despair occurred as
targeted for violence during the recent 1991-94 they presented and were implicitly required to
coup years; from 1998 to 19991 participated in perform their suffering in order for it to be
therapeutic sessions at an outpatient clinic at "recognized" in a variety of institutional and
the Mars/Kline Center for Neurology and clinical contexts.
Psychiatry at the State University Medical Hos- After a brief analysis of Western notions of
pital located in the capital, Port-au-Prince; from trauma and their links to the recent shifts in
1997 to early 2000 I worked at a non-profit security talk in political theory, I will analyze
nongovernmental organization (NGO) funded how historical stereotypes of Haitians and
by the United States Agency for International Haiti affect how Haitians are able to adopt
Development (USAID) that housed a rehabili- subject positions within these discourses of
tation program for victims of organized security, suffering, hope, and despair. Through
violence also located in Port-au-Prince. a discussion of the deployment of discourses
The time period in which I conducted my of security and trauma during this period of
research was considered to be a period of research in Haiti, and their effects on the
"democratic consolidation" after the US and experience and tactics of viktim, I will show
UN Multinational Force restored democracy how these discourses can generate new econ-
on October 15, 1994. Despite this military omies based upon commodifications of
intervention, Haiti continued to be plagued by suffering. Nonetheless, the ability to partici-
political and criminal violence, called ensekir- pate in these debates depends on positioning,
ite (insecurity) in everyday discourse. With its whether geopolitical, communal, or individual.
economic stagnation and ongoing instability This piece is a meditation on how current con-
there is a pervasive climate of fear and "ner- cerns for safety and suffering are highly moral
vousness" (Taussig 1992) within the Haitian discourses that involve questions of compas-
social body, but it is both acute- with regularly sion, ethics, obligation and action, and are
high levels of fear and social paralysis - and inextricably linked to history and political
chronic for viktim, those who claim to be the economy.
victims of state-sponsored violence from the
recent 1991-94 coup years. Within this "inse-
cure" environment I worked with viktim as Trauma in the 'Post-Cold War' Era
they searched for assistance from a swarm of
governmental and nongovernmental agencies The post-Cold War era has been viewed by
that comprised the humanitarian assistance many sociopolitical theorists through the lens
apparatus in Haiti at the time. I examined of "postmodernity," a term which signifies the
how the discourse of trauma is employed, and breakdown of grand narratives of politics, eco-
by whom, within the broader realm of govern- nomics, culture, and ideals of progress.
mental and nongovernmental humanitarian According to theorists of postmodernism, the
assistance in Haiti and the ways that deployment "symptoms" of the postmodern condition are
THE POLITICAL ECONOMY OF 'TRAUMA' IN HAITI 483
also characterized by the experience of space like Haiti. That being said, the transnational
and time as chaotic, fragmented, schizo- efforts to rebuild post-conflict nations appeal
phrenic, or incoherent. This "postmodern con- to modernist or universalist languages of
dition'' is indelibly marked by the disordering rights, civil society, law, and economic and
yet productive, or "titillating," effects of global human development in a manner reminiscent
capitalism (Harvey 1990: 39, 63; Jameson of the missions of colonial expansion. I will use
1991; Lyotard 1984). While the content of the term "neo-modern," therefore, to refer to
geopolitical fears has changed since the end of the nco-Enlightenment theories and practices
the Cold War opposition between democracy, of governance that arise in relationship to the
liberty, or capitalism and communism or so- crisis of the state in what has been called the
cialism, the form or structure through which post - Cold War era. In this formulation, both
these discourses manifest continues to have a governmental and nongovernmental develop-
similar pattern -that of identifying threats to ment and humanitarian assistance efforts
the security of the West or to "civilized engage in practices of intervention, social
nations," and resulting in some form of inter- rehabilitation, and political and economic
vention. The continuation of these practices reformation. These interventions are designed
calls into question whether or not the Cold to build "civil societies" that respect the "rule
War has truly ended; however, the particular of law" and promote equality and citizenship
strategies by which current geopolitical threats for all of their members - aspects of "human
are identified and managed are new. Against security" - even as the states in which these
this perception of discontinuity or ruptures be- assistance or development efforts are deployed
tween modern and postmodern ideals and open their markets to the unrestricted ebbs and
practices, I argue that the era begun by the flows of global capital. The technologies of
end of the Cold War is neo-modern in character intervention that arise in the effort to promote
and hinges on security at the international, human security are reminiscent of what Fou-
national, community, and individual levels. cault calls bio-power - "techniques of power
Since the end of the Cold War, emerging present at every level of the social body and
proto-democracies - nations like Haiti that utilized by very diverse institutions (the family
have struggled free from the shackles of dicta- and the army, schools and the police, individ-
torship, socialism, or political conflict - have ual medicine and the administration of collect-
been targets of intervention. In some ways the ive bodies), operated in the sphere of economic
modes of representation and practices of inter- processes, their development, and the forces
vention in "transitional'' states trace their ge- working to sustain them" (Foucault 1990:
nealogies at least as far back as the colonial era, 141, emphasis in original).
but are not identical to interventions from In the neo-modern, post-Cold War era, the
that time. Nonetheless, the way in which the discourse of trauma permits the exercise of
humanitarian assistance and development ap- global bio-power by the humanitarian assist-
paratus designs and attempts to implement ance apparatus as nations make the transition
social, political, and economic change in toward the respect for the rule of law, human
nations that are undergoing "transitions to rights, democracy, and capitalism. The res-
democracy" or "post-conflict reconstruction" ponses to the traumatized victims of politically
is unsetdingly familiar, but involves new bur- motivated violence become the meter by which
eaucratic technologies of suffering that are states, criticized for their past predatory or
required to legitimize the activities of the negligent practices, are now measured in order
intervener. With these practices the interveners to determine their competence and account-
establish their accountability to those whom ability toward their citizenry. This is also a
they are responsible. manifestation of what Foucault calls the prac·
In describing this phenomenon I hesitate to tice of "governmentality" (1991)- the discipM
use rhetorics of "neocolonialism," "neoliberal- line and management of populations through
ism," or "supracolonialism" (Pandolfi 2000) to particular forms of government rationality.
describe what is currently happening in nations In the case of transnational humanitarian
484 ERICA JAMES
for US and European political and economic during the 1915-34 American Occupation of
security. Haiti (Craige 1933, 1934; Renda 2001) and
Since its successful achievement of inde- more recently with the onset of the AIDS pan-
pendence in 1804, after the 12 years of the demic. In the early 1980s the CDC designated
Saint-Domingue struggle for sovereignty, Haiti Haitians as vectors of HIV. As members of the
entered its postcolonial period as a political infamous "4-H club," which also included he-
outcast within the slaveholding "international mophiliacs, heroin addicts, and homosexuals,
community." At the same time, however, the Haitians as a racial and cultural group were
new nation was a source of inspiration and labeled as a danger for the spread of infection
hope for enslaved blacks and colonized Mri- (Farmer 1992; Sabatier 1988). While the sick
cans throughout the world. Nevenheless, inde- or diseased have long been considered threats
pendent Haiti would be viewed continually as w the United States and other nations, those
a threat to hemispheric and global security, and recognized as fleeing political repression have
the "cancer of revolution" and the "contagion been given asylum. Nevertheless, as tens of
of black liberty" sparked numerous policies to thousands of Haitians fled to the United States
secure American borders against the influx of in the 1980s and 1990s and were labeled "eco-
Haitian revolutionaries (jordan 1968: 375- nomic refugees,'' they were denied recognition
402). Haiti would be denied political recogni- as political subjects because of the potential
tion of its sovereignty and right to exist for the threat that they represented. Upon analysis of
next two hundred years. the peculiarities with which Haitians have been
Instead of receiving the same protections treated in asylum cases and in US foreign policy
that the United States proclaimed in its Monroe (DeConde 1992; Lawyers Committee for
Doctrine (1823 ), Haiti and Haitians were Human Rights 1990; Miller 1984; Plummer
depicted as insane, highly sexed and syphilitic, 1992), it is possible to say to some degree that
deficient in both intellectual and moral cap- Haiti and Haitians continue to be symbols of
acity, superstitious, hysterical, and easily influ- horror, violence, pathology, and the chaos of a
enced by the charisma of Vodou priests and nation that the United States views as willfully
priestesses. Indeed, in the 19th century racialist refusing to follow a democratic path. Recur-
works of Gobineau (1999), LeBon (1974), and rent images of the violence of the Haitian
Southern American physician Cartwright Revolution and the ongoing negative stereo-
(1851), Haiti and Haitians became the case typing of the nation's people and leaders sug-
study to illustrate the genetic roots of black gest that Haiti is an archetypal object of
incapacity. For example, Cartwright defined consciousness upon which the international
drapetomania as a propensity for slaves to flee imaginary remains fixated (Dash 1997; Freud
from the plantation. Using Haitians as evi- 1997: 207; james 2003; 2008).
dence, he described dysaesthesia Aethiopica Beyond the screen of fantastic images, the
as a tendency for free blacks to suffer from reality is that Haiti remains infamous for being
"insensibility'' that manifests as mischief due the poorest country in the Western Hemisphere
to stupidity, destruction of property and theft, and for its struggles wward democracy in the
diminished mental capacity and lassitude, and 21st century. While the accuracy of statistical
insensitivity to pain when subject to punish- measures may be questioned, the following fig-
ment for these actions. In this respect, Haitians ures are generally accepted as valid. Life
were not viewed as having the capacity to feel, expectancy in Haiti is estimated at 50.36 years
to love, or to reflect in a cognitive manner that for men and 52.92 years for women (Central
would engender the moral capacity that was Intelligence Agency 2004). Six percent of the
prerequisite for what one would categorize as entire population of Haiti is considered to be
"shell shock" or "trauma" at the turn of the HIV positive; however, the infection rate may
20th century. be as high as 13 percent in the Northwest
From the 19th to the 20th century, stereo- Department (Dubuche 2002), which has been
types of Haitians as superstitious and sexually plagued with drought, food shortages, and
liberal continued to proliferate, especially heavy damage in the aftermath of Hurricanes
THE POLITICAL ECONOMY OF 'TRAUMA' IN HAITI 487
Georges and !vlitch in the fall of 1998. The Haiti's post-coup era? Given the crisis of the
2000 Human Development Report (United Haitian state and the ongoing international
Nations Development Program 2000) affirms ambivalence toward assisting the nation, who
that 63 percent of the population lack access or what institution or state should be held
to safe water, 55 percent do not have access to accountable for recognizing and repairing the
health services, and 75 percent lack access to legacy of egregious suffering in the recent and
basic sanitation. Twenty-eight percent of chil- distant past?
dren under age five are below normal weight.
The infant mortality rate is 95 per 1,000 live
births. Overall, at least 80 percent of the popu- Torture and its Consequences
lation lives in abject poverty (Central Intelli-
gence Agency 2004). At the time of this writing Gender, sexuality, production, and reproduction
the unemployment rate is believed to be nearly were explicit factors in the mode of repression in
70 percent. In terms of its economy, Haiti ranks Haiti during and after the coup d'etat of 1991.
a low 170th out of 206 countries, with a GNP This section is a general overview of the types of
of only US$460 per year (World Bank 2001). violence perpetrated during the coup years and is
Certainly, as a result of its dire poverty and based upon my analysis of case files representing
political insecurity, many Haitians still attempt more than 2,000 viktim, my own documenta-
to flee Haiti in order to find a better future tion of cases in the field and physical therapy
in the United States. While the anxiety that work at the clinic, and participation with
these hopeful migrants provoke continues to viktim in discussion groups in a variety of set-
be acute, it inspired the most concern for the tings. The majority of the poor who were
United States and its own bio-political security targeted were designated Lava/asyen - sup-
during the coup years of 1991-94, when porters of Aristide. Just as Das and Nandy
Haitians were interdicted at sea and returned (1985) observed in their discussion of sacrifi-
to Haiti's politically and economically insecure cial and political violence in South Asia, there
shores in the thousands without adequate were differences in the particular "style" of
hearings. Nonetheless, it is striking that what violence employed to maintain the climate of
continues to be elided within national and terror in Haiti during these years. Men were
international discourses of Haitian democracy attacked for their involvement in the popular
is acknowledgment of the legacy of violence democracy movement - whether as organizers
from the Duvalier dictatorships (1957-86) or supporters. When apprehended, they may
and the post-dictatorship period, as well as have been arrested or kidnapped, interrogated
the egregious uses of torture and terror be- in a detention facility, beaten - at times with
tween 1991 and 1994. Just as the extremity of the intent to damage their sexual organs -
the violence has yet to receive thorough recog- whipped, derided, or humiliated. In order to
nition and analysis in the manner that has been ensure that they could never again perform
attempted in other "post-conflict" nations manual labor or other work, they may have
(Hayner 2001), the ongoing suffering of had a hand chopped off, or been cut in ways
Haitian viktim, among the general population that left permanent physical damage. At times
living in the climate of ensekirite, remains these attacks on the body and mind were ac-
acute and nearly invisible. companied by theft and destruction of
What actually happened during the years of property, livestock, or other possessions.
the coup d'etat in Haiti, and how were victims Women were also targeted for their active
of human rights abuses coping in the aftermath organizing role in the political domain, as well
of conflict? Did they, in fact, suffer from 'post- as in their roles as small-scale merchants; how-
traumatic stress' and how did this manifest ever, they were also victimized in place of their
according to gender? What assistance could husbands, fathers, brothers, or spouses as sur-
be provided to help them rebuild their lives, rogates- what Girard (1977) has called "sac-
and how could this be done successfully con- rificial substitutes." They were often unable to
sidering the ongoing crisis of insecurity in go into hiding because of their responsibilities
488 ERICA JAMES
for their children and because their commer- articulations of suffering are also gendered.
cial activities bound them to local markets, Women who had been raped were often aban-
so they were vulnerable to further attacks doned by their partners or husbands and fam-
by the various military-affiliated groups. Al- ilies and labeled as fanm kadejak - "the wives
though politically motivated rape occurred of the rapist." Alienated from their social
immediately after the coup, by late 1993 group, they often fled to other areas in order
rape, repeated rapes, gang rapes, and even to restart their lives. Many of these women
forced incest were tools of repression that were market vendors and had also lost their
were used systematically to terrorize families livelihoods at the time of the attack. In many
and communities generally, but women cases, however, their only recourse for survival
specifically. was to appropriate their own sexuality as
The use of gendered and sexualized forms a means to generate income, much as the
of torture and terror was intended to destroy coup apparatus appropriated power from their
the productivity and reproductivity of the in- bodies during its reign of terror. Haitian
dividual victim, and to rupture the social women lamented their inability to care for
bonds between the direct target of violence their children - to send them to school, feed
and his or her family and community through and clothe them- in accordance with cultural
the use of physical pain, threats, and other ideals of femininity and parenthood. Further-
coercive acts. As Scarry (1985} suggests, more, women viktim and their children often
power and productivity were stripped from suffered from tuberculosis, malaria, and mal-
the targets of violence and transferred to the nutrition, as well as somatic forms of emo-
torturer(s}, and to the coup apparatus as a tional distress arising from the imbalance of
whole as it sought to consolidate its hold over san (blood) in the body.
the nation. The efficacy of torture used in Haitian men who were victims of violence
Haiti during this period, however, lay beyond similarly articulated feelings of humiliation
its use against the "body" in the short-term. and shame at having been powerless to protect
The forms of torture perpetrated were effect- their families, and at having been subjected to
ive in controlling social space as well as the abasing forms of torture. What they lamented
subjectivity of their targets over time. Beyond most strongly in the therapy groups in which I
the initial attempt to extract legitimacy and participated was their rage and anger over the
power from victims' physical bodies through loss of their property, livestock, and public
the use of pain, the purpose of these horrific status - essential aspects of the ideals of mas-
acts was to inculcate what Patterson (1982) culinity. Indeed, the perceived loss of social
has described as "social death'' of the victim status was among the greatest factors in the
and "natal alienation'' from his or her social way that Haitian men experienced and nar-
network of responsibility through the viola- rated their trauma, depression, and anxiety. In
tion of moral norms. In this respect, the psy- many cases, however, the personal sense of
chosocial sequelae of torture leave their traces shame, ongoing economic impotence, and fail-
on the individual psyche or self over time, as ure to meet their expected social roles- fulfil-
well as on the extended family and commu- ling their domestic responsibilities to provide
nities of viktim. for their children and support their conjugal
partners - culminated in the total abandon-
ment of their families. The care and subsistence
The Traumatic Sequelae of Torture: of the family was left to other relatives, or to no
Social Death and Natal Alienation one, leaving women and children even more
vulnerable.
In the aftermath of the coup years, the Earlier in this paper I asked if PTSD mani-
most common laments among viktim were fested in Haiti following the coup years, and in
feelings of shame, humiliation, powerlessness, what way. I can speak of "posttraumatic stress
and isolation or disconnection from their fam- disorder" in Haiti, but only in a guarded sense.
ilies and communities. These experiences and Many victims of organized violence in Haiti
THE POLITICAL ECONOMY OF 'TRAUMA' IN HAITI 489
have suffered memory loss - not simply from Haidan human security was not given without
dissociation in the psychological sense, but be- a simultaneous goal of protecting US national
cause of blunt trauma to the head. Viktim are security and the US's own image in the inter-
generally hypervigilant and have feelings of national community: explicit within the draft
detachment from others. Many expressed a documents for the first incarnation of this as-
"sense of a foreshortened future," or feelings sistance project was the recognition that US
of depersonalization - the sensation that their credibility was low regarding supporting dem-
bodies did not feel like their own. But these ocracy and human rights in Haiti. Providing
"symptoms" do not capture the despair assistance to Haitians at this juncture was cru-
and social dislocation of people like Elsie, a cial to creating an image of the United States as
60-year-old grandmother who still searches accountable to its own citizenry and to the
for her son who has been missing since 1992. Haitian government and civil society whose
She spoke of him each time I saw her in the democracy it intended to help consolidate;
Martissant clinic. Her perpetual torment is not however, it can be debated whether this effort
knowing if he is dead. If he is, her inability to was successful.
lay his body to rest through proper funerary The second phase of the project continued
rites leaves her in a state of moral limbo in this assistance to victims of state-sponsored
which she is vulnerable to haunting and perse- violence without restriction to time period,
cution by the zonbi, an aspect of the disembod- but required that beneficiaries be members of
ied soul of the deceased. But who or what victims' associations or advocacy groups, or
institution or government is or should be re- have a recommendation from a recognized insti-
sponsible for repairing these moral cleavages? tution like the Ministry of Justice, the Episcopal
justice and Peace Commission, local or inter-
national human rights groups, women's groups,
Humanitarian Assistance, or other formal institutions. The project con-
Security, and Bio-power tinued to provide assistance to individuals and
families until its untimely demise, when a series
In the aftermath of the denials of gendered and of attacks by disgruntled members of the
sexualized forms of torture and the political victims' advocacy groups forced the rehabilita-
motivation for acts of terror in Haiti in the tion program to close in order to preserve the
early 1990s, a cacophony of dissent erupted security of its staff in May of 1999. During the
from international and national human rights suspension of services, however, individual
organizations and other supporters of the members of the Democracy office of USAID/
nation's fragile democracy against the US gov- Haiti informed USAID/Washington that "there
ernment. In response to the criticisms of its were no more victims in Haiti" and that funding
practices and the accusation that the United for the program should be discontinued. This
States was not a credible promoter of global occurred at nearly the same moment as USAID/
human rights, the US government, through Washington's presentation of the Haitian
USAID, provided humanitarian assistance to rehabilitation project to Congress as an example
viktim from the 1991-94 period. The vehicle of their success in providing relief to torture
for this aid was a rehabilitation program for victims (US Congress 1999a, b).
victims of organized violence housed at a non- In this field site the recognition of collective
governmental organization. The program func- suffering by USAID was a security strategy for
tioned in various incarnations from July of the US government: the rehabilitation project
1994 until February of 1995, and again from was viewed as a step toward building US cred-
July of 1996 until May of 1999. During the ibility in Haitian civil society, legitimizing the
early phase of 1994-95, the project provided impending US intervention into Haiti, as well
complete medical care to viktim, including as assisting individuals and families who might
surgeries, trauma counseling, legal assistance, otherwise have lost their lives trying to reach
and stipends, to help alleviate suffering. None- asylum in the United States. The project was
theless, the attention to and promotion of also viewed as useful in demonstrating the
490 ERICA JAMES
sincerity of US human rights practices over- often asked to pay the local representative or
seas, as well as the US's own image as a hu- investigator who documented their cases and
manitarian nation. Nevertheless, when this built their trauma portfolios before they were
assistance became challenging or problematic linked to the individuals and organizations that
and it was no longer necessary to maintain US would assist them. In many cases, the dossiers
authority or authenticity in this domain, the were withheld until the ransom was paid to the
funding was discontinued and the existence of investigator.
viktim denied once again. The abrupt with- In some cases, those who could pay the local
drawal of aid left many individuals and fam- investigator would have false portfolios assem-
ilies who were beneficiaries of the program bled for them. They might be recognized as
with little time to find other resources to help victims locally, nationally, or internationally
them continue to rebuild their lives. because of their purchased portfolio and their
Within the privately funded humanitarian ability to perform a convincing tale of woe.
assistance apparatus, the political economy of Within the environment of poverty and insec-
trauma functioned in a different manner. I urity that Haiti has experienced in the past
also worked at a women's clinic that had been decade, victim status- whether legitimate or
established in Martissant by the joint efforts purchased - offers the possibility for political
of two women's organizations, one Haitian recognition and economic assistance. In this
and one US-based. One of the main goals of respect, one of the social consequences of the
creating this space was to address concerns intense international gaze placed upon trauma,
for the ongoing suffering of women who had rape, and victimization is the creation of what I
been raped during the coup years. These am calling trauma brokers - gatekeepers to the
women were encouraged to form survivors' humanitarian assistance apparatus who profit
organizations in addition to establishing their from the suffering of others and who supply the
membership in the Haitian women's group demands of consumers of performed suffering
that founded the clinic. They were provided in the international humanitarian apparatus.
with small business grants to help them re- I remain haunted by my own part in this
cover financially, and many of them received cycle of the appropriation, transformation, and
subsistence supplies from the storehouse that commodification of suffering. I wonder how
the organizations maintained in the neighbor- many voices have been silenced within or ex-
hood. The US-based women's organization cluded from recognition within the discourses
solicited funds on behalf of the clinic through of trauma and victimization as they are cur-
its extended membership and frequently rently conceived as originating from some past
updated those on its mailing lists about the traumatic event. For example, I had been
progress in assisting these "survivors." At working at the women's clinic in Martissant
times, however, those funds were slow to for about a month when Louise came to ask
reach the clinic staff. me for a physical therapy session. I told her
Over the course of my fieldwork, however, that my appointment book was full, as I had
I learned that within the local community already arranged to work with rape survivors
outside the clinic and the rehabilitation pro- for the majority of my time at the clinic. Never-
gram, certain individuals acted as gatekeepers theless, she came every day and waited for a
who facilitated or prevented the victims' chance that I might see her. Louise was not a
access to either the Haitian or the inter- member of any women's organization or
national assistance organizations. In a country human rights group. She was not a survivor
where as much as 70 percent of the popula- of state-sponsored terror. In focusing on the
tion is illiterate, those who can read and write trauma of systematic rape at this time I could
have tremendous power as mediators between not recognize her suffering. Nor did I recognize
the local and the international domain of her need for a listening ear and a compassion-
charity, and are often sought as field assist- ate, nonthreatening touch.
ants. In both of my field sites I became aware I agreed to see her when one of my clients
that outside of the institutions viktim were was unable to keep her appointment. We went
THE POLITICAL ECONOMY OF 'TRAUMA' IN HAITI 491
back to the small room where the massage deployed in the aftermath of each recognized
table stood in the center of an overflow state of emergency. It encodes the inequality
waiting area. Mosquitoes buzzed near the between those who identify and label the
floor and underneath a table in the room. We suffering of others as disordered and those
could hear the loud banter of some young boys who have survived life-shattering circum-
in the neighborhood and the cries of the stances and become 'victims,' 'rape survivors,'
newest addition to the family who lived next or 'patients.' In this era of traumatic citizen-
door. Louise apologized to me because she did ship, an era in which individuals and groups
not have soap to bathe or to wash her clothes seek recognition, agency, political and eco-
before coming to the clinic. Then she began to nomic power, and security through attempts
tell me her story. "I was almost raped," she to seek justice and restitution for past wrongs
said, as if to justify her worth in my eyes. or experiences of victimization, we must ask
"What happened?" I asked. "Pd been sleeping ourselves what is at stake when we recognize
on the gallery of a house in Martissant. For the and materially compensate others because of a
past year and a half I've had to sleep with men single attribute- their suffering, their injury or
for money in order to feed my children and to trauma, their gender, or their race?
try to send them to school. One of the men As Brown {1995) suggests, does this par-
tried to rape me but I fought him off. Please ticular form of recognition perpetuate a
don't tell anyone here at the clinic what I do." second-class or underdeveloped status for
I assured her that I would not. In prepar- those who are the objects of humanitarian
ation for the physical therapy session I asked intervention? Does the recognition of trauma
her how she felt and she complained of intense in this manner perpetuate forms of bio-power
low back pain. One night while she was "at that are rooted in the imperial past? In discus-
work" on the gallery she had been drenched in sions of international security must the trauma
a flash flood with water that flowed through and suffering of some nations be denied for
the garbage and sewage that were dumped fear that prolonged victim assistance may turn
from each household onto the street in this into forms of welfare or managed care without
neighborhood. She felt that the water had borders? Furthermore, when our compassion is
afflicted her with the pain in her back and fatigued or our gaze turns to other global
pelvis. When I inquired further about her situ- terrors or dramatic forms of suffering that
ation, Louise told me that often she had slept we witness from a distance (Boltanski 1999;
with ten men per night, accepting whatever Nussbaum 2003), what are the repercussions
they would give her in payment, which was of withdrawing the "gift" of humanitarian aid?
often a slap in the face instead of money. She Maurice GodeJier has written the following
only used condoms with those who requested on the "tyranny of the gift":
it. As she grimaced from pain with the effort to
Giving . . . seems to establish a difference and
lie down on the table, I was reluctant to work
an inequality of status between donor and
with her before she had seen a doctor to deter- recipient, which can in certain instances
mine what was the immediate cause of her become a hierarchy: if this hierarchy already
physical pain. She misinterpreted my hesitation exists, then the gift expresses and legitimizes it.
and said to me, "Don't worry. I'm not going to Two opposite movements are thus contained
sleep with anyone after this massage. I still in a single act. The gift decreases the distance
have two months before I have to pay the between the protagonists because it is a form
registration fee for school." of sharing, and it increases the social distance
between them because one is now indebted to
the other. . . . It can be, simultaneously or
Ongoing Ethical Challenges successively, an act of generosity or of vio-
lence; in the latter case, however, the violence
The global discourse of trauma is quickly is disguised as a disinterested gesture, since it is
becoming a language of entitlement in neo- committed by means of and in the form of
modern discourses of human security that is sharing. (Godelier 1999: 12)
492 ERICA JAMES
The development of the ethical economies organizations - that are not accountable to
outlined in Mauss' formulation of the gift those they serve in local realms- may abuse their
(Mauss 1950) is extremely relevant to this own power or contribute to occult economies of
discussion of suffering, security, reparations, suffering.
and restitution, but also to the way in which There are no easy answers to the ethical and
violence may involve economies of appropriM moral dilemmas that I have presented in this
arion and exchange in the form of taking. As article, nor are the problems I describe new
I discussed in this article, the economies of ones. The fact remains that the ubiquitous
extraction of suffering or trauma occur in presence of human suffering caused by the per-
different ways, depending on whether one nicious acts of others, as well as the responses
examines the practices used during the repM to it, is inextricably bound to local, national,
ression of the coup years or the unintended and international histories, politics, econ-
generation of occult economies by the omies, and cultures that are not easy to disen-
humanitarian assistance apparatus. Nonethe- tangle. In order to examine adequately issues of
less, to examine these activities solely from agency, causality, inequalities, prejudices, and
the present without regard to history would oppression, questions of suffering, insecurity,
be an error. and security will continue to require more
Haiti's infamous position as the "poorest complex analyses than can be encompassed
country in the Western Hemisphere" has roots by the conceptual frameworks of 'trauma,'
in colonia] economies of violence, terror, and 'human rights,' or even the trope of 'structural
extraction of productivity from the bodies of violence.' Thus the ethical task at hand is also
slave laborers. Since its independence, the not a new one.
"state of extraction, remains linked to its cur- Social theorists, activists, advocates, and
rent "state of pathology, (James 2003) - the other humanitarian actors involved in tech-
perception on the part of international donors nologies of bio-power and knowledge produc-
that the government of Haiti can neither arrest tion must still acknowledge and grapple with
the political, criminal, and economic insecurity new forms of complexity in this neo-modern
within its borders, nor consolidate its democ- age, including our own unforeseen roles in per-
racy according to their expectations. The di- petuating cycles of inequality and exclusion of
lemma remains that in nations like Haiti, those who would achieve equality and citizen-
where the state is incapable of meeting the ship within the international community. In the
needs of the poor majority, any means toward domain of humanitarian assistance the chal-
political recognition or assistance is crucial for lenge remains one of balancing the economy
its citizenry and may result in tragic tactics of of gifts and exchanges and limiting dependen-
survival, including transforming, appropriat- cies and the perversion of aid (Terry 2002). The
ing, and circulating narratives of the suffering reality, however, is that for injured individuals
of victims as currency in the global political and families who have no other recourse in
economy of trauma. In this respect trauma these "cultures of insecurity" (Weldes et al.
portfolios lie at the nexus of economies of 1999) and uncertainty, the path of survival
compassion and terror (Nussbaum 2003) in may lie in crime or the appropriation of others'
which are linked local, national, and inter- suffering for personal gain. The remainder may
national forms of gift giving; security practices risk death on the high seas to reach asylum on
in insecure social and institutional environM other shores, or may appropriate their own
ments; questions of global reparations; and bodies and risk disease in order to survive.
quests for justice. The danger for the humani- Those of us from cultures of relative security
tarian assistance apparatus, however, is in must acknowledge that while our intentions
assuming an obligation to a population that may be to "do good," there is always the
the state cannot or will not fulfill - and that potential that we who profit from the partial
the international community ignores or is recognition of our subjects' humanity will
reluctant to assume. While their actions are wellM perpetuate the cycle of global inequality. But
intended, even transnational nongovernmental perhaps this is a stepping-stone toward global
THE POLITICAL ECONOMY OF 'TRAUMA' IN HAITI 493
Mariclla Pandolfi, "Contract of Mutual (ln)Difference: Governance and the Humanitarian Apparatus in
Contemporary Albania and Kosovo,., Indiana journal of Global and Legal Studies 10 (2003): 369-80.
CONTRACT OF MUTUAL (IN)OIFFERENCE 497
administrative bodies. 8 The increased rele- sovereignty today: (1) domestic sovereignty;
vance of their role vis-a-vis donors (nation- (2) independent sovereignty; (3) Westphalian
states and public institutions) is the result of sovereignty; and (4) international legal sover-
their flexibility, mobility, and transnational ex- eignty.11 In contrast, over the last decade,
pertise. This strategic capability allows them to anthropology has approached the problem
intervene promptly in all comers of the globe, of sovereignty ethnographically, "confronting"
to maintain a transnational communication these typologies of sovereignty with a biopoli-
network, and finally to produce testimony. tical notion of sovereignty. This work has
In the "New World Order," crisis management drawn on theoretical concepts from the
integrates the roles of military and humanitarian writings of Michel Foucault and, more re-
aid. Veronique de Geoffroy discusses the military- cently, those of Giorgio Agamben. 12 Such dis-
humanitarian or civilian-military formula by placement toward a "critical" zone of
noting that the vocabularies of these two realms sovereignty - an intertwining of sovereignty
are beginning to come together. 9 In both con- and biopolitics - has allowed anthropology
texts, one speaks of an "area of responsibilityn to adopt a more refined position than that
or of "projecting onto an area," and so forth- of a mere accountant of different forms of
originally military expressions. Humanitarian- sovereignty.
ism, as john Prendergast reminds us, cannot be Foucault summarizes the formula for clas-
viewed as a civil religion, or as an act of faith. sical sovereignty as the prerogative to the
In other words, it is a mode of historical action, right over life and death: the power to take
which has social, economical and political life or let live in a given territory. 13 Biopoli-
consequences. 10 tics designates a reversal, or rather the contem-
Observing the diverse interpretations of hu- porary metamorphosis, of this sovereign
manitarian intervention, one soon discovers power, in that it is also exercised as the power
that the conventional discourse conceals a para- to let die or to make live. Power, understood
dox. On the one hand, humanitarian aid is this way, implies an enormous expansion in its
perceived as action that tends to consolidate potential to dominate. While classical law
state sovereignty, understood as a form of gov- reasoned about the individual and society,
ernment in its multiple local and global political and the disciplines considered individuals and
forms; on the other hand, humanitarian inter- their bodies, biopolitics has as its focus entire
vention is constructed as a measure of the pro- populations, considered as biological and pol-
gressive erosion of state sovereignty - in the itical problems.
name of the principles and practices of its In the case of the fall of traditional forms of
own political organization- that extends over sovereignty, there is also a collapse of official
the whole planet. Both of these positions are identity, which is what allows people to locate
projected onto a transnational scene in which their lives at the juncture between the present
relations and institutions distinct to each sover- situation within living humanity and one's
eign state are increasingly confused due to the belonging to the eternal human race. Politics
more general pressure of globalization. The is no longer geopolitics, and power no longer
entire humanitarian apparatus legitimizes its stops at the domination of subjects retained
presence in the name of an ethical and temporal within real and institutional frontiers of States,
rule that may be defined as the "culture of or in the no-man's land of international rela-
emergency." tions. Power has become biopolitics.
The exercise of biopolitical sovereignty
extends so far that the sovereign human being
II. Problematizing Sovereignty: is stripped to the barest choice of life. In other
Biopower and Bare Life words, the only choice left is located in what
Primo Levi called "the gray zone," that is, the
From varying perspectives, political scientists nonliving and the non-dying. 14 Agam ben
and international lawyers have identified four describes this space as Bare Life - the absolute
different ways of defining the concept of political substance that, once isolated, allows
CONTRACT OF MUTUAL (IN)DIFFERENCE 499
the total definition of the subjecfs identity in also means recognition of the paradox and
demographic, ethnic, national or political the risk implied in the rule of law in modern
terms. 15 democracies.
This slippage of our present age has oc- For Agamben there are two models of
curred not only in order to legitimize ethnic power, a juridical one focused on the problem
cleansing and genocide, but also in the name of the legitimacy of Western power (the prob-
of compassion, for the sake of protection and lem of sovereignty}, and a non-juridical model
cure, in the name of what Passin has defined as centered on the problem of the effectiveness of
Ia politique du vivant (the politics of life). 16 Western power. 19 These two models meet in
This is the paradox that I want to address. the dimension of exception. 20 Agamben writes:
The radical and central aspect of our demo-
\Vhat is the place of sovereignty? If the sover-
cratic management- protecting victims, organ-
eign, in the words of Carl Schmidt, is the one
izing health policies, codifying the new
who may prodaim the state of exception and
frontiers of genetics, intervening during "emer- thus legally suspend the validity of law, then
gency" humanitarian catastrophes - assumes the space of sovereignty is a paradoxical space,
the logic of biopolitical technology. as it lies both within and without the juridical
Biopolitics thus reveals an inversion in the order.
deployment of power - the reduction of sub-
jective trajectories, of individuals, of men and What is an exception? It is a form of exclusion.
women, to bodies. Such indistinct, displaced, It is a single case that is excluded from the
and localized bodies come to be classified general rule. But what characterizes the excep-
and defined as refugees, legal or illegal immi- tion is that what is considered as excluded in
reality maintains a relationship with the law,
grants, or traumatized victims according to
albeit in the form of a suspension.21
the diagnostic categories of humanitarian
management. The fundamental operation of power is to
I would thus locate the catalogue of human isolate a bare life in each subject, a life that is
suffering inscribed by the deployment of "hu- irremediably exposed to sovereign decisions.
manitarian" biopower at the juncture between Within the space of exception, a sovereign de-
two conceptual domains: that of "governmen- cision is exercised without mediation. Agam-
tality," which Foucault defined "as running ben observes and describes with ruthless
through the totality constituted by instruc- sobriety the human destiny of the individual,
tions, procedures, analyses, tactics that allow the group, and the population at the moment in
the exercise of this very specific though ex- which it enters into this zone of arbitrariness. 22
tremely complex form of power, which has as In many areas of anthropological work, we are
its locus the population and as its essential similarly confronted with the arbitrariness of
technical instrument, security apparatuses," 17 rendering the human being no longer as a citi-
and that of the intersection of rights with bio- zen, but as a bare life, a zoe.
power as developed by Agamben. The separ-
ation between humanitarianism and politics
that we are experiencing today is the extreme Ill. "Bare Life" and Emergency in
phase of the separation of the rights of man Kosovo and Albania
from the rights of the citizen. In the final
analysis, however, humanitarian organizations - The places where the juridical state of suspen-
which today are more and more supported by sion is activated may be refugee camps, or, as I
international commissions - can only grasp have found in my research in Kosovo and
human life in the figure of bare or sacred life, Albania, the ambiguous setting-in-motion of the
and therefore, despite themselves, maintain a entire humanitarian apparatus. In aH of these
secret solidarity with the very powers they places individuals become a "population'' to be
ought to fight. 18 Following Foucault, I view numbered, ethnicized, and catalogued. In the
biopower as an articulation of the political process of humanitarian intervention, the state
with the biological; following Agamben, this of exception is legitimized by the category of
500 MARtELLA PANDOLFI
"emergency,, which is a category of action rec- any dissident or alternative voice. Witnessing
ognized by Ia w. is the central element in this regime of
Determined as a temporal and temporary governmentality.
derogation in a precise context, the emergency
category is "logically" opposed to the category
of the ordinary. Paradoxically, emergency no IV. Migrant Sovereignty in the
longer constitutes an extraordinary or excep- Aftermath of Emergency
tional temporal category in humanitarian inter-
vention. In the territories of humanitarian The overall feature present in most interviews
intervention, it has become the sole temporal of experts or aid workers active in the humani-
modality of the new social contra(..'t, which tarian apparatus is the trope of personal wit-
includes the right of interference, temporality nessing: "I saw, I was ... ''is often rendered as
of emergency, and necessity of action. 23 "I did Bosnia, Albania, Kosovo, and I will
The occupation of space, the invasion of surely do Macedonia and Afghanistan. '' 27
territory, and the crossing of borders are char- As Rufin notes, the temptation to conceive
acterized by the need for mobility and speed in all humanitarian matters as inherently innocent,
intervention; the humanitarian apparatus is in so deep-seated in Western consciousness, is
fact constructed on the logic of action. Re-
sponding to the priorities of international increasingly at variance with reality, because
donors and bureaucratic frameworks, a thou- today humanitarianism has entered the era of
sand traces of action, often contradictory, high complexity ... which cannot accommo-
propagate. They are performed by social actors date either romantic tendencies or the desire to
concealing a profound ambivalence, if not hos- "naturalize" war, which forgets that conflicts
are not engendered by some sort of barbarian
tility, toward the institutions that require
absurdity born out of some kind of tribalism,
action. 24 Humanitarian universalism bears an
or the result of an excess of extremist fury, but
anti-state and anti-institutional current of always have "political" origins. 28
rebellion, moving instead according to what
La'idi has more recently called planetary One cannot dispute the legitimacy of an
time. 25 The emotional components of the intervention seeking to help victims on the
single humanitarian choice are also multiple ground or to rebuild a nation where massacres
and confused, and are often experienced in have taken place. Yet as soon as the media
contradictory ways by single individuals, who leave the scene of the "humanitarian disaster,"
may experience a mixture of pietas and cyni- the theater of generosity loses its actors.
cism, of the desire for adventure and the neces- In Albania, during the three-month-long
sity to be present in the mediatized arena, of war of 1999, the emergency provoked the
money and emergency, of bureaucracy and deployment of an enormous apparatus of
anti-ideology. humanitarian organizations29 to accommodate
Edward Said has held that the discursive 500,000 refugees. In so doing, for the sake of
forms that feed a colonial power function efficiency and experience, it also interrupted
not only as an instrumental form of conscious- negotiating activities with local institutions
ness, but also as an ambivalent protocol for and with international diplomats present in
imagination and desire. 26 Such recognition Albania. Within twelve days, NATO, the
appears central for understanding how the hu- international military force (AFOR 30 ), and
manitarian emergency constructs, feeds, and the bilateral and multilateral bodies active in
reinforces a power that under the guise of neu- Albania at the time had superseded the
trality imposes rules of spatial and temporal embassies and local government. The inter-
compression. national organizations proposed that they
The rhetoric of pietas, the one-dimensional administer ninety percent of the necessary aid
construction of the enemy, and the "moral, themselves, with the remaining ten percent
necessity of simultaneous and fragmented administered at the local level. Yet within
action are discursive constructions that stifle two weeks, even this ten percent had been
CONTRACT OF MUTUAL (IN)DIFFERENCE 501
appropriated by the ad hoc intervention force. Three years later, projects that had been
NATO's military logistical infrastructure was financed in Kosovo for the first year after the
deployed with such "efficiency" that it had war have been put on hold because the "emer-
the whole territory under its control, assigning gency" provisions have expired. 32 As a conse-
responsibilities and distributing roles. It was quence, available funds can no longer be used.
a global strategy of control that took Moreover, the changed political situation in
advantage of economists, business consultants, Serbia and the emergence of conflicts between
and administrators who had earned their KFOR, the UN mission in Kosovo, and the
Masters' from the most prestigious American Albanian guerrillas in Macedonia have yet
universities. again displaced the focus of the "emergency."
Wearing the badge of an international Emergency and post-emergency are effects
organization was enough to gain entry into of suffering and violence that are consistent
the pyramid mausoleum built by Hoxha in with categories recognized by international
the center of Tirana, which had become NATO protocols. The line separating so-called "emer-
headquarters, to view the maps- reports (up- gency" projects from "post-emergency" ones
dated every three hours) on the precise number forces project directors constantly to revise
of refugees, the situation of individuals dis- their strategies at all levels in order to adopt
placed from one extremity to the other of the the right rhetoric and thus be able to keep
country, epidemics, the quantity of available getting the funding necessary to keep their
drugs and where they were needed, the number intervention afloat. Lardi draws attention to
of showers, how many toilets were needed in a the existence of a supply-effect of emergency.
specific location, and so forth. In short, it was "As soon as emergency is professionalized, it
an organizational strategy so pervasive that it tends to structure itself as social supply waiting
immediately eliminated any possible alterna- for its demand. And if the demand does not
tive mode of intervention. All this, as I have exist, one tends to create it. " 33 In other words,
said, in the name of the need to cure, nourish, certain humanitarian organizations justify
and save ''human lives." their existence with a circular logic: a state of
The day after the war ended, in June emergency is legitimate because urgent action
1999, I was still in Albania. Within a few has to be taken.
days, the limelight of media compassion The media-generated triangle of NATO,
was turned off. Hotels were emptied of humanitarians, and refugees has eliminated
journalists, officials, and international aid the other social partners involved in the conflict
workers; apartment leases were canceled. from the game. At the same time, however, the
The transnational "army" was renting heli- "political" role that the humanitarian industry
copters and cars to move on to another site plays has become evident as certain sectors
of humanitarian compassion. At the same are developed while others are neglected, and
time, ethnic Albanians were quickly heading as strategic priorities that go beyond the logic
back to their homes in Kosovo. The end of of defense, shelter, and protection are con-
the war and the mass return of the Kosovars sidered, constructing transnational priorities
resulted in the suppression of the "emer- and weakening entire sectors of the local soci-
gency" in Albania, which in a few days was ety that do not correspond to standards priori-
to be displaced to the "liberated" territory of tized and recognized by the intervention.
Kosovo. The result was that NGOs and inter- A series of categories drawn from the
national agencies active in Albania closed discursive and operative strategies of humani-
down their local operations and laid off their tarianism is thus applied to the territory and
Albanian employees, leaving behind unused to human beings. Such categories may be
material which had not even been cleared by extended to the world system of potential and
local customs. The emergency had moved real donors, multilateral and bilateral accords,
elsewhere, and new operations, new logistics ad hoc UN agencies and, finally, to programs
and apparatuses, had to be put in place in that are much less controllable - in terms of
and for Kosovo. 31 execution of project, budget, and so forth - if
502 MARIELLA PANDOLFI
they are constructed and enacted in the period legitimized by its humanitarian intentions,
labeled as an "emergency." never by its defense of specific interests. The
The "do something syndrome" is the re- legitimacy of a humanitarian operation derives
sponse adopted by governments, UN agencies, from its being conceived of as an end in itself,
and international NGOs when confronted by the expression of a humanitarian impulse. Such
the public's concern about a crisis. "Something an operation should not be understood as an
must be done" is a powerful justification, par- instrumental form of political action. Second,
ticularly when further strengthened by the intervention most often occurs where there is
spectacle of distant suffering. Yet in the final the sudden breakdown of a pre-existing equi-
analysis it shows the dangerous gap that exists librium. Humanitarian action is constructed
between humanitarian "needs" and humanitar- out of such a "crisis/' for it is here that it
ian "budgets." legitimates its operation. Yet the notion of the
It is a practice that constitutes subjects, both breakdown of a pre-existing equilibrium is am-
the operators of the intervention whose agency biguous, as dramatic examples can testify. As
is cast within the humanitarian ideology, and underlined by the independent commission in
those who would be their beneficiaries - the Kosovo (August 1999-0ctober 2000), we need
mute subjects whose dense sociality is reduced a critical approach to the interpretation of
to thin descriptions in bureaucratic reports. emerging doctrine of humanitarian interven-
Thus, in exemplary fashion, the bureaucratiza- tion. We need to shed light on the grey zone
tion of pietas, couched in the rhetoric of uni- that lies between an extension of international
versalism, efficiency, good intentions, and the law and a proposal for an international moral
need to act, imbues and determines the stream consensus where humanitarian interventions
of pamphlets and confidential reports that proliferate. In essence, this grey zone goes
document the humanitarian universe. beyond strict ideas of legality to incorporate
The dimension of experience or previous more flexible views of legitimacy. In a time
individual and collective history is erased by characterized by "failing states" and "ethnic
the new categories in which human beings are conflicts"- an explosion in the number of refu-
pigeonholed; the terms "victim," "refugee," gees and stateless persons - the humanitarian
"trafficked woman," or "trauma case" do not industry has emerged as an immensely power-
relate to experiences of traumatic events, but ful biopolitical force, effectively having power
are labels by means of which it is possible to of life and death over millions the world over. It
activate procedures such as fundraising, proto- is time for this industry to be subjected to
cols, the establishment of transversal and trans- critical scrutiny.
national institutions and, ultimately, of a
business whose importance and amplitude is
concealed by charitable pietas. A refugee is a NOTES
completely exportable and generic category,
whether from Bosnia or the Philippines; a traf- 1 Bernard Kouchner, Le Malheur des Atttres
313 (1991).
ficked woman enters into repatriation proced-
2 See Mariella Pandolfi, "L'industrie humani-
ures whether she is in Kosovo or in Thailand;
taire: une souveranete mouvante et supracolo-
and demilitarization is accomplished with niale. Reflexion sur )'experience des Balkans."
similar procedures whether in Africa or in 3 Multitudes 97-105 (2000); see also Arjun
South America. Appadurai, "Sovereignty Without Territorial-
ity: Notes for a Posmational Geography." The
Geography of Identity 40-58 (Patricia Yaeger
Conclusion: The Kosovo
ed., 1996); Arjun Appadurai, Modernity at
"Exception" Now Exists for Better Large: Cultural Dimensiotts of Globalisation
and Worse {1996). Drawing on Appadurai's notion of
mobile sovereignty, we can define these trans-
In conclusion, let me draw the following national formations as migrant sovereignties
points. First, all humanitarian action is which serve to link transnational forms of
CONTRACT OF MUTUAL (IN)DIFFERENCE 503
domination over local political practices. The time the industry intervened; in 1992, when
intricate network of the humanitarian polit- Somalia witnessed Operation Restore Hope,
ical-economic-military complex that is super- forty international NGOs were present in that
imposed as a migrant sovereignty upon country. The second example of this type of
Albanian society does not conceive any strat- mobilization was in November 1993, when
egy of negotiation with its political, institu- seventy-six NGOs were set up in Rwanda.
tional, and social actors. 9 See Veronique de Geoffroy, "Militaro-
3 See generally Anne Marie Clark, "Non- humanitaire ou civilo-militaire?." 12 Mouve-
Governmental Organisations and Their ments 49-54 (2000).
Influence on International Society." 48 ]. Int'l 10 See genera1ly John Prendergast, Crisis
Aff. 509-24 (1995). Response: Humanitarian Band-Aids in
4 See, e.g., Mariella Pandolfi, " 'Moral entre- Sudan and Somalia 3 (1997).
preneurs' ", souvrainetes mouvants et bar- 11 Stephen D. Krasner, Sovereignty: Organized
beles. Le bio-politique dans les Balkans post- Hypocrisy 3 (1999).
communistes. 26 Anthropologie et Societe 12 See generally Giorgio Agamben, The
29-51 (2002). Coming Community (Michael Hardt trans.,
5 See Jean-Christophe Rufin, L'aventure huma- 1993) [hereinafter The Coming Commu-
nitaire (1994); see alsojean-Christophe Rufin, nity]; Homo Sacer, supra note 7; Giorgio
"Pour Phumanitaire. Depasser le sentiment Agamben, Means Without End: Notes on
d'echec." 105 Le Debat 4-21 (1999) Politics (Vincenzo Binetti & Cesare Casarino
[hereinafter Rufin, Pmtr /'humanitaire]. trans., 2000) [hereinafter Means Without
6 See generally Noarn Chomsky, The New End].
Military Humanism: Lessons from Kosovo 13 Foucault develops the term classical sover-
(1999). eignty at length, expressing classical sover-
7 I use the term biopolitics in the manner de- eignty most succinctly as the power of life or
veloped by Michel Foucault to refer to the death exercised by the sovereign ruler over
ensemble of administrative practices - his subjects: the King can condemn to death,
schooling, policing, caring- that came to be or allow to live, anyone in the territory he
used to administer populations with the rise of rules. See generally Michel Foucault, II {aut
the modern state. See genera1ly 1 Michel defendre Ia societe: cours au College de
Foucault, History of Sexuality (Robert Hurley France 1975-1976 (1997).
trans., 1978); see also 3, 4 Michel Foucault, 14 See Primo Levi, The Drowned and the Saved
Dits et ecrits: 1954-1988 (1994). Giorgio 20,42-3 (Raymond Rosenthal trans., 1988)
Agamben wrote "[a]ccording to Foucault, a (1986).
society's 'threshold of biological modernity' 15 The notion of bare life is more fully de-
is situated at the point at which the species veloped in Homo Sacer, supra note 7.
and the individual as a simple living body 16 Didier Passin, "Entre politiques du vivant et
become what is at stake in a society's politiques de Ia vie. Pour une anthropolo-
political strategies." Giorgio Agamben, giede Ia sante." 1 Les Notes de recherche du
Homo Sacer: Sovereign Power and Bare Cresp 13 (2000), available at www.inserm.
Life (Daniel Heller-Roazen trans., 1998) fr/cresp/cresp.nsf.
[hereinafter Homo Sacer]. Michael Hardt 17 Michel Foucault, "La gouvernementalite."
and Toni Negri have further developed this 54 Actes 10, 18 (1986).
concept to examine how these practices 18 Homo Sacer, supra note 7, at 133.
produce regimes of rule in the contemporary 19 Id. at 5.
world that are radically limited to the 20 See generally Homo Sacer, supra note 7;
management of life in the barest terms, as in Means Without End, supra note 12; The
concentration or refugee camps or in capitalist Coming Community, supra note 12; Giorgio
production. See generally Michael Hardt & Agamben, "Politica dell'esilio." 16 Derivee
Antonio Negri, Empire {2000). Approdi 25-27 (1998) [hereinafter
8 After Bosnia, the humanitarian industry has Agamben, "Politica dell'esilio"].
constructed its own legitimacy to intervene, 21 Agamben, "Politica dell'esilio;" supra note
even militarily. Yet Bosnia was not the first 20, at 25 (author translation).
504 MARIELLA PANDOLFI
22 See generally Giorgio Agamben, Remnants passive objects of knowledge. In this sense
of Auschwitz~ The Witness and the Archive we can speak of a machine for producing
(Daniel Heller-Roazen trans., 1999). hierarchies and top-down power flows. On
23 Many protagonists of the humanitarian one side, one finds the sectors of society in an
scene belong to the generation of 1968, implicit partnership with transnational
which has always been mistrustful of insti- values and agencies maintained through con-
tutions and local and national governments. tinuous dialogue and collaboration. On the
24 See generally Giorgio Agamben, Means other side, one finds a passive marginalized
Without End: Notes on Politics (Vincenzo sector of the local society, which may also
Binetti & Cesare Casarino trans., 2000); see include those government representatives
also generally Michael Hardt & Thomas who have failed to become part of the inter-
Dumm, "Sovereignty, Multitudes, Absolute national organization circuit. Humanitarian
Democracy: A Discussion Between Michael intervention introduces a wedge within local
Hardt and Thomas Dumm About Hardt and societies, splitting them into two separate
Negri's Empire." 4 Theory & Event (2000), parts.
at http://muse.jhu.edu/journals/theory_and_ 28 Rufin, "Pour l'humanitaire," supra note 5, at
eventlv004/4.3 hardt.html. 10, 20.
25 Zaki Lardi, "L'urgence ou Ia devalorisation- 29 In Albania from April to July 1999, AFOR
culturelle de )'avenir." Urgence, souffrance, had 19 nationalities in its ranks, over 7,000
misere: Lutte humanitaire ou po/itique so- NATO soldiers, 4 groups of observers, in-
ciale? 43-59 (Marc-Henry Soulet ed., 1998). cluding two from the Organisation for Co-
26 See generally Edward W. Said, Orietztalism operation and Security in Europe (OCSE),
(1978). and a dozen people from Western special
27 The "confidential" report is a key cultural government missions. During the Kosovo
facet of the humanitarian world connecting conflict, 180 international NGOs were pre-
press officers, general managers, officers-in- sent in Albania. The result in Kosovo, one
charge, local elites, intellectuals, and espe- year after the conflict: 40,000 soldiers from
cially journalists. Anyone who possesses, KFOR (a NATO-Jed, international security
transmits, or receives a confidential report force), and 20,000 civilians (working for
immediately increases his or her own cred- UNMIK, United Nations Mission in Kosovo,
ibility within the local context of humanitar- and international NGOs).
ian operations. During the war in Kosovo, 30 Albanian United Nations Military Forces.
strictly "confidential" documents from Brus- 31 These observations are culled from two years
sels, Washington, the World Bank, and other of fieldwork from 1998 to 2000, during
strategic studies' think-tanks circulated which I interviewed key officials, politicians,
widely in Tirana. The effect of confidential and civil society actors before, during, and
reports, then, is two-fold. On one level, they after the conflict in Kosovo.
produce a discourse on the locals which is 32 I observed from my interviews that the
taken up in the international circuit. On "emergency" period was an administrative
another level, their channels of circulation definition that allowed loosening the rules
serve to create a bipolar society within the for the allocation and distribution of re-
local with, at one end, the elites who lavishly sources, regardless of the actual situation
display their access to information and, on the ground.
at the other, those who are constructed as 33 Lai"di, supra note 24, at 57.
39
Darfur through a Shoah Lens
Sudanese Asylum Seekers,
Unruly Biopolitical Dramas,
and the Politics of Humanitarian
Compassion in Israel
Sarah S. Willen
The calamity of the rightless is not that they are deprived of life, liberty, and the
pursuit of happiness, or of equality before the law and freedom of opinion -
formulas which were designed to solve problems within given communities - but
that they no longer belong to any community whatsoever. (Hannah Arendt)
. . . as one gets deeper into humanitarianism a series of dimensions of what
may be called a complex ontology of inequality unfolds that differentiates
in a hierarchical manner the values of human lives. (Didier Passin)
Compassion begins from where we are, from the circle of our cares and concerns.
It will be felt only toward those things and persons we see as important, and of
course most of us most of the time ascribe importmtce in a very
uneven and inconstant way. (Martha Nussbaum)
In this essay, I explore how people seeking and the Ivory Coast - trekked through the
refuge and political asylum become engulfed Sinai desert and across the long, porous
in fraught biopolitical dramas that expose the Egyptian-Israeli border in 2007-2008. Those
inconsistencies, the contradictions, and even who arrived on Israel's southern doorstep seek-
the violence that lurk within contemporary ing protection are far from alone; they join a
forms of humanitarian compassion. Ethno- growing population of more than 16 million
graphically, I focus on the governmental unruli- refugees and asylum seekers worldwide
ness and the hierarchy of suffering that emerged (UNHCR 2009). And like many of these mil-
when more than 13,000 people - among them lions, their flight has not thrust them into an
men, women, and children fleeing Darfur, the open-armed human rights-based or humanitar-
civil war in South Sudan, Eritrea, Somalia ian embrace, but rather flung them against rigid
Sarah S. Willen, "Darfur through a Shoah Lens: Sudanese Asylum Seekers, Unruly Biopolitical Dramas, and the
Politics of Humanitarian Compassion in Israel." Substantially modified version of a piece that appeared in
French in Cultures & Con{lits n72, autumn 2008, as "L'hyperpolirique du 'Plus jamais ~a!': demandeurs
d'asile soudanais, turbulence gouvernemema1e et politiques de controle des refugies en Israel."
506 SARAH S. WILLEN
walls- some metaphoric and some quite literal- novel kinship formulations was the ubiquitous
of exclusion, denial, and dehumanization. refrain, if not the central organizing principle,
Despite any moral obligations that may cling to of contemporary Jewish identity: "Never
(or exude from) imperial histories, lingering again!" 1 Thus the slogans of one refugee ex-
postcolonial ties, or contemporary neocolonial perience were adapted to evoke humanitarian
imbrications, countries in the Global North - compassion for other refugees- but not with-
especially Western Europe, North America out friction and conflict.
Australia, and now Israel - have been loath t~ The localized biopolitical drama that
accept or integrate refugees from the Global ensued reveals new layers of complexity in the
South. At times, however, historical memory contemporary politics of international human
and "political emotions" (Hage 2009) are in- rights and refugee migration. First it intersects
voked in ways that mitigate these exclusionary with the already complicated refu~ee stories of
attitudes. Here I draw upon fieldwork conducted both Israelis (not only from Europe, but also
in Israel in 2007 to explore one such instance from North Africa, Yemen, Iraq, Iran, and
which challenges us to ask: How ought a count~ elsewhere) and Palestinians (in the West Bank
and Gaza and in the wider Middle Eastern and
b~ilt, to a great extent, by refugees fleeing geno-
global diaspora). Second, it shows how Israel
ctde respond to a contemporary influx of refu-
has become a fortified way-station on the outer
gees escaping similar circumstances?
perimeter of "Fortress Europe"; now, its new
Given the volatile politics of refugee claims-
"detention centers" must be added to similar
making around the globe, it should come as no
carceral apparatuses in Turkey, North Africa,
surprise that the unanticipated influx of over
and Eastern Europe.
10,000 African refugees into Israel generated
In ana.lyzing the ideological, performative,
an almost instantaneous wave of public atten-
and emotional dynamics of Israeli reactions to
tion, political controversy, and grassroots
this particular refugee influx, I aim to shed
activism. Although these anxious Israeli reac-
light on both the power and the danger embed-
tions echoed similar concerns in other North-
ded within contemporary configurations of hu-
ern refugee destinations, they bore a decidedly
manitaria~ sentiment including, in particular,
local cast. In one sense, public discussion and
those mottvated by symbolic (mis)identifica-
debate were framed by the country's demo-
tion and political emotion. I begin by exploring
graphically inflected self-definition as a
the governmental "unruliness" that resulted
"Jewish and democratic state" and infused
when thousands of asylum seekers made their
with a sense of "demographic trepidation" con-
way through the Sinai desert and across the
cerning the possibility that a much larger wave
border into Israel. Unruliness, here, has two
of refugees from distressed African countries
referents, both applicable far beyond the par-
would soon follow. Interrupting this xenopho-
tic~l~rities of the present case: first, the legal,
bic chorus, however, was a separate array of
polmcal, and administrative disorder faced by
voices focusing on the small group of asylum
asylum seekers and all those who interact with
seekers who had survived horrors that
them on the ground; and second, the failings
evoked collective Jewish-Israeli memories of
and failures of the ~'international refugee
the Shoah, or Holocaust: those fleeing what
regime" (Malkki 1995) and its local counter-
the international community described as
parts which, although purportedly anchored in
genocide in Darfur. According to the leaders
rules, rights and laws, often do not deliver on
and citizen-activists who publicized this
their promise. I then turn to questions of rhet-
morally freighted historical analogy, Israeli
oric and representation to explore how a stun-
Jews and refugees from Darfur are bound to-
ningly diverse array of Israeli activists quickly
gether in what one newspaper called a "kinship
took up the "kinship of genocide" analogy and
of genocide" (Burston 2008). This analogy also
cast themselves as legitimate "trauma brokers''
spurred a high profile grassroots campaign led
(James 2004) on behalf of Sudanese asylum
by Jewish communities in the United States
seekers from Darfur. In analyzing the power
under the slogan, "Save Darfur." Driving these
and the limits of this potent historical analogy,
DARFUR THROUGH A SHOAH LENS 507
I explore how different stakeholders respond to closely onto the moral agendas and concerns
contemporary processes of asylum seeking, of those who are empowered to bestow, with-
and to the forms of state violence that can arise hold, or withdraw the "gift" of humanitarian
in response, by reasoning through history in compassion (Fassin 2005, 2007; James 2004;
markedly different ways. Nussbaum 2003; Pandolfi 2003). In other
In probing the dynamics of this unruly bio- words, humanitarian economies of concern
political drama, my broader goal is to explore are not neutral; they are always and inevitably
three problems that complicate contemporary shot through with politics, ideology, and his-
enactments of humanitarian compassion. First, torical consciousness.
this ethnographic case clearly reveals the labil- What happens, then, to those who have
ity and arbitrariness of the terms used not only endured the "wrong kind'' of suffering? The
by states but also by humanitarian actors to answer to this question reveals a third paradox:
classify and, in effect, to rank candidates for humanitarianism's not-so-hidden potential to
empathy and compassion. Not only are terms generate, rather than alleviate, violence (James
like "asylum seeker," "refugee," "illegal immi- 2004; Nyers 2000; Ticktin 2006). In the pre-
grant," and "infiltrator" implicated within sent case, two groups have become casualties
broader techniques of governmentality, but of this derivative form of humanitarian vio-
they also reduce the "subjective trajectories" lence. First, the vast majority of African asylum
of individual men, women, and children to seekers in Israel are not from Darfur; as a
"indistinct, displaced, and localized bodies" result, they rank much lower in the local "hier-
(Pandolfi 2003: 374) - that is, to a form of archy of suffering" that has emerged (Farmer
what Agamben (1998) calls "bare life," or bio- 2003: 29-30, see also Fassin 2007). Second,
logical life stripped of agency or political voice the everyday struggles of another, nearby refu-
(cf. Arendt 1973). When subjectivity and polit- gee population are thundering in their absence
ical identity are sheared away, human distinct- from public and political conversation: Pales-
iveness and dignity are deactivated and tinians in the West Bank and Gaza who are
suppressed; they are "erased by the new cat- caught in the brutal gridlock of Israeli occupa-
egories in which human beings are pigeon- tion. I return to the roots and implications of
holed" (Pandolfi 2003: 381). Once such this glaring absence in the article's conclusion.
unique, subjective trajectories have been an- First, we must situate this biopolitical drama in
nulled, it is only through suffering that hu- ethnographic context.
manitarian biopolitics can make room for
compassion (Ticktin 2006}. Such biopolitical
operations beg important questions, both eth- Refugee Migration Against
ical and ethnographic, among them: "What is the Backdrop of a Globalizing
at stake when we recognize others through the Labor Market
lens of their suffering and not through their
political subjectivity?" (James 2004: 132; cf. The recent influx of African asylum seekers
Biehl this volume, Ticktin this volume). into Israel arrived at a tumultuous time -
Not all suffering is equal, and this brings us although it is always a tumultuous time in the
to the second troubling dimension of humani- region of Israel-Palestine - but nonetheless, it
tarian compassion. In the growing literature on began just as the Israeli government and the
migrants and refugees within local and global Israeli public were finally, if reluctantly, begin-
economies of humanitarian concern, three ning to acknowledge the country's new status
characteristics are particularly noteworthy. as a destination for transnational migration
Suffering that engenders a particularly strong from the global South. From 1993 to 2000,
humanitarian response typically (1) bears the between 200,000 and 300,000 transnational
marks of trauma; (2) can be "proven" and migrant workers arrived in Israel, about half
packaged convincingly (Fassin and D'Halluin unauthorized and the other half unauthorized,
2007; Giordano 2008; McKinney 2007; Tick- and by 2000 they comprised over 10 percent of
tin 2006); and crucially (3) tends to map the country's labor force (Kemp and Raijman
508 SARAH S. WILLEN
2008; Willen 2007e). In the same time period, newly arrived border-crossers, whom the state
small numbers of asylum seekers, mostly from resists describing as either asylum seekers or
unstable African countries including Liberia, refugees, instead calling them "infiltrators"
Sierra Leone, Ivory Coast, Ethiopia, and most (mistanenim). More precisely, the Israeli gov-
recently Sudan and Eritrea, entered the country ernment, military, and police have been reluc-
as well (Adout 2007; Ante by-Yemini 2009; tant to distinguish between economically
Ben-Dor and Kagan 2007). motivated migrants, like the "illegal migrant
In 2002, ostensibly in response to rising workers" the state has invested heavily in
unemployment, the Israeli· government initi- rounding up and expelling since 2002, and
ated a costly, heavily mediatized, and occasion- "asylum seekers" or "refugees" fleeing war, pol-
ally violent mass deportation campaign itical conflict, or government repression. By
targeting the country's non-Jewish, non-Arab mid-2008, national politicians had fused their
residents (Willen 2007b, 2007d). Although parallel accusations of unlawful entry and un-
"illegal" migrant workers were the campaign's lawful work-seeking into a new term altogether:
primary targets, others - including asylum "labor infiltrators" (mistanenei avoda).
seekers- were occasionally caught in its drag- The state's reluctance to proclaim Israel a
net (Willen 2010). More than 140,000 un- destination for legitimate asylum seeking stems
authorized residents were "distanced'' from from two facets of the "demographic trepida-
Israel, to employ the Immigration Police's sani- tion" noted earlier: first, an explicit desire to
tizing euphemism, including about 50,000 who limit the number of non-Jews arriving in the
were arrested and forcibly deported and thou- country from the global South, and second, a
sands of others who were "encouraged"- that concomitant desire to avoid acknowledging
is, regularly and systematically intimidated - any debts - material or otherwise - to Palestin-
into leaving "voluntarily." Meanwhile, Israel ian refugees. As a result, Israel has avoided
has continued to recruit "legal" transnational developing any national asylum legislation,
workers to perform work that Israelis won't, any systematic procedure for reviewing asylum
and Palestinians now can't, perform. petitions, or any infrastructure to accommo-
Although the larger story of Israel's encounter date or protect asylum seekers. Instead, it has
with transnational labor migration lies beyond studiously avoided precedent-setting moves,
the scope of this discussion (but see Kemp and resulting in a "juridical void" (Akoka 2006,
Raijman 2008; Willen 2007c}, it is important to cited in Ante by-Yemini 2009) that severely
emphasize that the smoldering conflict between impedes the translation of international legal
the Israelis and the Palestinians, the recent glob- statutes into national-level practice. One way
alization of Israel's labor force (partly in response the state has evaded these internationally
to the conflict), and the harsh government crack- defined legal obligations is by simply calling
down on burgeoning populations of trans- asylum seekers by another name. The strategic
national labor migrants alJ contribute to the redefinition of new arrivals using a creative
overall "unruliness" animating Israel's response neologism, "labor infiltrators," is consistent
to this new wave of African refugees. So, too, do with the state's habitual rejection of potential
persistent memories of the Shoah, Israel's immigrants who do not arrive via the "Law of
"founding trauma" (LaCapra 2001), as I will Return," the law that grants virtually auto-
elaborate momentarily. matic Israeli citizenship to anyone of Jewish
heritage while denying it to almost all others.
The Lability of Labels and the Despite the state's vigorous resistance to
Arbitrary Deployment of recognizing asylum or refugee claims, two
forms of protection are nonetheless available
Juridical Categories in Israel: "temporary protected status" (TPS)
and formal refugee status. Petitioners from a
Another, broader factor contributing to this group facing danger in their country of origin
governmental unruliness is the epistemological can apply to UNHCR (not to the Israeli gov-
and classificatory confusion associated with ernment) for TPS as "humanitarian refugees."
DARFUR THROUGH A SHOAH LENS 509
Bearers of this provisional form of status re- numbers of non-Sudanese refugees from Eri-
ceive a letter declaring their temporary immun- trea and several other African countries.
ity to deportation and, in some instances, Unlike asylum seekers from other troubled
granting them authorization to work. Import- African countries, those from Sudan were ini-
andy, bearers of TPS are not entitled to any tially denied the opportunity to apply for TPS
social rights or benefits. In contrast to TPS in Israel. Instead, Sudanese asylum seekers
petitions, applications for permanent refugee were classified by the Israeli state as "enemy
status must be filed individually. Although nationals" - i.e., as citizens of a state with
Israel has made limited use of TPS provisions which Israel has no diplomatic relations- and
to grant temporary protection to small groups detained without judicial review (Ben-Dor and
of asylum seekers - just over 500 people as of Kagan 2007). Importantly, many Sudanese
2005, mostly from Congo, Liberia, Sierra asylum seekers had fled because of violence
Leone and Ivory Coast- it has been much more inflicted upon them by Sudan itself - as had
conservative in its allocation of recognized Jews fleeing Nazi persecution in the 1940s. In
refugee status (Kritzman 2007}. For instance, effect, Israel's policy of detaining refugees from
Israel granted refugee status to 12 of 922 peti- Darfur as "enemy nationals" is tantamount to
tioners in 2004, 11 of 909 in 2005, 3 of 832 in World War 11-era British (and, in some cases,
2007, and just one of 1586 in 2008.2 American) policies of detaining German Jews
who fled the Nazi regime on the basis of their
German citizenship (see Ilan 2006). (As an his-
Sudanese Asylum Seekers: torical note, the fledgling Israeli state worked
A "Kinship of Genocide," with the International Refugee Organization,
predecessor of UNHCR, to sponsor an article
"Enemy Nationals," or a New
in the Fourth Geneva Convention exempting
Captive Labor Force? refugees from classification as "enemy nation-
als" (Ben-Dor and Kagan 2007).)
The recent influx of African refugees into Israel In a savvy rhetorical move, attorneys at Tel
has proven particularly prone to ideologically Aviv University's Refugee Rights Legal Clinic
motivated redefinition. The event that precipi- called attention to this Nazi-era analogy in an
tated this wave of border-crossing was the vio- effort to bolster their legal argument that de-
lent dispersal of a peaceful demonstration at a tention of Sudanese asylum seekers as "enemy
protest camp of about 2,500 Sudanese men, nationals" violates international law. On sev-
women, and children outside the offices of the eral key occasions, their arguments proved per-
United Nations High Commissioner on Refu- suasive in court. For instance, in an August
gees (UNHCR) in Cairo. Refugees had estab- 2006 decision to release four Sudanese from
lished the camp in September 2005 to Darfur who had been imprisoned without judi-
demonstrate against their harsh living condi- cial review, the deciding judge determined that
tions in Egypt and UNHCR's failure to attend their situation
to their petitions for refugee status and resettle-
ment. After three months of fruitless protest, is not qualitatively different from the fare of tens
the Egyptian police dispersed the camp in of thousands of German Jews who felt their very
December 2005 using tear gas, water cannons, souls were threatened when they fled from the
and live ammunition. Twenty-seven Sudanese Nazi regime and arrived in England seeking
demonstrators were killed, and hundreds of refuge. These refugees were first treated as en-
others were arrested, interrogated, and in some emies and were put in custody, but the British
cases tortured by the Egyptian police (Azzam authorities realized pretty soon the ... moral
2006). In the wake of these events, the numbers injustice and changed their attitude in favour of
the refugees of the Nazi regime. (Ibid.)
of Sudanese men, women, and children fleeing
Cairo and heading toward the Israeli border Rather than relying only upon codified law, the
increased - among them Muslims from Darfur judge's decision tapped into deep wells of pol-
and Christians from South Sudan- as did the itical emotion that lie beneath, and on occasion
510 SARAH S. WILLEN
substantively influence, the Israeli legal system. implemented, and imbued with practical and
Building upon court decisions like this one, and moral dilemmas - further exemplify the grow-
working in close collaboration with local ing unruliness characterizing Israel's response
human rights NGOs, lawyers at the Refugee to this new refugee influx.
Rights Clinic succeeded in convincing the
courts to release first dozens and later hun-
dreds of Sudanese (and eventually other Mri-
Inter-agency Bickering and
can) refugees from detention through what are
described as "alternative to imprisonment'' Growing Governmental Unruliness
arrangements.
These "alternative" arrangements typically Another facet of this unruliness involves the
involved the release of a small number of de- inter-agency tensions that erupted as the
tainees from prison into the hands of an em- number of asylum seekers arriving daily began
ployer - at either an agricultural settlement to climb in spring 2007. At first, the army
(kibbutz or moshav) or a hotel - who has threw up its hands and declared asylum seekers
agreed to provide them, and sometimes their the responsibility of the Immigration Police,
families, with housing, food, and other basic which originally was created in 2002 to deport
needs in exchange for their labor. Significantly, unauthorized migrant workers. The military
these employment conditions, in which reserve units stationed on the border initiated
detainee/employees are bound to a single em- an informal policy of bringing asylum seekers-
ployer and place of residence, were strikingly sometimes one or two, sometimes entire bus-
similar to the "binding arrangement" (hesder loads- to the southern city of Beersheva with
ha'kvila) that governed the employment of the intention of handing them over to the Im-
"legal" migrant workers until it was struck migration Police. The police, however, refused
down by Israel's High Court in 2006 as a form responsibility as well, declaring their "deten-
of "modern slavery" following a lengthy battle tion centers" full to capacity with unauthorized
waged by local human rights groups. migrant workers slated for deportation. As a
Indeed, these "alternative" arrangements result, hundreds of asylum seekers were left -
were riddled with legal, political, and moral effectively dumped- on the streets of Beershe-
problems. First, they were coordinated neither va: on one occasion near the central bus sta-
by the state nor the courts, but rather on an tion, on another near the train station, and on
ad hoc basis - ironically, by the very human another outside of City Hall (Bereshovsky
rights groups that spent years fighting for the 2007; Grinberg 2007b, 2007d).
abolition of the "binding arrangement.'' These jurisdictional disputes became both
Second, it is particularly striking that these lighting rods for public attention and clear
human rights groups' efforts to "free" refugees illustrations of growing governmental unruli-
from detention put them in cahoots with pri- ness. On one occasion in June 2007, for in-
vate commercial interests that benefited finan- stance, a busload of refugees was dropped off
cially from the state's willingness to transform by the army at a local police station- and then
detained asylum seekers into a new captive promptly transported back to the regional mili-
labor force. Third, the release of detainees to tary command center by the police. The mili-
such work arrangements has created a "revolv- tary spokesperson issued an indignant
ing door" in jails, which have now become response:
spaces of circulation; as more detainees Does the army know how to provide formula
are released, space becomes available to and diapers to children of refugees? Does the
arrest and detain others. Fourth, reports army deal with registration and giving medical
quickly emerged about the exploitation and examinations? Someone forgot what the role of
abuse of newly released refugee workers, espe- the IDF [Israel Defense Forces] is along the
cially in agricultural settings. Overall, these Israel-Egypt border. ... This is an absurd situ-
"alternative to imprisonment" arrangements - ation. Where is the Immigration Administration
fragile, haphazardly organized, sporadically [i.e., the Immigration Police]? (Azoulay 2007)
DARFUR THROUGH A SHOAH LENS 511
support Jews' return to the biblical Holy "do something syndrome." Within a day or so
Land), and congregations of Messianic Jews, of this final incident, a majority of Israeli par-
or "Jews for Jesus." Some groups collected liament members - 63 of a total 120 - had,
food, clothing, and toiletries; others organized indeed, done something; they signed a petition
housing, medical care, or Hebrew language asking the government not to deport any more
lessons; and still others helped asylum seekers Sudanese asylum seekers to Egypt. The MPs
navigate the UNHCR and Israeli legal systems. signing the petition represented a stunning
Although motivated by good intentions, this cross-section of the Israeli political spectrum
broad-based, patchwork movement has not including not just the left-center Labor party
only struggled with, but also contributed to and the center-right Likud, but also the Na-
the overall atmosphere of unruliness. tional Religious Party, which represents right-
Five events propelled this movement for- wing Jewish settlers in the Occupied Territor-
ward. First, then-Prime Minister Ehud Olmert's ies, and the mixed Jewish-Arab Communist
controversial policy of "hot return" provoked party. According to the petition's "kinship of
considerable public debate. According to 01- genocide" logic, "The refugees need protection
mert, the arrangement had been coordinated and sanctuary, and the Jewish people's history
with Egyptian President Hosni Mubarak, and as well as the values of democracy and human-
individuals deported to Egypt would be safe ity pose a moral imperative for us to give them
from further deportation to Sudan (refoule- that shelter" (Grinberg 2007c). Despite this
ment). Mubarak, however, publicly denied the lofty rhetoric, a group of more than 50 refu-
existence of any such agreement. gees, most of them from Darfur, were deported
Second, in an effort to pressure the state to to Egypt just a few weeks later.
develop a coherent policy response, the munici- Fifth, in late summer, the government an-
pality of Beersheva transported several busloads nounced a decision to grant Israeli citizenship
of asylum seekers to Jerusalem for a staged dem- to 498 refugees from Darfur already residing in
onstration in the Rose Garden outside the Knes- the country. A newspaper article reporting on
set (Parliament). Although the Prime Minister's the decision employed the same reasoning as
office paid little attention, the demonstration at- the petition; Israel cannot ignore the refugees'
tracted a great deal of local media attention and fate because of the history of the Jewish people.
captured the interest of still more local organiza- The same article reiterated Olmerfs earlier
tions and Israeli citizens. declaration that anyone attempting to cross
A third key development involved reports of the southern border would be deported imme-
Egyptian police brutality at the border. In late diately to Egypt (Mualem 2007).
July, Egyptian police officers shot and killed a As this chaotic situation unfolded, I inter-
Sudanese woman from Darfur (Grinberg viewed representatives of ten organizations in-
2007a). A few weeks later, in a TV news inter- volved in responding to the refugee influx;
view, several Israeli military reservists described a attended several key public meetings and policy
scuffle at the border in which three asylum conferences; interviewed several refugees; and
seekers trying to cross into Israel were shot dead visited two impromptu shelters. Two themes
by Egyptian police and a fourth, who jumped dominated these meetings and encounters: first,
onto the wire fence in an attempt to cross, was generalized state of governmental unruliness,
dragged back and bludgeoned to death by the and second, the Shoah!Darfur analogy and
Egyptians in view of the Israeli soldiers on the "kinship of genocide" logic.
other side. These and other reports of Egyptian
police violence weakened Olmert's argument
that immediate deportation to Egypt - which "Founding Trauma," "Political
Israeli human rights organizations insist is a clear Emotion," and Grassroots Activism
violation of international law- could take place
without endangering lives. To begin making sense of the privileged pos-
These brutal events precipitated a strong ition of Sudanese from Darfur within Israel's
case of what Erica James {2004) has called emerging local hierarchy of suffering, we
DARFUR THROUGH A SHOAH LENS 513
must consider the particular forms of "polit- that, "the growing number of signatories exem-
ical emotion" evoked by the Shoah/Darfur plifies a unity rare in Israel's heterogeneous
analogy. This historical analogy clearly acti- society" (Gerver and Klass 2007). Yet this
vates what Dominick La Capra (2001) calls a ostensible unity masks a much deeper matter:
"founding trauma" for Jewish Israel: a col- the degree to which Darfuri refugees in Israel,
lective memory of mass trauma that can be like refugees the world over, quickly become a
reactivated when a group feels threatened. In kind of discursive blank canvas upon which
some instances, the reactivation of a diverse actors begin to project their own moral
"founding trauma" might catalyze violence values and political emotions.
and destruction; indeed, some would argue Clearly the trope of "never again" has
that this process explains (or partly explains) become hyper-politicized in ways that beg
the tone and tenor of Israel's occupation of ethnographic investigation. One might be
the West Bank and Gaza. tempted to write off such invocations as hollow
Yet a founding trauma might offer the seeds rhetoric, political correctness, or cynical ex-
of not only violence and destruction, but also ploitation of a searing historical analogy, and
their inverse. In the present case, for instance, it would be easy enough to find support for any
numerous Israeli leaders and groups quickly of these arguments. And yet, I contend, invoca-
began to invoke the "never again'' analogy as tions of "never again" must be taken quite
an ethical injunction, first, to remember an seriously as both an appeal to and an expres-
episode of violence, destruction, and trauma sion of what Ghassan Hage (2009) describes as
in Jewish-Israeli history, and second, to trans- "political emotion." For some Israelis who wit-
late that collective memory into a beneficent ness the arrival of refugees from Darfur and
ethical imperative. Sharp-tongued Israeli polit- hear politicians or rabbis saying "never again,"
ician and Holocaust survivor Yosef (Tommy) the analogy is a form of banal, hollow, or cyn-
Lapid, for instance, said, "I don't think that the ical rhetoric. For others, like Dov Lior, chief
Jewish people can look the other way when rabbi of the radical right-wing Jewish settle-
such a horrible genocide is being conducted. It ment in the West Bank city of Hebron, the
is our obligation to be of as much help as we parallel must be wholly rejected as a kind of
can" (in Kraft 2007). In a similar vein, Chair- mis-remembering. According to Lior and other
man of the Yad Vashem National Holocaust militant Zionists, the "refugees" who matter
Memorial in Jerusalem said that, are the Jewish settlers who were forcibly
removed from Gaza by the Israeli military
As Jews who have the memory of the Holocaust
during its withdrawal in 2005 (Wagner 2007).
embedded in us, we cannot stand by as refugees
from the genocide in Darfur knock on our But for many mainstream and left-leaning Is-
doors. The memory of the past, and the Jewish raelis, the Shoah/Darfur analogy holds power-
values that underpin our existence, require us to ful resonance. For some newly minted refugee
show humanitarian solidarity with the perse- advocates, it represents a deeply felt political
cuted. (quoted in Uchitelle-Pierce 2007) emotion that demands immediate translation
into social practice. For savvier, more seasoned
Even some religious leaders, like the politically activists, it is a political emotion to be stra-
conservative Chief Rabbi of Tel Aviv-Jaffa tegically mobilized - one might say manipu-
Yisrael Lau, joined in this chorus of sentiment. lated - in support of certain forms of action
In a letter to the Prime Minister, Lau described and practice (including fundraising).
aid to the Sudanese refugees as "our moral ob- Not surprisingly, such appeals to political
ligation as a Jewish state" (Ma'ariv 2007). emotion bore substantial and immediate con-
Emotionally laden comments like these were sequences. Existing organizations grew quickly
remarkably common in spring and summer in strength; organizations that emerged virtu-
2007. Indeed, when a student petition protest- ally overnight quickly ballooned in size, staff,
ing the deportation of Sudanese refugees began and stature; and the groups listed earlier were
to circulate in May 2007, an article in the con- literally overwhelmed with offers of food,
servative Jerusalem Post accurately observed clothing, volunteer energy, and money. Yet
514 SARAH S. WILLEN
these grassroots efforts - well-intentioned but Everything else the community organized on
completely uncoordinated, unsupervised, and its own and, I must say, the community really
even on occasion working at cross-purposes- warmed even though initially there was a lot
also contributed to the overall atmosphere of of objection to them being here .... [R]eally I
unruliness. can't tell you the extent to which people came
forward to help them and- I'm really proud of
this community.
Despite the initial objections, Ilana and Michal
"The Genocide Issue" and "the were quickly overwhelmed with offers from neigh-
Heart of Israelis" bors who wanted to help, including some
who later called to apologize for their earlier reJuc-
According to Ilana Weisman, 4 a seasoned tance. "In the end it turned out that I had to rack
public health nurse in her early 50s whose my brain every day to think of things for people
small, upper-middle class community in the to do to help because they so wanted to help."
Jerusalem hills provided temporary shelter to When I asked Ilana about her motivations,
21 Sudanese refugees for nearly a month in the and her neighbors', for providing asylum
summer of 2007, the "kinship of genocide" seekers with temporary shelter, she turned im-
logic is the primary cause of this upwelling of mediately to the Shoah/Darfur analogy. "Did it
public energy and concern. matter that these people were Sudanese?"
At the july demonstration outside the Knes- I asked. "Would it have mattered if they were
set, some refugee advocates began to suspect a from another Mrican country?" "I am abso-
government plan to arrest and detain Sudanese lutely convinced it does make a difference,"
demonstrators en masse. In response, they she responded unequivocally.
quickly began searching for temporary housing
People are more likely here to come forward to
arrangements for refugees. A member of Ilana 's
help people from Darfur because of the whole
community agreed to take in several families
Holocaust issue ... people identify with their
and house them in the community's kindergar-
plight. I myself am a child of [Holocaust]
ten, which was vacant for the summer. When a
survivors, and I'm sure that has something
local human rights organization placed 21 to do with why I was basically willing to
refugees in their community, among them 14 do another shift every day in addition to my
adults and 7 children ranging in age from 10 regular job. . .. I think that the genocide issue
months to 6 years, it had virtually no concrete particularly speaks to the heart of Israelis.
assistance to offer. As a result, Ilana, one of
only two community members who spoke any Alongside her sharp criticisms of both the gov-
Arabic, along with another neighbor, Michal, ernment's chaotic actions and the refugee
took on the formidable task of attending to all advocacy groups' lack of coordination, Ilana
21 of their guests' basic needs, including food, spoke proudly of her small community's
shelter, and health care. "The organization that achievements. She was especially glad that in
brought them here didn't organize anything," welcoming these 21 asylum seekers into their
she told me. community "under the radar" of the author-
ities, she and her neighbors had succeeded in
Nothing. Not food, not health care, not shel- preventing their arrest and detention. Indeed,
ter, nothing. I called the organization when I the very morning after these families moved
realized there would be babies and asked them into their vacant kindergarten, the authorities
to send diapers and formula . . . and they did, had descended upon the Rose Garden, arrested
but that was it. That's what we received from
the remaining Sudanese demonstrators - men,
them in two weeks time.
women, and children - and bussed them to the
Initially the refugees' presence generated objec- detention camp in the southern Negev desert.
tions from community members but, as The "kinship of genocide,, logic that moved
Ilana explained, their efforts gradually came Ilana and many other Israeli refugee advocates
together and sentiments shifted. hinged on a choice to recognize, and identify
DARFUR THROUGH A SHOAH LENS 515
with, a very specific kind of pain and suffering seekers but not others involves squeezing social
and, in effect, to ignore others. I1ana addressed reality into a "grid of victimization" in which
this issue obliquely in explaining why she was "psychological, moral, and political ambiguity
willing to turn her life upside down, even for a and complexity are eliminated" (2007: 285).
month, to aid the Sudanese refugees who had The "never again'' paradigm, I contend, in-
arrived on her doorstep. volves precisely such a grid of victimization.
Implicitly, it creates the possibility of express-
lW]hile I completely recognize the fact that
ing a certain kind of political emotion - we
hunger and the other issues and AIDS that
are plaguing Africa are incredibly important, might call it empathy - toward a group whose
I think that the rest of the world can also do suffering is deemed analogous to collective
something about those issues, but I think that memories of Jewish suffering. Those whose
it's very very important for Israel as a nation suffering fails to map onto the grid, however,
based on our history to address issues of geno- are ignored or, in the extreme case, abandoned.
cide. It's even more important for us than Veena Das has suggested that, "we need to
issues of hunger or ... other sorts of issues. think of pain as asking for acknowledgment
and recognition; denial of the other's pain is
Speaking from her practical experience as a not about the failings of the intellect but the
public health nurse, Ilana argued that no indi- failings of the spirit" (Das 1997: 88). In his
vidual, community, or country can solve all of response to Das, Stanley Cavell writes that in
the world's humanitarian problems; instead, it facing another's pain,
is necessary to prioritize. In her view, such
priorities should be influenced by two factors: You are ... not at liberty to believe or disbe-
first, a realistic understanding of available re- lieve . . . at your leisure. You are forced to
sources and capacities, and second, a carefully respond, either to acknowledge it in return or
reasoned moral caJculus. In the present in- to avoid it; the future between us is at stake.
stance, she proposed, this moral calculus . . . Not to respond to such a claim, when it is
should take into account both history and col- you to whom it is addressed, is to deny its
lective experience - or, put differently, existence, and hence is an act of violence
(however momentary, mostly unnoticeable);
"founding trauma" and "political emotion." 5
as it were, the lack of response is a silence that
On one hand, a "kinship of genocide" logic
perpetuates the violence of pain itself. (Cavell
has emerged as an important impetus for di-
1997: 94, emphasis added)
verse forms of ethically informed social prac-
tice, including the efforts of Ilana and her In choosing to respond to or avoid another's
neighbors. On the other hand, however, the pain, Cavell writes, "the future between us is at
Shoah/Darfur analogy and its implicit logic of stake"; to acknowledge or not to acknowledge
selective compassion also can have powerful another's pain in the first instance will inevit-
negative, even violent, consequences. The ably shape how any subsequent relationship
recent deployment of "never again" discourse unfolds. I take Cavell's comment to mean that
in Israel offers a clear illustration of how mobilizing political emotions through the
exceptionalist forms of humanitarian logic, al- rallying cry of "never again" offers both the
though motivated by compassion or empathy, possibility of recognition, of intersubjective
can conceal not-so-hidden forms of violence. engagement, and of justice and, at the same
time, the possibility of doing further violence
to others whose pain continues to go unrecog-
The Violence of Humanitarianism nized. In the present context, choosing to rec-
ognize the pain of Sudanese survivors from
What forms can such violence take? One such Darfur by refracting their experiences through
form is the production of what Paul Farmer this political-emotional lens involves avoiding
(2003) calls hierarchies of suffering. As anthro- or denying the pain of other refugees, including
pologist Kelly McKinney observes, choosing to South Sudanese, Eritreans, and other African
acknowledge the suffering of some asylum asylum seekers- not to mention the Palestinian
516 SARAH S. WILLEN
refugees living under Israeli occupation and from Congo hasn't suffered less than someone
military gridlock. This avoidance and this who's come here from Sudan, maybe more.
denial constitute what we might call, following Particularly given his partners' history of insist-
Miriam Ticktin (2006), "the violence of hu- ently human rights-based advocacy for both
manitarianism" (see also Nyers 2000). migrant workers and refugees, Boaz' explicitly
humanitarian commitment to Sudanese refu-
gees alone - not to refugees from Eritrea or
"A Very Arbitrary Distinction" Congo, not to migrant workers - was a major
The privileged place of Sudanese from Darfur bone of contention within the coalition.
within IsraePs local hierarchy of suffering For the human rights advocates, all asylum
emerged with stark clarity in an interview I seekers possess legal rights and moral entitle-
conducted with Boaz Friedman, 6 spokesman ments that the state is legally and politically
for the most publicity-savvy organizational co- obligated to ensure. For humanitarian advocates
alition working on behalf of Darfuri refugees in like Boaz, history and collective memory -
Israel. The coalition was, by all measures, a experiences of "founding trauma'' and "political
"strange bedfellows" endeavor involving emotion"- produce a moral obligation that both
human rights NGOs, liberal religious leaders, individual citizens and the state ought, but are
and two rather different celebrity members: a not obligated, to fulfill. As Ticktin observes,
renowned senior Holocaust scholar, and Boaz. "Humanitarianism is about the exception rather
A slick public relations agent and local celeb- than the rule, [and] about generosity rather than
rity, Boaz became famous after winning an entitlement", whereas, "Rights entail a concept
Israeli "reality TV" competition that garnered of justice, which includes standards of obliga-
him the opportunity to spend a year touring tion and implies equality between individuals"
United States college campuses and commu- (2006: 45). A humanitarian logic hinges not on
nities promoting IsraePs public image. Staff intrinsic properties of asylum seekers as rights-
members at several coalition organizations - bearing human beings, but on the cultivation of
all sharp-tongued human rights activists I knew an adequately compelling rhetorical or symbolic
through my earlier fieldwork with "illegal" mi- relationship between provider and recipient
grant workers - strongly encouraged me to of compassion or aid (cf. Nussbaum 2003). It
interview him even as their measured words is the arbitrary and contingent nature of this
revealed varying degrees of disagreement with relationship-building process that inflicts vio-
his personal agenda. lence upon those who, although equally "deserv-
I began to understand these reservations the ing," are abandoned by those whose primary
moment Boaz began articulating his goals for the intention is to "do good" (Fisher 1997). Within
coalition, which diverged markedly from those of the refugee rights coalition, such differences of
the human rights activists I knew well. The coali- opinion were of great consequence, not least
tion's primary objective, he explained in the un- because the line Boaz drew profoundly affected
apologetic language of a public relations the sort of public statements he was prepared to
strategist, is "to distance the refugee issue from make, the forms of aid he would coordinate or
the issue of migrant workers at the level of support, and the messages he would bring to the
[public] consciousness. It's to call it by a different Knesset and to the Israeli public.
name so people will like it more." As our conver-
sation continued, the chasm between Boaz's own
goals and those of his coalition partners came Conclusion: Political Emotions,
into sharp focus. "Personally," he said, Governmental Unruliness, and
I am not here to help migrant workers. I'm
the Politics of Humanitarian
here to help refugees fleeing genocide. I'm Compassion
working on behalf of [refugees] from Sudan.
I'm not working on behalf of rrefugeesl from Israeli responses to this unanticipated influx of
Eritrea . . . In objective terms, it's a very arbi- asylum seekers reveal much about the contem-
trary distinction. Someone who came here porary politics of humanitarian compassion,
DARFUR THROUGH A SHOAH LENS 517
which often functions not only as a salve for a Darfur, in a perverse, provisional sense, have
wide array of postcolonial disorders (Good "won," and other refugees -South Sudanese,
et al. 2008 ), but also as a catalyst for new Eritreans, and Mrican refugees already living
forms of dis-order. First, Israel's haphazard in the country, among others- have "lost." As
use of classificatory labels highlights the arbi- Boaz put forth unapologetically, success or
trary and fluid nature of terms now used to failure is a function of rhetorical power and
characterize people who move, generally with discursive prowess - not of asylum seekers
complicated motives and personal stories, themselves, but of self-appointed "trauma
across political borders. When three dozen Su- brokers" (james 2004) like Boaz himself,
danese asylum seekers were abandoned on the along with diverse others including Ilana
streets of Beersheva by the Israeli military, for Weisman, the Chief Rabbi of Tel Aviv, the
example, some eventually were granted protec- judge in the "enemy nationals" case, and even
tion by the municipal welfare authority, who Boaz's skeptical (but complicit) human rights
consented to view them as vulnerable persons partners.
whom the state is obligated to protect and These trauma brokers' analogical mode of
assist. 7 And yet, as Ha'aretz newspaper reasoning through history is clearly double-
reported, "The remaining refugees" were to edged. Although it does create possibilities for
be "held by the police as illegal aliens." the expansive cultivation of empathy and eth-
Depending upon who is doing the labeling, ically motivated intervention, these political
the same border-crossers may be cast as emotions do not necessarily translate into hu-
"asylum seekers," "refugees," "illegal migrant manitarian gestures of practical, legal, or
workers," or even, in the Israeli government's moral consequence. Asylum seekers from
accusatory neologism, "labor infiltrators." Darfur have come to inhabit a privileged pos-
Clearly these "new categories in which human ition within Israel's local hierarchy of suffering
beings are pigeonholed" (Pandolfi 2003: 381) on the basis of their trauma brokers'- and, at
are only marginally grounded in the circum- times, their own - skillful and strategic repre-
stances of individual lives. They strip away sentation of their experiences of suffering
individuality, subjectivity, and dignity, leaving and trauma. Yet this infelicitous status offers
only faceless, often defenseless masses of no real guarantee of protection. Even as a
people whose last shred of hope for eliciting small number of Darfuris have been promised
humanitarian compassion or reestablishing a the state's greatest gift- the gift of full political
meaningful political identity may hinge on and social recognition in the form of Israeli
their ability to successfully market their citizenship - many others have been detained
suffering. and expelled, and those who persist in
Moreover, as a growing body of scholarship attempting to enter Israeli territory are imme-
reveals, one must have endured the "right" diately deported (Ravid et al. 2007). Humani-
kind of suffering in order to make a successful tarian gestures, divorced from any standard of
claim within prevailing economies of humani- law or justice, clearly can be strategically
tarian sentiment. Suffering with the strongest enacted, discursively manipulated - and
currency is that which is traumatic, verifiable, refused, revoked, or terminated at will.
and/or significant - for reasons supported by This local hierarchy of suffering has also
ideology or political emotion - in the eyes of played another, more hidden role in framing
those empowered to grant, refuse, or revoke public and political conversations about the
the "gift" of compassion. How are such deter- recent refugee influx in Israel. Throughout this
minations made? In order to achieve humani- unruly biopolitical drama, there has been vir-
tarian subjecthood, one's suffering must map tually no discussion of Israel's obligations to
onto the locally salient "grid of victimization." another refugee population: Palestinians living
In the present instance, and within the under Israeli occupation. This is no coinci-
emerging hierarchy of suffering based on the dence; the logic of humanitarian exception
Shoah/Darfur analogy and the arresting rhet- has made it possible for the state to respond
orical power of the slogan, ''never again," there with calculated beneficence toward a small,
are clear winners and losers. Sudanese from hyper-politicized group of refugees in response
518 SARAH S. WILLEN
to pressing popular demand while continuing making that choice, he contends, "the future
to ignore its responsibilities toward Palestin- between us is at stake." As the events analyzed
ians whose lives it regulates, constrains, and here would suggest, such futures are always,
controls. Only a tiny handful of Israeli refugee perhaps inevitably imprinted with lingering,
advocates have commented upon this link. potent, often hyper-politicized traces of emo-
Groups that that have, most of them estab- tion, of elsewhere, and of the past.
lished human rights organizations with multi-
pronged agendas, take pains to keep their
struggles separate, largely because it is so much
easier to mobilize political emotion in support NOTES
of the former struggle than the latter. Thus the For an incisive critique of the contemporary
logic of humanitarian exception - charity- Jewish preoccupation with the Shoah, see
based, discretionary, and subject to ideological Burg 2008.
manipulation- has proven particularly expedi- 2 Data from the Knesset Research and Informa-
ent, especially from the states point of view. tion Center, and UNHCR-Israel, provided by
Overall, the key features of the Israeli state's the TAU Refugee Rights Clinic (personal com-
response to this refugee influx- dubious and munication).
ideologically motivated modes of classifica- 3 For more on this movement, see Kemp and
tion, including the failure to operationalize Raijman 2004; Willen 2005, 2007a.
the distinction between economic migrants 4 Pseudonym.
and political refugees; bureaucratic and admin- 5 Ilana's comments echo those of Martha Nuss-
istrative disorder; the mixing of policymaking baum, quoted in the epigraph above.
and political emotion- are in no way unique to 6 Pseudonym.
Israel. Rather, they are all features of a much 7 On July 1, 2009, the Israeli government
broader, global pattern of classificatory and reorganized the Immigration Police and
initiated a new expulsion campaign with a
moral "unruliness" regarding the status, rights,
declared target of 200,000 deportees. Asylum
and entitlements of asylum seekers and other
seekers and refugees, as well as Israeli-born
border-crossing populations. In the absence of
children of unauthorized migrants, were
systematic or enforceable rules or laws, states,
among the explicit targets of the campaign.
including those that proudly proclaim their At the same time, the Knesset passed the first
commitment to human rights, effectively are reading of a legislative bill that would allow
free to respond however they wish. In some not only for the immediate expulsion of
cases, irregular migrants' presence is simply newly arrived asylum seekers and refugees,
ignored. In other instances, irregular entrants but also the imprisonment of individuals
are systematically arrested and deported, and who assist them.
those who try to enter are banished to liminal
spaces of exception like "detention centers" at
airports (in France, Israel, and other countries};
on remote islands (Like the Italian island of REFERENCES
Lampedusa or the independent island of Nauru Adout, R.
near Australia); or in desolate desert regions (in 2007 Trafficked Women and Political Asylum
Australia and now in southern Israel). This Seekers, in Transnational Migration to Israel in
unruliness can have deeply repressive, and even Global Comparative Context. Edited by S. S.
violent, consequences. Yet even repressive and Willen. Lanham, MD: Lexington Books.
violent governmental techniques like mass de- Agamben, G.
tention and expulsion are proving ineffectual 1998 Homo Sacer: Sovereign Power and Bare
as means of containing or preventing "irregu- Life. Stanford: Stanford University Press.
lar" migration flows. Akoka, K.
Cavell observes that the choice to either 2006 La demande d'asile en Israel: Vers Ia
acknowledge or avoid the pain of another has "nationalization" de Ia procedure de prise en
weighty and far-reaching consequences; in charge.
DARFUR THROUGH A SHOAH LENS 519
have struggled to retain ancestral lands. This loss of a loved person, or to the loss of some
conflict persists, intensified by real estate abstraction" (1989:586). It designates a
speculation, in-migration, and labor magnets psychic process to loss where the mourner is
such as Los Alamos, Santa Fe, and Albuquer- able to gradually work through grief, reaching
que. Today, many Hispanos resist further dis- a definite conclusion whereby the lost object or
placement through strategies of cultural ideal is let go and the mourner able to move on.
preservation and memoralization. In the realm Melancholy, by contrast, designates mourning
of tradition, for example, there are yearly re- without end. It entails an incorporation of the
enactments of the Hispano colonial past, in- lost person or ideal as a means to keep it alive.
cluding the arrival of 16th-century Spanish Regarding its somatic features, Freud describes
settler Don Juan de Onate. Agricultural prac- the sleeplessness of the melancholic, suggesting
tices with Spanish colonial roots, such as the that it attests to the steadfastness of the condi-
community-based system of irrigation and tion. "The complex of melancholia," he writes,
water governance known as acequias, remain "behaves like an open wound" (1989:589).
vital to the economic survival of some villages, In Freud's conception, the melancholic's
and are the locus of cultural preservation. And sustained devotion to what is lost is patho-
language itself speaks to the past, as the unique logical. He warns that the intensity of the
Spanish dialect of Hispanos is still peppered "self-tormenting" condition can culminate in
with archaisms that date back to the original suicide (1989:588). More recent efforts to
pobladores, or townsfolk. But these traditions examine Freud's exploration of melancholia
and practices, which Hispanos claim have been are critical of his understanding of it as path-
around "forever," are also being abandoned. ology and offer important modifications to his
Many have surrendered claims to their ances- theory (see Butler 2004; Cheng 2001; Eng and
tral land and language and, by extension, the Kazanjian 2003; Munoz 1997). But here, I
life they represent. Indeed, many younger His- pursue Freud's original suggestion regarding
panos poignantly refer to themselves as "heirs the danger to life melancholy may pose. In
of nothing." The Ego and the Id (1960), Freud writes that
Since the 1990s, the Espanola Valley has had the unrelenting nature of melancholy trans-
the highest rate of heroin overdose and heroin- forms the subject into one who mourns- trans-
induced death in the country. With just over forms her, first and foremost, into a
30,000 residents, nearly 70 people died from melancholic subject. But what if we conceive
heroin overdose in one recent 18-month period. the subject of melancholy not simply as the one
The social and emotional wake of these deaths who suffers but, rather, as the recurring histor-
reverberates with the still tender wounds of ical refrains through which sentiments of "end-
recent history, such as the ongoing disposses- less" suffering arise? How to attend to these
sion of land, and the consequent fragmentation wounds?
of social order and intimate life. These consti- The melancholic subject that the title of this
tute a recurring experience of loss that, if not essay refers is thus about Alma, and about the
directly assimilable, is nevertheless familiar - structures in which her fatal overdose took
familiar in the sense of the very structure of root. And it refers to the all-too-familiar
recurrence, and in the sense of the close connec- experiences of loss, articulated now as addic-
tion this structure has to forms of loss: the loss tion, which have been shaped, in part, by the
of a tradition, a village, a daughter, a friend. kinds of attachments that the logic of chron-
My concern here is about these experiences of icity assumes. The recent work of anthropolo-
loss and memories of it, how intersecting forms gists show us how medical and technical forms
of history come to bear on the present, and of knowledge and intervention shape the
how heroin use - and overdose in particular - experience and course of illness, and more
exposes the painful recognition that the future broadly affect subjectivity (Biehl 2005; Cohen
has been swallowed up by the past. 1999; Petryna 2002; Young 1997). In the con-
In "Mourning and Melancholia" Sigmund text of addiction, chronicity as knowledge and
Freud defines mourning as "the reaction to the practice has become the ground for a new form
THE ELEGIAC ADDICT 525
of melancholic subjectivity, one that recasts a recent anthropological works on violence and
long-standing ethos of Hispano suffering into a subjectivity, which examine discursive prac-
succession of recurring institutional inter- tices that seek to make possible the repair of
actions. As Michael Fischer describes, "We injury and of the everyday (see Das and Klein-
are embedded, ethically, as well as existentially man 2000, 2001; Seremetakis 1991). This
and materially, in technologies and techno- work of mourning is in another tradition, the
logical prostheses" and these take us into new Hispano tradition, which commemorates
models of ethics in which "our older moral the singularity of death while insisting on the
traditions have little guidance or experience inevitable repetition of it. It is a tradition that
to offer" (2003:51). In the context of emerging includes the creation of memorials called "des-
technologies, Fischer aptly describes us as cansos" (resting places) that are publicly placed
being "thrown . . . to new forms of social life" at or near the site of death. The descanso does
(2003:51, emphasis added). I want to suggest not seek to reinhabit the site of loss, or repair
that the Hispano ethos of suffering is a social the everyday, but insists on death's essential
referent for addiction's recent biomedical turn, relationship to life. Over the years, heroin-
and the disparate technologies in which this related descansos have gathered on the Hispa-
turn is embedded (drug treatment centers, re- no landscape. Frequently adorned with the
search conferences, NA meetings, and so on) used syringes that contained the lethal dose of
deepens this ethos of suffering in unexpected, drug, they highlight just how enmeshed heroin
even dangerous, ways. In the context of its has become in physical space and everyday life,
preceding Hispano forms, I examine how these and pose the question of whether and how
technologies not so much throw us, but bury us "mourning as repair'' is possible or even de-
beneath the weight of that which does not end. sired in the face of unrelenting loss. Rising
along the edges of dirt roads and scattered
among the VaHey's juniperdotted hills, the un-
A Work of Mourning disturbed presence of the descansos constitute
a kind of ethical commitment to that which
Anthropology has shown how following the was lost; they keep vigil over it; they coexist.
life history of a single person can illuminate One day, while sitting together in my
the complex intimate and structural relations parked car in front of the Espanola Public Li-
that constitute a life, a community, and a social brary, a certain memory flashed up for Alma,
world (Biehl 2005; Das and Kleinman 2000; urgent and unannounced. It was a cold after-
Desjarlais 2003; Pandolfo 1998). I also engage noon, already dark despite the early hour. I
in this form of inquiry, while recognizing that turned on the car's ignition and was ready to
there are many elements of Alma's story that I return Alma to the halfway house in which she
do not know, and other elements that could be resided following 30 days of heroin detoxifi-
told in the voice of Bernadette, Yvette, johnny, cation. To my surprise, Alma grabbed my hand
Marcus, or the many other subjects I followed and told me to wait; she wasn't ready to go
during the course of my research. They were all back. For a few moments we stared quietly at
caught within the same cycle of trying to live the library's iron-barred windows, our breath
their lives without heroin and succumbing their visible in the chilly air. Alma broke the silence
lives to it. I thus present Alma as embodying a and said that her older sister Ana, whom she
condition that is more than hers alone. never mentioned to me before, loved to read.
While there are certain refrains in Alma's Ana . . . killed by a drunk driver four years
experience that belong to Hispanos more before. She had been on her way to work, Alma
broadly, one of my goals here is to convey recalled, driving along the windy, two-lane
Alma as she appeared to me - generous, highway that connects Espanola to the village
reflective, and deeply engaged in trying to find of Chimayo.
a way to live. In rendering Alma's life, and in Following local custom, the Gallegos family
trying to account for her death, I undertake a put up a handmade descanso in the spot that
kind of "work of mourning." This differs from Ana was killed. Alma told me that afternoon
526 ANGELA GARCIA
that it still marks her sister's death, and asked if actively felt sensibilities derived from lived,
I'd seen it. She described the plastic yellow material histories. According to Williams, at
flowers and the fading family portrait that any given time, there are multiple structures
adorned Ana's wooden cross. I knew the des- of feeling in operation, corresponding roughly
canso and offered to drive her there. Alma to the generations living at that time. Each
shook her head no, adding that for years she generation creates its own structure of feeling
would have to turn her head and look away in response to the world it inherits- taking up
every time she passed the cross on her way to or abandoning the sensibilities of its predeces-
Chimayo to meet her dealer. She confessed that sors. His way of thinking about "the living
she still turned her head away, but was able to substance of perceptions and relationships"
conjure the image of the descanso in her mind. thus has a temporal dimension that helps eluci-
"Ahi esta," she said, "mirandome" [There it is, date the interlocking nature of experience and
looking at me). affect (1977:34).
In his examination of the English elegy, Consider, for instance, expressions often
Peter Sacks notes that the traditional forms repeated among elder Hispanos: "Todo es his-
and figures of the genre relate to an experi- coria" [History is everything]. It is a saying that
ence of loss and the search for a consolation simultaneously acknowledges the loss of times
(1985). The passage from grief to consolation past and the longing for continuity in a precar-
is often presented in the form of repetition - ious and changing world. Another: "La historia
through the recurrence of certain words and es una herida" [History is a wound] which is
refrains. According to Sacks, the elegy's re- frequently evoked in the context of expressing
petitive structure functions to separate the the material and cultural losses that resulted
living from the dead and forces the bereaved from the region's past. And another, repeated
to accept a loss that she might otherwise by the addicted: "Chiva es el remedio para
refuse. In this way, the repetition creates a todo'' [Heroin cures everything]. Thus, while
rhythm of lament that allows grief to be sim- elders worry that the younger generation is all
ultaneously conjured forth and laid to rest. too willing co forget the past, the young are just
But what if the structure of repetition creates as likely to understand the heroin problem as a
not a working through of grief, but its intensi- contemporary consequence of it, while still
fication? How might the structure of repeti- offering heroin as a remedy for the pain chat
tion become constitutive of a kind of endless accompanies the past. In this way, young and
mourning? old insist chat to meaningfully address the
Passing her sister's roadside memorial on heroin problem, one must also address the
her way to score heroin, Alma created her region's deep historical scars.
own rhythm of lament: a counterpoint of yes- There are other kinds of scars, such as those
terday and today, memory and forgetting, on the skin. The needle marks and abscesses
death and life. Like her sister's descanso, the that mapped Alma's body- open wounds in the
elegiac character of Alma's narrative offers a literal sense - powerfully attested to how ad-
continuous double-take on thinking about the diction is also a historical formation and im-
relationship between history of loss and the manent experience. These are wounds in which
present: what is lost remains. In Alma's words, the future, the present, and the past commingle
it is "sin fin" (without end) forging the patterns through the force of recurring need: the need to
of her experience. score heroin, to get high, to find a vein. AJma
once described it to me like this:
The Entanglements of Time The thing about being hooked is you're always
thinking ahead, thinking about your next fix,
In thinking about the temporal dimensions of how you're going to get the money, where it's
loss and sentiment, I have found Raymond going to come from. It goes on and on. . ..
Williams's concept of "structure of feeling" And now, I've been using so long, nothing ever
particularly useful. Structures of feeling are lasts. The high ... it's over before you know it
THE ELEGIAC ADDICT 527
and you're back to it, thinking about the next drug use in new economic and social settings -
fix, making caJis. It never stops. out of the "shadows" and into the white,
middle-class mainstream. New constellations
Byron Good notes that in illness narratives, of disciplinary interests emerged that reexa-
the autobiographical narrator tells a story that mined addiction. This turn culminated with
is not yet finished - there is more than one the introduction of methadone maintenance
temporality woven together in a narrative in the 1960s.
(1994). Indeed, in talking about her addiction, The concept and practice of "maintenance"
Alma could express all of the following: the ushered in a new addiction research agenda for
experience of past heroin use, the vicissitudes the behavioral and biosciences. Recent develop-
of her current condition, and the inevitability ments in bioscientific knowledge point to the
of further heroin use. Such entanglements show genetic and neurological basis of addiction, usu-
how time and the Hispano trope of endlessness ally described in terms of "adaptive changes,
are reworked through the experience of addic- or "habituation" (Cami 2003; Mclellan et al.
tion. This point begs a larger question, which 2000). Mediated by a new set of medical
relates to addiction's physiological dimensions and scientific translations, the current vision of
and to what extent the structure of endlessness addiction as "chronic" bears contradictions that
is embedded within it. are both enabling and disabling. It can indeed
From the point at which heroin enters the counter old, reductionist explanations of behav-
bloodstream, the physiological effects - the ior or culture and potentially relieve the moral
rush - occurs very quickly, usually within 20 repercussions of "relapse." But such a framing
seconds to a minute. Affected are the central risks obfuscating other, perhaps more vital
nervous, cardiovascular, respiratory, endo- dimensions that encompass a local sense of what
crine, gastrointestinal and genitourinary it is to suffer from an unending condition.
systems, as well the skin. Morphine, the psy- The ideologies and practices associated with
choactive ingredient in heroin, causes the state addiction's biomedical turn, and the institu-
of euphoria, analgesia, and sedation associated tions in which they are embedded, have gener-
with a heroin high. Over time, increasingly ated new affects and narratives of those
larger and more frequent doses of heroin are struggling with addiction. Heroin addicts fre-
needed to achieve this state. Using becomes less quently express that they had little or no
about achieving a high and more about staving chance of recovery, and often explain their pes-
off withdrawal. Heroin is medicine- it relieves simism in biological terms. Their addiction,
the pain its use creates. There is a complex, they say, is in the blood, like a virus, something
even geometrical, relationship between the they could not eradicate or recover from, even
Hispano trope of endlessness and the physio- if they wanted to. But this local understanding
logical experience of heroin addiction. And it is of addiction differs from the medicoscientific
made more complex through the explanatory view. In the Hispano milieu, the family is often
model of chronicity. the primary domain of heroin use, and heroin
Briefly, the model of chronicity likens addic- is frequently shared between fathers and sons
tion to a lifelong disease. It is enduring and or mothers and daughters. Heroin addiction is
relapses are an expected occurrence. Treatment conceived of as a kind of contemporary "inher-
is lifelong and partially effective (Appel and itance"- an intergenerational and intersubjec-
Kott 2000; Brewer 1998). The chronicity tive experience that accesses, literally, the
model emerged in the 1960s, partly as a re- bloodline. Thus, while addicts emphasize the
sponse to the high incidence of repeated relapse biological language of "chronicity," particu-
seen among addicts who entered publicly larly when talking about their "lifelong
funded treatment programs. It was intended struggle" with heroin, their experiences reveal
to dispel the long-held assumption that heroin profound differences in the symbolic ordering
addicts were innately psychopathic and irre- of addiction and time, whereby the "lifelong"
deemable (see Acker 2002). Underpinning this struggles of an addict may exceed that which is
rescripting of addiction was the explosion of traditionally conceived of as "a life." Here,
528 ANGELA GARCIA
"lifelong" may represent several, related lives, example, spent a total of 18 months at a
entangled together in ways that make a strictly women's detention center for two separate sen·
biologized and individualized approach to tences relating to drug possession charges. At
treatment futile. the time of her death, she was awaiting her
Despite the increasing reliance on meta· court date for "offenses" relating to her failure
phors of chronic disease, practically speaking, to comply with an earlier round of court·ap·
the motivating factor behind drug recovery is pointed treatment. The great irony is that her
invariably understood in terms of personal relapse was expected, even innocent, at least
choice or will. This is largely because of two from a medical perspective. From the juridical
factors: first, the prevailing "Twelve Step" perspective, however, it represented a failure of
model of recovery, which emphasizes personal will and was to be reckoned - either through a
power over addiction (made possible through sentence for further treatment, incarceration,
the sustained reflection over past behaviors - or both.
what is described as a "moral inventory" - as How have the seemingly incompatible dis·
well as the personal act of "surrender" to a courses of "chronicity" and "choice" sup·
"higher power"); and, second, the ever· planted alternative ways of understanding and
expanding punitive approach to addiction, treating addiction? What are the psychic effects
which emphasizes the addict's capacity to of these discourses, particularly for those that
reason and, therefore, control her drug·using have been through repeated cycles of recovery
behavior. Both the Twelve·Step and the jurid· and relapse? How do medical and juridical
ical institutions draw their justification and responses to addiction lock addicts into an
legitimacy from liberalism, which purports per· incommensurate "medical·moral identity"
sonal autonomy of each rational agent and, (Young 2006) in which the outcome of relapse
correspondingly, treats individuals as respon· is not only expected, but produced?
sible for their freely chosen actions. There are Jean Jackson has written of the uncertain
clear tensions between these arguments and ontological status of the chronically ill (2005).
institutional practices and the biomedical She describes how this status provokes stigma,
model of addiction. Whereas from a biomed· and forces the patient into deeper modes of
ical perspective relapse is understandable and suffering. Many of the heroin addicts I inter·
even expected, from a juridical perspective the viewed- addicts who, in today's lingo would
relapsed addict is ultimately assigned the blame be described as chronically ill - told not of
for relapse and is seen as lacking the will to uncertainty, but of fixity. Alma, for instance,
recover. described her life and the struggles and losses
Increasingly, the mechanism through which that defined it as being without end. She
addicts enter publicly funded treatment is echoed the sentiments of many addicts I spoke
through the drug courts, which leverage the with when she told me that the only way
threat of imprisonment if the "offending she could exit this cycle of endlessness was
addict" does not comply with treatment. Here, through a heroin high. Alma once said to me,
the traditional boundaries between the thera· "The only time I feel really ok is when I don't
peutic impetus of medical and social services, feel anything. When I'm high, it's like . . . it's
and the state's authority to control "criminal" hard to explain, but just for a little while every·
individuals and populations, are further thing goes away. But that feeling of nothing ...
blurred, even eradicated. Nearly all of the It's gone before you know it."
addicts I encountered during my research were
court·appointed, or sentenced, to detox and
treatment - a finding that mirrors national Hoy-Today
statistics of publicly funded treatment pro·
grams. 2 Those with the highest rates of Hoy Recovery is a publicly funded, commu·
"relapse'' were eventually incarcerated one or nity·based drug program located on the out·
more times as a consequence of not complying skirts of Espaftola. Established in the early
with prior treatment sentences. Alma, for 1970s, Hoy, which means "today" in Spanish,
THE ELEGIAC ADDICT 529
initially provided peer support for male alco- officials spoke movingly about the opportunity
holics, many of who were returning from the to reduce heroin overdoses and many
war in Vietnam. Former clients and staff recall recounted their own struggles with addiction.
those early years of operation as fraternal. "It A prayer for healing was murmured. With the
was like a house," one staff member remem- cutting of the yellow ribbon, the troubled
bered. "We all lived together and helped each memory of Piiion Hills was laid to rest and
other out. We were like family.'' Over time, Hoy Recovery was born.
there was an increasing number of younger The year of Hoy's opening, there were 40
men seeking services for heroin addiction. fatal heroin overdoses in the Espanola Valley.
In the 1980s, heroin addicts were being trans- I had just been hired as a detox attendant at
ferred to Hoy on release from the local hospital the newly opened facility and was on duty the
or the county jail. The facility became morning Alma was admitted. She was in a state
cramped, and the waiting list to gain entrance of acute heroin withdrawal. Alma immediately
to it grew. In 1998, a support group was estab- began to beg for medications to ease the pains
lished for women, and they began accessing in her stomach and limbs. The male counselor
Hoy's limited services. With the rising case- on duty explained that she needed to undergo a
load, the recovery home took on an increas- drug search before she could receive a dose of a
ingly institutional feel. A thick, Plexiglas wall Robaxin, a muscle relaxant. As the only female
was added in the lobby, separating staff "on the attendant on duty, I was instructed to lead
inside" from the increasing needs of addicts Alma to the women's dormitory and perform
"afuera" [on the outside]. Most addicts stayed the routine search.
for only a few days; many returned within I had observed drug searches in the past, but
months; still others died on release from the this was the first I would carry out. We stood in
program or died waiting to get in. a room the size of a school bus, beside one of
In 2004, Hoy established a medically moni- six narrow beds that would briefly become
tored detoxification clinic, which focused on Alma's. She was familiar with the procedure
the unique and growing needs of heroin addic- and began removing her clothes. I hastily
tion. Located in the nearby village of Velarde, combed through her sweaty garments - my
Hoy's detox program was comprised of a fingers tracing the inside seams of her jeans,
group of small adobe houses that surround a her tank top, the crotch of her panties, the
larger building. The detoxification clinic was underwire of her bra. When I was finished, I
once a state mental institution for Hispanic told Alma that I could arrange to have personal
adolescents called Pifton Hills. For years, the belongings delivered to the recovery center.
facility sat vacant, its exterior walls scorched Alma responded that she had none.
by the fire that led to the facility's closure. She would sleep in that bed for only a frac-
County officials considered condemning the tion of her "drug sentence," leaving early on
building, but a 1999 special congressional her third morning because she said there were
hearing on the region's heroin problem identi- mice in the women's dormitory, and she did
fied it as a potential site for a much needed not feel safe when there were no women on
drug treatment center. Five years later, Hoy's duty. I asked the head counselor if he knew
Detoxification Clinic opened its doors. where Alma went. He responded with a shrug
The clinic signified certain cultural, eco- and added that he knew Alma; she'd be back
nomic, and medical advancements in a histor- soon enough. I was struck by the counselor's
ically impoverished and drug-weary region. It sense of the inevitability of her return, which I
was the first facility in the region specifically came to understand as similar to the hopeless-
for heroin addiction. It was also the first to ness and "burnout" that many clinicians and
promote a medical model for detoxification mental health professionals feel, particularly
by offering antiopioid medications in a "clin- those who work in resource-poor hospitals
ical setting." At the opening, musicians per- with high caseloads (see Raviola et al. 2002}.
formed traditional rancheras as journalists Mental health professionals working at Hoy
and state politicians toured the facility. County seemed to succumb to a kind of moral
530 ANGELA GARCIA
detachment that results from working too long staying, or if I asked her about "Ia vida afuera"
in an environment of mounting need and [life outside]. "I don't like thinking about
repeated loss. I worried about how the dis- that," she would say, referring to her future,
course of chronicity strengthened the assump- to what existed beyond the clinic walls. Or,
tion of return that was expressed, and perhaps "Don't throw me a party yeti" suggesting that,
fostered, by caregivers. any day, she might just lose it. In the end, Alma
In fact, I did see Alma again a few months remained in detox for 30 days. She was then
later, during the counseling session recounted transferred to Hoy Recovery Program's 90-day
at the beginning of this essay. She had just been "Community Integration Program" - a kind of
readmitted to the detox clinic following an halfway house where she would begin the pro-
overdose, for which she was hospitalized less cess of "finding one's feet," to use the language
than 24 hours, and then transferred to Hoy, of the program's mission. Alma liked to joke
as directed by her parole officer. According to that, after 15 years of heroin use, she had no
her patient file, Alma's heroin overdose was feet, only collapsed veins.
labeled an "accidental poisoning," the circum- The Community Integration Program was a
stances of which remained unclear. The chaotic, run-down facility on the outskirts of
attending physician recommended that she Espanola. There were more bodies than beds,
begin a regimen of antidepressants to treat and residents spent most of their days watching
what was described as "underlying emotional television, usually one of the many Cops-like
issues," the nature of which also remained un- reality-based programs, or Court TV, both pro-
clear. I shuffled through the other papers in grams in which clients essentially saw them-
Alma's patient file, and learned that she was selves criminalized on screen. Alma and I saw
29 years old, married, and had no reported each other only occasionally during this time -
children. Her mother was listed as her emer- sometimes over lunch, sometimes during shop-
gency contact, and her permanent address was ping trips to the Super Wal-Mart, where she
located in Tierra Amarilla, the county seat briefly worked while a resident of the program.
about 70 miles north of Espanola. Built in 1999, the Espanola Super Wal-Mart is
I began to see Alma regularly in the even- now the second-largest employer in the Valley,
ings, at the start of my shift. She would linger after Los Alamos National Laboratories. Most
around my "station"- a desk positioned at the employees are part time and earn less than
crux of a L-shaped hallway that led to the seven dollars an hour. Onsite drug testing is a
patient dormitories, which were separated by mandatory requirement for employment. Alma
gender. As a detox attendant, my primary once described her dark blue work smock as
duties were to watch and record the activities reminiscent of her former prison attire.
of patients between the hours of 6 p.m. and During my visits with Alma during this
8 a.m., details which might become significant time, it was apparent to me that she was grow-
in case of any legal issues, which were ing demoralized and anxious. Her days at the
common. I also dispensed medications, sup- residency program were long and monotonous,
posedly according to the orders of a clinic just as they were at work. Her only respite, she
nurse, but there was no such nurse - the clinic told me, was the mile-long walk down Rail-
could not afford to maintain one. road Avenue, an industrial artery that connects
During her second stint at the detox clinic, Hoy's residency program to Espanola's River-
Alma would lean on my desk and fill me in on side Drive, where Wal-Mart is located. During
the details of the day's events- which patients her walks to and from work, Alma considered
walked out, which got kicked out - stressing, it her options. Stick out the rest of her treatment
seems, the hard-won fact that she had made it, sentence with no real promise of a different
she had stayed. She became, in a way, my future; move back into the trailer she had
friend. Each time I would return to the clinic shared with her estranged husband; or return
and find that she was still there, I felt some- to the family home back in Tierra Amarilla.
thing akin to relief. She grew uncomfortable, None of these options appealed to her. She
though, if I commended her in any way for didn't know what to do.
THE ELEGIAC ADDICT 531
Yellow Earth she paused for a long time, and then she said,
"It all keeps me awake at night." And, minutes
Sometimes I shoot up and I'm sure it's gonna later: "it weighs heavy on my heart." Alma
be the last time. The needle'll be in me and I'll repeated the phrase "it weighs heavy on my
be pushing the plunger in thinking, this is it! Se heart" throughout the recorded narrative.
acab6! [It's over!]. But I wake up all sick and Detective-like, I kept rewinding the recording
life for me ... [pause] it doesn't stop. Even and replaying it, trying to locate all the events
when it should, you know? There's no reason
that explained such heaviness. But Alma's
to live a life like this. Not one like this.
admission of feeling was temporally discon-
It was 2:45 in the morning when I recorded nected from specific recollections of the past.
these words. Shortly after our afternoon at the Throughout her recorded narrative, such
public library, Alma went on a four-day heroin phrases of pain dangled precariously, isolated
binge. She was passed out in an Espanola laun- utterances that seemed to speak, as it were, for
dromat, where she had sought shelter from the themselves. Whatever the reason for the appar-
cold, and was arrested for heroin possession. ent disconnectedness between feeling and
After two nights at the county jail in Tierra event, one of the themes that Alma kept
Amarilla, Alma returned to the detoxification returning to in her narrative was the sense that
clinic - her final opportunity, as her parole nothing changes, that life and its ensuing pain
officer put it, to "straighten up." It was Alma's is unalterable - "without end" [sin termina].
third admission to Hoy in 14 months. On ad- Indeed, it was within such terms that she ex-
mission, the intake counselor asked why she plained her relapse, and at one point acknow-
"sabotaged" her recovery yet again. Alma re- ledged that she knew she would return to the
sponded that there wasn't anything to sabo- clinic, as if her relapse and readmission were
tage, that this was her life. simply part of the order of things, cause and
On her second night back, Alma remained effect. Referring to the so-called responsibility
with me in the clinic's common room. Plagued and challenge of staying clean - which is
by memories, she couldn't sleep. I suggested stressed by counselors at the clinic -Alma said,
her sleeplessness was related to heroin with- "It's not that I wasn't ready ... it's that there's
drawal and, in the absence of more effective nothing to be ready for."
medications, suggested a warm bath. Alma
shook her head no, said it was the thoughts Shortly after transcribing Alma's narrative, I
"messing with'' her head, thoughts she needed drove up Highway 84 to Tierra AmarilJa. It
to get out lest she would explode. was fall and the cottonwoods along the Chama
And it was a tangle of thought and memory River were in full yellow bloom. As I climbed
that she related to me that night. She talked higher into the San Juan Mountains, tall, full-
about her home in Tierra AmariiJa, the village bodied ponderosa pines flanked the road. Set
where her family has lived "forever," and back from the highway were clusters of adobe
where she had just spent two nights at the houses and trailers and, adjacent to these, neat
County Jail, trembling alone in a windowless stacks of firewood ready for the coming chill of
cell. She left her village when she was 17 years winter.
old, a year short of high school graduation, As I entered Tierra Amarilla, Alma's
because she said she was choking on the mem- words began to echo in my mind. I imagined
ories of her elders, particularly her father's vio- that she were in the passenger seat beside me,
lent despair over the loss of ancestral lands. accompanying me with her memories. What
Her retreat from their memories, she said, memories might she have of that empty lot,
was drugs. or the burned-out trailer next to it? Did she
Several weeks later, I began the process of know who scratched out Reies Lopez Tijeri-
transcribing Alma's recorded narrative, She na's name on the historic marker that wel-
spoke of her sister, of Tierra Amarilla, of mem- comes visitors to the infamous mountain
ories that were her own and memories that she village? Only a generation ago, the residents
had inherited. At one point in the recording, of this village worked on the land - in
532 ANGELA GARCIA
ranching, farming, and forestry. Now, each Here, the idea that the land was "lost" is no
weekday morning, the village empties out mere exercise in nostalgia; over generations it
and becomes a virtual ghost town as locals has given rise to a constant stream of rebellion,
make the 85-mile drive to Los Alamos or most famously in Tierra Amarilla 40 years ago
Espanola for work. Among the abandoned when Reies Lopez Tijerina and a group of
lumber mills, dilapidated corrals, and armed insurgents stormed the local court-
boarded-up houses, I imagined events Alma house, a symbol of an "outsider" authority that
might have participated in or witnessed: drove a wedge between the people and the
parties, marriages ... overdoses, deaths. She land. The "Courthouse Raid" - as it is now
had spoken to me of some of these things that known - prompted the governor to activate
night at the detox clinic and told me, for the National Guard and send in tanks to sup-
instance, about the suicide of a trusted press the rebellion. A five-day manhunt by 500
schoolteacher who had tutored her in read- law enforcement agents ensued. The rebellion
ing. "She slashed her wrists in the woods and was successful in symbolizing how deep pas-
didn't leave a note," Alma said. "My broth- sions run on the issue of the land and who has
er's friends found her when they were out rights to it. In an interview following the raid,
partying. The only thing we could think is Tijerina exclaimed, "These people will always
that her son died in Desert Storm." remember how they lost the land ... they have
Tierra Amarilla: "Yellow Earth., Perhaps not forgotten after hundreds of years . . . they
more than any other nortefto (northern) New will never forget" (Kosek 2006:344). Indeed,
Mexican village, it is the symbolic ground of memories and sentiments regarding land loss
the Hispano history of dispossession and remain powerful tropes, particularly among
longing for land and times past that has in- elders. The ultimate irony is that which was
spired decades of political struggle - by turns "lost" is still there for Hispanos to see- it's all
mainstream and underground, through means around them in the mountains, rivers, mesas,
violent and not. Tierra Amarilla was first and buttes. One wonders how Freud's concep-
settled as a land grant in the mid-1600s. Like tion of melancholy can be extended to address
all land grants in northern New Mexico, Span- such material losses, losses like land that
ish and, later, Mexican settlers were allotted remain present but out of reach, particularly
land for an individual home; an irrigable plot in a context where land is constituent to cul-
for personal farming; and the right to share tural identity and economic survival.
common land with other settlers for pasture, As I drove through Tierra Amarilla on that
timber, and hunting. According to the deeds, fall day - through the plaza anchored by the
personal allotments could be sold as private infamous courthouse - Alma's narrative was
property, but common lands could not. The fresh on my mind. I couldn't help but wonder
commons were just that - collective property what role "the land" plays in memories of
- and were to be used and preserved for the women like Alma: women who, in her words
community's wellbeing. "didn't exist" during the most militant phase of
Since 1848, when New Mexico became the land grant movement; women whose lives
part of the United States, generations of have been dominated not by the loss of land,
land-grant heirs have found themselves strug- but by the loss of people. Certainly these forms
gling to regain lost lands. Even today, they of loss intersect in powerful ways. Alma's
continue to argue that the United States broke insistence that there is "nothing there ... noth-
the Treaty of Guadalupe Hidalgo, which was ing but memory" speaks to tragedies of earlier
intended to protect titles secured before the generations that are indelibly linked to the pre-
war, thereby preserving the economic and cul- sent. And the material legacy of land loss in
tural integrity of Hispano people. The heirs of northern New Mexico is the very stage for
the Tierra Amarilla land grant, which include losses associated with heroin use. Indeed, the
Alma, alone lost over half a million acres, first time Alma shot up was deep in the forest,
much of it now part of the Carson National in a crumbling adobe on a large parcel of land
Forest. that once belonged to "la familia Mascaranes,"
THE ELEGIAC ADDICT 533
a shepherding family who lost land-use rights short story "The Circular Ruins," a man who
when much of the common land were desig- suffers from insomnia walks miles through a
nated a National Forest, a transformation that jungle in hopes of tiring himself, losing himself
erased their livelihood. Their old adobe to sleep. "In his perpetual state of wakeful-
remains locked in the forest and is the site of ness," Borges writes, "tears of anger burned
many of Alma's heroin-related memories, in- the old man's eyes" (1998:98).
cluding the first time Alma witnessed a heroin According to the attendant who was on
overdose. duty the night of Alma's departure, no one
I wanted to talk to the Mascaranes family, picked her up at the clinic, suggesting that she
but I didn't know how to find them. I thought would have had to walk 15 miles of dark high-
of asking a clerk at the general store, but the way to reach Espanola. I called the only phone
general store no longer existed; it was boarded number that I had for Alma, which was for the
up. I drove to the County Offices - a newer trailer that she shared with her on-again, off-
complex painted the color of adobe and the again husband. There was no response. Over
only building in the plaza that wasn't in a state the next week I tried calling again and again.
of complete disrepair. Despite being a weekday Eventually, a recorded voice answered, curtly
afternoon, even it was closed. informing me that the number I was trying to
As I drove home, I thought of Alma's words. reach had been disconnected.
"There's nothing up there no more. Nothing Several weeks after my visit to Tierra Amar-
but memories." illa, Alma called me. She wanted me to know
that she was okay and that, although she knew
what people must have thought regarding her
Intolerable Insomnia discharge, she hadn't "screwed things up yet."
Her tone was casual, even happy. She lived
Alma left the heroin detox clinic three days alone, worked at the local Subway sandwich
after our predawn interview. According to the shop, and was atcending services at Rock
detox attendant on duty at the time of her Christian Fellowship - a growing evangelical
departure, she simply walked out at approxi- church in Espanola. Like Victory Outreach, the
mately two in the morning. I asked to see her church's faith-based activism is embedded
discharge papers, which patients are required within a larger ideological framework of drug
to sign in acknowledgment that they had re- recovery and tries to ensure that recovering
ceived counseling on the potential conse- converts are kept busy with activities so as to
quences - legal and not - of leaving detox be able to "save" their lives. Indeed, the Rock's
before "successful completion." Alma signed pastor preaches regularly about his own
her name in bubbly, childlike script. In re- struggle with drugs, including heroin, and
sponse to the question "Reason for Self-Dis- appeals to his congregants to "get clean"
charge," she wrote, "CANT SLEEP.'' through rebirth, spiritual training, and evan-
Jorge Luis Borges writes of the "unbearable gelizing. It was a message that appealed to
lucidity of insomnia" (1998:98). He describes Alma. I wondered how Alma's transition from
sleep as a state in which one is able to forget Catholicism to Evangelicalism might be under-
oneself. When one awakens, however, time, stood as a reflection of her complicated rela-
places, and people return - the self returns. tionship not only with drugs but also with her
One of the many words in Spanish for "to past and of a desire to forget.
awaken" and which Borges regularly employs The following afternoon I drove to the
is recordarse, which translates literally to trailer that Alma had shared with her hus-
"remember oneself." In this sense, when one band. Although it was still light outside, it
awakens, one remembers oneself; in the was almost completely dark inside the trailer.
absence of sleep, the self never leaves, never Alma invited me in, informing me as she did
forgets, and, thus, remains vigilant over itself that her home currently lacked phone service
and its memories. Borges understood that this and electricity. But she quickly added that she
vigilance leads one to a state of despair. In his was confident that her utilities would be
534 ANGELA GARCIA
reinstalled within the week, thanks to help about the night she left the clinic. She told me
from the Fellowship. I asked Alma if she that it was a mistake to have been sent back -
was warm enough, worried that winter was that the clinic didn't work because its focus on
on its way and the trailer would get terribly the past made life unbearable. "They want you
cold. Did she need anything? Alma told me to always be thinking about what you did, why
that she was okay and laughed that her recent you did it, how you're always gonna be an
weight gain - a benefit from quitting heroin addict and you got to stay clean, fight the
and eating on the job -was helping to keep temptation. You're always 'ceptible to heroin
her warm. and there's no cure ... [that's why) I like it here
Votive candles flickered on a small coffee [the Fellowship]. They're not always looking
table in the living room where I waited for back, you know? Pastor Naranjo talks about
Alma to change out of her work clothes. the future; he says that's what counts. The
Aside from a threadbare couch, the coffee future - so you can be blessed and go to
table, and a large wall hanging depicting the heaven." Alma continued,
Virgin de Guadalupe, the living room was
completely bare. I wondered if this was a At Hoy, with 12 Steps . . . it's like with Luis
consequence of her husband's departure or if [her husband], always reminding me of the
fuck-ups, you know? The things I've done.
it was simply amplified by the absence of heat
It's like, you don't have to keep reminding
and light. I looked at the votives and the
me! I know better than anyone else what
Virgin de Guadalupe. It seemed to me that
I've done and where I've been. I can't forget.
Alma had not entirely yet let go of her Cath- But don't keep pushing me down there, you
olic roots, her ties to the past. I was curious know? I have a hard enough time dealing
about her foray into Evangelicalism and with it.
wondered about her desire to be "born
again," for a future. Alma's account of being "pushed" into
remembering that she is at perpetual risk of
Positioned between a discount grocery store relapsing into "past" addictive behavior pro-
and a mobile home showroom, the Rock Chris- vides a powerful critique of the model of
tian Fellowship is a sprawling cinderblock chronicity, an approach that began, in part, as
complex located in the center of Espanola. Its a well-meaning attempt to dispel the moral
presence can be spotted from some distance by implications of being a drug addict. But Alma's
an enormous neon billboard depicting the face framing suggests that there are, in fact, moral
of Jesus and which reads, "Rock Christian Fel- and psychological repercussions to approach-
lowship: Making Disciples." In addition to ing addiction as a chronic, unending process.
traditional church services, the Fellowship Anthropologists have described how the uncer-
offers a childcare center, a men's recovery tain ontological status of the chronically ill- be
home, a "spiritual university," and a restaur- they depressed, asthmatic, or addicted - can
ant. The Solid Rock Cafe sits on the northern provoke stigmatizing reactions in others
edge of the complex. Alma suggested we go (Jackson 2005; Luhmann 2007). This is true
there for a light dinner. When we arrived, the in Alma's experience, although I would add
cafe was nearly empty. We sat at a small table that the idea that her addiction is chronic -
near the window and watched the evening rush that is, its chronicity, it's unendingness- may
hour traffic gather along Riverside Drive. To provoke othet; perhaps more dangerous,
my surprise, Alma pulled out two Subway responses, including a deep sense of hopeless-
sandwiches from a backpack. I ordered each ness. And while some might read Alma's appeal
of us a soft drink and we ate our sandwiches - for "the system'' and her husband to stop
which had grown soggy with time- in com- "pushing [her] down there" as "denial," an
fortable silence. alternative reading may be that it is a genuine
Alma told me that the Fellowship was plea for a new understanding and approach to
helping her and added that she didn't know addiction. I began to understand Alma's turn
what she would do without it. I asked her toward Evangelicalism as an attempt to carve
THE ELEGIAC ADDICT 535
out such a response. "I don't want to go This is what I kept thinking that night.
through this anymore," she said of the seem-
ingly perpetual cycle of treatment and relapse. "Insomnia," the Romanian philosopher
Perhaps it was in Evangelicalism, and through Emil Cioran writes, "enlarges the slightest vex-
the promise of being "born again" that Alma ation and converts it into a blow of fate, stands
was able to envision putting an end to chron- vigil over our wounds and keeps them from
icity as such and to seek for herself a true and flagging" (1992:140). Night after night, the
lasting recovery. same thoughts appeared to Alma. She asked
Indeed, that evening in the restaurant, Alma me why that is - asked me why, during the
quietly swore to me that she hadn't used heroin day, she was able to get by, but why at night
since she left the clinic, crediting the Fellowship the same thoughts and memories swelled up,
and her new, forward-looking perspective with always in the same way.
her sobriety. The only problem, she said, was Alma asked the social services coordinator
that she still couldn't sleep. I could see by her at the Fellowship for help - hoping that she
eyes that this was true. Bloodshot and watery, would be referred to a physician who could
Alma's eyes conveyed the culmination of too write her a legitimate prescription for a sleep
many sleepless nights. She told me she hated aid. Her request was denied. She admitted to
nighttime because she worried, even before me that she resorted to buying prescription
getting into bed, that sleep would not come. I meds - mostly tranquilizers - off the street.
asked her how many nights it had been since But it was too expensive, costing up to ten
she slept. "Nights!" she laughed. It had been dollars a pill, and the effect too temporary.
so long since she'd slept that she didn't even The thoughts, Alma told me, always returned.
remember what it felt like. They were, in her words, without end.
True insomnia is not merely tossing and The only time I can sleep is with chiva
turning on a bad night. Rather, it is sleepless- (heroin). That's the only time and ifs the best
ness night after night, a mind and a body in sleep, before you forget everything. There's
revolt against itself. Alma described wanting nothing, just this quiet. I can't explain it to
sleep like a hungry person wanting food; her you. It's the best medicine.
insomnia was a kind of starvation, or another
I asked Alma that evening whether she was
kind of withdrawal. It had gotten to a point
worried that she'd start using again - if her
where normal patterns of wakefulness and
insomnia would cause her to return to heroin.
sleep no longer made sense or seemed perman-
"Yes ... always," she said. It was always on
ently unavailable to her. During the hours that
her mind.
preceded her departure from the clinic, Alma
said her mind started "playing tricks":
her ancestors and her parents- losses she in- Biehl, Joao
herited, and reaffirms, in death. 2005 Vita: Life in a Zone of Social Abandon-
In this essay, I have tried to show how Al- ment. Berkeley: University of California Press.
ma's need to forget was made to cohere through Borges, Jorge Luis
a multiplicity of losses, memories, injections, 1998 Collected Fictions. New York: Penguin
places, institutions, and practices. This multi- Putnam.
plicity produced a new dimension of chronic in Brewer, D. D.
which Alma felt herself irrevocably tied. The 1998 Drug Use Predictors of Partner Violence
in Opiate Dependent Women. Violence Vice 13
connection between feelings of endlessness,
(2):107-15.
medical notions of chronicity and relapse, and
Butler, Judith
juridical categories and responses to recidivism
2004 Precarious Life: The Powers of
are more than metaphorical. They are cocon-
Mourning and Violence. London: Verso.
stitutive. Here, feelings of endlessness give rise Cami,Jordi
to heroin use, which lead to forms of interven- 2003 Drug Addiction. New England Journal
tion premised on return. Alma struggled to find of Medicine 348(10):375-86.
a way out, but the promise of rebirth, like the Cheng, Anne Anlin
work of "recovery," was undermined by the 2001 The Melancholy of Race. New York:
powerful presupposition of return that was Oxford University Press.
always already in place. Cioran, Emil M.
1992 Anathemas and Admiration. London:
Quartet.
NOTES Cohen, Lawrence
1999 Where It Huns: Indian Material for
1 In this essay, I use the term Hispano to refer to an Ethics of Organ Transplantation. Special
the Spanish-speaking people of northern New Issue, "Bioethics and Beyond," Daedalus 128
Mexico, many of whom trace their ancestries (4):135-65.
back to the region's original Spanish settlers. Das, Veena
They thus consider themselves Hispano or 1996 Language and Body: Transactions in the
Spanish. Construction of Pain. Daedalus 125:67-92.
2 See Office of Applied Studies, U.S. Depart- Das, Veena, and Arthur Kleinman
ment of Health and Human Services 2005. 2000 The Act of Witnessing: Violence, Poi-
Treatment Episode Data Set (TEDS): 2002. sonous Knowledge, and Subjectivity. In Vio-
Discharges from Substance Abuse Treatment lence and Subjectivty. Veena Das, Arthur
Services (OASIS Series S-25, DHHS Publica- Kleinman, Mamphela Ramphele, and Pamela
tion No. (SMA) 04-3967). Rockville, MD: Reynolds, eds. Pp. 205-55. Berkeley: Univer-
Substance Abuse Mental Health Services Ad- sity of California Press.
ministration. Retrieved on 10/10/07 from 2001 Introduction. In Remaking a World:
http://wwwdasis.samhsa.gov/teds02/ Violence, Social Suffering, and Recovery. Veena
2002_teds_rpt_d. pdf. Das, Arthur Kleinman, Mamphela Ramphele,
and Pamela Reynolds, eds. Pp. 1-30. Berkeley:
University of California Press.
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Tavistock Group 440-1, 443,444,446, Dr. S. 300-1, 303, 304, 307, 309, 310-11,
447n14 315,316-17
Taylor, Charles 65, 75n1, 79-80, 162, 484 green card regulation 312
Tellenbach, H. 109 hemodialysis center 312
Terry, Fiona 492 insurance system 306
testimony 461-2, 463 Istanbul and cadaveric donation 306-8
tetracycline 431, 434 kinship defined 305
Thackray, Arnold 89n1 launching kidney transplantation 304-6
Thailand, mot luuk (uterus) problems in 392, Ministry and politics of organ sharing 308-9
422-36 privatization 307, 309-12, 316
theodicy 10 Turkle, Sherry 218
therapeutic emplonnent 81, 121-36 Turner, Victor 10-11, 26-37, 90n7, 91
creating stories in time 123-5 Tuskegee Syphilis Study 437-8, 439, 446,
four plot structures 122 447n1
narrative time in clinic 126-7 Twelve Step model of recovery 528
tour of hospital 126-8 Tzintzuntzan (Mexico) 397
therapeutic groups 410
Theweleit, Klaus 298n8 UchiteJle-Pierce, B. 513
Thomas, Lewis 441 Ugandan AIDS study 438-40
Thompson, E. P. 160 Ukraine, Chernobyl-exposed populations 178,
Ticktin, Mirian 179, 260n8, 260n9, 507, 516 199-212
see also chapter 20 United Nations Development Program 486-7
tissue culture 334, 353-66 United Nations High Commissioner for
Tobin, G. A. 412 Refugees (UNHCR) 505, 509, 512
Toch,Hans 197n15 United States
Tomes, Nancy 441, 448n19 -aided health programs 394-6
Tooker, Deborah E. 75 bodily cleanliness 53
Torrey, E. Fuller 104-5, 403 and cosmopolitan medicine 61
torture 153-4, 487-9 and Haiti 485-6, 487,489-90
Towghi, F. 412 heroin addiction among Hispano
traditional healers 396, 397, 402-3 people 4 71, 522-39
traditional medicine, use of term 59 history of HeLa cell line 353-66
transmission, hypothesis of 16, 17 homeless mentally ill 81, 160-74
transnational institutions 413 medical imaginary and biotechnichal
transnationalism 405-6 embrace 272-81
Transplantation of Human Organs Act 1994 Salvadoran refugees 143-59
(India) 285, 288, 295, 296 surplus health in 386-7
trauma unwitcher 68
brokers 490, 506-7, 517 USAID 489
occult economies of 470, 484,492 US Committee for Refugees 147
political economy of in Haiti 470, 481-95 US Congress 489
portfolio 484, 485, 492 Uz, Naci 308
Salvadoran refugees 152-5
treatment programs 484 Valdez, R. B. 427
see also suffering values 53
traumatic citizenship 193, 491 van der Geest, S. 410, 411, 414
Traweek, Sharon 333 van der Hart, Onno 152
Trostle, J. 407, 410 van der Kolk, Bessel A. 152
Tsing, Anna 216 van der Leeuw, Gerardus 101
tuberculosis (TB) 328, 329, 398, 407-8, 412 Van Hollen, Cecilia 286, 298n5, 298n6,
and medical ethics 442, 443, 446, 447 298n7,298n9
Turkey, organ trafficking in 267, 300-18 Van Loon, F. G. H. 475
and crime 302, 303, 311 Varmus, Harold 274
INDEX 559