Revisiting the margins

Towards a praxis for critical global health

Michelle Pentecost

13 Jul 2016

On June 3rd 2016, a group of scholars gathered at Green Templeton College at the University of Oxford for ‘Revisiting the Margins: Towards a Praxis for Critical Global Health’. This event was organised by Michelle Pentecost, a Green Templeton member and a doctoral candidate at the Institute for Social and Cultural Anthropology at Oxford, and funded by the Green Templeton Annual Fund and a Green Templeton Academic Grant. The aim was to bring together a diverse group of anthropologists working across the global North and South on what might be termed ‘critical global health’.‘ Critical global health’ is the subject of new volumes, research groups, and journals, but its remit is fluid across these platforms, and the term itself unstable. This conference gathered scholars working at the margins of this new framework – as researchers, teachers, clinicians, and activists – to discuss the ethical, methodological, and disciplinary challenges that this work presents, as well as the intellectual and pedagogical opportunities it affords.

Medical anthropologists have been grappling with ‘that obscure object of global health’ (Fassin 2012) for some time now, but the ‘critical’ prefix is a somewhat newer development (Biehl and Petryna 2013). On the one hand, the turn to critical global health is the renewal of a long-held concern within our discipline: the need for close attention to the broader knowledge field of ‘public health’ and its practice. On the other hand, ‘critical global health’ is a construct that emerges specifically with the contemporary biopolitical configurations in which working towards ‘something called health’ (Pigg 2013) are now shaped, characterised by variable state involvement and public-private and philanthropic partnerships (Geissler 2015).

The conference offered a forum for a discussion of these issues, between ‘old hands’, who have grappled with such challenges before and who have helped to frame practice in terms of a critical engagement, and a new generation of scholars who are encountering similar challenges in the field today. What does it mean to be ‘critical’ in the practice of ‘critical global health’? If such an approach is desirable, how might this be achieved? Can we reimagine how practice and critique might be inhabited by practitioner-scholar-activists in new global health contexts?

Georgina Pearson’s (London School of Economics) work on schistosomiasis along the river Nile in northwestern Uganda showed how the purview of global health might be confined to predetermined demarcated areas: her interlocutors expressed surprise at her choice of field site for studying schistosomiasis, given that one would usually head to ‘Schisto Central’ (as a town along the shore of Lake Albert was described) for this kind of work. Physical margins for global health work are constructed, and yet in this case those margins did not meaningfully bind the fishermen who were the object of epidemiological enquiry. The ‘random sample’, then, Pearson argues, is an unstable entity: ‘It is difficult to make these fishers wait; you must take them when you can’ (see Pearson forthcoming). The theme of the ‘space of global health’ was echoed in Thomas Cousins’s (Stellenbosch University) account of territory, labour, and authority in Kwazulu Natal, South Africa. Cousins’s cartographies of local history, demographic surveillance, clinical intervention, and changing HIV prevalence offer a new picture of distributional regimes and forms of biopower in this postwork locality of the global South.

Branwyn Poleykett’s (Cambridge University) offering on ‘learning hierarchy and practising friendship in global health science’ reminded us that the values espoused by practising  ‘critical global health’ are themselves unstable. Observing from both ends of a Danish–Tanzanian capacity-building project reveals how power shifts and arrangements change as ‘capacity building’ unfolds, to produce tensions between a culture and ethos of science that maintains a ‘moral discernment’, in the Danes’ formulation, and a production of ‘capacity’ which commoditises skills to produce ‘marketable’ scientists. Frederic le Marcis’ (École normale supérieure de Lyon) discussion of ‘doing science in an emergency’, in which he examined outcomes and pitfalls of a clinical trial during the Ebola outbreak, extended this conversation on values and ethos, highlighting how the validity and relevance of evidence may be in tension with appeals to compassion and the need for quality care. Michelle Pentecost (Oxford University) drew on her ethnography of a global perinatal nutrition intervention to interrogate the underlying values that inform global health’s (re)turn to the maternal, and the continuities and disjunctures between the authorising image of the maternal-child dyad in health interventions on the African continent.

Katherine Warren (Oxford University) interrogated attempts to put ‘global health’ back into Euro-American landscapes. While thinking about Detroit as ‘the other Global South’ (Meyers and Hunt 2014) draws attention to inequalities closer to ‘home’, Warren cautions that the practice of ‘global health at home’ may have the indirect effect of pathologising the margins; ‘the other Global South’ is distanced further from the wider social framework that has produced it and its accompanying global health ‘emergencies’, such as the rising rates of drug use and suicide Warren describes for communities in Baltimore and Montana respectively. Seonsam Na’s (Oxford University) ethnography of a rebellion by doctors in South Korea offered a different picture of ‘global health at home’, in which the protest of junior doctors – both tied to and in tension with the state – takes a form of ritual.

Hayley MacGregor (Sussex University) offered a nuanced view into the challenges of collaboration, specifically: how to be a participant observer in a public health intervention when you are also the principal investigator for that intervention? She discussed her navigation of processes couched in the language of evidence, innovation, and relevance, and the emerging tensions and necessary trade-offs required of a praxis of critical global health. Seth Holmes (University of California Berkeley) was also concerned with collaboration, and made a case for reconsidering anthropologists’ roles in witnessing and attending to suffering. He responded to recent calls to move away from the ‘suffering slot’ to practice ‘an anthropology of the good’ (Robbins 2013). Holmes found this turn only partially productive, and illustrated ways in which the practitioner-scholar-activist might utilise their role to highlight injustices in partnership with their interlocutors – in Holmes’s case, the migrant Mexican farm workers with whom he has worked for a number of years. Reflecting later on this binary of suffering and ‘the good’, I recalled Veena Das’s caution (2015, 4) about whether one should ‘take sides’, given that it is questionable ‘how these two modes of doing anthropology are put into opposition in the first place’.

Similarly, this conference did well not to reinforce the familiar critique/practice binary. More apparent were the different discourses of ‘critical global health’ at work across the range of papers, with their own genealogies, aims, and frameworks. Global health, reimagined by organisations like Partners in Health, is based on a ‘vision of health equity and social justice’ (Farmer et al. 2013, 16). But, flagging the ease with which anthropologists might adopt global health rhetoric and the moral stance it conveys, Fassin (2012, 114) challenges medical anthropologists to ‘recognise the fine line between scientific detachment and moral involvement’ in critical global health research. These different views are part of a long conversation in anthropology about the place of advocacy and activism in the discipline, under the rubrics of ‘applied’, ‘public’, and now ‘engaged’ anthropology (Hastrup et al. 1990; Singer 1995; Susser 2010; Baer 2012; Hopper 2013). While the discipline has long held the view of the margin between medicine and anthropology as a productive and vital space (Kleinman 1995), critical practice in global health must take seriously Fassin’s (2012, 115) contention that ‘our sole legitimacy to speak and our sole claim to be listened to depend on our capacity to contest the untested assumptions, the most insidious being that on which we found our moral certainties’. Michael Osterweil’s (2013, 617) take on engagement is useful here: engagement is not ‘something we do “out there”’, but is rather a form of critical self-reflection that recognises and questions the common ideologies and epistemologies in which our practice is situated. In this vein, the keynote address by Vinh-Kim Nguyen (Graduate Institute, Geneva) aimed to diagnose the current milieu in which global health is ‘the symptom’. He was concerned with thinking through a more fully historicised and contextualised version of ‘global health’, working with what is left out of the global health story and with the new forms of labour, value, and anticipation that characterise this paradigm.

The day’s offerings stimulated thought-provoking discussions that both furthered the conversation on well-worn questions (Does global health exist?), and posed new enquiries and points of departure for future work (How do we harness the social knowledge that is inevitably produced in and by projects of global health but so often falls by the wayside?) If the conference itself was taken as an ethnographic moment, then what good participant observation made clear were the regional and singular histories of (critical) global health that inform practice.

About the author

Michelle Pentecost is a DPhil candidate in anthropology at the University of Oxford (Green Templeton College), and an affiliate of ‘The First Thousand Days’ research group at the University of Cape Town. She is currently completing her doctoral thesis, titled ‘The First Thousand Days: Global Health and the Politics of Potential in Khayelitsha, South Africa’. Her research engages with critical medical anthropology, science and technology studies, and postcolonial theory within anthropology’s growing corpus of critical studies of global health. Michelle is also a practicing clinician with special interests in perinatology and internal medicine. She completed her medical training at the University of Cape Town before obtaining an MSc in medical anthropology at the University of Oxford. 


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