For this installment of the Top of the heap we spoke to Warwick Anderson, Professor at the Department of History and Centre for Values, Ethics and the Law in Medicine at the University of Sydney, and an Australian Research Council Laureate Fellow.
Having written provocatively—and somewhat irritatingly, it seems—on the impossible history of global health already this year, perhaps I should wait till the dust settles before broaching the topic again. But in a time of Ebola, that obscure object called global health demands further critical attention. We need to know what to expect from global health in the current emergency. Accordingly, over the past few weeks I’ve set about reading, and reading again, some recent books that might come under the rubric of global health history. In general, I’ve found that the most compelling accounts of global health manage to localize medical interventions: they examine the messy and often confusing, even conflicted, interactions of foreign doctors and aid-workers, domestic and traditional health practitioners, and their patients. No surprise, then, that historically sensitive anthropologists, rather than medical historians, have written many of the more plausible of these situated narratives. An ethnographic sensibility appears to be a requirement for understanding global health—for explaining its past as well as contemporary forms. I’m also struck by the prevalence of “crisis” in the discourse of global health, whether in reference to humanitarian crises or biosecurity crises. Thus the acute timescale of global health (which often proves more rhetorical than practical) seems distinct from the chronicity of late-colonial medicine, and other programs of development and modernization—indeed, from normal public health. Perhaps those who are anthropologically minded can deal better with “crisis talk” than most historians.
If recent case studies are a reliable guide, then Africa has emerged as a sort of laboratory for global health. In the late-nineteenth century, Henry M. Stanley (1878) described his journeys through the “dark continent”; but in the 1980s, Africa became known as the “sick continent”—Gwyn Prins in 1989 must have been among the first scholars to use the term. The obvious prompt was the HIV/AIDS epidemic ravaging African societies. All the books I’ve read over the past few weeks imply that global AIDS became the major incitement to global health—and Africa was regarded as the seedbed and prime grounding for AIDS. Of course, a few telling supplements to the African global health story are now emerging to complicate it, especially studies like Elizabeth F.S. Roberts’ God’s Laboratory (2012), located in Ecuador, and Alice Street’s forthcoming Biomedicine in an Unstable Place (2014), set in Papua New Guinea. One might even re-interpret Paul Farmer’s early work on Haiti as providing an alternative Caribbean story for global health. But Africa evidently is global health’s hot zone.
In just a few years, Julie Livingston’s Improvising Medicine (2012) has become a classic among studies of global health. As most readers of Somatosphere are aware, Livingston, trained as a historian, describes movingly the conditions of life and death on Botswana’s sole dedicated cancer ward—the chapter on the moral intimacies of nursing care is stunning. Writing in the aftermath of AIDS, she uses ethnography to complicate facile diffusionist or triumphalist accounts of global health: this is not, she tells us, one of those “tales of redemption via biomedicine that make up the fantasies of global health” (p. x). And yet, she concludes, the cancer ward is nonetheless “an instantiation of global health” (p. 181), perhaps in the very failure of its sovereign claims. For me, however, Livingston’s interruptions to address North American and European readers, to appeal to their sensitivities, mar this excellent evocation of global health’s decomposition in Africa. Despite this redolence of Margaret Mead, Improvising Medicine brilliantly shows us how ethnography can contribute to the postcolonial critique of the ambitions –and hubris- of global health. It therefore sits on my bookshelf next to Clare Wendland’s A Heart for the Work (2010), that revealing ethnography of a Malawian medical school.
Stacey A. Langwick in Bodies, Politics, and African Healing (2011) engages with the “postcolonial ontological politics” of medical experts and their patients in Tanzania. Her study of the interaction of traditional and modern medicine makes visible a range of new entities, from “enchanted parasites” to “biomedical devils” (p. 7). Drawing artfully on postcolonial science studies, Langwick demonstrates the continuing colonial shaping of hybrid healing practices in East Africa, thereby complicating and challenging notions of global health. The word “colonial” appears in this book far more frequently than “global.” In Scrambling for Africa (2013), Johanna Tayloe Crane takes even further the postcolonial critique of the supposedly laminar flows of global health. In this extraordinary transnational ethnography of Ugandan AIDS clinics and medical laboratories in San Francisco and Seattle, Crane shows how global health programs extract value from neocolonial structural inequalities. Disease-centered global health projects can displace and thus cripple local public health systems. North American universities divide up Africa as they scramble for “clinical material” for their global health programs. While not discounting the good that comes from many interventions, Crane reveals the dark side of North American and European humanitarianism.
Many of the anthropologists who contributed to Ruth J. Prince’s and Rebecca Marsland’s edited collection, The Making and Unmaking of Public Health in Africa (2013), also argue that public health must be studied on the ground, not through the sovereign telescope of global health. Too often, Prince explains in her introduction, from that distant viewpoint estimates of health are “reduced to survival needs, and public health care provision is reduced to a technologically driven humanitarian intervention” (p. 31). Prince explicitly criticizes what is sometimes a “pharmaceutical paradigm of health” (p. 33). In contrast, these critical studies of the terrain of public health in Africa trace the legacies of colonialism, developmentalism, and modernization theory. Another collection of essays, Global Health in Africa (2013), edited by Tamara Giles-Vernick and James L.A. Webb, Jr., also addresses the colonial antecedents of global health and emphasizes the impact of the AIDS epidemic—but I expect its functional tone will prove far more appealing to global health faculty and students in U.S. medical schools.
In Life in Crisis (2013), anthropologist Peter Redfield recounts sympathetically the history of Médecins sans Frontières since its foundation in 1971, post-Biafra. His book is an ethnographic Bildungsroman: it is the story of the self-formation of a global humanitarian organization, the growth and institutional condensation of a worldwide emergency sensibility. Redfield uses this story to examine globalization on the ground in Africa. He tries to subvert the view from the Land Cruiser as much as the view from Paris. At one point he asks if MSF’s prized mobility had fostered disconnection from the devastated communities it serves: “Had MSF simply devolved into a neocolonial enterprise?” (p. 133). Redfield charts the painful steps that its staff took toward “decolonization” early in this century, the hard-won benefits of interrogating and deconstructing colonial legacies.
And now I’m about to turn to Renée Fox’s Doctors Without Borders (2014)….
As you no doubt can tell, my reading over the past two weeks has been as depressing as it is illuminating—particularly in the light of the Ebola epidemic, which is both human tragedy and, increasingly, global health debacle.
Warwick Anderson is an Australian Research Council Laureate Fellow and Professor at the University of Sydney. His most pertinent contribution to what might loosely be called global health history is The Collectors of Lost Souls: Turning Kuru Scientists into Whitemen (Baltimore: Johns Hopkins University Press, 2008). For a recent attempt to use postcolonial studies to reframe global health see “Making Global Health History: The Postcolonial Worldliness of Biomedicine,” Social History of Medicine 27 (2014): 372-84. His book, Intolerant Bodies: A Short History of Autoimmunity (with Ian R. MacKay, Johns Hopkins University Press, 2014) will be the subject of a Somatosphere Book Forum in November.
Image: White Library, Wilfredo Prieto. MONA, Museum of Old and New Art, Hobart, Tasmania, Australia.