Affliction: Health, Disease, Poverty
by Veena Das
Fordham University Press, 2014. 255 pages
In Affliction: Health, Disease, Poverty (Fordham 2014) we listen with Veena Das to ordinary ethics in challenged lives of poverty, illness, and family relations; and in three often conflicting registers of (a) advocacy, (b) moral engagement, and (c) acknowledgement of inherent uncertainties (in the very fabric of living these lives, including hers and ours). 
(1) Advocacy. Somewhere – in the vast practical and dramatic spaces – between the disconnects of global health models constructed with poor/flawed statistics and piecemeal moralistic nudging of behavioral economists relying on naïve individualistic psychological models rather than intimate knowledge of how lives are lived — somewhere in this vast multi-dimensional space of living lies the ethnographic task that for the last fourteen years Veena Das’ band of researchers has pursued in the hopes of producing anthropological evidence of another kind, “of the kind that could be used for serious advocacy on sanitation, health care, or everyday violence.”
Advocacy is troubled and troubling terrain. In cases of cancer clusters, citizens often were told that they were incompetent to distinguish coincidence and statistical significance, meaning, in environments of sequestered information, as are so many of our corporatized and legally defended environments from Bhopal to Woburn, Love Canal to Fukushima, in such environments citizen science had to learn to gather epidemiological knowledge that would stand up in court and survive cross-examination. In the case of U.S. Superfund legislation passed in 1980, citizen action panels were given money to hire independent experts. In the aftermath of Bhopal, Right to Know legislation was passed in the U.S., and later in India. In terrains of proprietary knowledge, government statistics not made public, and other forms of sequestering knowledge, especially in worlds of metrics and audits that stand in for, and constitute, legally defensible knowledge, experiential knowledge of the sort anthropological tools reveal often have a hard time.
There are at least two critical and effective tools however that anthropology wields: (a) exposing to the light the ways in which bureaucratized statistics and models lie, hide reality, are made up, or are tissues of unrealistic extrapolations. Veena treads carefully in this terrain, referring occasionally to celebrity projects like MIT’s Poverty Action Lab, proposing her own Standardized Patient methodology (to which I will return) as a way, a metric even: visits to 305 practitioners (926 visits), for three common diseases, presented by 22 simulated standardized patients; a weekly morbidity survey of 300 households (with 1,620 individuals participating. and a refusal rate of less than 1%), done weekly for 17-18 weeks, then monthly; detailed interviews with at least one and ideally all members of each household; a full day spent in each of 291 practitioners’ clinics. This was done not just to expose poor quality medicine, but also positively as a pedagogy (teaching how to articulate disease diagnostic symptoms in vernacularly recognized ways). (b) The second anthropological tool is powerfully staging the living realities of life. Anthropology often operates like the theater: putting characters and plots on stage that illustrate competing interests, affects, emotions, idioms, strategic ploys, conflicts, and temporary tragedies and resolutions. Veena does this skillfully, and, as she warns, not for its sentimental persuasive value, not just cultivating unmediated sympathy or empathy – she repeats this several times – but in pursuit of calling the community, politicians, policy-makers, experts alike from everyday trance-like forgetfulness into awareness. The challenge she notes a number of times following Emmanuel Levinas, (or Stanley Cavell’s reading of Levinas), that the problem is rarely just attending to the face of the other, but in a world of competing obligations to the living, the dead and the dying, learning how to suffer separation from the other, limiting the desire for infinite responsibility, allowing a person, an attachment to life, space to breathe. At times, as in the case of Bilu who blames himself for not being able to gather the resources for his brother’s kidney transplant in time, a possibility that would have suffocated his own life and that of his new son with debts and on-going demands for immuno-suppressants and other life supports, this is a story of individuation, but at other times it is a cycling through one’s contesting (almost Kantian) faculties of (i) the courtroom (the accusatory voices of obligations one is unable to fulfill); (ii) the artisanal workshop (the cultivation and care of the self in traditionally given virtues); and (iii) the laboratory (the experimental innovation of new plotlines for one’s own life and one’s consociates). Here is Ordinary Ethics, but of the most profound sort, scenes of instruction that should make the distanced policy-maker see anew, differently, come out of the trance of rules, excuses, and impossibilites for helping those in need.
(2) Ethics. Among the virtues of India amidst the poverty, conflicts, and crowding is its vitality as a land of philosophy, not just in its ancient civilizational roots in conversation with the Greeks and Chinese, but in contemporary life, affording a diversity of “scenes” of profound “ordinary ethics” in engagements with illness, access, quality of care, the technological, and the psycho-spiritual webs of relational socialities. Das’ text is structured roughly like Wittgenstein’s Philosophical Investigations, moving through “scenes of instruction” are arranged in pairs and triads of increasing complexity, not unlike Laura Bohanan’s classic and ingeniously structured Return to Laughter.
The theaters of ordinary ethics are modern, contemporary productions, staged within the folds and social stressors of urban renewal-removal after communal riots, structural violence of rural-urban migrants living with low-income and education, unattended-to illnesses and family tensions, dispensaries that give out Tetracycline no matter what your illness because that’s all they have been supplied with this month. The theaters of ordinary ethics are both performative (acting out, fusing together visceral-emotional and cognitive-moral poles of understanding) and enchanted with modernity’s extravagant promises, for instance of commodities for which one only can manage the down-payment but then must sell or have repossessed; and of capacities for which one struggles, only to get beginners’ incomplete schooling. Sometimes these promises are fulfilled enough to keep hopes and fantasies alive. Sometimes they are fulfilled only enough to generate dreams, visions, ghosts, jinn, bhot and pretu, generated — as the double-binds of Bilu’s life dramatize — by what Veena calls “the pressure on thought.” These pressures on thought are “something other than rational argumentation, not simply emotion or empathy, but wakefulness,” a state Bilu reaches in terms of his duty to his son.
It is a beautiful case or scene of instruction, a case of choices between circles of obligation expanding infinitely in Bilu’s quest to make a kidney transplantation for his brother possible versus circles of obligation narrowed instead by saturating his immediate surroundings with care and love that make it livable. He is able to achieve this narrowed focus, only with great pain and continuing “post traumatic stress,” through the woman in white who comes in dreams or visions to call him first to his responsibility to care for his village (widening his circles of obligation), but then later (narrowing them) only to his new born son. She has granted his devotional prayers for a new son after the loss of an earlier one, but on condition of his absolute devotion to that gift. The pressures of interpreting visions, dread, panic, full of dilemmas of error, misinterpretations, false leads, satanic confusions, visions expressing dark drives – these all are part of the dramatic tension of the enchanted theaters of ordinary life, of the pressures of thought, the social stressors of impossible double-binds and obligations.
(3) Contradictions and Ambi-valences. Amidst the desire for “a theology of suffering,” with terms such as “soul”, and a troubling anti-consequentialist Bhagvad Gita maxim (“you have authority only over your action, never over the consequences”, which Veena reads in a comforting Levinasian mode of limiting infinite responsibilities, but which sounds uncomfortably close to the warrior Krishna’s self-justification in war or the urgency used in self-justification of humanitarian aid industries for pushing aside local capacity building), Veena’s text registers “emotional and intellectual frictions,” cycling through internal voices of the accusatory other, invocations of traditional virtues, and demands for innovation attuned to present needs. Irresolvabilities structure these scenes of ordinary ethics: (i) limiting the desire for infinite responsibility; (ii) finding quality care, not just access to care; (iii) acknowledging voices this side of mental illness (“My problem is not that I am ill”; “But Aunty, I was not the one who was ill.”) ‘Hard to tell what is Shaytanic confusion’ in worlds where things are not always as they seem (dunya nadeedani).
Indeed it is a truth of parables in many traditions (Fischer 1990:110; Jain parables; and Musa-Khizr stories in Islam) that things are not always as they seem. This is a truth, as well, of psychoanalysis and counseling, of medical practitioners who attend to the corporeal demands of hope and spiritual distress (Hyun 2013), of the unseen world in its many dimensions.
Veena deals with these in a series of “scenes of instruction” built around nine main figures. The opening two scenes are of failures of quality of care, each complicated by a structural aporia of imposed not knowing. The next three are further complicated by family dynamics. This is intensified in the sixth and seventh of classic family systems dynamics in which a child is designated to be the problematic figure of failure or distress, but of course without knowing if there is also a genetic or physiological cause. The last and most elaborate is of the play of forces – psychic, social, political, economic, seen and unseen causes and influences – that make interpretation dangerous, and like the philosophical pharmakon, potentially poisonous rather than healing.
The first scene of instruction is a story of a four year old child who died from a fall and head injury but was misdiagnosed in hospital with an X-ray, and only correctly diagnosed with a CT scan too late to do anything. A technician had told the parents a CT scan was needed, but the doctor in the first hospital responded to them, “are you the doctor or am I?” It is a story used first to draw attention to how the poor are treated in hospitals, but also then to raise the question about the different idioms in which husbands and wives express emotion after “cumulative adverse reproductive events (miscarriages, abortions, still births, child deaths).”
In the second story, Ballo, who complains of stomach ache, weakness, lack of appetite and a heart condition or perhaps tuberculosis (dil ke bimari, ya shayad TB), gets medicines intermittently whenever her son would go to the chemist and present old prescriptions for viral hepatitis, liver function, or TB. Bad enough the old prescriptions, the lack of contact with a doctor, the intermittency of taking courses of drugs; but underlying all, says Veena, was the demand of the sixty year old woman for more attention from her son and his wife. She would periodically return from town to visit her daughter’s village to display displeasure at her son.
The third scene of instruction becomes more complicated. Prakash is a periodically hallucination-suffering, shivering old man who refuses to wear even a newly purchased sweater because he can smell a Muslim in it. His hallucinations, for which he was hospitalized already once forty years ago, obsessively repeat an abduction by Allah, during the grip of which Prakash speaks in a high feminized voice, claiming love of Allah and fatal attraction for Islam, from which he is saved by Shiva. Like Shiva, he can become violent. Released from the hospital he lives with the widow of his younger brother and her now adult son. This arrangement is imposed upon the widow by her biradari (kin group) who insist she have a male guardian in the house, never mind mentally impaired. She manages him with lithium and sleeping pills. Life in this scene is complicated by family and hallucinations.
In a fourth scene of instruction, Meena dies of TB after having successfully completed several courses of TB-DOTS treatment, each time being declared cured. A relative gets her admitted to a hospital as a dependent, and another helps her get into a treatment center under a false name to avoid regulations against going to treatment clinics beyond one’s local zone. A physician told Veena, there was no point testing for multi-drug resistant TB since they could not treat that. Meena died after much seeking of care, leaving her family saddled with debts, and having negotiated much anxiety that her husband would leave her for a woman he was having an affair with. There was no way to know if she was repeatedly re-infected because of compromised immunity, environmental factors, concomitant HIV infection, or whether she was infected by an acquired or transmitted drug resistant strain. Meanwhile the records of each DOTS center classified her as cured case, and all together she counts in the official statistics as multiple cured cases.
The fifth scene of instruction involves children covering up for their patents. Meena’s son Mukesh, an 8-12 year old during the fieldwork, covers for the dysfunctional relation of his parents, his mother’s descent into illness, her fear of being sent away, and her refusal of her medications when angry with her husband. His story is paired with that of a young girl who tells the police that her mother’s death by kerosene was an accident, and is praised in the neighborhood for the “correct response”. Meena before her death tried to support Mukesh’s education, with the help also of Veena, but after Meena’s death the new stepmother, whom the father gives the first wife’s name, is not so supportive. Still, when Veena meets Mukesh again a few years later, his smattering of English has gained him a job, a watch, and a practice of attending church, where he finds a sense of peace unlike, he says, the jostling in a Hindu temple).
A sixth scene of instruction is that a brother and sister with different life outcomes. Swapan [“Dream”], a twenty-year old migrant from Multan, a Dalit (or untouchable), who suffers an unsupportive family environment, in which his sister succeeds at education, while he fails. He is undermined by his mother and becomes designated as the problem child. He says to Veena, “My problem is not that I am mad. My problem is that no one takes interest in me.” But while he has moments of lucidity like this, he also, less strong than his sister Vayda, really is driven to the verge of madness, having bouts of rage, acting out, defecating on the floor, beating his mother, and eventually after a stay in a psychiatric hospital, trying to master the world by memorizing the English dictionary, a key he thinks to power. Experiencing “illusory qualities of modernity” always out of reach, He stumbles through life “as if made into a ghost.” This scene of instruction, of a splitting of the mother into good and bad mothers sounds Kleinian or Bion(ian) or Kali-like, and offers a possible opening to building upon the psychoanalytic accounts of mental illness in South Asia pioneered by Gananath Obeysekere, Alex Roland, and others. Abandonment in these stories is not so much an act of the will resulting from choice, but rather an exhaustion of the will and the capacity to marshal yet more energy. Swapan’s mother says her son has remade his own mother into a demonic being who could wish death upon the son she had borne. Here actors are not transparent to themselves, and the pursuit of the moral within such scenes of trancelike everyday ordinary ethics is analogous to being called to awaken from forgetfulness.
Vidya [“Knowledge”], by contrast, is quite aware of her family systems role as the overly bright girl under such close supervision that, were she less strong, would make her ill like her brother Swapan. Subbornly insisting on studying against internal family pressures, she becomes withdrawn and is taken for psychiatric treatment. Vidya says to Veena, “But Aunty, I was not the one who was ill – it is my Father who needs treatment . . . my Father has created such a situation that every one was watching me all the.” And she succeeded, if not all the way to college, still to a clerical job and steady income.
The most elaborate scene of instruction is that of the Muslim healer, Hafiz Mian, with whom Veena shares her own dream of dread, of being on a train helping protect an Indian nationalist terrorist disguised as a Sikh who is being tracked down by British soldiers on the train. The psychological “I” of the dream is a young woman, who Veena says doesn’t really physically look like her, whose job it is to distract the soldiers. The dread would seem to be easily explained, to this observer, as a reflection of Veena’s work with Sikh and other victims of the riots after Indira Gandhi’s assassination, and her continued work in low-income neighborhoods suffering further structural violence. In her story, however, Veena claims to be “bewildered” by the dream. Hafiz Mian cautions her that she should not tell dreams to just anyone because they could have dangerous effects, transforming what is latent and hidden into manifest realit, and he significantly asks if in the dream she had seen the revolutionary or the British soldiers, and she realizes she had not. Dreams, he says, are only partly about images, what you see, but primarily about what you sense, dread in this case, and dream interpretation is always subject to misrecognition, and to be mislead by shaitan. The term shaitan, of course, has different registers. It too often is translated by what in Christian imagery is called Satan, a fallen angel and figure of intentional evil, like the Zoroastrian Ahriman. But shaitan is also used of mischievous little boys, a jokstering misdirection, not necessarily evil. In dream interpretation, therefore, it can be various forms of error, of misrecognition, of false cues or leads. And so, Veena’s anxiety about misrepresenting the vujud, the essence, the real truth, of the people she only comes to know partially through ethnographic fieldwork, is a burden that Hafiz Mian also lays out as the burden of a healer who is always dealing with the hidden, that shadows the manifest: the unspoken desires and motivations unknown even to the afflicted themselves.”
Conclusions. The anthropological advice/advocacy in theaters of ordinary ethics under conditions of contradiction and ambivalence are perhaps like risk scenarios used to prepare community workers and outside aid workers for many and often changing situations. But more powerfully, they also call for real investment in education and local economies, maybe even in local shrines where hope and spiritual distress are mediated, perhaps a Dalit Peace Corps with Fab Labs and entrepreneurial incubators, putting tools in community hands, for self-repair rather than for fantasies of being saved by knowing outsiders. It is a prescription for a “necessary theater” (I take the name from an important local theater group in Singapore) that no doubt will come with much pushback and conflict of interests invested in reserve labor pools, cheap wages, unorganized and sequestered knowledge. Veena Das’ book, Affliction: Health, Disease, Poverty provides an important, ethnographically powerful, laddering of scenes of instruction for us all.
Michael M.J. Fischer is Andrew W. Mellon Professor in the Humanities and Professor of Anthropology and Science and Technology Studies at MIT, and Lecturer in the Department of Global Health and Social Medicine at the Harvard Medical School. He is a co-editor with Byron Good, Sarah Willen, and Mary-Jo DelVecchio Good of A Reader in Medical Anthropology: Theoretical Trajectories, Emergent Realities (2010); and author of Anthropological Futures (2009), Emergent Forms of Life and the Anthropological Voice (2003); (with George Marcus) Anthropological as Cultural Critique (1986, 2nd ed 1999); Mute Dreams, Blind Owls, and Dispersed Knowledges: Persian Poesis in the Transnational Circuitry (2004); (with Mehdi Abedi) Debating Muslims: Cultural Dialogues between Tradition and Modernity (1990); and Iran: From Religious Dispute to Revolution (1980). He is currently in Singapore doing fieldwork on Biopolis and the life sciences, the aging society, global university reform, and the arts.
Das, Veena. 2014. Affliction. New York: Fordham University Press.
Das, Veena. 2013. “Ordinary Ethics.” in Didier Fassin, ed., A Companion to Moral Anthropology. New York: Wiley-Blackwell.
Fischer, Michael M.J. 1990. Debating Muslims: Cultural Dialogues in Postmodernity and Tradition. Madison: Univeristy of Wisconsin Press.
Hyun, Insoo. 2013. “Therapeutic Hope, Spiritual Distress, and the Problem of Stem Cell Tourism. Cell Stem Cell, 12 (May 2): 506-507.
 Orally presented at the American Anthropological Association meetings in Washington D.C., 4 December, 2014, as part of a panel, “Affliction: a discussion with Veena Das,” organized by Clara Han with Veena Das as respondant.
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