Clinic and crisis

Eileen Moyer, Vinh-Kim Nguyen

10 Sep 2018

A common thread runs through the articles of this issue of MAT: the conjoining of clinic and crisis. Here we refer, in the manner of Foucault (1963) to the clinic as both an epistemology (a way of knowing) as well as a material space where the ill seek care. Crises are moments of rupture, where the surface of everyday life splinters to reveal what lies underneath and new dangers can appear; they are also turning points where futures can be grasped and foretold. Moments of social crisis manifest in bodies, and therefore in the clinic. Das’s notion of ‘critical events’, as discussed in Affliction: Health, Disease, and Poverty (Das 2015) and also taken up in MAT’s September 2017 issue, furnishes perhaps the most thorough consideration of crisis. As she and others have pointed out, crisis is an everyday reality for many who live in conditions of precarity and existential instability. More generally, the current geopolitical climate and the growing urgency of climate change contribute to the sense of crisis. The clinic is symptomatic of crisis, a place where a state of emergency becomes finally visible. Medical anthropology has a long history of clinical inquiry: one need only recall Taussig’s (1980) seminal ‘Reification and the Consciousness of the Patient’, Estroff’s (1985) Making It Crazy, anearly ethnographic study of schizophrenia in the era of psychiatric deinstitutionalization, as well as a long line of hospital ethnographies, including Hours’ pioneering 1985 study L’État sorcier, and more recently Livingston’s Improvised Medicine (2015) or Street’s Biomedicine in an Unstable Place (2014). Our September issue continues in this tradition, revealing the growing precariousness of life rooted in an ongoing crisis of citizenship. If, as Enria and Lees argue, writing about Ebola in Sierra Leone, ‘encounters with biomedicine … are part of broader conversations about citizenship and the social contract’, medical anthropology offers both a register and a hermeneutics for these conversations and the insight they shed on our world today.

Bras’s contribution to this volume draws on ethnographic stints in clinics treating multidrug-resistant tuberculosis in Brazil, a rising industrial power (despite current political troubles) that has enshrined the right to life in its constitution. However, as she shows, that right sometimes only becomes exercised after people have fallen ill, often because entrenched factors have generated these very illnesses. Having an illness appears to be the only way these individuals access citizenship. The nexus between infection and citizenship is not surprising in the case of such a slow infection as tuberculosis (or HIV), infections that play out over lifetimes and generations, timescales commensurate with the political dynamics of citizenship. But, perhaps unexpectedly, it is also found to be very much at stake in the fastest of epidemics: Ebola. While there has already been an explosion of anthropological writing on the epidemic, much of it at best ‘hit-and-run’ ethnography, Enria and Lees’s contribution to this volume is notable as it draws on actual, in-depth fieldwork conducted during and after the epidemic. Not surprisingly, then, the findings depart from those that have been reprised from over fifty years of anthropology in international health and the now well-worn liturgy of community engagement, empowerment, and structural violence reissued with a shiny new cover with every new outbreak. Enria and Lees note that Ebola was the apogee, in the eyes of their informants, of a ‘failed social contract’, proof that the state could no longer protect Sierra Leoneans from foreign dangers. And paradoxically, this ‘externalisation of sovereignty’ offered a strategic resource, whereby the state’s failings could be measured up against the ‘gold standard’ of biopolitical care: internationally funded clinical trials.

Lerman’s contribution is offered here as a provocative outlier in the genre of medical anthropology. Drawing on epidemiological literature, she seeks to flesh out the concept of syndemogenesis, first advanced by Merrill Singer to refer to ‘interacting, co-present, or sequential diseases and the social and environmental factors that promote and enhance the negative effects of disease interaction’ (quoted on p. 1). In a fitting reversal, an anthropological concept is used to interrogate the epidemiological literature. In this review, depression provides a case study and a lens for shedding light on interconnections rarely viewed all together. Syndemics are another symptom of crisis, the manifestation of overlapping biosocial fault lines exposed in moments of political collapse.

Caduff’s contribution to this issue examines how clinic and crisis are conjugated in the rhetoric of preparedness that now has now become the chorus of post-Ebola global health. ‘We must prepare for the next epidemic!’, we are urged, and the next one and the one after that; prediction has become the stock and trade of this growing industry. Declaring unpreparedness has been shown to be a particularly effective rhetorical strategy for capturing resources in an age of biosecurity anxiety. The ‘preparedness’ industry has been a lucrative one for global health actors and researchers, founded in a tautology common to divinatory and oracular practices first identified by Evans-Pritchard in 1937.  The preparedness industry  can claim a spectacular string of epidemiological failures since 9/11, to which the answer is always – more preparedness! Caduff offers a new take on the preparedness industry, focusing on its discursive logics to demonstrate what is also at stake: the production of seriality, which after all, is a way of keeping the exceptional always already present. Thus is crisis woven into the fabric of the everyday.

Yates-Doerr tackles a recurring problem at the intersection of anthropology and global health. Anthropologists, as specialists of ‘culture’, are called in to help get things moving when global health interventions get stuck or to help right them when they go off the rails or fail altogether. The usual suspects have been identified: cultural beliefs and/or practices, traditional values, etc., of the targeted group. The anthropologist must translate or devise strategies to bring the targets ‘on board’. The refusal to countenance culture as a culprit – eloquently summarized in the critique of culturalism – has become a rote response of anthropologists. Yates-Doerr, reflecting on extensive fieldwork in Guatemala with programs tackling the growing phenomenon of obesity and on her own work in Amsterdam, engages the notion of culture as fashioned through social interaction. Rather than cultural competency, with its implications of cultural essentialism, she argues for ‘translational competency’ as a method for addressing cultural issues in health without falling into the trap of culturalism. 

The issue is rounded out with reviews of six recent and important books for medical anthropology that concern an array of topics: the growth of breast milk exchanges (Abadie), the use of metrics in global health (Arteaga), pharmacotherapeutic revolutions (Lozano), migraines and gender (Sierman), the Zika epidemic in Brazil (Stalcup), and care (Van der Geest). 

We are pleased to announce that Liz Cartwright of Idaho State University will be joining our editorial team, picking up the reins for the Photo Essay section, as Danya Fast will be stepping down from the post at the end of the year. We are thankful for the tremendous work Danya has done in establishing the section over the last four years, and we look forward to seeing what Liz will bring to it in the future. 

And, finally, we acknowledge the passing of Armin Prinz, the former head of the Department of Ethnomedicine at the Medical University of Vienna, on 25 August. An obituary remembering his life and his work will be published shortly.


Das, Veena. 2015. Affliction: Health, Disease Poverty. New York: Fordham University Press.
Estroff, Sue. 1985. Making It Crazy: An Ethnography of Psychiatric Clients in an American Community.Berkeley: University of California Press.
Foucault, Michel. 1963. Naissance de la clinique. Paris: Presses universitaires de France.
Hours, Bernard. 1985. L’État sorcier: santé publique et société au Cameroun. Paris: Karthala.
Livingston, Julie. 2015. Improvising Medicine: An African Oncology Ward in an Emerging Epidemic. Durham, NC: Duke University Press.
Street, Alice. 2014. Biomedicine in an Unstable Place: Infrastructure and Personhood in a Papua New Guinean Hospital. Durham, NC: Duke University Press.
Taussig, Michael T. 1980. ‘Reification and the Consciousness of the Patient’. Social Science & Medicine 14B: 3–13.