Beyond Chronicity and Culpability: Toward A New Ethic of Care

This article is part of the series:

A Commentary on Angela Garcia’s The Pastoral Clinic: Addiction and Dispossession along the Rio Grande
University of California Press, 2010
264 pp., US$ 28.95 (paperback)

In his sprawling and widely lauded novel Infinite Jest, the late David Foster Wallace offers a riveting portrait of modern addiction. Scenes of the banality of Twelve-Step programs drew on Wallace’s own experiences in treatment for alcoholism, which began while he was a student at Amherst College, but his analysis of addiction extends beyond drugs and alcohol—as the thousand-page work progresses, any dichotomy between addict and non-addict the reader may have perceived at its start disintegrates (Max 2009: 1; Wallace 1996). Modernity’s enticements—whether success athletic or academic, pleasure narcotic or cinematic—take hold over each of the book’s characters. At the same time, the book’s central intrigue traces the path of a film, also titled Infinite Jest, which is “lethally entertaining” and “renders anyone who sees it a catatonic infant capable of nothing more than repeated viewing,” to a Quebeçois terrorist group bent on bringing down the current US regime (Wallace 2006: 122). The film melds characters’ varied capacities for addiction into a generalized capacity for self-destruction: the desire to “be fed this death of pleasure with spoons, in their warm homes, alone, unmoving” (Wallace 2006: 318). While Wallace initially provides the reader with a rich understanding of the texture and history of each addict’s life, addictive specificity ultimately coalesces into a narrative about the perils of addiction writ large. Drug addiction is seen as different in degree, but not in kind, from addiction to sex or beauty[1].

Critical reviews in the wake of the book’s release largely reified this generalized perspective on addiction and reframed it as a national clarion call, as epitomized by journalist Patrick Skene Catling’s take: “The central point is that Americans, who cherish a constitutionally guaranteed right to pursue happiness, are pursuing it with addictive avidity that could prove fatal” (Catling 1996: 34). Only later did another angle to Wallace’s conclusion emerge from the critics’ box, one which emphasized the individual agency at the root of the addictive process, and which asserted the following:

We are capable of making choices: of recognizing that substances and entertainment and other habitual compulsions distract us from simple but difficult truths […] of choosing awareness over denial; of reversing our retreat into ourselves; of honoring the reality and necessity of our dependence on each other; of risking connection with other people; and of choosing action over stasis (Carlisle 2007: 486-487).

Wallace’s clearest distillation of this message, a 2005 speech entitled This Is Water, is perhaps his greatest popular legacy.

While Wallace’s depiction of addiction as a near-universal condition is at odds with Angela Garcia’s place-specific ethnographic portrayal of heroin addiction in the New Mexico county with the highest rate of overdose in the country, both recognize and evoke the deep social basis of addiction, “the reality and necessity of our dependence on each other.” It is this social—rather than asocial—element that has long been missing from discussions of addiction, and in this regard both Wallace and Garcia have moved beyond the standard approach. However, Garcia goes further: In her view, “the reality and necessity of our dependence on each other” is not diametrically opposed to addictive practice, but constitutes it. She goes about tracing this process in The Pastoral Clinic.

Garcia’s approach accords with broader shifts in the study of intoxicants. In the archaeology of alcohol, for example, a dominant view of alcohol as pathological, “grounded almost exclusively in the disciplines of biology/medicine, public health, and social psychology,” and which began “with the emergence of the temperance movement in the early nineteenth century” made way in the 1960s for a “focus on alcohol as an integrated social artifact and culturally valued good” (Dietler 2006: 230).  In the case of heroin, where the drug’s addictive potency is so strong, it is easy to assume that the addict experiences a loss of agency from which no meaningful social life can emerge. How quickly we forget that heroin was named for its “heroic” qualities, and that for much of its American history opium was decidedly rooted in mainstream social practice: In the 19th century, “the venerable opium and its many preparations belonged firmly to the pharmacopoeia of regular medicine and were thus generally spurned by ‘irregular’ sectarian practitioners” (Aurin 2000: 419, 418). Despite this history, however, the more recent portrayal of heroin as a drug of the marginal has taken hold of the popular imagination, producing two ways in which heroin use has been conceptualized by broader society, and around which treatment strategies have been forged, in recent years.

According to a first perspective, addiction is a personal problem—not, as Zarathustra spoke, “a most secret affliction of the will,” but an affliction perceived in terms of its relationship to a broader social network (Nietzsche 1964 in Negri 1995: 2).  Addicts are seen as disembedded from the social fabric—even when their ranks are significant and their lives are conducted in legal domains of methadone management, as in Amsterdam in the 1980s[2].  As Dutch physician-philosophers Henk ten Have and Paul Sporken wrote in 1985, in the eyes of their own society, heroin addicts are transgressors because they supposedly deny what it means to be “homo respondens […] one who can be addressed by his fellow man and is responsible to them” (ten Have & Sporken 1985: 176). They continue, “The heroin user seems to be considered as one who rejects these cultural values. He refuses the task of self-actualization; he refuses to contribute positively to society. […] Besides rejection of social relationships, heroin addiction implies a parasitical use of these very relationships” (ten Have & Sporken 1985: 176).

A second perspective places blame for addiction and its attendant harms in the substance itself, which changes the addict’s physiology such that a lifelong struggle with the drug is not only expected but inevitable. This is the view of chronicity, for which Garcia saves her most considered criticism. While a chronic conception of addiction may mitigate some of the blame that resulted from a framework of strict personal responsibility, the cycles of melancholy repetition such a conception predicts—and, in Garcia’s view, creates—may actually compound the pains of addiction. As she eloquently puts it, a chronic label “can indeed counter old, reductionist explanations of behavior or culture and potentially relieve the moral repercussions of ‘relapse.’ But such a framing risks obfuscating other, perhaps more vital dimensions that encompass a local sense of what it is to suffer from an unending condition” (Garcia 2008: 726). Both of these perspectives persist today, embodied by various nodes of the legal system, which either separates addicts from society and penalizes their actions or sequesters them in treatment programs largely resigned to the certainty of relapse.

Garcia’s argument against this medico-legal complex is profound. Ten Have and Sporken, in their day, criticized a plan to provide free heroin for addicts in order to cut down on crime for infringing on addicts’ liberty—their choice to pursue pleasure in the face of potential danger, just as alcoholics, smokers, and mountaineers do—and for co-opting medical professionals into a biopolitical game. Their argumentation implies that to sacrifice addicts as “hopeless cases” and further entrench addiction so as to reduce crime by a small degree is unethical; Garcia further criticizes the relegation of addicts and calls for a new ethic of care. To counter the idea that addicts are asocial, amoral, or deprived by their very condition of social interaction, she illustrates addicts’ social lives—as she puts it, following Wittgenstein’s call to revel in the details and “to attend to the unscripted and the ordinary” (Garcia 2010: 155).

To those unfamiliar with it—to those accustomed to seeing addiction through the stark lens of the medical literature, the maudlin tone of Twelve-Step principles, or the quantitative ponderings of the numerous game-theoretical perspectives on the topic[3]—Garcia’s style will be anathema. Rare are the firm conclusions, bookended with careful qualifications and assumptions, that are so characteristic of academic writing; in their place are “conversations, encounters, recollections, and incidents—between them, between us—[which] form the heart of this book and make it move” (Garcia 2010: 35). The understanding that ethnographic writing (like just about everything in the time-space compression of today’s world) travels at ever-accelerating speed informs the caution with which this book is written; ethnography has been known to wreak havoc, and Garcia’s caution is compounded by accidental complicity (Garcia 2010: 34). The author’s ethic of care goes beyond caution, however; it is a recognition that, despite the uncertainties contained in the fieldwork process, the writing of ethnography presents an opportunity to reassert the human relationships wrought and altered by it. Less a matter of eliding the author’s footprints, less still of immortalizing or lionizing them, Garcia reanimates the paths of her interlocutors with grace, “captur[ing] the[ir] humanity, vulnerability, and hopefulness” (Garcia 2010: 35).

While Marcus Aurin recounts, in painstaking detail, the ways in which apparatuses of power-knowledge have been assembled around opium, casting nets and aspersions over its use, Garcia’s allusions to power are just that—outlines and marginalia that counterpose, but do not provide a completed frame for, the individual narratives she presents (Foucault 1994 in Aurin 2000: 436). In this way, she moves beyond a deterministic historical approach, which Ann Stahl has criticized in the context of archaeology, warning that by “potentially collapsing variability into homogenized holistic models we build in assumptions of persistence[4]” (Stahl 1993: 246). The very diversity of heroin’s moral and medical associations over its hundred-year history that Aurin describes speaks to the need to understand its use in the context of specific temporal and physical settings. A structural approach is problematic in a very different way from the individual responsibility model: it transfers the burden of addiction and the impetus for recovery onto broader historical and structural forces, thus siting the opportunity for change outside of the communities most impacted by addiction. In neglecting the great flexibility of the human relationship with opiates, it limns the steep climb of recovery as even steeper—when in fact this flexibility ought give us hope.

Rather than constructing a textual trap for her subjects along the axes of power—colonial, narcotic, penal—by which their lives are shaped, Garcia’s approach is one that reflects instead the way in which her subjects seek to shape their lives—through resistance to the cycle of treatment, familial ties, suicide, and experiments with new forms of care. These chapter themes provide a loose structure for the book, one that “let[s] things be vulnerable and uncertain” (Garcia 2010, 35). The fact that theory often curbs uncertainty accounts for its sparse mention in this volume, and its considered application where it does appear (Garcia 2010, 35).

As in Paul Farmer’s now-seminal 1996 article on making sense of suffering in contemporary Haiti, The Pastoral Clinic is not about proving that structural violence exists, but about providing a window into the human costs and reclamatory strategies of an addictive landscape (Farmer 1996). Structural factors furnish a backdrop, but do not take center stage: In her article The Elegiac Addict, Garcia’s brief description of New Mexico’s strata of dispossession—first at the hands of Spain, then Mexico, and then the United States—quickly makes way for residents’ own understandings of being “heirs of nothing” (Garcia 2008: 721). Just as Adriana Petryna populates Chernobyl’s surroundings with “sufferers,” individuals who are drawn into the explosion’s aftermath and who stake their citizenship on their dose level, Garcia sketches the painful negotiations of Nuevo Dia’s residents (Petryna 2002). Alma, for example, “was expected to prepare the grounds for her “recovery,” even if the biomedical model of chronicity, on which the clinic’s practices were based, alleged that her condition was, by definition, unending. Embedded in these simultaneously opposed and conspiring worlds, Alma struggled to confirm her existence against their shared presupposition of inevitable return” (Garcia 2008: 720).

Seen in this light, Garcia’s theoretical developments are not neologisms coined for the sake of innovation alone, but cogent encapsulations of the central problems of the text and worthy contributions to anthropology’s conceptual repertoire (Rabinow and Marcus 2008: 48, 52, 70). Her description of Alma’s addiction as “elegiac” evokes both the repetitiveness and the mournful quality of this addict’s life, while, in turn, her pensive return to “certain historical and discursive refrains” mirrors the process of being caught in such a constructed cycle (Garcia 2008: 720). Her borrowing from poetry is apt, for poetry, like Garcia herself, balances a concern for structure with an understanding of the depth and significance of language. Unlike Peter Sacks, who sees in the elegy a search for “consolation” that, in its repetitive structure, “forces the bereaved to accept a loss that she might otherwise refuse,” Garcia finds in this repetition an intensification of mourning (Sacks 1985 in Garcia 2008: 724).

Freud saw melancholy as “mourning without end,” and ironically, in his own Cocaine Papers, prescribed cocaine use for morphine addiction and melancholy alike, denying that it results “merely in the exchange of one kind of addiction for another” with the assertion that the cocaine use would be “only temporary” (Freud in Shannonhouse: xix). Garcia’s own application of melancholy to opiate addiction draws, unsurprisingly, a divergent connection, one that conceives of melancholy as an “open wound” (Garcia 2008: 721). This comparison is richly evocative, simultaneously recalling Pandolfo’s thin line of painful post-colonial reckoning and the physical sites of heroin injection, and it reconstitutes addiction as an embodied process, just as Alma saw it: In advance of her relocation to a halfway house with the mission of helping her “find [her] feet,” Alma joked that “after 15 years of heroin use, she had no feet, only collapsed veins” (Garcia 2008: 731) Alma’s history of addiction was written in a palimpsestic network of scars that ran together with, and saw her trying to outrun, historical loss.

Though not quite as obviously as in the cases of Bernadette and Eugenia and Lisa and Michelle, mother-daughter pairs who used heroin together, this network of scars extended beyond Alma’s own body. In the Espanola Valley, the aforementioned “heirs of nothing” conceive of addiction “as a kind of contemporary ‘inheritance’—an intergenerational and intersubjective experience that accesses, literally, the bloodline” (Garcia 2008: 726). The intergenerational aspect of addiction that Garcia identifies forms the basis for her critique of current treatment approaches. To view addiction as a lifelong condition to be conquered by each affected individual is to reinforce a singularity of human lifespan that is at odds with Garcia’s familial understanding of addictive practice. She impels readers to recognize the interconnectedness between Alma’s “father’s violent despair over the loss of ancestral lands” and Alma’s own turn to drugs and religious conversion (Garcia 2008: 732). Chronicity, if it can be said to exist, does so in the community. Experiments with care, in this context, like Adela Campos’ home detox services, actively grapple with a shared past and present pocked by loss that resists a strictly medicalized or pathological narrative[5] (Garcia 2010: 194).

Garcia recounts one respondent at a question-and-answer session who said “that she could not possibly conceive of a way to gather the myriad issues” contained within Garcia’s talk “into a plan for treatment and prevention” (Garcia 2010: 203). Garcia’s response came later, in the pages of this book:

While it may be true that she and even I cannot conceive of a plan of care that could incorporate all the history, all the losses, this is precisely what families try to do for one another every day. They conceive of ways to care for one another in a context where their very relations, and the very struggle to maintain the everyday, are at stake. Of course, they often fail, and tragically so. But they keep trying to the very end. (Garcia 2010: 203)

This is a notion of care at once blasphemous and decidedly necessary. To paint addiction as antisocial and therefore immune to social mitigation, as has so often been done, casts a cloud of fatalism and futility over the process of recovery. Recovery in the way in which it is conceived in the biological realm must be founded on the recovery of humanity in the specific social realms in which that humanity has been denied. Ethnography can trace the networks of people, words, and symbols built around, through, and despite these denials, reexpanding our compressed (mis)understandings of social phenomena. The Pastoral Clinic gets at the heart of debates unfolding in literature, philosophy, archaeology, and economics about the nature of human engagement with addictive substances—but as addiction becomes all the more ubiquitous, its particularities ought not be forgotten. Indeed, these particularities are precisely what make healing—in its present reality and its hoped-for future forms—possible. Each addictive context shoulders its own stratigraphy of suffering, which can be overlaid but not entirely razed, and which highlights the delicate balance of structure and agency in which all human life hangs.


Lilia Kilburn is an aspiring anthropologist and graduate of Amherst College. Her research into voice modification among American transgender women won the Sylvia Forman Prize from the Association for Feminist Anthropology.


Works Cited

Aurin, Marcus. 2000. “Chasing the Dragon: The Cultural Metamorphosis of Opium in the United States.” In Medical Anthropology Quarterly 14: 414-441.

Becker, Gary S. and Kevin M. Murphy. 1988. “Toward a Rational Theory of Addiction.” In The Journal of Political Economy 96: 675-700.

Biehl, João. 2005. Vita: Life in a Zone of Social Abandonment. Princeton: Princeton University Press.

Byck, Robert. 1974. Cocaine Papers by Sigmund Freud. Edited with an Introduction by Robert Byck. New York: Stonehill.

Carlisle, Greg. 2007. Elegant Complexity: A Study of David Foster Wallace’s Infinite Jest. Los Angeles, CA: SSMG P.

Catling, Patrick S. “Laughing ourselves to death.” The Spectator 20 July 1996: 34.

Dietler, Michael. 2006. “Alcohol: Anthropological/Archaeological Perspectives.” In the Annual Review of Anthropology 35:229-249

Farmer, Paul. 1996. “On Suffering and Structural Violence: A View from Below.” In Daedalus 125: 261-283

Garcia, Angela. 2008. “The Elegiac Addict: History, Chronicity, and the Melancholic Subject.” In Cultural Anthropology 23: 718-746

——–. 2010. The Pastoral Clinic: Addiction and Dispossession along the Rio Grande. Berkeley: University of California Press.

Hayashida, Frances. 2009 “Chicha Histories: Pre-Hispanic brewing in the Andes and the use of Ethnographic and Historical Analogies.” In Drink, Power, and Society in the Andes, edited by Justin Jennings and Brenda J Bowser. Gainesville: University Press of Florida.

Max, D.T. 2009. “The Unfinished: David Foster Wallace’s struggle to surpass Infinite Jest.” In The New Yorker

Negri, Antonio. 1995. “On Gilles Deleuze & Félix Guattari, A Thousand Plateaus,” translated by Charles T. Wolfe. In Graduate Faculty Philosophy Journal 18:2.

Nietzsche, Friedrich. 1991. Thus Spoke Zarathustra. New York: Columbia University Press.

Pandolfo, Stefania. 2000. “The Thin Line of Modernity: Some Moroccan Debates on Subjectivity.” In Questions of Modernity. Minneapolis: University of Minnesota Press.

Petryna, Adriana. 2002. Life Exposed: Biological Citizens after Chernobyl. Princeton: Princeton University Press.

Rabinow, Paul and George Marcus. 2008. “Anthropology Today” and “The Anthropology of the Contemporary.” In Designs for an Anthropology of the Contemporary. Durham, N.C.: Duke University Press, 45-72.

Scheper-Hughes, Nancy. 1992. Death Without Weeping: The Violence of Everyday Life in Brazil. Berkeley: University of California Press.

Shannonhouse, Rebecca. 2003. Under the Influence: The Literature of Addiction. New York: Modern Library.

Stahl, Ann. 1993. “Concepts of time and approaches to analogical reasoning in historical perspective.” In American Antiquity 58: 235-260.

Wallace, David Foster. 1996 (2006). Infinite Jest. New York: Little, Brown.

[1] Or killing neighbors’ pets—another addictive pattern Wallace, most disconcertingly, portrays.

[2] When ten Have and Sporken wrote, the population of heroin addicts in Amsterdam numbered at least 10,000, and the biopolitical question of how to control this population was a subject of frequent debate (ten Have & Sporken, 173).

[3] Indeed, the fact that economic perspectives on addiction see the application of “rationality” to the matter as so very novel speaks to just how decontextualized the public discourse on addiction has been from the lives of individual addicts. The economic approach often demystifies the experience of addiction for just a moment, before concealing it again behind a veil of equations.

[4] Archaeologist Frances Hayashida has applied this criticism to her study of a very different intoxicant, chicha, or corn beer, which is the center of a complex Andean ritual context and was the subject of many colonial attempts at extirpation. She writes that in determining where to draw analogies between various ethnographic and archaeological sources, we must “question rather than assume the persistence of traditions, thus avoiding the construction of ‘pastiche’ histories”—a point I found instructive in considering Garcia’s work (Hayashida 2009: 239).

[5] In, I might add, very much the same way as Biehl retraces Catarina’s path to Vita, her zone of social abandonment, and progressively de-estranges Catarina’s condition and her life from the reader (and even, in some cases, from Catarina herself) (Biehl 2002).


Image credit: Hiroshi Sugimoto. Polarized Color 032, 2010.

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