Circulations, becomings, and doings in global health
How does an epidemiological category such as ‘MSM’ circulate across global health contexts? In what ways is this label implicated in and productive of global health knowledge-making practices? The papers in this special section take up these questions by showing how the MSM category, across an array of social, cultural, and political backdrops, comes into existence as a ‘category, thing, technology’ (see Biruk, this issue), and especially as a vital or doing thing (see Boyce and Cataldo, this issue; Lorway, this issue). Rather than reiterate the already well-documented and important scholarly work detailing the (mis)uses of this category in global public health[note 1]For excellent critiques on the inadequacy of the MSM category in global public health, see for example Carrillo and Hoffman (2016); Muñoz-Laboy (2004); Perez-Brumer, Parker, and Aggleton (2016); Thomann (2016); Young and Meyer (2005).
– a critique that stresses the erasure of lived realities that should be recognized to better understand people and promote sexual health – the contributions to this special section focus on the more ‘ontological’ materiality of ‘MSM’ and the work it does as it travels. That is to say, what comes of ‘MSM’ being in the world; and how does ‘MSM’ in turn call for new kinds of becomings? In short, our starting point for this special section extends beyond what MSM does not do, and instead emphasizes what it has done and can do. These contributions, then, examine the ontology of the term ‘MSM’: what it does and what it becomes in the concrete world of health and development interventions.
The impetus for this special section – and our arrival at an ontological approach to making sense of the MSM category and its ‘doings’ in global health – emerges out of several years of informal conversations concerning our distinct yet overlapping ethnographic encounters with ‘MSM’ as a particular kind of thing. All working outside of Euro-American contexts, we shared our puzzlement at how our interlocutors often self-identified as and with a clinical category, in ways that exceeded the bounded, behavioral limits that the MSM category was originally intended to capture. At the same time, we recognized the ‘capaciousness’, as Biruk (this issue) describes, of the MSM term that consolidated ever more sexual alterities into its fold. Indeed, we saw, in real time, how MSM became more than a referent to the typing and making of people. From boardroom meetings in San Francisco and Beijing to the daily work of community-based organizations in Abidjan and Windhoek, and to participation and reflection during academic conferences around the globe, we similarly noticed something crystallizing and coming into being, with a concomitant evidentiary creep that seemed to be extending its reach into the subjectivities, collectivities, and very doings of global health.
This special issue, then, speaks to the ‘proleptic’ turn of the MSM category, beyond and back to its original purpose (Boellstorff 2011). From this perspective, the contributions reveal the emergence of ‘MSM’ as a highly affecting element that draws together diverse registers and scales of sociality, ideologies, desires, materialities, and auditing practices. Our ontological elaboration points to the multivalent ‘nature’ of ‘MSM’, which, as Boyce and Cataldo (this issue) deftly show, is made up out of an array of effects that are manifold and even contradictory; they write: ‘the term has also come to function as an epithet for self, marker of communal connectedness, antithesis to community and a putatively objective public health category among other possibilities, often all at once’ (this issue). For Boyce and Cataldo, ‘MSM’ is as ‘multiply encoded’ as it is ‘capacious’ for Biruk, who writes that its deployment as a technology ‘links together multiple temporalities and projects in the age of audit’ (this issue). For Lorway, it similarly forms the connective tissue that holds together ‘heterogeneous networks of unruly contestations, identity politics, and diverse actors and domains of health practices’ (this issue). Rather than showing the failings of the category to fully capture the complexities of erotic desires and social identifications, this special section reveals more about how the category itself produces and proliferates multiple and lively new forms of sociality, even as it retranslates in highly technocratic regimes.
Moving beyond the idea of ‘MSM’ as an ‘incomplete signifier’, there are various conceptual threads that can be followed across the articles by Biruk, Boyce and Cataldo, and Lorway. Firstly, owing to its seemingly neutral appearance, ‘MSM’ is remarkably mobile, traveling widely and perhaps even more readily than other categories that attach to, coexist with, or are replaced by it (for example, gay, homosexual, bisexual, or other ‘local’ identifications). As all these authors point out, ‘MSM’ is thought to evade the cultural and sexual politics of other LGBTQI labels, but this is a myth that each of the authors disrupts. As this category traverses among varying scales of analysis (Boyce and Cataldo), domains of practice (Lorway), and bureaucratic infrastructures (Biruk) – it at once interlinks and makes legible these disparate elements that might otherwise be lost in translation. This intelligibility is made possible because of the plasticity of ‘MSM’ to both flatten and expand diversity at the same time. As the articles show, ‘MSM’ has now become a critical node in global health interventions that aim to mobilize, measure, and manage ‘key populations’.[note 2]In recent years there has been a proliferation of scholarly works about the rise of metrics and evidence-based health interventions in medical anthropology and critical global health studies; a few of these include Adams (2016); Fan and Uretsky (2017); Lorway (2017); Sangaramoorthy and Benton (2012); Storeng and Béhague (2014); Thomann (2016).
The application of the MSM category, by virtue of its ‘capaciousness’, standardizes sexual difference so that it is thinkable and actionable in evidence-making regimes, and one’s lived difference is transformed into ‘interchangeable counts, data points, or goals’ (Biruk, this issue).
Yet, despite its movement toward universalism and uniformity in its attempts to sort out behavioural ambiguities in evidence-making regimes, the MSM category generates, ironically, new forms of ambivalence and incommensurability. Although ‘MSM’ as a referent is made intelligible across contexts as it works to smooth out the rough edges in producing uniformities across time and space (Timmermans and Epstein 2010), its circulation does not necessarily follow a linear pathway of knowledge production. That is to say, the role of MSM in producing a standardized (key) population meanders through the irregular route of historical contingency, entangling itself in various fields of politics along the way. ‘MSM’, then, is not only an object of global health intervention nor a strategic identity category – it is a ‘doing thing’ that is embedded in, rather than insulated from, postcolonial identity politics (Lorway, this issue). The animation and mobility of ‘MSM’ comes as much through rejection, denial, and contestation as through the multitude of utilitarian imaginings it inspires as it travels across various localities.
As suggested by the title of this special section, all authors take Hacking’s (1986) notion of ‘making up people’ as an important analytic starting point. Categories applied to people are neither entirely ‘given’ by nature; nor are they entirely socially constructed and imposed in any straightforward, coercive, or neocolonial fashion. In many ways people discover themselves in categories that seem to be created for and about them, as though they were given by nature (Lorway 2014), a shift all of us recognized in our ethnographic encounters.[note 3]A number of scholars have written about the emergence of same-sex identities, including Boyce (2007) and Cohen (2005) on kothis in India; Boellstorff (2003) on gay and lesbi in Indonesia; Ho (2010) and Rofel (1999) on tongzhi and gay men in China; Dave (2012) on lesbian identity in India; Awondo (2010) on LGBT social movements in postcolonial Cameroon; Broqua (2012) on sexual minorities in public spaces in Africa; Wright (2005) on nongovernmental organizations and global gay identities in Bolivia; Murray (2012) on ‘queens’ in Barbados; and Parker (1998) on miché in Brazil. This is by no means an exhaustive list.
How do these processes of ‘making up’ MSM collide with national and global health programs within which this category gains purchase (see McKay 2016)? How does the standardization of ‘MSM’ facilitate the expansive inclusion of more and more sexual alterities under its umbrella, making it possible to ‘make up’ MSM? A key question directing this special section, and critically addressed in the papers, is: for what purpose is ‘MSM’ mobilized? In this regard, Biruk’s (this issue) argument that MSM ‘makes up’ sociotechnical infrastructures inasmuch as it makes up people is incisive.
As the articles reveal, there is a performative vitality in the category MSM. That is, as people react to the category (which stirs imaginations, see Pigg and Adams 2005), they somehow alter, rework, and reassemble the very category itself, which may, in turn, influence its redeployment. ‘MSM’, therefore, acts as a ‘moving target’ (Hacking 2006). This point is certainly evident in the multiple inflections that the MSM category has come to take on as it travels. But the authors seek to move beyond both the notion of making up people and the narrow focus on sexuality, gender, and HIV that tends to pervade anthropological critiques of ‘MSM’. Instead, they consider how divergent forms of social life – governmentalities, systems of aid, alliances, and rifts – come into being. Biruk, for instance, considers how ‘MSM’ acts as a vital technology in the making of performance-based aid economies that answers to and reconfirms its own internal logics of aid dispersal. For Lorway, ‘MSM’ both makes up and holds together ‘dissonant ensembles’ of diverse sexual health responders, in the makings of a ‘unified’ population that can be intervened upon (also see Nguyen 2009). And for Boyce and Cataldo, people ‘become global health categories’ as they react to and even resist being encoded in data sets.
At the same time, the MSM category, importantly, makes up the anthropologist, as Biruk rightly notes, embedding them within the very logics and temporalities of the global health projects they study. Unlike extended ethnographic fieldwork (‘anthropological time’), the anthropologist embedded in the often frantic work of nongovernmental organizations (‘project time’) (Benton, Sangaramoorthy, and Kalofonos 2017) comes to feel the tempo of their interlocutors’ lives in new ways. Such a position, of both proximity and distance, offers rich understandings of global health categories like MSM. Assuming anthropological positionalities allow us to be present in various places and moments in the category’s making, and to witness multiple meanings come into view and then perhaps dissolve and vanish through reassertions of the category (Boyce and Cataldo, this issue), or bring together unruly sets of politics, identities, and global health practices (Lorway, this issue). In other words, ‘knowing’ MSM as an analytic construct or ethnographic object is highly contingent on location. The authors locate themselves in various places – finding themselves among other actants (to borrow Latour’s  term), including nonhuman agents (paperwork, proposals, and pharmaceuticals) – all of which enable the anthropologist to see how the MSM category gives birth to, even as it is birthed out of, an array of connections, transactions, translations, and terrains of possibility.
There is indeed a sense of immanence and becoming, an incompleteness that inheres in the MSM category as it travels (see Biruk, this issue), as it can never fully conceptually contain the realities it presumes to stand for (see Boyce and Cataldo, this issue). It thereby continually opens up in lines of flight (Deleuze and Guattari 1987; Biehl and Locke 2017), as refutations, resistances, and denials intensify under its weighty standardizing imposition. Beyond binary critiques of the MSM category that hinge on notions of the artificial or the (in)authentic, or of nature or culture, what these authors make clear is its complex open-endedness and not-yet-completeness. For Biruk, this dimension is key for understanding the past, present, and futures of MSM projects and how they might manifest actual queer practices. For Boyce and Cataldo, it renders an account of nonlinear time, continually bobbing and weaving in (mis)communications across various scales and divergent meanings in which people speak past each other (this issue). And in Lorway’s genealogical ethnographic approach, we see the emergence of ‘MSM’ not merely as an inevitable outcome of global health ‘progress’ but as a product of historical contingency, what Biruk views as the complex workings of the category through ‘frenetic, patchy, and contingent unpredictable rhythms’ (this issue). In this way, the special section tells us something profound about how social transformation itself comes about in and through global health projects.
About the authors
Elsa Fan is Associate Professor of Anthropology at Webster University. Her research examines how global health interventions unfold across social and cultural contexts, and her recent work focuses on HIV testing among MSM (men who have sex with men) in China. She has published in Critical Public Health and Global Public Health. Elsa has also worked extensively in the development and philanthropy sectors in the United States and Asia.
Matthew Thomann is Assistant Professor of Anthropology at the University of Memphis. His work focuses on sexuality and the politics of health in sub-Saharan Africa and the United States, crossing the subfields of medical anthropology, public health, and queer anthropology. His work has been published in Critical Public Health, Global Public Health, Culture, Health, & Sexuality, and Critical African Studies.
Robert Lorway is Associate Professor of Community Health Sciences in the Centre for Global Public Health, University of Manitoba, where he holds the Canada Research Chair in Global Intervention Politics and Social Transformation. As a medical anthropologist, his research explores how contemporary global health interventions shape new forms of subjectivity and collective existence. He has written two books on the subject, Namibia’s Rainbow Project: Gay Rights in an African Nation (Indiana University Press, 2014), and AIDS Activism, Science and Community across Three Continents (Springer, 2017). Robert’s conceptual engagements are firmly rooted in public health projects conducted in close collaboration with health and social justice activists.
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