Editor’s note: in the following author discussion, the authors of the books reviewed in this forum respond to a series of questions and, in the indented text, to one another’s responses as well.
1. One of the themes that emerges across these three books is the importance of labor within global health orders in Africa. The forms that work takes often cuts across distinctions between volunteering, menial labor, and professional career. How do you see your book contributing to the understanding of the labor of global health work?
Biruk: From its earliest conception, I knew my book project was mostly going to be about Malawian data collectors, whose labor on the front lines of such projects is crucial to the production of high-quality data. In archival documents and into the present, African data collectors are cast as interchangeable cogs in a larger research machinery. Their contributions to knowledge projects have been minimized by accounts that center western scientists, and they have long been viewed with racialized suspicion, as potential liabilities who might fabricate data, for instance. Across the middle three chapters of my book, I counter this mythology by showing that standards of data collection make stability and fixity in numerical representation possible, not despite, but because of, the negotiations, improvisations and knowledge – the labor – of Malawian fieldworkers. I also show how these projects become a platform for potential economic and social mobility for fieldworkers who cobble together serial research jobs that in an ad-hoc livelihood strategy they call “living project to project.” I hope my work contributes to a growing literature on “middle men” or minor actors, past and present, that adds nuance to narrations of science and medicine that focus in bipolar fashion on Northern researchers and target populations, with little attention to the individuals who build contingent and fragile relations between them, who do the work of connecting science to its contexts. I am excited by recent work that brings new depth to theorizations of labor by illustrating how the fetishization of and demand for data reconfigures local economies, regimes of value, social worlds, and subject positions.
Tousignant: I think all three of our books work on prying open and thickening out this substantial and crucial “middle” space of labor and life between the positions of greatest decision-making and resource- mobilising power almost always located in the North (whether White male doctors and scientists or the many other actors — health economists for example! — who orchestrate and regulate what flows from universities and funders and so on) and “target” bodies and communities in the South. And I hope by showing what a huge and lively space it is, we encourage others to keep engaging with it, whether as ethnographers and historians or as practitioners and policymakers.
McKay: For me, centering questions of labor and work were a way of trying to undo the notion of global health as something distinct and bounded. Instead, work draws attention to how a wide array of actors, practices, and objects are brought into relation at a particular historical moment. In particular, I tried to make three broad points about global health labor. The first was informed by feminist STS approaches that have emphasized care as a set of practices, rather than moral orientations, that not only destabilize but also exist together with and reinforce forms of racialized and gendered inequality and domination. Second, I argue that global health projects “work” in part by constituting and relying upon forms of labor that are simultaneously rendered external to them. This externalization often happens through distinctions between paid and unpaid labor – for instance, the central role played by “family” or “community” caregivers in efforts to justify relatively narrow forms of intervention or to speak to the sustainability of projects. It also happens through distinctions between paid/ formal employees and volunteers, and between global health workers (often expatriates) and national health employees. Finally, I was interested in how professional labor categories, especially professional medical and academic hierarchies, come to overlap with other hierarchies, especially of race, class, and/or national origin. Sometimes the hierarchies overlap in obvious ways – for instance, when differences in professional qualifications are used to justify inequalities of pay or employment that also overlap with racialized difference, difference in national origin, and difference in employer (NGOs “vs” the state). One frequent example would be foreign and NGO-employed doctors earning more than public employees in the National Health System. But sometimes these relations unfold less predictably; those same foreign doctors might be less skilled in terms of language ability and therefore might rely on nurses, counselors, administrative staff, and other clinic employees or volunteers to translate for them. Here, status within professional hierarchies and inequalities in national identity were also articulated through a comfort with certain kinds of incompetence or inability. Attending to labor, for me, was a way of asking who is actually doing the work of caring for patients, at what expense, and with what skills, without allowing professional hierarchies to circumscribe those answers.
Biruk: I really appreciate Ramah’s discussion of work here as inclusive of that which global health projects render outside of or external to themselves. In this regard, the work done by volunteers, or by local doctors and nurses who translate in the clinic for foreign doctors who do not speak a local language, is not merely obscured or overlooked or undercompensated by projects (though these things are true). instead, it is constitutive of those projects–they would not exist without it. Your insights here about the ways (certain kinds of) INcompetence or INability paradoxically become associated with status are helpful for thinking about how and why certain skills, capacities, and forms of care become valued and legible and others invisibilized in global health infrastructures. As I read this section, I was reminded of how the fieldworkers I spent time with often gave poor research participants gifts from their own pocket (even money). Not only is this an unscripted and adhoc form of care; it also does important work in connecting projects to their contexts. Yet, on the whole, the labor of fieldworkers is minimized relative to foreign researchers, who are granted a kind of implicit moral goodness for working on African health.
Tousignant: Externalisation is a hugely important point, both historically (the ways in which the migrant labor system for example left the burden of reproduction and care to mostly women, as shown among others by Packard’s classic White Plague, Black Labour) and with the neoliberal turn to “participatory” endeavours in development, health and public services in general (for example in trash collection, see Frederick’s Garbage Citizenship).
Tousignant: Labor is a crucial issue for those “doing” global health and I’m glad to see more and more work, like the books in this forum, addressing it (and them, the workers) seriously. What I think my book contributes are classic insights from the sociology of science – that making knowledge is work, that it is unevenly divided and valued, that its hierarchies are imprinted in the qualities of made knowledge – drawn into a reflection about the nature of scientific labor under conditions of material limitation. What is scientific about scientific labor when it cannot generate knowledge, or only partial, fragmented, temporary forms of knowledge? This question is also applicable to care, therapy, protection, and more broadly to enactments of the state, and draws attention to the labor not just of making knowledge, but also of (re)making capacity over time, as well as of imaginations of labor.
Biruk: “What is scientific about scientific labor when it cannot generate knowledge, or only partial, fragmented, temporary forms of knowledge?”I love this question! It reveals–as does your book–how theorizing science from Africa can productively destabilize assumptions about “science” (linear or progressive temporality, systematicity, innovation, e.g.) In many ways, it is these assumptions that inform arbitrations of whether an experiment, project, or intervention succeeded or failed; yet, I think all three of us are quite interested in looking beyond the success/failure or good/bad binaries, in capturing all the things that happen along the way, ‘in the meantime’ (as Ramah puts it!)
2. Each of you analyze the means by which hybridities of state and non-state actors attempt to produce spaces of wellbeing and care in a time of the erosion of public goods from healthcare to basic infrastructure. How are you thinking about the role of “public science” or the nature of the “public” in healthcare at this time?
Biruk: In tracking matters of life, death, and morbidity, the projects I spent time with enact, following Michelle Murphy, a biopolitics that becomes an alibi for nurturing or disinvesting from issues, groups of people (publics) and infrastructures. The public in public health or public science is often imagined as a target, goal, or end point of well-intentioned efforts to improve or educate, but my work reveals that publics are always emerging, moving targets that challenge (and expose the partialness of) the imaginaries and blueprints of those who seek to care for them. I try to show how data collection—which might appear from above to be a seamless, orderly and benevolent project in the name of the public good—also produces publics, groups of people who stake claims on projects, the state, and politicians through shared idioms and solidarities. Engagement with research projects prompts reflection on the political relationship of citizens to institutions around them, and on the value of information they surrender. Attention to the transactions that link global health projects to local contexts—even transactions of items as small as a bar of soap!—can bring depth to analyses of how science and publics interact. All three of our books, I think, reveal how technoscientific formations channel and shape the desires, hopes, and anxieties that circulate through and remake diverse publics.
McKay: I think this is such an important way of nuancing accounts of the transformation or erosion of public goods, showing how publics are always public and always in transformation. I see Noémi as speaking to this as well, through attention to the partiality of scientific projects, of aspirations to public science, and of the temporalities of scientific publics (and of the publics in need of protection).
Tousignant: The question of the value of information surrendered is an important one. The negotiations and transactions of which, we, as researchers too, become so intimately entangled and complicit in… an often uncomfortable position which also reveals much about the unequal terms of exchange
McKay: This is a great question. I think many ethnographies of global health have understood the public (as in public health) as the state (as in national or public health systems). This has enabled some productive critiques of how non-state entities (including corporate, humanitarian, and global health actors) have eroded public goods. But it’s also important to think about the other forms of the public that are engaged with questions of health and well-being yet that don’t align with, or may be opposed to, the state or state interests. For instance, in the book I show how a variety of publics or political collectives are mobilized through (and sometimes in opposition to) particular configurations of public and non-governmental health; these include the patient-publics targeted by interventions or making use of the public health system, but also those shaped by political parties or affiliations, by NGO-generated socialities, and by gendered relationships. In relation to global health literature, attending to forms of public claims-making in ways that problematize as well as affirm public health systems also opens space for thinking about various forms of activism, critique, and collective health action that extend beyond health systems and the state. Although not specifically within global health literature, I’ve found Ruha Benjamin’s The People’s Science as well as Gabrielle Hecht’s Being Nuclear to be two helpful examples of how to disentangle various modes of public health, science, activism, and the state.
Tousignant: “Forms of public claims-making.” This is a really useful formulation of what it is we should attend to, as openly as possible, but without pretending that we are immune to the histories and legacies of imaginations of the state in relation to the public (service, interest, obligation, good, etc.) in Africa, both celebratory and condemnatory.
Tousignant: Indeed, I see this as a central thread in my book. There’s been a lot of valuable work marking out an overarching trend, and the various modes, of privatization of health and the state in Africa. But I and others have started also attending to the ways in which institutions and individuals sustain aspirations to “the public” in a kind of contrapuntal tempo to the materiality of privatization. How I’m thinking about “public science” or other meanings and practices of public service, responsibility, goods, etc. in Africa today, is that we need innovative ways of discerning these ethnographically, ways that are attuned to the past and past-in-the-present of “the public” – in ruins, failure, loss, nostalgia – but also, importantly, vigilant to new and perhaps highly specific ways of thinking about and doing redistribution, social justice, the state, and so on.
Biruk: What I loved about your book was the way you attend so closely to the polyrhythms of science and how these inflect its ability to protect publics from toxins. I especially appreciated your close readings of science’s material wreckage in chapter one, where gleaming but inoperable apparati, a two-decades old gas chromatograph, and “antique” flasks and pipettes become traces of relationships and transactions between people. In the chapter, you excavate the efforts of local scientists to do “good” science and enact care from a laboratory paradoxically “rendered impaired” by a long history of efforts to build its capacity. The palimpsest of objects and machines in this chapter, laden with meaning, nicely reveals toxicologists’ unflagging investment in and performance of a public science in the waiting.
3. Each of these books shows how valuable critical ethnography is for understanding global health. What’s been limiting and what’s been liberating about the work of ethnography? What decisions have you made about how involved or uninvolved to be in bringing your insights into the ethnographic spaces where you work? How have you tried to balance critiques of power and inequality while acknowledging the visions of social good that motivate you as a scholar and your colleagues who are practitioners in global health?
Biruk: As an anthropological cog in the global health wheel, I participated in and made possible the becomings of numerical data that, by anthropological standards, will never transcend their shortcomings, but nonetheless do crucial work to make visible patterns of suffering and poverty and direct capacitating resources (a version of the “good”). I think the question about involvement, which I’ll focus on here, intersects discussions of how anthropology can or should make itself relevant or useful and to whom. When I share my work with audiences, a common question is: “How can they [researchers] do better?” This question resonates with one I hear often from my students: “These critiques of global health are compelling, but what do we actually do to change the world?” Both questions are weighed down by normative assumptions about what it means to “do better” or to “do something,” and demand that anthropology be useful, implying that anthropologists should tell global health researchers things that might make projects or plans work better, for example. But to view anthropological knowledge as a packageable, sellable, and expedient nugget of information frames it as a magic bullet, a technical fix. The validity and ‘good’ of global health’s templates and core concepts go unremarked in this model. I’ve been inspired by scholars working in feminist STS (María Puig de la Bellacasa, Donna Haraway, and others) to think about how care, as a practice of the everyday and uneventful, might be a better aspiration than being “useful.” Anthropologists are well aware that a pure ‘good’ detached from relations and entanglements does not exist: ethnography is itself a practice of care that can model how obligation, fragile solidarities, and complicities are enabling as much as constraining. What I find most liberating about ethnography is its willingness to sit with uncertainty, to embrace awkward and hard-won solidarities and intimacies, to think before it speaks, to reshuffle and undo the fixity of taken for granted concepts that structure global health worlds. (Stacy Pigg’s classic essay “On sitting and doing” articulates all this much better than I do!) The best kind of knower may not be legibly “useful,” but rather curious, caring, and humble, one who centers other people’s stories before settling on their own, and never cedes the possibility of more radical worlds to the allure of easy fixes.
Tousignant: “Ethnography is itself a practice of care.” Lovely formulation, which I think acknowledges how unresolvable remains the tensions, and dilemmas we therefore face, between commitments to what is, which we seek to witness and listen to and do justice to, and to what might be, a less unequal, less violent future that might emerge from critique, transformation, desires, activism, especially if these are not being formulated or enacted by our respondents yet often also being demanded by them… there’s no easy way out…
McKay: One thing I try to show is that my ethnographic critiques were frequently known to — and better articulated by — both patients and health practitioners in Mozambique. Moreover, many of those actors saw ethnography as a key means by which global health was constituted. Global health spaces seemed to come with an ethnographer attached! As a result, I have been less invested in bringing my critiques “back” to my ethnographic participants and interlocutors than in thinking about the role of ethnography in constituting (or destabilizing) global health as our descriptions circulate, for instance in the classroom. Attending to the limits of critique in realizing social change also opens space for articulating a vision of a social good. I find Cal’s discussion, drawing on Deb Thomas, of reparation in the context of global health and development very helpful in this capacity. Concretely, I think one site in which the work of realizing social change is always available is in engagements with students – for instance, by thinking critically about the authors I assign (and therefore who I constitute as an “expert” in and on global health), by thinking about what’s enabled or obscured by drawing distinctions between applied and critical medical anthropology, or by drawing on critiques that are articulated by those directly engaging with or impacted by aid structures. In teaching, I also try not to rely solely on a relatively narrow set of academic markers for what counts as expertise (such as particular kinds of publications or narrow and relatively hierarchical notions of academic or professional qualifications).
Tousignant: I very much agree with your observation that ethnographic critiques are frequently known by others. I think that we all three pay attention to how much our respondents participate not just by giving information but actively interpreting and analysing and critiquing in ways that shape our understanding of what is going on. At the same time, I still wonder about how we can and should bring more back to them, not from some “superior” analytical vantage, but simply from having spent lots of time on our “material” — collecting (from other people, other times, other places) and sifting and ruminating and presenting, debating, teaching…
McKay: Yes, that’s an important point, especially noting that time is among the resources that are unevenly available!
Biruk: I love your point about how global health spaces sem to come with an ethnographer attached! And to return to some of your thoughts above, anthropology, too, is the constitutive outside of global health. Anthropology is somehow constrained by its enduring relation to global health (deemed inferior by virtue of its ‘slowness,’ the inability of its insights to ‘scale,’ or its smallness relative to the big ambitions or big data of global health). In this regard, its utility, if any, is framed as its ability to contextualize or explain contexts, to translate the local to the global in order to make the global work better. I’ve learned a lot from my students’ frustrations with anthropology “always critiquing everything all the time.” Together, in class discussions, we try to divest ourselves of normative definitions of critique, utility, critical v. applied, theory v. practice, or success/failure and build up our own working concepts for capturing social realities, those familiar and unfamiliar to us. This orientation to normative concepts, which falls somehow adjacent to, but not completely under, dominant definitions of ‘critique,’ feels ethnographic to me and helps usher in other visions of the social good. Attending to the multiplicities of labor, care, and visions of the good that constitute a global health project in any given moment likewise makes anthropology and its projects multiple.
McKay:“Anthropology as the constitutive outside of global health” is such a great way to put it!
Tousignant: These are tricky, and therefore really important questions for anyone working on global health. In my case, even in what is mostly a historical narrative, I do indeed privilege an ethnographic “closeness” with the scientists who are the main subjects, using empathy as a way into the meaning and texture of their “struggle for capacity” – something that illuminated their position of what I call “partial privilege,” which I think also made this empathy easier and more “comfortable” than if I had been dealing mainly with better-funded, whiter, more mobile and arrogant kinds of scientists. At the same time, I tried not to lose sight of the very limited reach of this “struggle,” and keep somehow present – as a critical strategy – what lay outside my own ethnographic reach which more or less follows the lines of toxicologists’ capacity: the exposures it leaves unknown, the vulnerabilities untouched, the contestations muffled, those with the most to lose from incapacity.
McKay: I love this phrasing as a way of describing how our ethnographic “reach” isn’t only — or primarily, or even at all — about revealing something hidden. It’s also about articulating the contours of the capacities, knowledge, and relations of our interlocutors. It suggests, as your book does, how much ethnographers can learn from attention to the limits of knowledge or the interruptions and fragilities that our interlocutors encounter.
4. How did you grapple with legacies of race and racism within both global health and anthropology, particularly the role of whiteness of each of these fields?
Biruk: The common response to a question like this one is a manifestation of a kind of confessional reflexivity, an effort to grapple with how one’s Whiteness and other forms of privilege affect one’s methods and the knowledge one produces about other people and places. While this is an important starting point, it is essential that we also grapple with these legacies as they structure our contexts of knowledge production and social life. It is imperative that we continuously reflect on how race (and the racism that birthed this concept) are constitutive of anthropology and African Studies (and, more broadly, the academy), and work from our individual positions of privilege within the institutions we navigate to dismantle White supremacy. In my view, some of the humble efforts that are crucial at this moment in anthropology are: Read, cite, and assign work by scholars of color, activists, African scholars published in grey literature (rather than fancy presses), queers, crips, and cis/trans women. Speak up in meetings at our home institutions when racialized (or gendered, transphobic, or ableist) language seeps into conversations pertaining to promotion, teaching evaluations, or hiring. Build political consciousness in ourselves, students, and colleagues and ensure that spaces are more accessible for all the brilliant people who want to contribute to them. Mentor, support and amplify the wonderful work being done by marginalized scholars. Because global health is so tightly associated with Africa, I’m also hopeful that—on the heels of Jean Allman’s important talk at the recent ASA, titled #HerskovitzMustFall?—African Studies will more meaningfully grapple with the legacies of race and racism that have been acutely felt by black scholars in ASA spaces and circles. Allman described, for example, how the ASA refused to support and build up black studies in the sixties, excluded black scholars from its inner circles, and missed key opportunities to engage with black liberation projects in the US. American Africanists (aside from those working in South Africa, perhaps) rarely see race as integral to their other objects of study, often dismissing it as a particularly American concern irrelevant to their work in Africa. (Jemima Pierre discusses this in great detail in thinking the lineages and investments of African and African diaspora studies, respectively, in the US). I’ve been reading a lot of scholarship I should have read long ago by black scholars (many who were writing at the same time as some of anthropology’s canonical heroes) in order to broaden the frames that produce the kinds of research questions about Africa I’m interested in. In short, I try to ask myself: What small things can I do every day to chip away at the white supremacy that infuses every corner of the institutions I navigate, whether at ‘home’ or abroad?
Tousignant: I just want to emphasize yourimportant point abouthow much more we can engage with African scholarship (and science — for example, what is published in local medical journals or student theses) that does not penetrate international spaces that we so easily access through our university libraries.
McKay: I agree, and Noémi, your response to Cal also makes me think of the central role of knowledge infrastructures in shaping work on global health. It highlights how access to scholarship isn’t just about university libraries, questions of pay-walls vs open access, etc. but also the journals that are *not* included in the library, or the relations through which drafts, articles, reports etc circulate.
McKay: For me, the whiteness of anthropology and of global health are co-constitutive and mutually stabilizing in ways that reflect shared intellectual foundations. So looking for opportunities to destabilize global health as an analytical object – for instance, by exploring how it is constructed or by historicizing it, or by thinking about modes of redress – is one way I have grappled with it. Because the racial formations at work in these fields are deeply embedded in the historical formation of anthropology as a discipline, grappling with these questions has also more recently pushed me to engage with literature on the disciplinary foundations of anthropology and on the foundational role of racializing distinctions in the making of anthropological thought. As Cal’s answer points out, this question is also structured by the close association between global health and African Studies and by the history of African Studies as a field. [The phrase “reading things I should have read long ago” seems to me as a good way to put it!] It seems to me that a crowdsourced syllabus/reading and citation list aimed at a decolonial anthropology of global health – along the lines of a recent environmental anthropology effort: https://culanth.org/fieldsights/citation-matters-an-updated-reading-list-for-a-progressive-environmental-anthropology— could be generative. At the same time, scholars like Sara Ahmed have suggested that “any project that aims to dismantle or challenge the categories that are made invisible through privilege is bound to participate in the object of its critique” (2007: 149-150). To me this suggests that there might also be a critical limit inherent in taking global health as an analytical object, and that de-centering whiteness might also mean centering concepts that are adjacent to global health instead of or as well as global health.
Biruk: I love the idea of a crowd-sourced reading list! I’d be interested, as well, to know how people who are teaching such courses conceptualize the canon of (critical) global health studies.
Tousignant: Yes, fantastic idea, let’s!
Tousignant: Insufficiently, overall… I do address histories of race and racism in African science, which I think tends to be somewhat overlooked in reflections on race in global health – often suggesting a smooth arc from colonial through international and “global” paternalism and arrogance without really examining the complex work of race in the construction and imagination of “national” and “African(ised)” healthcare and health science from the 1950s or so. As for how I dealt with my own whiteness and these legacies? I guess I mostly avoided it, which was made easier by the fact that the Senegalese scientists I interacted with were rather on the margins of the global health enterprise and its particular racial hauntings (and amnesias) and performances…. But at the same time, I think I was, or became, more attuned to class dimensions of these interactions, as I explored a bit in the epilogue, to the ways in which difference and inequality – but also sameness, mutual comfort and identification – are constituted through class-based forms of material security, anticipation, expertise, vocation, etc. and experienced in ethnographic relations.
5. What are you reading at the moment in critical global health? What is a book (other than the ones in this forum, of course) that is at the top of your to read list this coming year?
Biruk: I think anyone doing critical global health studies should take a look at Traces of the Future: An Archaeology of Medical Science in Africa (Noémi is one of the editors)! The book is really more like an interactive museum—using a diversity of material artifacts to think through the multiple temporalities, dreams, and affects of medical science in Africa. I appreciated the experiments in writing and representation the authors staged; it is an epic and highly teachable book! Right now, I’m learning a lot from Toby Beauchamp’s book Going Stealth: Transgender Politics and U.S. Surveillance Practices, in which he takes up transgender as analytic, rather than bounded identity, to consider what gender noncomformity reveals about surveillance practices as they pertain to diverse bodies, behaviors and identities in our historical moment. At the top of my reading pile is Deidre Cooper Owens’ book Medical Bondage: Race, Gender, and the Origins of American Gynecology, which shows how advances in early gynecology relied on presumptions of black enslaved women’s bodies as disposable subject-objects, as flesh for the taking. I’m revising my syllabi, and I think selections from this text will help students see how health—and the narrated history of ‘medical breakthroughs’—are entangled with and constitutive of enduring racial formations. I’m also looking forward to digging into Rachel Louise Moran’s Governing Bodies: American Politics and the Shaping of the Modern Physique, which intersects an autoethnographic project I’m working on about metrics, gender, and queer self-fashioning as they play out in technology tracked fitness experiences amid the second fitness boom. (Oh, and for fun, some novels or memoirs I’ve read recently and loved: Confessions of a Fox, Gun Love, The Parking Lot Attendant, Heavy).
McKay: Other than Noémi’s and Cal’s wonderful books, I’ve been reading some of the extensive work around questions of reproduction and population in relation to global health – including revisiting some classic works like those by Betsy Hartmann’s Reproductive Rights and Wrongs: The Global Politics of Population Controland Dorothy Roberts’ Killing the Black Body: Race, Reproduction, and the Meaning of Liberty– and particularly around economy, resources, and population, including Michelle Murphy’s The Economization of Life. A lot of this reading is at the intersection of research, teaching, and personal interest – to all those ends, I’m looking forward to reading Laura Briggs’ How All Politics Became Reproductive Politics: From Welfare Reform to Foreclosure to Trump and Jade Sasser’s On Infertile Ground: Population Control and Women’s Rights in the Era of Climate Change. I’ve also recently learned a lot from Marisol de la Cadena and Mario Blaser’s volume, A World of Many Worlds.
Tousignant: I’m reading Rosalind Frederick’s excellent Garbage Citizenship, about waste infrastructures in Dakar, Senegal, which isn’t really “global health” but has lots to say about the history of the public, and the politics of labor and healthy spaces, in African cities. As I’m newly working on care, I’m also digging into books that had been on my reading list for a while, like Alice Street’s Biomedicine in an Unstable Place, set in Papua New Guinea, particularly for its insights into the problem of diagnosis, and Lisa Stevenson’s Life Beside Itself, set in the Canadian Arctic, on the potential violence of “care” in a colonial situation. I look forward to reading Omar Dewachi’s Ungovernable Life and have my eye out for Katie Kilroy-Marac’s An Impossible Inheritance and Amy Cooper’s State of Health.
McKay: Yes, I think that Rosalin Frederick’s book would be great to teach with!
Biruk: Life Beside Itself is one of my favorite books to teach!–students find the material troubling, but in a productive way that really makes clear why interventions presented as life-saving and caring were received by the Inuit as violent.
6. Where do you think critical global health should go next? What has not been addressed by the field?
Biruk: I’m excited to see many folks in critical global health studies thinking about data and metrics! This work models anthropology’s potential amid a Big Data boom, specifically its ability to fracture and erode concepts too often taken at face value or as stable entities (“Big Data” or “metrics” for example). Anthropology and scholars of critical global health can make important contributions to existing data studies literature—largely concerned with arbitrating the accuracy or limits of data—by tracing data’s vexed ontologies and social lives, by showing what data actually do and how people inhabit, engage or resist them. While my ongoing research projects very much fall under the umbrella global health/medical anthropology, I hope to bring other literatures to bear on my questions (surveillance studies, queer studies, and media studies, for example): I think many of us in this sub-field could benefit from reading more widely. Many of the kinds of metrics and technologies deployed within the global health and development apparatuses embed the same assumptions of moral bankruptcy, greed, or criminality that have undergirded projects of colonialism, enslavement, carcerality, and domination in the past and present. Global health is a formation with origins in quantifying others to better govern them, a legacy that should figure centrally, I think, in future theorizations of audit culture, datafication, and the past and present violences wrought by metrics and counting.
Tousignant: I absolutely agree that global health’s practices of quantification are tied to governance, but I also think there are aspirational projects invested in the hope of better numbers, numbers that better reveal inequalities and exclusions, that will lead to more critical and caring decision making… so I think we also need to be attuned to diverse demands for knowledge, including quantitative, in diverse health enterprises, even as we are aware of the enormous pull that data exerts, etc.
Biruk: Yes! Very important—numbers, for better or worse, are capacitating, and make things legible and countable, visible as events, etc.
McKay: I think this follows on the question about whiteness in a way, and on the limits of centering global health as an object of analysis. To me, some of the most interesting approaches to global health are historicizing and provincializing it, by situating it within larger contexts in which global health formations shape but don’t determine experiences of health and illness. That could be situating global health within attention to environment, or at shifting attention to communicable and non-communicable disease, or looking at the limits of global health knowledge, as Noémi shows in her book. In my own work, I’m interested in the ways global health exists alongside and even gives rise to quite distinct modes of medical provisioning, including the expansion of insurance and private medical industries. This has meant engaging more broadly with the anthropological literature on capitalism and finance, as well as audit, data, and accounting. That said, I also think that provincializing global health entails a wider range of approaches to the modes of subjectivity we identify within health and global health spaces, attending to the “plasticity,” as Biehl and Locke put it, of both global health and global health subjects regardless of the particular diseases, problems, or interventions with which we’re concerned.
Biruk: So well put!
Tousignant: In these books, I see a welcome trend of attending more to history and to the national frame (without being limited by it), in which “the public” and its politics have unfolded, which I think really enriches our understandings of “the global” and its public-private forms. I think it’s also obvious we need to keep, as some like Susan Reynolds White and Megan Vaughn and others have started doing, studying and thinking about chronic illness in Africa, especially at the rural primary care level, and to figure out ways of looking simultaneously at the emergence of novel health labors and anxieties about diet, food and toxicity and at broader political-economic structures of food and chemical production, circulation and regulation. And I can’t resist throwing in my particular obsession of the moment, although it also resonates with current work on health insurance in Africa, which is to look and think harder about protection as an (often absent) effect and value of public health, and its potential politicization, in relation to expectations of the state and new forms of social insurance and redistribution.
Crystal (Cal) Biruk is an Associate Professor of Anthropology at Oberlin College whose research explores the ethics and politics of intervention in the global South. Biruk’s first book, discussed in this book forum, Cooking Data: Culture and Politics in an African Research World, is an ethnography of the production of quantitative data by survey projects in Malawi. Biruk’s body of work traces the social and political lives of metrics and data amid the rise of audit cultures, particularly in global health worlds, contributing ethnographic insights to the emerging field of critical data studies.
Ramah McKay is an Assistant Professor at the Department of History and Sociology of Science at the University of Pennsylvania. Trained as a socio-cultural and medical anthropologist, her research focuses on the politics of health in Mozambique. Her first book, discussed as a part of this book forum, is called Medicine in the Meantime: The work of care in Mozambique, and it traces the lives and afterlives of two transnational medical projects – projects that enacted deeply divergent understandings of what care means, what it does, and who does it. Her ongoing research in and beyond Mozambique focuses on the making of transnational medical economies between Africa and India, and on the forms of knowledge production that they entail.
Noémi Tousignant is a historian of science and public health in late-colonial and postcolonial Africa, specifically focused on Senegal. She is a lecturer in Science and Technology Studies at University College London. Tousignant studied the History of Medicine at McGill University and since 2006, has been working on the history and ethnography of pharmaceuticals, pharmacists, and health research in colonial and post-independence Senegal. Her first book, Edges of Exposure: Toxicology and the Problem of Capacity in Postcolonial Senegal, is discussed in this book forum and investigates the attempts by Senegalese scientists to build a robust system of monitoring and controlling toxins in their environment and the ways that structural adjustment and decolonization have impacted their abilities to do so.
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