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Turning Care Inside Out: The Occupied Clinic x Virulent Zones

Saiba Varma’s The Occupied Clinic begins with an entrance: descending from an auto-rickshaw, she walks in through the Kathi Darwaza gate into old Srinagar, on foot now, passing “imperial debris” on the way to the clinic: the Government Psychiatric Diseases Hospital, Kashmir. Inside the clinic, it’s a busy Saturday, with crowds of patients seeking appointments with the few psychiatrists on outpatient duty. Many tell of a syndrome referred to in Kashmiri as dag, a “restless pain,” which the doctors translate as a “somatization” of psychological trauma – part of the “epidemic of trauma” that has accompanied decades of war and counterinsurgency in Kashmir.

In these first pages of The Occupied Clinic, everything appears as if we are on the stable ground of medical anthropology: a clinical encounter, medical semantics, an illness syndrome defined by a local cultural system. As I read, I began to feel that familiar centrifugal force that defines the classical genre of the discipline – expecting to soon move toward the outside of the clinic, where the particular history of military conflict and cultural “frames” would provide the hermeneutic context for understanding patient suffering, complementing the psychiatric diagnosis and pharmaceutical therapy with a more complete meaning.

But instead, Varma soon realized she “had it inside out.” Her book could not be a story of medicine in violence. Far more disconcertingly, it is a story of “violence through medicine” (9). The clinic is occupied: here, counterinsurgency makes its most effective campaigns through infrastructures of care, such as the fact that the best substance abuse treatment center is located inside a police post; or the unstoppable transfers that take place between the use of electric shock as a means of torture (by the military) and as a means of healing in psychiatry. Violence, militarization and war are not only contexts around the clinic; they don’t just shape, influence, affect, constrain, limit, or oppose the clinic and its work of care; violence and war are inside the clinic, internal to care.

Varma’s point is not by any means a reductive one: as if everything were at bottom violence, as if care is merely violence by other means, Hobbes in the clinic. Like other recent work contributing to the reimagination of care[1], she highlights the ambivalence of carei—medical therapy is neither independent from military occupation nor strictly instrumentalized to military rule. Rather, it is “disturbed” (67). To take one example of this disturbance, the doctor-patient relationship—that keystone of the medical anthropology genre—becomes a setting of “two-way mistrust” that fragments politics and healing, regardless of the intentional commitments of the participants.

To understand this relationship of violence through medicine, occupation as care, we should dwell on the spatial diagram that Varma introduces: turning inside out. She draws the image from Annelise Riles’ (2000) book The Network Inside Out. Riles was concerned above all with the fact that, as she puts it, “the insights of anthropological studies of globalization often seem oddly anticipated by the subjects of transnational ethnographic inquiry themselves” (5)—that is, the apparent “outside” of anthropology is actually already “inside.” An anthropology “inside out,” for Riles, is one which embraces the doubling of concepts like “network” which are both part of our anthropological repertoire and part of the repertoire of our subjects. By turning the discipline inside out, Riles finds new forms: a cultural topology rather than “cultural translations” (Asad 1986; cf. Rabinow 1983).

For Saiba Varma this topological “doubling” offers a twisting pathway to understanding the ambivalence of care, and the overlap of war and medicine. To turn the clinic inside out means to address the occupied clinic not as a fork in the road, as if one could choose between medicine and violence, but rather as the topology of a Klein bottle: not either/or but both/and.

A Klein bottle, Giovanni da Col (2013) writes in an essay on Marilyn Strathern’s anthropology, “has neither an inside nor an outside, or rather, depending on one’s point of view, it is all inside and outside and nothing else.” Take any moment in Saiba Varma’s book, and it is impossible to determine whether it is inside or outside the clinic, inside or outside the war—if you travel along the ‘outside’ you suddenly find yourself on what appeared to be the ‘inside,’ and vice versa.

As I read The Occupied Clinic and thought through this topological image, I found myself turning my own book inside out as well.[2] Where Varma turns the clinic inside out, I realized, I had tried to do the same with the ‘laboratory.’

Virulent Zones traces the global efforts to study and contain the emergence of viruses in China, a place long seen as the ‘point of origin’ of influenza pandemics, as well as the source of SARS in 2003 and, most recently, the novel coronavirus that caused the Covid-19 pandemic. Global health programs to monitor viruses and contain pandemics exhibit a distinctive geography of knowledge and care: violent interventions into particular sites marked as potential sources of future pandemics—including culling of animal hosts, quarantine of human bodies, and closure of market activities—are justified in the name of protecting the health of global populations. Andrew Lakoff (2010) has described this as a logic of “self-protection” designed to “biomedically insulate” wealthy countries from emerging pathogens—and not, for instance, to expand access to medical care in the developing world. In order to identify these zones of virulence, research expeditions are sent to the fringes of nature and culture where virus hunters isolate pathogens from human and animal bodies, carefully preserve them, and bring them back to the laboratory to assess the threat that they pose. A particular relationship between the global and the local developed, one that could be called a “geography of blame” (Farmer 1992): again and again, scientists in global laboratories (in Australia, Hong Kong, or the United States) identified China as a viral ‘hot spot’ because of its distinctive local ecologies of animal farming, live animal markets, and wild animal consumption.

Medical anthropologists have often decried this “geography of blame” for ignoring the more complex economic, cultural, social and political “contexts” in which these viruses emerge. This, too, is often framed as a question of care, or more precisely, the absence of care. As Arthur Kleinman and colleagues (2008) put it, “Global discourses regarding the origin and spread of H5N1 avian influenza all too often consist of allegations of blame and assumptions of cultural shortcomings rather than of serious investigation of the political, cultural, and socio-economic realities of the societies that have come to be associated with the virus.”

However, when I began to follow global health scientists, primarily working with the UN Food and Agriculture Organization, who had moved into China in order to work towards containing the emerging flu viruses, I found that medical anthropology’s classical critical lens—exposing the failure of biomedical sciences to locate illness in the context of culture—obscured more than it revealed. For far from ignoring the contextual “realities” of viral emergence, context had already become a primary object of global health.

In addition to the surveillance of viruses or sampling of viruses, researchers began designing new forms of inquiry into the nonvirological: Migrations of wildlife species, rapid population growth trends, changes in livestock production, almost anything, I soon realized, could become part of the context of viral emergence and therefore part of their ever-expanding research programs. And as a result, their research did not center in the laboratory, even if some of it took place inside laboratories, but rather in particular field sites such as the Poyang Lake that were treated as in situ experimental systems.

It would not be correct to describe this as a substitution of field science for laboratory science, because scientists continued to be interested in lab research and virological knowledge. I was also unsatisfied with many of the metaphors used in science studies to understand the relationship between lab and field science, such as “borderlands” (Kohler 2002); “hybrids” (Callon, Lascoume, and Barthe 2001) or “trading zones” (Galison 1997). Instead, I argued that the search for the pandemic epicenter involved the displacement[3] of the laboratory as model of scientific practice. Put another way, the laboratory was turned inside out.

In science and technology studies, displacement is a key concept used to understand the distinctive pathway of scientific knowledge. However, the concept of displacement has focused on the agency of the scientific expert—and the laboratory as a model of scientific practice. For example, Bruno Latour (1983) shows how French bacteriologist Louis Pasteur’s vaccine for anthrax disease relied on “the displacement of the laboratory” into actual cattle farms, where he conducted field experiments and tests, and then the subsequent “transform[ation] of the farm back into the guise of a laboratory.” Laboratories create displacements through mastery of scale, as when Pasteur re-creates a cattle farm in miniature inside his lab in order to make microbes visible. “The change of scale,” Latour writes, “makes possible a reversal of the actors’ strengths; ‘outside’ animals, farmers and veterinarians were weaker than the invisible anthrax bacillus; inside Pasteur’s lab, man becomes stronger than the bacillus, and as a corollary, the scientist in his lab gets the edge over the local, devoted, experienced veterinarian.”

But the scientists I observed searching for the pandemic epicenter were much less heroic than Pasteur, or at least Latour’s rendering of Pasteur: although they moved outside to farms and fields, they did not simply extract materials, bring them back inside the lab, and declare victory. I began to see another trajectory of scientific change that did not begin and end in the lab but followed a centrifugal movement that questioned the contexts of viral emergence. And when they replaced virus discovery with spatial ecology models of duck farming or remote sensing of rice paddy landscapes, they unexpectedly found the origin of pandemics retreating into a vanishing point. With models of planetary risk in hand, the search for points of origin lost its relevance, as pandemic risk appeared across a global geography that tracked modern practices like industrial poultry operations rather than cultural or ecological regions (cf. Leibler, et al 2009; Gilbert, et al., 2017). Like the empty halls, unfinished hospitals, and missing persons of Varma’s occupied and “disturbed” clinic, the so-called epicenter had disappeared—or more accurately, it was turned inside out.

As I finished the final typographic corrections of the book manuscript in late 2019, the other virus appeared, predicted and yet still unexpected. The COVID-19 pandemic both reaffirmed and threw into question many of my own assertions about pandemics, science, and China. The life of my anthropological inquiry entered its own topological twist[4]: My book could not end with a clean surgical exit that sewed its objects up inside a stable context once I had left China—instead, what had appeared to be the inside became the outside, and the epicenter was all around us.


 Lyle  Fearnley is a medical anthropologist and Assistant Professor at Singapore University of Technology and Design (SUTD). He is author of the book Virulent Zones: Animal Disease and Global Health at China’s Pandemic Epicenter (Duke, 2020).  

 

References: 

Asad, Talal. 1986. “The concept of cultural translation in British social anthropology.” In James Clifford and George E. Marcus, eds. Writing Culture: The Poetics and Politics of Ethnography. Berkeley, Calif.: Univ. of California Press.  

Caduff, Carlo. 2019. ‘Hot Chocolate’. Critical Inquiry 45 (3): 787–803. https://doi.org/10.1086/702591. 

da Col, Giovanni. 2013. “Strathern Bottle: On Topology, Ethnographic Theory, and the Method of Wonder.” In Strathern, Marilyn. Learning to See in Melanesia. Manchester: HAU Society for Ethnographic Theory. 

Farmer, Paul. 1992. AIDS and Accusation: Haiti and the Geography of Blame. Berkeley: University of California Press. 

Gilbert, Marius, Xiangming Xiao, and Timothy P. Robinson. 2017. ‘Intensifying Poultry Production Systems and the Emergence of Avian Influenza in China: A “One Health/Ecohealth” Epitome’. Archives of Public Health 75 (1): 48. https://doi.org/10.1186/s13690-017-0218-4. 

Kleinman, Arthur, Barry Bloom, Anthony Saich, Katherine Mason, and Felicity Aulino. 2008. ‘Asian Flus in Ethnographic and Political Context: A Biosocial Approach’. Anthropology &; Medicine 15 (1): 1–5. 

Lakoff, Andrew. 2010. ‘Two Regimes of Global Health’. Humanity: An International Journal of Human Rights, Humanitarianism, and Development 1 (1): 59–79. 

Latour, Bruno. 1983. “Give Me a Laboratory and I Will Raise the World.” in Science Observed: Perspectives on the Social Study of Science, ed. Karin D. Knorr-Cetina and Michael Mulkay. London: Sage.  

Leibler, Jessica H., Joachim Otte, David Roland-Holst, Dirk U. Pfeiffer, Ricardo Soares Magalhaes, Jonathan Rushton, Jay P. Graham, and Ellen K. Silbergeld. 2009. ‘Industrial Food Animal Production and Global Health Risks: Exploring the Ecosystems and Economics of Avian Influenza’. EcoHealth 6 (1): 58–70. https://doi.org/10.1007/s10393-009-0226-0. 

Murphy, Michelle. 2015. ‘Unsettling Care: Troubling Transnational Itineraries of Care in Feminist Health Practices’. Social Studies of Science 45 (5): 717–37. https://doi.org/10.1177/0306312715589136. 

Rabinow, Paul. 1983. “Humanism as Nihilism: The Bracketing of Truth and Seriousness in American Cultural Anthropology.” In Social Science as Moral Inquiry, Edited by Norma Haan, Robert N. Bellah, Paul Rabinow, and William M. Sullivan. New York: Columbia University Press. 

Rabinow, Paul and Stavrianakis, Anthony. 2020. From Chaos to Solace: Topological Meditations. Berkeley: Anthropology of the Contemporary Research Collaboratory. https://www.snafu.dog/new-page-1 

Redfield, Peter. 2014. Life in Crisis the Ethical Journey of Doctors without Borders. Berkeley, Calif.: Univ. of California Press. 

Riles, Annelise. 2000. The Network Inside Out. Ann Arbor, MI: University of Michigan Press. 

Stavrianakis, Anthony. 2020. Leaving: A Narrative of Assisted Suicide. Berkely, Calif.: Univ. of California Press. 

_____. 2021. “Anthropotopology: From One Life to Another.”  https://www.academia.edu/46955242/Anthropotopology_From_a_life_to_another 

 

Notes 

  1. For selected recent work on the ambivalence of care, see Caduff 2019; Murphy 2015; Redfield 2014; Stavrianakis 2020; as well as work by other participants in this  Somatosphere forum. 
  2. In a reading of an early draft of Virulent Zones, Anthony Stavrianakis suggested that I think through Strathern’s topology and drew my attention to da Col’s essay. Although I was incapable of incorporating the suggestion into the book manuscript, Stavrianakis’ comments closely shaped my approach to this essay. 
  3. The displacement of the laboratory in Virulent Zones parallels the disturbance of the clinic in The Occupied Clinic as responses to topological configurations that go beyond interiorization or exteriorization. 
  4. On the topological form of the life of inquiry, see Rabinow and Stavrianakis 2020;  Stavrianakis 2021. Rabinow and Stavrianakis use topology to show how  (anthropological) inquiry into an object twists and returns to transform the subject. 

 

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