Introduction

Objects of critique in critical global health studies

Cal (Crystal) Biruk, Ramah McKay

14 May 2019
doi.org/10.17157/mat.6.2.718

Abstract

As an emerging subfield of medical anthropology with roots in histories and geographies of colonial and international health, critical global health studies reflects both changing modes of health practice and the centering of critique as a core anthropological endeavor. This special section seeks to analyze and reflect on the meanings, valences, affects, and entailments of anthropological critique, taking the rise of global health and flourishing of global health ethnography as key sites of investigation. Each of the contributing pieces is oriented around a global health object or technology.

 

Editors’ note: This special section includes pieces by Cal BirukTomas MatzaRamah McKay, and Alex Nading.

A bar of soap, a psychological screening kit, a grievance document, a focus group, and a photograph. This special section curates an unruly mélange of objects, each of which somehow bridges ‘here’ and ‘there’ or ‘home’ and ‘field’ for the anthropologist who contributed it. Objects such as these are props that bring ethnographic writing to life, lending materiality to our narrations, like visible hinges between intersecting social worlds. Objects are memorable, often standing in for or acting as metonyms for theories, concepts and authors: take, for example, Geertz’s cocks, Turner’s milk tree, Ferguson’s livestock, Malinowski’s kula objects, Tsing’s matsutake mushrooms, and deLaet and Mol’s beloved bush pump. Anthropology’s disciplinary archive of objects reveals shifts in ways of seeing over time; in studying the relations between narrative and the objects it describes, and between objects and the processes through which they were isolated from their worlds as significantby the anthropologist, we can sketch our disciplinary histories and glimpse the epistemological norms and orientations that have constituted schools of thought. Yet, anthropologists have been generally unified in their criticalstance toward the worlds they study, translate, or represent. It has long been the anthropologist’s role to see what others miss out on, to focus on mundane practices or objects that are unexpectedly laden with meaning. Often, methodological skills and arts of observation are mobilized toward translating ‘other worlds’ with an eye to building better ones.

These imperatives are at the core of projects that can be loosely grouped beneath the moniker ‘critical global health studies’. Taking the emergence, consolidation, and perhaps dissolution of the field of global health as their object of analysis, critical global health approaches have mobilized ethnography to understand the rise of ‘humanitarian biomedicine’ as a means of delivering medical services, organizing health policy, generating knowledge, and reformulating relations between states and citizens, donors and recipients (Lakoff 2010; see also Beshar and Stellmach 2017). In this context, critical ethnographic narratives have often sought to temper the triumphalist rise of ‘evidence-based’ medicine and policy, whose success is often (mis)measured according to metrics and standards that fail to capture on-the-ground complexities. By now, a wonderful body of ethnographic work has used ‘global health’ as an entry point for examining social and cultural dynamics on the ground (Wendland 2007; Kalofonos 2010; McKay 2018, Nguyen 2010; Biruk 2012; Erikson 2012), the complex market forces and political forces at play (Foley 2009; Bornstein and Redfield 2011; Peterson 2014; Smith 2014), the modes of evidence making that emerge from them (Adams 2016a; Biruk 2018), and the often overlooked things that matter most to people in precarious positions (Das 2014; McKay 2012; Biehl and Petryna 2013; Benton 2015; Storeng and Mishra 2014; Adams 2016b; Prince and Brown 2015).[note 1]See also the Duke University Press series, ‘Critical Global Health: Evidence, Efficacy, Ethnography’, edited by Vincanne Adams and João Biehl.

Amid the rapid temporalities of global health – funding cycles, epidemics, humanitarian crises, and drug development research, for instance – anthropologists have remained committed to careful and long-term inquiries, endorsing ‘slow research’ as an accompaniment or alternative to the frenetic tempos and thin social relationships that constitute normative global health (Adams, Burke, and Whitmarsh 2014). Yet while such commitments contextualize and interrupt normative global health approaches, they may also work to further constitute global health itself as a field of intervention. As social science renders global health visible, teachable, and open to critique, it may also domesticate or erase the messiness and incoherence of a wide range of biomedical practices and interventions that articulate in diverse and sometimes surprising ways with the locations in which they are generated and implemented. Criticalglobal health, in other words, may do as much to render global health ‘real’ as the normative approaches it exposes and seeks to challenge.

Critique in critical global health studies

As will be seen in the essays collected here, ethnographic critique requires not just objective distance or abstraction from but also intimacy with our objects of study (Candea 2010). Though anthropologists’ polished work in disciplinary journals often obscures these entanglements, ethnographic intimacy also enlists us in global health projects. Questions of complicity thus seem to shadow imperatives of critique. Indeed, while fieldwork in its classic and contemporary formulations calls upon ethnographers not only to (critically) observe but to participate, these entanglements are particularly evident in critical studies of global health (see Dilger, Huschke, and Mattes 2015). Ethnographic fieldwork has proven to draw anthropologists into global health’s medical, care-giving, evidence-producing, and fundraising practices in diverse ways. Practitioners may see ethnographic research as a way to extend understanding beyond the clinic walls, helping them to determine how and whether their interventions are helping, or adding ‘texture’ (see Matza, in this special section) to statistical aggregates. Anthropologists, meanwhile, may struggle to reconcile their investments in a politics of critique with their yearning to ensure anthropology has a ‘use-value’, with, as Pigg (2013) puts it, the tensions between ‘sitting’ and ‘doing’. As global health projects engender new possibilities for health and care, therefore, they not only transform patients, caregivers, and places, but also ethnographers themselves, shaping what it means to engage in fieldwork and ethnographic analysis – as forms of critique – today.

The essays collected here reflect on these transformations in anthropological orientations, agendas, and selves. Anthropologists of global health, for example, may find themselves ambivalently caught up in a cat’s cradle of relations and transactions they are also aiming to critique, as the contributors demonstrate. Such instances of complicity have a long history in medical anthropology, a subdiscipline formed within colonized contexts, where anthropologists were often enlisted into state projects. Perhaps it is a fear of complicity, and the shame and discomfort associated with this legacy (see Rancière 2009), combined with an often-felt loyalty to the downtrodden or marginalized that prompts us to disavow any resemblance our tasks in the field might have to the endeavors of the physicians, scientists, missionaries, statisticians, NGOs, and companies who constitute the unwieldy thing we call ‘global health’. We, after all, are meant to see what they are doing wrong; bringing to light that which projects overlook, anthropologists as critics ‘retrieve a concealed or camouflaged truth’ (Felski 2015, 7).

The predicaments of critical global health thus also reflect the peculiarity of critique more broadly. Critique dominantly entails a corpus of rhetorical gestures and embodied stances orchestrated by paranoid desires to unmask, demystify, reveal, expose, or unsettle; it is a hermeneutics of suspicion that produces well-worn habits and a critical habitus negatively oriented toward its objects of study (Ricoeur [1965] 1977; Sedgwick 2003; Felski 2015; Love 2017). Anthropological critique, too, tends toward a kind of critical distance that ‘casts the social scientist as one who can see or know better than her interlocutors’ (Fassin 2012, 246). Yet as Sedgwick (2003, 124) notes, such ‘paranoid’ habits can become stultifying; the aversion to being surprised manifests as a foreclosure of the multiple possibilities and emergences inherent in an encounter with an object. Just as the person who nods enthusiastically when someone mentions a book he has not read misses an opportunity to have it summarized for him (or to extend his relationship with the speaker), so too does the anthropologist intent on diagnosing what is wrong with global health miss out on everything that is then necessarily relegated to the background. Here, we suggest, objects provide an analytic opening.

Objects in global health: Between critique and postcritique

Entering the field, the anthropologist encounters a world replete with objects that beckon for her attention: metrics, clinical trials, pharmaceuticals, workshops, soap, bed nets, PreP, and condoms are some of the more obvious fragments of a postcolonial lexicon through which anthropologists might represent the messy worlds and ethics of well-intentioned interventions (borrowing here from Nancy Rose Hunt’s [1999] colonial lexicon). As they articulate with the decidedly more-than-medical worlds of relations, law, work, representation, care, and exchange in which they are enmeshed, objects not only constitute the ‘stuff’ of global health but also unsettle and mediate fixed relations of intervention and critique, of worlds and evidence; they are not solid ‘things’ but enmeshed in ‘material discursive practices’ that make things matter, or not (Barad 2003, 810; Haraway 1988; Mol 2010; Russell and Widger 2018). The objects here, then, are ‘not fixed or frozen; they speak to, but also beyond, their own moment, anticipating future affinities and conjuring up not yet imaginable connections’ (Felski 2015, 159). Yet, the productivity of objects for revealing not only things about global health but also things about anthropology, has remained underexamined. This collection of essays aims to capture how objects create worlds and worlds create objects, including the ‘critic/anthropologist’ herself, to ruminate on the work of critique in critical global health studies.

The authors in this collection put forth diverse objects drawn from across the globe (Malawi, Mozambique, Nicaragua, and El Salvador) to stage critique as entangled and entangling project.[note 2]The authors would like to thank Claire Wendland, Neil Kodesh, and Pablo Gomez, organizers of a 2016 conference on ‘Big Stories and Close (Up) Research: Health and Science in the African World’, from which we borrowed the structure of our 2016 AAA panel around ‘objects’. We would also like to thank Eugene Raikhel who served as a generous and insightful discussant at the AAA panel where these papers were first presented.
 Across the contributions, ethnography emerges as not only an attentiveness to the people but also to the objects of knowledge and ontological framings that ‘generate consequences by way of their own narratives’ (Adams 2016a, 194). Alex Nading explores the role of documentary mechanisms in making chronic kidney disease in Nicaragua, as linkages between a range of documents (clinical record, work record, land title, news article, complaint form, epidemiological survey, and anthropological ethnography) also link plantation history, global health, and environmental advocacy. Engaging documents as interlinked objects, Nading shows, promises to unsettle single-factor explanations of chronic kidney disease and, in so doing, to enable more robust critical interpretative and causal frameworks. Further, working across documentary mechanisms suspends the anthropological impulse to settle on a singular or ‘best figure’ with which to mobilize a political or critical project.  Using the heavy suitcase carrying the accoutrement of a psychological screening tool he brings to the field as an entry point, Tomas Matza explores the weight of critical imperatives under complex conditions of collaboration, showing how it is not the practice of critique that distinguishes the anthropologist from the practitioner but the ends to which critique is put. Tracking the tensions he experienced between being a critic and a collaborator to NGO projects in El Salvador, he suggests that ethnography might be ‘productively incommensurable with global health agendas’, resisting the imperative that anthropology be ‘useful’.

Cal Biruk likewise reflects on how collaboration with demographic survey projects in Malawi and intimacy with their quantitative data collection processes in the field helpfully reframed normative investments in critique as ‘showing what global health gets wrong’. It was through caring for numbers that would never be ‘good’ in anthropologists’ eyes that allowed Biruk to shift her attention to the ways that numbers make worlds, rather than merely mismeasure them. Biruk uses the object of soap, a gift given by demographic projects to rural research participants, to trace her own becoming an anthropologist of global health and to show how anthropologists’ commitment to the ‘small things’ makes ethnography an enduring practice of care that destabilizes tired definitions of negative critique. Finally, Ramah McKay explores the social life of social science practice and critique through the modes and objects of social scientific representation in Mozambique. While anthropology promises to make the strange familiar and the familiar strange (as the old saw has it), here, the anthropologist is herself made strange as she encounters the tools and repertoires of social science research, representation, and critique already at work and in circulation among health practitioners and policymakers. Faced with an object that already understands itself to be critical  (Rancière 2009), anthropological critique confronts the political conditions through which global health and global health ethnography come to be.

Together, these essays explore how ‘critique need not be only corrosive, but it can also represent a commitment to tracing social arrangements in-the-making’ (Love 2017, 69), including ethnographic arrangements. Closely tracking the people, investments, and stories that attach to objects can help us know ourselves (as anthropologists) better and expand our received notions of critical affects, tools, generic conventions, and feelings. It is through global health that the anthropologists here have become who they are and such entanglements necessarily spill over into our own work. As Matza puts it in his essay, ‘critique has to be a praxis, not a theoretical or ideological position’. Nading, citing Marcus (2013), meanwhile documents in great detail how documentary mechanisms become a ‘para-site’, ‘where anthropological critique, international law, global health, and transnational activism emulsify’. Collectively, then, we call for a critique that embraces and narrates the messiness of its own emergence. The matter and material practices and artifacts of global health, we suggest, are fruitful platforms from which we might more deeply understand the convergences and divergences of anthropology and global health and their dual ‘unfinishedness’ (Biehl 2016).

About the authors

Cal Biruk is Associate Professor of Anthropology at Oberlin College. Cal is the author of Cooking Data: Culture and Politics in an African Research World (Duke University Press, 2018). Her research and teaching interests are at the intersection of medical anthropology, critical data studies, queer studies, and global health studies. Her current research projects – which focus on geographies of aid in Malawi and on theorizing wearables as queer technologies amid the second fitness boom in the United States – take the form of ethnographic treatments of metrics, indicators, and genres of measurement and counting in the era of Big Data and audit culture(s).

Ramah McKay is Assistant Professor in the Department of History and Sociology of Science at the University of Pennsylvania. Her book, Medicine in the Meantime: The Work of Care in Mozambique (Duke University Press, 2018), examines the critical and temporal politics of development and global health projects in Mozambique. Her ongoing research focuses on for-profit medical care and the role of global health projects in shaping transnational medical markets, and on the role of feminist social science in aid and relief work, focusing particularly on technologists of audit and accountability.

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