Health care, ordinary, traditional, and contemporary ethics
In memoriam, N. Sunder Rajan,
who strove to keep the state honest
and loved life
(b. 1944 Pondicherry – d. 2014 Chennai)[note 1]Sunder rose to the position of deputy comptroller and auditor general, the top position in the Indian Audit and Accounts Department, equivalent to that of a permanent secretary to the government of India, having served internationally in Washington and elsewhere, in various positions in the central government such as the parliamentary (Lok Sabha) secretariat of the Public Accounts Committee, the Ministry of Civil Aviation, as well as many posts around India.
In Das’s Affliction: Health, Disease, Poverty (2015a) we listen with her to ordinary ethics in lives challenged by poverty, illness, and family relations. These are expressed in three often-conflicting registers of (a) advocacy, (b) moral engagement, and (c) acknowledgement of inherent uncertainties in the very fabric of living these lives, including hers and ours.[note 2]A portion of the beginning of this article was orally presented at the American Anthropological Association meetings in Washington D.C., 4 December, 2014, as part of the panel, ‘Affliction: A Discussion with Veena Das’, organized by Clara Han with Veena Das as respondent, and appeared as a book review in Somatosphere in February 2015 (http://somatosphere.net/2015/02/affliction.html).
Some ask how advocacy contributes to a larger social politics or strategic vision; whether moral engagements have action-critical alternative cultural registers; and how local tactics, enforced slow temporalities of resilience, and personal ethics can feedback into grassroots social politics, and articulate with new developments in bioscience and biotechnology.
Some of these questions may be productively reframed through juxtaposing and ‘mosaic-ing’ them with other instructive scenes from India. India provides powerful sites of production of poverty and precarity along with its expanding middle-class culture and entrepreneurial inventiveness. The unevenness of its terrain of opportunities contains loci of hope as well as cul-de-sacs of decay and frustration. On the policy level, India poses daunting strategic questions about how to disseminate effective health care. On the theoretical level, India’s cultural-mythic registers of different traditions (sometimes coded as Hindu, Islamic, Jain, etc.) provide opportunities, as Das suggests, to draw parallels among Wittgenstein’s scenes of instruction, Levinas’s limits on infinite responsibility, and the Sanskrit stories that inhabit popular discourse and moral reason.
I have organized my discussion of these themes in three parts: after beginning with the text of Affliction, I comment on moral engagements and sparks of reference to the Mahabharata and other traditional, especially Muslim, modes of ethical thought, the commentary performing what in Islamic scholarship often are called hashiye, marginal notes on the main text. I then conclude by describing a mosaic of coverage and gaps in the contemporary ethics of Indian health care and its anthropologies.
Reading Das’s Affliction
Somewhere – in the vast practical and dramatic spaces between the disconnects of global health models constructed with poor/flawed statistics and piecemeal moralistic nudging of behavioral economists who rely on naïve individualistic psychological models rather than intimate knowledge of how lives are lived – somewhere in this vast multidimensional space of living lies the ethnographic task that for the last fourteen years Veena Das’s band of researchers has pursued in the hopes of producing anthropological evidence of another kind, ‘the kind that could be used for serious advocacy on sanitation, health care, or everyday violence’ (Das 2015a, 5–6).
Advocacy is a troubled and troubling terrain. In cases of cancer clusters, citizens often are told that they are incompetent to distinguish coincidence and statistical significance, meaning, in environments of sequestered information – as are so many of our corporatized and legally defended environments from Bhopal to Woburn, Love Canal to Fukushima – citizen science had to learn to gather epidemiological knowledge that would stand up in court and survive cross-examination. In the United States, in the Superfund legislation that was passed in 1980, citizen action panels were given money to hire independent experts. In the aftermath of Bhopal, ‘Right to Know’ legislation was passed in the United States and later in India. In terrains of proprietary knowledge, government statistics not made public, and other forms of sequestering knowledge, especially in worlds of metrics and audits that stand in for, and constitute, legally defensible knowledge, experiential knowledge of the sort revealed by anthropological tools often has a hard time.
There are at least two critical and effective tools however that anthropology wields. First, anthropology can expose how bureaucratized statistics and models lie, hide reality, are made up, or are tissues of unrealistic extrapolations. Das treads carefully in this terrain, referring occasionally to celebrity projects like MIT’s Poverty Action Lab, and proposing her team’s Standardized Patient methodology (to which I will return) as an alternative methodology, a metric even. The methodology included visits to 305 practitioners (926 visits) for three common diseases, presented by twenty-two simulated standardized patients; a weekly morbidity survey of 300 households (with 1,620 individuals participating and a refusal rate of less than 1 percent), done weekly for seventeen to eighteen weeks, then monthly; detailed interviews with at least one and ideally all members of each household; and a full day spent in each of 291 practitioners’ clinics. This was done not just to expose poor quality medicine but also, positively, as a pedagogy that teaches patients, ordinary people, doctors, and anthropologists how to articulate disease diagnostic symptoms in vernacularly recognized ways. The second anthropological tool is powerfully ‘staging’ the lived realities of life. Anthropology often operates like the theater. Putting characters and plots on stage can illustrate competing interests, affects, emotions, idioms, strategic ploys, conflicts, and temporary tragedies and resolutions. Das does this skillfully, and, as she warns, not for its sentimental persuasive value, not just for cultivating unmediated sympathy or empathy – she repeats this several times – but in pursuit of calling the community, politicians, policymakers, and experts alike from everyday trance-like forgetfulness into awareness. The challenge, she notes, following Emmanuel Levinas (or Stanley Cavell’s reading of Levinas[note 3]See also Cavell’s introduction to Das 2007.
), is that the problem is rarely just attending to the face of the other, but, in a world of competing obligations to the living, the dead, and the dying, learning how to suffer separation from the other, limiting the desire for infinite responsibility, allowing a person, an attachment to life, space to breathe (Das 2015a, 87, 114–15, 119, 130). At times – as in the case of Bilu, who blames himself for not being able to gather the resources for his brother’s kidney transplant in time, a possibility that would have suffocated his own life and that of his new son with debts and demands for immunosuppressants and other life supports – this is a story of individuation. But at other times it is a cycling through one’s contesting (almost Kantian) faculties: (i) the courtroom (the accusatory voices of obligations one is unable to fulfill), (ii) the artisanal workshop (the cultivation and care of the self in traditionally given virtues), and (iii) the laboratory (the experimental innovation of new plotlines for one’s own life and one’s consociates).[note 4]Das takes this triad from Mattingly’s work (2012) in clinical settings, and I expand it also to Kant’s conflict of the faculties, or different pedogical forms of reasoning. Note that Das (2015a, 118) distinguishes her own interpretation of the triad from Mattingly: ‘Whereas for Mattingly these three modes … are in opposition to each other, I hope to show … that one cascades between these different modes … [and they] do not happen to an isolated individual’. My note on Kant supports Das in this, and adds a further layer of philosophical reference and meaning. Both of us appreciate Mattingly’s triad, and merely make it do even more work, in different settings.
Here is ‘ordinary ethics’, but of the most profound sort, scenes of instruction that should make the distanced policy maker see anew, and come out of the trance of rules, excuses, and impossibilities for helping those in need.
Among the virtues of India, amidst the poverty, conflicts, and crowding, is its vitality as a land of philosophy, not just in its ancient civilizational roots in conversation with the Greeks and Chinese, but in contemporary life, affording a diversity of ‘scenes’ of profound ordinary ethics, as people engage with illness, access to and quality of care, the technological, and the psycho-spiritual webs of relational socialities. Das’s text is structured roughly like Wittgenstein’s Philosophical Investigations (1953) moving through ‘scenes of instruction’ that are arranged in pairs and triads of increasing complexity, not unlike Laura Bohannan’s 1954 classic and ingeniously structured Return to Laughter.[note 5]Elinore Smith Bowen (the pen name of Laura Bohannan) stages scenarios twice, first as she is learning about Tiv culture, and then in much richer contextualized versions with revised understandings. Other classic ethnographies using a serial case method include Victor Turner’s Schism and Continuity in an African Society (1957) and Gananath Obeyesekere’s Medusa’s Hair (1981).
The theaters of ordinary ethics are modern, contemporary productions, staged within the folds and social stressors of urban renewal/removal after communal riots; the structural violence experienced by rural-to-urban migrants living with low-income and education, unattended-to illnesses and family tensions; and dispensaries that give out tetracycline no matter what your illness because that’s all they have been supplied this month. The theaters of ordinary ethics are both performative (acting out, fusing together visceral-emotional and cognitive-moral poles of understanding) and enchanted with modernity’s extravagant promises, for instance of commodities for which one only can manage the down payment, but then must sell or have repossessed, and of capacities for which one struggles, only to get a beginners’ incomplete schooling. Sometimes these promises are fulfilled enough to keep hopes and fantasies alive. Sometimes they are fulfilled only enough to generate dreams, visions, ghosts, jinn, bhot, and pretu, all generated – as the double-binds of Bilu’s life dramatize – by what, in reading Das, I have come to call the of ‘the pressure on thought’.[note 6]Das (2015a, 128) uses the phrase ‘pressure that such a case as this might put on us’ (and moves directly into a discussion of the academic ‘us’), but many other chapters and especially the chapter on Bilushow how pressures of thought, double-bind viscerally felt obligations, cannot be resolved by ‘rational argumentation, not simply emotion or empathy’. The woman in white (goddess or vision) creates a compromise formation and solution, as Sigmund Freud might put it in psychodynamic terms, or a new con-fusion of visceral-emotive and cognitive-moral poles, as Victor Turner might put it in ritual process terms, or a coming to wakefulness as Das and Cavell put it in a more mystical-philosophical framework of mulitple levels of conscious realities.
These pressures on thought are ‘something other than rational argumentation, not simply emotion or empathy, but wakefulness’ (Das 2015a, 130), a state Bilu reaches in terms of his duty to his son.
It is a beautiful case or scene of instruction, a case of choices between circles of obligation expanding infinitely in Bilu’s quest to make a kidney transplantation for his brother possible versus circles of obligation narrowed instead by saturating his immediate surroundings with care and love that make it livable. He is able to achieve this narrowed focus, only with great pain and continuing ‘post-traumatic stress’, through the woman in white who comes in dreams or visions to call him first to his responsibility to care for his village (widening his circles of obligation), but then later (narrowing them) only for his newborn son. She has granted his devotional prayers for a new son after the loss of an earlier one, but on condition of his absolute devotion to that gift. The pressures of interpreting visions, dread, panic, full of dilemmas of error, misinterpretations, false leads, satanic confusions, visions expressing dark drives – these all are part of the dramatic tension of the enchanted theaters of ordinary life, of the pressures of thought, the social stressors of impossible double-binds and obligations.
Contradictions and ambi-valences
Amidst the desire for ‘a theology of suffering’, with terms such as ‘soul’, and a troubling anti-consequentialist Bhagavad Gita maxim (‘you have authority only over your action, never over the consequences’) – which Das reads in a comforting Levinasian mode of limiting infinite responsibilities, but which sounds uncomfortably close to the warrior Krishna’s self-justification in war or the urgency used in self-justification of humanitarian aid industries for pushing aside local capacity building) – Das’s text registers ‘emotional and intellectual frictions’. These frictions cycle through internal voices of the accusatory other, invocations of traditional virtues, and demands for innovation attuned to present needs. Irresolvabilities structure these scenes of ordinary ethics: (i) limiting the desire for infinite responsibility, (ii) finding quality care, not just access to care, and (iii) acknowledging voices this side of mental illness (‘My problem is not that I am ill’; ‘But Aunty, I was not the one who was ill’ [Das 2015a, 110]). Hard to tell what is Shaytanic confusion in worlds where things are not always as they seem (dunya nadeedani).
Indeed, it is a truth of parables in many traditions that things are not always as they seem (Fischer and Abedi 1990, 110; see Jain parables and Musa-Khizr stories in Islam). This is a truth, as well, of psychoanalysis and counseling, of medical practitioners who attend to the corporeal demands of hope and spiritual distress, of the unseen world in its many dimensions.
Das deals with these in a series of ‘scenes of instruction’ built around nine main figures. The opening two scenes are of failures of quality of care, each complicated by a structural aporia of imposed not knowing. The next three are further complicated by family dynamics. This is intensified in the sixth and seventh scenes, which feature classic family systems dynamics in which a child is designated to be the problematic figure of failure or distress, but of course without knowing if there is also a genetic or physiological cause. The last and most elaborate is of the play of forces – psychic, social, political, economic, seen and unseen causes and influences – that make interpretation dangerous, and, like the philosophical pharmakon, potentially poisonous rather than healing.
The first scene of instruction is a story of a four-year-old child who died from a fall. The child’s head injury was misdiagnosed in the hospital with an X-ray, and only correctly diagnosed with a CT scan, but too late to do anything. A technician had told the parents a CT scan was needed, but the doctor in the first hospital responded to them, ‘Are you the doctor or am I?’ It is a story used first to draw attention to how the poor are treated in hospitals, but also then to raise the question about the different idioms in which husbands and wives express emotion after ‘cumulative adverse reproductive events (miscarriages, abortions, stillbirths, child deaths).’
In the second story, Ballo, who complains of stomach ache, weakness, lack of appetite, and a heart condition or perhaps tuberculosis (dil ke bimari, ya shayad TB), gets medicines intermittently whenever her son goes to the chemist and presents old prescriptions for viral hepatitis, liver function, or TB. Bad enough the old prescriptions, the lack of contact with a doctor, the intermittent drugs, but, underlying all, says Das, was the demand of the sixty-year-old woman for more attention from her son and his wife. She would periodically return from town to visit her daughter’s village to display displeasure at her son.
The third scene of instruction becomes more complicated. Prakash is a periodically hallucination-suffering, shivering old man who refuses to wear even a newly purchased sweater because he can smell a Muslim in it. His hallucinations, for which he was hospitalized already once forty years ago, obsessively repeat an abduction by Allah; in the grip of these, Prakash speaks in a high-pitched, feminized voice, claiming love of Allah and fatal attraction for Islam, from which he is saved by Shiva. Like Shiva, he can become violent. Released from the hospital he lives with the widow of his younger brother and her now adult son. This arrangement is imposed upon the widow by her biradari (kin group), who insist she have a male guardian in the house, never mind if he is mentally impaired. She manages him with lithium and sleeping pills. Life in this scene is complicated by family and hallucinations.
In the fourth scene of instruction, Meena dies of TB after having successfully completed several courses of ‘directly observed treatment’ for tuberculosis (TB-DOTS), each time being declared cured. A relative gets her admitted to a hospital as a dependent, and another helps her get into a treatment center under a false name to avoid regulations against going to treatment clinics beyond one’s local zone. A physician told Das that there was no point testing for multidrug-resistant TB since they could not treat it. Meena died after much seeking of care – leaving her family saddled with debt – and after having negotiated much anxiety that her husband would leave her for a woman with whom he was having an affair. There was no way to know if she was repeatedly reinfected because of compromised immunity, environmental factors, or concomitant HIV infection, or whether she was infected by an acquired or transmitted drug-resistant strain. Meanwhile, the records of each DOTS center classified her as a cured case, and, all together, she counts in the official statistics as multiple cured cases.
The fifth scene of instruction involves two children covering up for their parents. Meena’s son Mukesh, who aged from eight to twelve years old during fieldwork, covers for the dysfunctional relations of his parents, his mother’s descent into illness, her fear of being sent away, and her refusal to take her medications when she was angry with her husband. Before her death, Meena tried to support Mukesh’s education, with the help of Das, but after Meena’s death the new stepmother, whom the father also gives the name Meena, is not so supportive. Still, when Das meets Mukesh again a few years later, his smattering of English has gained him a job, a watch, and a practice of attending church, where he finds a sense of peace unlike, he says, the jostling in a Hindu temple. Mukesh’s story is paired with that of a young girl, similarly covering up about family problems. The girl tells the police that her mother’s death by kerosene was an accident. For this she is praised by the community.
A sixth scene of instruction is that of a brother and sister with different life outcomes. Swapan (a name that means ‘Dream’) is a twenty-year-old migrant from Multan and a Dalit, or untouchable, who suffers an unsupportive family environment, in which his sister succeeds at education while he fails. He is undermined by his mother and becomes designated as the problem child. He says to Das, ‘My problem is not that I am mad. My problem is that no one takes interest in me’ (Das 2015a, 95). But while he has moments of lucidity like this, he is less strong than his sister Vidya, and really is driven to the verge of madness, having bouts of rage, acting out, defecating on the floor, beating his mother, and eventually, after a stay in a psychiatric hospital, trying to master the world by memorizing the English dictionary, a key he thinks to power. Experiencing ‘illusory qualities of modernity’ that are always out of reach, he stumbles through life ‘as if made into a ghost’ (ibid., 106). This scene of instruction, of a splitting of the mother into good and bad mothers, sounds Kleinian or Bion(ian) or Kali-like,and offers a possible opening to building upon the psychoanalytic accounts of mental illness in South Asia pioneered by Gananath Obeysekere (1981), Alan Roland (1998), and others. Abandonment in these stories ‘is not so much an act of the will resulting from choice, but rather an exhaustion of the will and the capacity to marshal yet more energy’ (Das 2015a, 113). Swapan’s mother says her son has remade his own mother into a demonic being who could wish death upon the son she had borne. Here actors are not transparent to themselves, and the pursuit of the moral within such scenes of trancelike everyday ordinary ethics is analogous to being called to awaken from forgetfulness.
Vidya (‘Knowledge’), by contrast, is quite aware of her family systems role as the overly bright girl under such close supervision that, were she less strong, would make her ill like her brother Swapan. Stubbornly insisting on studying despite internal family pressures, she becomes withdrawn and is taken for psychiatric treatment. Vidya says to Das, ‘But Aunty, I was not the one who was ill – it is my Father who needs treatment… . My Father has created such a situation that every one was watching me all the time’ (ibid., 110). Vidya succeeds, if not all the way to college, still to a clerical job and steady income.
The most elaborate scene of instruction is that of the Muslim healer, Hafiz Mian, with whom Das shares her own dream of dread, in which she is on a train and helps protect an Indian nationalist terrorist disguised as a Sikh who is being tracked down by British soldiers on the train. The psychological ‘I’ of the dream is a young woman, who Das says doesn’t really physically look like her, whose job it is to distract the soldiers. The dread would seem to be easily explained, to this observer, as a reflection of Das’s work with Sikhs and other victims of the riots after Indira Gandhi’s assassination, and her continued work in low-income neighborhoods suffering further structural violence. In her story, however, Das claims to be ‘bewildered’ by the dream. Hafiz Mian cautions her that she should not tell dreams to just anyone because they could have dangerous effects, transforming what is latent and hidden into manifest reality. Significantly, he asks if in the dream she had seen the revolutionary or the British soldiers, and she realizes she had not. Dreams, he says, are only partly about images, what you see; they are primarily about what you sense, dread in this case, and dream interpretation is always subject to misrecognition, and to being misled by shaitan. The term ‘shaitan’, of course, has different registers. It too often is translated by what in Christian imagery is called Satan, a fallen angel and figure of intentional evil, like the Zoroastrian Ahriman. But shaitan is also used of mischievous little boys, a jokestering misdirection, not necessarily evil. In dream interpretation, therefore, shaitan can be various forms of error, of misrecognition, of false cues or leads. And so, Das’s anxiety about misrepresenting the vujud, the essence, the real truth, of the people she only comes to know partially through ethnographic fieldwork, is a burden that Hafiz Mian recognizes as the burden of a healer who is always dealing with the hidden, the shadows that manifest as displacements: the unspoken desires and motivations unknown even to the afflicted themselves.
Cultural acoustics inside pragmatic action
Each of his [Wittgenstein’s] scenes of instruction for example, I can produce from ritual Indian texts, for instance on the necessity to know the pain of the being of sacrifice.
A person, a woman, is building life already on some harms. Not by escaping, but by assimilating the violence and weaving your life in it.
Such a notion of witnessing is very present in the Hindu classical texts. And in some ways it is also a concept of embodiment of events or violence; in the sense that ‘the witness’ becomes able to let the events inhere in her. Memory is not at the level of representation, but at the level of a particular gesture with which you inhabit the world.[note 7]She goes on, without elaborating, to contrast this notion of witnessing to the notions of witnessing in Islam and Christianity, which this section gently questions, see ff. 14 and 19.
[My] notion of healing carried two ideas: endurance, capacity to establish a particular relationship to death… . I was very struck by the ways in which pain does write itself enduringly on people’s lives. It was not about a thunderous voice of pain, but about the manners in which pain was woven into the patterns of life.
– Veena Das, ‘Listening to Voices: An Interview with Veena Das’
‘Affliction’ is a strong word. To the Jewish ear, and perhaps to the Christian and the Marxian ear as well, it evokes Job.[note 8]See Antonio Negri’s ( 2009) reading of Job as a parable of human labor, and the ‘Commentary’ on Negri by Roland Boer (2009) in the same volume, who shows how even Negri’s revaluation is overdetermined in the end by mythic tropes.
‘Health’, ‘disease’, ‘poverty’ are, however, nouns of another kind: ‘health’ evokes the public health system, ‘disease’ evokes notions of pathology, and ‘poverty’ evokes the production of inequality. ‘Affliction’ has moral, psychological, physical, and biographical connotations written in various modes of pain and feeling. ‘Health’, ‘disease’, and ‘poverty’ are more statistical and comparative, alluding to the state and its institutions, economic and social status, states of governance and corruption, and even what Rajeswari Sunder Rajan (2003) calls the ‘scandal of the state’. The scandal of the state, rephrased, is also the affliction of the state, its incapacities, its blindnesses, and, so, its betrayals of its promises to its citizens.
For Das and her interlocutors, striations of fate or karma, revealed by the statistics of inequality, evoke, at certain moments, Sanskritic and Hindu traditions of interpretation of the Baghavad Gita and the Mahabharata, along with contrapuntal notes delivered via Muslim and occasionally Sikh and Jain tellings of how inscrutable worlds interact. Analogues of Job exist in the figures of Yudhisthira in the Mahabharata, Badrasingh in Jain stories, and the grief of Ashoka carved in his memorial stones.[note 9]Job, it has been speculated, might have a Buddhist story lineage. The trope of testing the most steadfastly moral person in the world structures both the Mahabharata (Yudhisthira) and the Ramayana (Rama). Echoes of the Job story may be found in the Jain story of Bhadrasingh, tested with Indra’s permission, though a long series of afflictions: ‘Suffering is the real test of life. And suffering has a fairly long course. Once it starts, it does not end soon’ (Mahendrakumar 1984, III:139–40 ff). On the Ramayana and the Mahabharata as overlapping but differently structured responses to testing an exemplary figure, see Shulman 2001, 23. The Ramayana is a transmutation of the emotion of grief into an aesthetic form: Valmiki’s grief (soka) over having issued a curse with unintended consequence becomes the first sloka (sung verse). And Rama grieving over what he has caused Sita and her descent to the underworld of the nagas, lost in his own story as sung to him by his sons, has to be reminded of what he has forgotten, his origins in Vishnu, and that he will be reunited with Sita. By contrast, the Mahabharata is about anger, ‘fire, burning and consuming its heroes, its own claims to autonomy and articulation of explicit truths’, and may not be told inside a house lest it burn the house down (Shulman 2001, 29). Two very different forms of affliction.
There are, of course, selective interpretations that have been made, in particular, of the Gita, by Gandhi, management gurus (Ramanathan 1982), transcendentalists, nationalists, and militants such as Gandhi’s assassin (Davis 2014). I am interested in the structural plenitudes of these epics and stories,[note 10]See for instance my exploration of the Persian epic, the Shahnameh (Fischer 2004).
their invocations for everyday moral commentary, and here especially for what their echoes or acoustics do in Das’s ‘scenes of instruction’ from Hindu ritual texts and epic transformations.
Within the Mahabharata and Gita, the most central figures may not be the Krsna instructing Arjuna on the war chariot to do his kshatria (warrior duty), even though the effects of war are already foreseeable everywhere, but rather two women: Dhraupadi and Gandhari. Dhraupadi is the wife of Yudhisthira, who stakes and loses her in a game of dice; she acts to partially repair the consequences by pointing out that when her husband staked her he had already bet and lost himself. She uses one of the many prasna (verbal puzzles) and riddling questions that structure the epic for the double meaning of loss of himself as free agent and loss of control of his ego, passion, and reason to addictive gambling. On both counts, he is incompetent to make the wager. Gandhari (daughter of the king of Kandahar) is the wife of the blind king Dhritashastra of Kuru (today’s Delhi, Haryana) and mother of the Kauravas. She wears a blindfold out of solidarity and pativrata (devotion, to her husband), one of the key virtues (and asceticisms, tapas) touted in the Mahabharata as giving power and access to heaven. She warns against war. Hearing the ill omen of jackals crying, she makes her husband stop the humiliation and disrobing of Dhraupadi, and sees up close the catastrophic effects of war. She sees this with the divine eye, divya caksus, given to her by Vyasa, the narrator of the Mahabharata. Her husband, blind Dhritashastra, had declined the divya caksus, preferring to hear secondary oral reports. Gandhari curses Krsna for having fueled the self-destruction of society, condemning him and his clan to perish.
Dhraupadi is described crucially as being both darsaniya (beautiful) and pandita (learned). Gandhari is an incarnation of Mati, the goddess of intelligence. The women are what the Mahabharata calls tapasvini (suffering women), not as passive objects of the power of males or others, but rather as the activating grounds for their work to repair the world (tikkun olam, in Hebrew). Social suffering is an important term in Das’s corpus (as in a different context it was for B. R. Ambedkar, the leader of the Dalit Buddhist Movement, author of the Indian Constitution, and campaigner against the social suffering of dalits or untouchables, against the caste system in general, as well as for women’s and labor rights, and like Das involved in the issues of poverty). The moral terrain of devastating war (the Kureshetra battle in the Mahabharata; the bloodletting of Partition) is what Stanley Cavell (2007, xiv) calls the ‘nearly inconceivable mismatch of harm and healing’. The interventions of Dhraupadi and Gandhari change the action of the story; as Das (2014, 189) puts it elsewhere, ‘Stopping the proliferation of the effects of an action independent of the intention of the agents (karta) is the great theme of the Mahabharata’.
Swallowing poison in the aftermaths of Partition
Working in the aftermaths of Partition, the 1984 riots that followed the assassination of Prime Minister Indira Gandhi, and the 1991 liberalization of the economy with its polarizing effects of inequality, Das turns, in Affliction, to health care and embodied inscriptions of pain amidst the production of poverty and disarray in the health care system. Methodologically or epistemologically, her work raises, and she often mentions, Wittgenstein’s query of how we can know another’s pain. Cavell scales up the question into one of how we overcome skepticism in the midst of failures of both the political order’s social contract as well as the unreliability of common language. He further notes that in Das’s account, ‘the roles of men and women are systematically contrasted in the events of partitioning … produc[ing] silence in women and, in men, a volubility that fails to express what they see and do … taking on the register of rumor, as if the events they describe were caused otherwise than by themselves’ (Cavell 2007, xii).
As Das (2010, 144) puts it, ‘a person, a woman, is building life already on some harms. Not by escaping, but by assimilating the violence and weaving your life in it’. Alluding to the god Shiva, who saved the world by swallowing the poison Halahala – generated when the devas (gods) and asuras (demons) churned the milky ocean to obtain amrita (the nectar of immortality) the god Indra needed to restore his immortality – and to Shiva’s wife Parvarti, who choked his neck to stop the poison from killing him, Das has powerfully feminized the image as the ‘poisonous knowledge’ that especially women swallow. The key exemplars are women saved after the bloody Partition, who are only partially reintegrated into society, their virtue tainted by suspicion. Shiva thematizes the swallowing of pain to save the world, to allow relations with others, and society to continue. One thinks of the many places, from Europe to Bali to Beirut, where one must live in proximity to those who have killed members of one’s family. ‘Amrit paane se pahle Vish pinna padta hai’ (before one can get amrita, one must drink poison) is the daily idiom, meaning: success follows many obstacles.
Code-switching between sarpa satra rituals and ordinary women
At times women’s pain rises to what Das calls ‘the pain of the being of sacrifice’, a phrase she uses in speaking of her debt to Wittgenstein, although his discussions on the meaning of pain never go very far beyond the grammatical problems of speaking about sensation, private language, and communication, even if at issue is not language and communication itself, but forms of life.[note 11]See especially Das 2015c, where she delightfully expands Wittgenstein’s examples showing how forms of life grow through many modalities of interaction.
Das’s powerful phrase, however, is concretized in the Vedic rituals that the Mahabharata (sometimes called ‘the Fifth Veda’) transforms into ‘women’s stories’ for ordinary life. Indeed, the Mahabharata opens with an account of its own telling in the intervals of the sarpa satra, or snake sacrifice, ritual.[note 12]The Mahabharata is said to have been dictated by Vyasa, and written down by Ganesha, to make the teachings accessible to those unlearned in the Vedas (especially women and sudras (workers). On the cultic forms celebrating Dhraupadi, see Hiltebeitel 1988.
Dhraupadi is a code-switching figuration between ordinary lives of women and those of queen and goddess (Sri). She is a sine qua non of sovereignty and rituals of state (kings, like ordinary householders, and celebrants of Vedic rituals, must have wives, who act independently. Without such independent wives, their status has no legitimacy).[note 13]In ‘What Does Ordinary Ethics Look Like?’ Das (2015c) notes that Dhraupadi is the daughter of Drupad and the dark ‘residue of a sacrifice that the king Drupad had performed for a mighty son who would defeat his enemies’. One of her names is Yagyaseni (born of fire, of a fire sacrifice), hence also Krishna (‘dark’).
Like ordinary women, although initially seeming a sacrificial pawn, Dhraupadi exerts her position and voice, and thereby changes the course of her husbands’ fates and her own. The sarpasatra rituals in the outer frame stories of the Mahabharata themselves have carnivalesque features, involving all the priests of the realm and their wives, who make noise, exchange lewd remarks, and engage in ritual copulation, simulating the inversions, unexpected consequences, and Shakespearian hidden identities in the stories of the epic (Hiltebeitel 2001, 166; Black 2007, 61). Not least of these are the copulations of the original teller of the tale, Vyasa, with his brothers’ widows from whom issue the unfit kings, the blind Dhritrashitra and the impotent Pandu (whose five social sons, the Pandavas, are sired by three gods). From these inauspicious births of the two kings begin the rivalries and mutual destruction that his family suffers. Vyasa, thus, is not just author or original narrator, but also father of the protagonists, retrospectively telling the tale of the destruction of his family, a figuration also of the Kaliyuga age and Kala, god of time and death (‘a particular relationship to death’ in the Das epigram of this section).
Mise-en-abyme of the snake sacrifice
That the sacrifice amidst which the epic is narrated is a snake sacrifice itself registers what Laetitia Zecchini (2014, 156) beautifully calls the ‘mise-en-abyme’ of the opening of the Mahabharata, registering the series of conflicts from those of the gods to the internal battlefield of the heart that are the ‘central drama of the epic’. Snakes, nagas, dangerous protectors across India and Southeast Asia, play a role in at least four of these conflict layers: control of shortsighted anger, of ego, of household, of environment.[note 14]Control of shortsighted anger: the snake ritual and sacrifice by Janamejaya, a great grandson of Arjuna, is the occasion of the telling of the canonical Mahabharata and one of its important themes. Janamejaya asks about his ancestors, and the epic is recounted by a Brahmin descended from Vyasa. Janamejaya intends to kill all snakes (nagas) in revenge for the snakebite by Naga Takshat that had killed Janamejaya’s father. But upon hearing that Tashat was but the means of fulfilling a sage’s curse, Janamejaya cancels the killings and makes peace with the nagas.
Control of ego: the great snake Vasuki was used as the cosmic rope to churn the milky ocean to produce the amrita to restore the god Indra’s powers. The devas held one end, the asuras the other, with Mount Meru (or a spur of it) as the churning pole. Indra had lost his kingdom because of his inability to control his own ego (not unlike Yudhisthira). Given a garland by the sage Durvasa, Indra placed it on his elephant’s trunk to show he was not an egotistical god, but the elephant, knowing Indra couldn’t control himself, threw it on the ground, enraging the sage, because the garland was the dwelling place of Sri (fortune) and had been given him by Shiva. Indra is also the divine father of Arjuna (when Kunti went to the gods for sons after her husband Pandu was cursed to die if he tried to father children).
Control in the marital household: when Dhrupadi is asked by Krsna’s wife Satyabhama how she controls her five husbands, why they obey her (vasagas tubhyam), she observes that women who use deceitful means of controlling their husbands are like snakes in the house: ‘I serve my truthful, gentle husbands, who have the ethics and the dharma of truth, and watch over them as if they were poisonous angry snakes’ (Patton 2007, 102).
Control of the environment: More generally, the Nagas are the great rivers that flow down from the Himalayas upon which agricultural life depends, but that can also flood and destroy.
The yajamana (ritual celebrant, sponsor) of Vedic cosmic rituals is translated into epic story terms as the dharmaraja (righteous king), whose dharma (righteous conduct) is restoring order, social justice, and harmony. It is interesting, Das notes, that when Yudhisthira is asked what is the highest dharma, he says noncruelty (anrishansya), rather than nonviolence (ahimsa). In the debates between Jains and Hindu Brahmins, she reminds, the tendencies in Jainism towards absolute ahimsa (nonviolence) are countered by the Brahmins pointing out that life depends on eating and killing others, symbolized by the sacrifice in ritual, and that minimizing cruelty is a more realistic this-worldly principle. Das (2014, 490) writes: ‘through this and other stories, the text seems to suggest that when principles like dharma are elevated to become absolute, they themselves become productive of the annihilating violence that the text documents’. And, as David Shulman (2001, 50) adds, Yudhisthira’s moralism of non cruelty is dissonant with his own actions towards Dhraupadi, which lends irony to his words and to the story.
The conscience morale and a poetics of dilemma
The veils of ignorance about causes and motivations, chains of consequences and collateral effects, intensify ethical trials in Hindu and Jain stories, particularly given the transitive reverberations of reincarnation and karma over time and across generations. The stories of Dhraupadi and Gandhari become ladders of instruction, phalasrutis (instructional, beneficial tales). They are stories of the development of what Emmanuel Levinas calls ‘conscience morale’, or ethical consciousness. The phalasrutis addressed to women are, on the surface, often conservative reminders of devotion to husbands (pativrata), but through careful managing of forms of power and ascetic self-restraint wives gain power. Dhraupadi holds the royal purse strings, supervising household and palace treasuries, and admonishes Yudhisthira to channel his kshatria wrath (manyu, like the wrath of Achilles), not merely his human emotional anger (krodha), which needs control, to regain his throne (Malinar 2007). It is the second time that Dhraupadi saves him.[note 15]The first time is her moral and legal assertion that Yudhisthira was not competent to stake her in the chess game. This, together with Gandhari’s hearing of the jackal’s ill omen and getting her husband to stop Dhraupadi’s disrobing and humiliation, provides the king with a rationale to release the Pandavas to exile. The second time asserts the difference between anger and wrath. During his exile Dhraupadi berates Yudhisthira for nursing his human, emotional, self-defeating, and impotent anger. She admonishes him to unleash his more powerful, honor-charged, and legitimate kshatria wrath, and rouses him to action. The complications of duties versus emotions are a constant theme both in the Mahabharata and the ordinary ethics Das observes, particularly in situations of multiple husband and wives. Dhraupadi has five husbands, of which her favorite is Arjuna, who however does not favor her among his wives. When he marries Krishna’s half-sister Subadhra, the new wife goes in disguise as a maid to assure Dhraupadi that she will honor her higher status. It is a doublet to a time when Dhruapadi disguises as a maid to ensure social harmony, and awaiting a different future. The marital issues in Das’s stories are no less complex.
The world of the Mahabharata is hurtling towards the self-destruction characteristic of the Kaliyuga age; it is ‘impenetrably enigmatic’, and the epic’s design is aptly a ‘poetics of dilemma’ (Shulman 2001, 24). ‘Reasoning (tarka) is without foundation, sacred texts are at odds with one another … truth about dharma is hidden in cave’: this is the answer to one of the Yaksa’s riddles (quoted in Shulman 2001, 54).
Crucibles of conflicting obligations and vulnerabilities
In such a world, Bilu, from Das’s book, may be read as a Levinasian figure, showing how the limits of infinite responsibility work, and how ethical consciousness (conscience morale) forms in a crucible of multiple, conflicting obligations that need to be managed lest one go mad or destroy oneself emotionally as well as economically. Levinas’s conscience morale is a sibling of Durkheim and Mauss’s conscience collective. Both are dependent on the double valence of conscience as both consciousness and conscience, both intentional compassion and obligatory compulsion. Both involve not just behavior towards single others, but also towards ‘the third’, which Levinas figures as multiplicities, and implies rethinking the state.[note 16]See the rich readings of Levinas by Diane Perpich (2008), Victoria Tahmasebi-Birgani (2014), and Madeleine Fagin (2013).
The state is alluded to in the ethnographic story that Das (2015b) provides in her essay on corruption. A local Muslim leader in a predominantly Hindu ‘low-income neighbourhood in Delhi made up of craftsmen, street artists and puppeteers, as well as migrants from Bihar who worked in lowly paid unskilled jobs’ (ibid., 333) says, ‘I am their Shakuni Mama’ (‘maternal uncle’, in the Mahabharata, brother to Gandhari) (ibid.). Like Shakuni, he is a clever and at times devious agent, who is ‘skilled in dealing with the local police and giving advice to people who had got entangled in some minor crime and needed a mediator to deal with the police. He also composed poetry and could revel in improvised poetic competitions that are the staple of crowds waiting for the big men to arrive during election rallies’ (ibid.).
This is a wonderful figuration: a Muslim leader in a Hindu environment, not unlike Hafiz Mian, where cultural resources are swapped in inter-religious local contexts, and who wields a ‘magical tongue’ (Zauberzunge, that wonderful German word for the silver-tongued, who with deft words can change an opponent’s mood and the course of events). In some tellings of the Mahabharta, Shakuni’s father’s thighbones were the material of which the dice were made, thus dice are loaded, always doing his bidding. His sister Gandhari, to his dismay, was married off to Dhitrashastra, born blind. She had been symbolically married first to a goat to cheat her destiny in which it was foretold that her husband would die soon after her marriage. Learning of this earlier marriage, Dhitrashastra flies into a rage and imprisons all of her male natal relatives. Shakuni is the only brother to survive because all the others gave him their meager prison rations, so that he might avenge their deaths.
When Das asks this Muslim man, Ghulam ‘Ali (the servant of Imam ‘Ali), to explain his allusion to being the Shakuni Mama, he laughs it off, saying, ‘understand whatever you wish’. Das chooses to read his response first as ‘the necessity of a deceitful but brilliant man to deal with the agencies of the state’ and then secondly as allowing a mythical register ‘to do the work of providing a social commentary on the conditions within which corruption is enfolded in everyday life’ (ibid., 334).[note 17]In her later essay on ordinary ethics, Das (2015c) returns to this scene and reads it as ambiguous as to whether he meant ‘he loved his neighbors or hated them and wanted their annihilation’, just as Shakuni is an ambivalent figure urging on the war, whether out of love for Duryodhana, who wants him to be supreme king, or out of hate for Duryodhana’s father, King Dhritrashtra, who had imprisoned and starved him with his ninety-nine brothers all of whom died. A less literalist variant of this is found in Hindu debates on the dialectics of justice, between the principles of niti and nyaya, the one being, as Amartya Sen (2009) glosses them, the organizational and appeal to rules and principles (niti), and the other the emergent, actual, and particular ways (nyaya) that people lead their lives.
Ethics and politics of vulnerabilities
Ghulam ‘Ali might be another Levinasian figure in what Victoria Tahmasebi-Birgani (2014) calls ‘the problem of the third and justice’ for Levinas, that is the connection of the everyday to larger politics. In the aftermath of the holocaust (a sacrificial term) or the shoah (‘destruction’), as in the aftermath of Partition and the anti-Sikh riots after Indira Gandhi’s assassination, the idea of ‘the third’ attempts to push beyond the ineffectiveness of ‘the Western Liberal Tradition’ that Levinas, like so many others, diagnoses as limited by its grounding in individualism and its utilitarian calculus, indifferent to the cry of the other. The cry of the other should at least makes you stop and recognize it. Even if you can do nothing, your conscience morale troubles you. The conscience morale constantly points out the betrayals of the state, the gap between the law and justice, as Jacques Derrida would say. The state is ‘always less than the ethics that inspired it’. So there is need for the work of Ghulam ‘Ali.
The ethical politics that Levinas calls for is built around the recognition of one’s own and others’ vulnerabilities. He writes against possessive individualism, of understanding the person as an accumulation of ‘merits, titles, professional competence’ that crushes others, and against the ‘hierarchized society maintained beyond the necessities of consumption’ (quoted in Tahmasebi-Birgani (2014, 22). He argues for an ethico-politics that would no longer be a matter of ‘the bourgeois peace of the man who is at home with himself behind closed doors, rejecting the outside that negates him’, of gated communities’ (ibid.). He writes, ‘Justice can have no other object than economic equality’ (ibid., 32). Tahmasebi-Birgani (ibid., 39) quotes Levinas: ‘Marx is the only Western philosopher who does not view the human as pure freedom, who acknowledges the chaining of the body and its consciousness to a concrete existence that no reason can undo completely’. And further: ‘Equality among persons means nothing of itself; it has an economic meaning and presupposes money, and already rests on justice, which when well-ordered begins with the Other’ (ibid., 32).
Cultural recognition of motifs across religions and cultures
The narrative motifs of visibility-invisibility, control over desire/passion, direct seeing/witnessing versus narrating/reporting, female power countering male hierarchy, humiliation by disrobing and power through restraint (tapas), ‘human beings propose, but destiny proposes otherwise’,[note 18]But this common observation, here from a Jain story, is intensified by the framing, ‘One could very well put an end to one’s life, but that would not liberate one from the bondage of karma’ (Mahendrakumar 1984, II:154, III:86.
and paired ritual/epic tales that refract one another are all at play across Hindu, Greek, Jewish, and Islamic myths in families of resemblance,[note 19]Shulman (2001, 23) for instance, compares the paired but contrasting poetics of the Mahabharata and Ramayana to that of the Iliad and the Odyssey (citing Ferucci): one offering a vision of life as an endless siege, the other holding our the dream of the return, of ‘recapturing lost happiness’. Another such pair with overlapping themes to the Dhraupadi story is the Hebrew story of Vashti and Esther (Purim) and the Pesach (Passover). The Vashti-Esther story stands things on their head (ve-hahafokh hu). Vashti shows the ineffectiveness of blunt opposition to male power, while Esther is more a Dhaurpadi figure, who changes the outcome. The Purim story is a comic endless seige story, while Pesach is a return story. The banquets of the Esther story further seem to parallel the beginning of the Job story, and Job performs sacrifices (as at the beginning of the Mahabharata) as prophylactic purification for sins his children might have committed at their raucous banquets. Das perhaps misrecognizes the term for ‘witnessing’ in Islam (shahid) when she suggests it does not include an embodied inscription of pain in the body. The hidden cases of adoption in Morocco seem another potent case of ‘poisonous knowledge’ in Das’s sense (Bargach 2002), and in any case there is also a paired dia-logue over the greater versus lesser jihad and shahadat and their forms of bodily inscription. The greater jihad and shahadat are always of the soul, interiority, and detached witnessing and war of position for social justice; only the lesser jihad is warfare, often claimed to be in defense of Islam, when it is merely a struggle for worldly power or coercive moralism.
as are embodiments of pain, and witnessing to morality in a world where appearances may hide many undercurrents, particularly in the aftermaths of war or civil strife, and where the scandal of the state, its margins, and promises (betrayed) are at issue, visiting affliction, pain and suffering upon the citizens.
At the interface of science, technology, and social organization
I think that I could write the history of anthropology by looking at how it always comes into being in certain scenes of collapse.
– Veena Das, ‘Listening to Voices: An Interview of with Veena Das’
Legal processes are tardy, the police corrupt, welfare and employment opportunities negligible, and the individual’s knowledge of her rights and entitlements vague. To speak of women as rights-bearing individuals in this context is to invoke a situation that does not exist in a meaningful way.
– Rajeswari Sunder Rajan, The Scandal of the State
Yet the hospital decided that the amount approved [by the Central Government Health Scheme] was insufficient, and refused to conduct any pre-operative tests or even attend to him until we changed his status to a private, full-paying patient. They did not deign to inform us of this however… . When we insisted upon the routine pulmonary tests that needed to be conducted before he could be passed fit for surgery, the pulmonologist responded that ‘if they want to see me so badly, let them come to my department and I’ll see them’. When he was transferred to his ward from the intensive care unit after his surgery, the surgeon asked the nurses to ensure that oxygen supply be constantly available to him; it took an entire day for it to be arranged… . The consulting doctor on morning rounds asked the nurse to have an x-ray taken; when he returned for evening rounds that day, the x-ray had still not been done in spite of our constantly badgering the nurse. At one point she helplessly proclaimed ‘we are trying, but the radiologist is not coming’.
This hospital was a major destination for medical tourists from around the world. A French couple in the room across from [us] stood with us in the corridor, in sympathy and horror… . [Thus we learned] the limits and apathies of elite profit-driven private medical care in contemporary India.
– Kaushik Sunder Rajan, Pharmocracy
Das’s Affliction probes life worlds, cultural acoustics, and philosophical registers. It reveals a series of bureaucratic failures in making health care institutions responsive to the actual conditions of the impoverished. The case of Meena is a particularly galling example, casting questions on the compilation of statistics on which public health care planning and metrics of success depend. As the former head of cardiology at the All India Institute of Medical Sciences and the current president of the Public Health Foundation of India notes, ‘Das critically examines how behavioral economics and global health policies are distancing healthcare from the contextual socio-cultural realities of poor communities… . Poor people are becoming “mere data points” as economists resort to the “benevolent paternalism” of using materialistic nudges’ (Reddy 2015, n.p.). He illustrates his review with a picture of a woman waiting with baby in arms outside Deen Dayal Upadhyay Hospital in New Delhi. Even more painfully, Roma Chatterji (2016, 12) notes that Das describes ‘how expanding medical technologies put more and more pressures on the poor to make more technological solutions for life-threatening illnesses available to their relatives as part of kin obligations, whereas the State pays little attention to improving risky conditions of life for the poor which lead to these illnesses in the first place’. Bilu again comes to mind.
The ‘women’s stories’ of the Mahabharata and the phalasrutis of Das’s ethnography lead to questions of how one should scale up to questions of governance of public health on the margins of the state, within its bureaucracies, and beyond its ability to see or care.[note 20]Yet another example made the international news as a dengue outbreak in Delhi in September 2015 overwhelmed the hospitals and clinics, and some thirty deaths occurred (Najar and Raj 2015).
Das focuses on the poor, but not only the poor suffer, nor only in the public sector, nor are these issues unique to India. The problems of medical attention in disaster response are iconically represented by Bhopal, but apply as well to Minimata, Love Canal, and many other toxic release and disaster sites (Fortun 2001; George 2001; Harr 1995; Reich 1991). It is detailed most powerfully perhaps in a Sinha’s riotous Bhopal novel Animal’s People,[note 21]‘Is Khaufpur the only poisioned city? It is not. There are others and each one has its own Zafar. There’ll be a Zafar in Mexico City and others in Hanoi and Manila and Halabja and there are the Zafars of Minamata and Seveso, of Sao Paolo and Toulouse’ (Sinha 2007, 296).
and analyzed in terms of advocacy by anthropologists and journalists within the destruction of health by late capitalism and pharma capitalism (Deb 2011; Fortun 2001; Sunder Rajan 2016). Likewise, which populations are recruited into clinical trials is an ethical issue crystallized in the case of the unemployed or underemployed former textile workers of central Mumbai, but is a concern globally (Sunder Rajan 2007; Petryna 2009; Cooper and Waldby 2014). Highly trained doctors returning to India to set up specialty clinics sometimes trigger unintended consequences, for instance: brokers beating the bushes for black market kidney donors in the wake of scandals and a ban on selling kidneys (Cohen 1999), or high-stakes financial pressures on vaccine development clinical trials under new patent laws in the wake of India’s adherence to GATT agreements. Similar issues with regard to a contraceptive vaccine were novelized in Nilekani’s Stillborn (1998), but recounted also to me and in an MIT workshop by a malaria researcher from the International Center for Genetic Engineering and Biotechnology, Delhi, in a story of the inability to get an India-designed malaria vaccine produced by an Indian company because the company could not come to an agreement over patents and licensing for a needed adjuvant owned by a multinational. The struggle over intellectual property regimes, drug pricing, and generic drug production is not only a problem in India. Nor are the toxic environments in which the poor are often consigned, such as Sinha’s Khaufpur, literally ‘city of fear’, or Bhopal. Arun Kolatkar’s equally improper Marathi Bombay poems, ‘Sarpa Satra’, the ‘Songs of Rubbish’, and ‘Rat-poison Man’s Lunch Hour’, detail bodies gone awry: ‘I’m a poor man from a poor land my age ain’t right my colour is wrong / my nose too big my chest too small my arm too long my grip too strong’ (quoted in Zecchini 2014, 199). The writings of Kolatkar, Nilekani, and Sinha constitute something of a contemporary urban folk Mahabharata, in which the characters are marginalized by poverty and the inequalities of innovation economies, structured from top to bottom by double binds, caught in contradictory imperatives.
We are beginning to have a series of important ethnographic studies of the (fragmented) Indian health care systems of the post-1990s liberalization era that not only realistically put in their place – both in terms of contextualizing and illuminating limitations – the claims of transformative technologies and political economies but also, as in a mosaic, throw light on disconnections and missing pieces. In addition to the work of Cohen (1999), Das (2013), and Fortun (2001), we also have the work of Stefan Ecks (2013) and Ecks and Ian Harper (2013) on drug ‘detail men’, or sales forces to physicians; Sarah Pinto (2014) on mental health services; Jean-Pierre Gaudillière (2014) on reformatting Ayurveda; Alison Fish (2010, 2014) on patenting yoga; and many others.
The state promises, the state betrays, the state is not one, particularly in the postliberalization era, when the margins of the state (another of Das’s foci) are as defining as the center. Bioavailability (Cohen 1999, 2004), surplus health (Sunder Rajan 2007), drug harmonization (Kuo 2009), public–private leveraging, and domestic commons versus global markets are emergent and urgent matters of concern. India has long had social movements for social justice, including Gandhian hygiene campaigns and cataract removal camps, government- and philanthropy-based general hospitals, targeted disability and disease campaigns, and here and there world-class elite research institutes, amidst decaying and decayed state universities and entrepreneurial private ones of variable quality.
There are many ways to narrate the history of the life sciences in India. The usual ways are to pick key sectors, key institutional developments, key policy initiatives, or key scientific leaders. I will use here instead a cross-sectional tactic reflecting on my own ‘scenes of instruction’ over the past forty years of periodic efforts to understand the leading edges of science and technology developments in India, beginning by following the established path of most historians of science with physics (including the most comprehensive social history done so far by anthropologist Robert S. Anderson ), but then branching out into biology, information technology, and ecology. The idea is to provide what in geology or archeology would be called a cross-sectional cut through historical strata. Obviously there are other names and institutions that could be included alongside the ones listed here (both those I know about and those I don’t), but I want to pose the following question: how do these developments in the leading edges of science and technology both in India and globally fail to articulate with the stories in Das’s Affliction? This is obviously not a criticism of her ethnography, but one of the gaps between, on the one hand, promises and results of development programs, scientific initiatives, and technological projects, and, on the other hand, the lives recounted in Affliction. I want to argue along with Das that the solution is probably not more top-down systems, econometric ‘solutions’, or auditing bureaucracies, propagated from a distance (whether Delhi, Geneva, or Washington), and that, as Chatterji, quoted above, notes, at times hopes in medical technologies place additional pressures on kinship obligations that make matters worse rather than better.
Communal hospitals to national science institutes
In the early 1970s when I was researching Parsis and Irani Zoroastrians in Bombay, I was impressed by the hospitals set up by Parsees for their own community but also open to the general public (for example, Sir Jamshed Jeejeebhoy Hospital and Cama Hospital in Bombay, and Jehangir Hospital in Pune). Among the initiatives at the time was a Parsi community-wide genetic survey in Pune and Bombay directed by a student of human geneticist Victor McKusick, and executed in collaboration with McKusick at the Johns Hopkins University. The survey was both to provide a baseline for comprehensive Parsi community care, and to attempt some ‘molecular anthropology’ or mapping, using GDP-6 as a possible marker of migration from malaria-endemic areas (the Mediterranean and Africa via the Iranian plateau). A decade later in 1984 I spent a tumultuous year in Ahmedabad – the year of communal riots against the Mandal Commission’s increase of reservations in medical and engineering schools for Other Backward Castes, Scheduled Castes, and Scheduled Tribes; the assassination of Indira Gandhi and the subsequent riots; and the Bhopal disaster – researching the Jain community. This time I was impressed by the communal institutions, including clinics, and their caste exclusivity. My wife and I had occasion to see a doctor, and were carefully guided through the hospital and private clinic system, becoming aware of the practice of families providing basic food and care while members were in the hospital.
In the 1990s I returned on several short research trips to explore the genealogies of modern science in India, beginning with physics at the Physical Research Institute of Ahmedabad, with physicists and biologists at the Tata Institute of Fundamental Research (TIFR), and also at the supercomputing and radio astronomy programs in Pune. I followed the move of the TIFR biology research program under Oveid Siddiqi to a new site in Bangalore, the National Center for Biological Sciences, and began talking to people also at the Institute of Indian Sciences (ecologists and biologists), and the National Institute of Advanced Studies (including Raja Ramanana, the long-time director of the Indian nuclear program and scientific director of the 1974 ‘Smiling Buddha’ nuclear bomb test, a classical pianist, who had become interested in resonances of Buddhist logic and nuclear physics).
At TIFR I found a number of molecular biologists working on malaria, and had the uncanny experience of simultaneously reading Amitav Ghosh’s Calcutta Chromosome (1995), in part a novelized account of the discovery of the transmission of malaria by the Anopheles mosquito to birds as well as humans, by India-born British medical doctor Sir Ronald Ross with the unsung help of a ‘native’ Indian assistant, as well as the use of malarial fever therapy for syphilis. I would many years later seek out, with Kaushik Sunder Rajan, all the Calcutta sites in the novel, including Ross’s memorial plaque in the Presidency General Hospital. In the meantime, from E.V. Chitnis, the former director of the Ahmedabad Space Applications Research Organization, I learned that his son Chetan Chitnis was a malaria researcher at the National Institutes of Health in Washington, DC, and went to meet him there. I followed him to his new posting at the International Centre for Genetic Engineering and Biotechnology (ICGEB) in New Delhi, where, as he was setting up his lab, I got my first tutorial on ‘clean rooms’ and the research laboratories’ limits in scaling up from small batches to batches large enough to run clinical trials.
Patent regime change, public–private investment, and open-source science
Through an MIT Parsi connection, on a subsequent visit to Bombay, I got an introduction to Yusuf Hamied (CEO of Cipla Pharmaceuticals), and had a long interview with him on the changes in the patent system (from the ‘processpatents’ that allowed the generics industry to grow in the 1970s and caused the multinationals to withdraw from India at that time, to a 1990s ‘productpatent’ regime to harmonize with the rules of international World Trade Organization agreements). We talked about Cipla’s efforts to provide cheap HIV/AIDS drugs to Africa, a conversation I relayed back to my colleagues at Harvard, Paul Farmer and Jim Kim, who would play key roles, with Cipla, in forcing down drug prices in South Africa.
Through MIT’s Industrial Liaison Program, I met Dr. Swati Piramal (chief scientific officer of Nicholas Piramal Pharmaceutical Company) and she provided a tour both of their soil- and plant-screening research facilities, and a state-of-the-art clinical trial center that they were establishing. Her idea at the time was that with new cheaper diagnostics (on a chip) the company could become a diagnostic service center for rural physicians across the country. I followed up in Bangalore with computer services start-ups Infosys and WIPO, and some new biotechnology companies, especially one that was pioneering the local production of reagents needed for basic pharmaceutical research. In Hyderabad, on the recommendation of Kaushik Sunder Rajan, who was beginning to do his own work on the life sciences in India (as well as globally), I went to interview people at Dr. Reddy’s and Ranbaxy. Sunder Rajan was doing fieldwork in New Delhi, and I went to visit him.
He introduced me to Samir Brahmachari, then director of the Center for Biochemical Technology (CBT), one of the national laboratories under the Council of Scientific and Industrial Research. Brahmachari had come from the Indian Institute of Science in Bangalore, and was in the process of establishing the CSIR-Institute of Genomics and Integrative Biology (IGIB). There were racks of new computers sitting around that would be built into powerful parallel processing machines. Brahmachari was full of organizational ideas: rather than try to reform an inertial old institution, better to build the new institute within, but separated from, the old CBT. He was a champion of the idea that India had missed the ‘genetics revolution’ and should not miss the genomics one. National laboratories were funded in ways that could not in fact create full translational systems (from bench to bedside): one could get funding for capital investments but not for recurrent costs; with liberalization, neither government nor private sector could do translational medicine for the public good alone. So India would need to experimentally create new forms of private–public partnerships. The first of these, as Sunder Rajan was to discover, was with Nicholas Piramal. Sunder Rajan would also visit the very same clinical trial facility that I had seen at a much earlier stage, and came to understand that it was a facility for the extraction of surplus health from a nearly captive population of unemployed former textile workers.
Meanwhile, I began observing Singapore’s investment in the life sciences, finding a perch at the Genome Institute of Singapore. I would return to Hyderabad in 2006 for Human Genome Meetings at the invitation of the president of the Hugo Genome Organization (HUGO), Edison Liu, who was also the director of the Genome Institute of Singapore. At that meeting and subsequent ones, I would come to know Brahmachari in his new role as head of the entire CSIR national laboratory system, and also as a key player in HUGO and host of the Hyderabad meetings. In his continued enthusiasm for organizational innovation, he had prepared for the HUGO meetings by holding many satellite preparatory meetings with university students around the country, and invited them to the Hyderabad meetings. They came in large numbers. Controversially he would then recruit them and others to crowdsource the annotation of the tuberculosis genome, doing it much faster than more conventional laboratories could do. Challenged, he would say that anyone who wished could verify the results, as they were posted on the web. This was the beginning of the India-led Open Source Drug Discovery Consortium, with global participation, focused on neglected tropical diseases.
One final experience will close, for the moment, this rapid race through Indian developments in the life sciences: the contract of the Indian Department of Biotechnology (Ministry of Science and Technology) with MIT to help create a new national-level institute for Translational Health Science and Technology Institute (THSTI). For MIT, the exercise appeared to be one of trying to recreate the ethos of MIT and Harvard Medical School’s Health Science Technology Program (HST), which has produced many physician-scientists and scientist-entrepreneurs. For India, the exercise was to be a seedbed to produce charismatic cohorts of biomedical leaders to transform health care nationwide. One of the intractable conflicts was between the HST and new Indian entrepreneurs, who were convinced that one could only get new technologies to patients by means of the marketplace, and on the other hand, the upholders of social democratic convictions that robust communities rather than market profits needed to be the crucial metric. Another axis of conflict was the HST’s commitment to interdisciplinarity and the creation of new hybrid fields, on the one hand, and established inertial commitments by leaders in established fields, such as vaccine development, who wished to do what they knew how to do and to run institutions in a traditional top-down manner. In the end, although MIT successfully helped hire a number of young professors, these conflicts stymied the transnational collaboration. MIT withdrew.
Much more remains to be said about each of the above-mentioned initiatives, but for the limited purpose here, it is enough to point to the efforts at organizational change that it was hoped could bring biomedical competence to affliction. Research and training institutes such the National Center for Biotechnology and the International Centre for Genetic Engineering and Biotechnology, one a purely Indian national institute, the other a UN-associated international center, appear to be successful in part because they are new institutions staffed with young internationally trained professionals. Within the Indian state and its older institutions, there are charismatic leaders such as Brahmachari and M. K. Bhan, formerly the secretary of the Department of Biotechnology, who however have to struggle to reform inertial institutions, using strategies ranging from rebuilding institutions from within (IGIB), trying to leverage transnational resources (THISTI), creating novel public–private partnerships (CBT-Nicholas Piramal), and open-source drug development.
The shift from a process to product patents intellectual property regime was profound and brought multinational companies back into India. The effort by Indian companies like Dr. Reddy, Ranbaxy, Nicholas Piramal, and Cipla to create their own research and development units to compete on the international stage involved acquiring units in the United States and Europe (Dr. Reddy’s strategy), mergers and alliances with multinationals (Ranbaxy and Daiichi Sankyo; Piramal Healthcare with Pfizer, Merck, and Abbott). More importantly, there has been an effort through the court system to rebalance the TRIPS agreement to push back against patents as proprietary monopolies rather than as means of licensing for the public good (notably the recent denial of a patent for Gleevec on the grounds that it failed to demonstrate any new biological mechanism of action [Sunder Rajan 2016]). These include struggles over patents and licensing to getting new vaccines locally produced (IGEMB), providing generic drugs to patients at affordable cost (Cipla, Dr. Reddy, Nicholas-Piramal), efforts to use crowdsourcing for genomic annotation to speed drug targeting (CSIR, HUGO), and participation of the Indian Institutes of Technology’s international synthetic biology competitions.[note 22]These include the International Genetically Engineered Machine competitions: in 2015, 280 collegiate and high school teams registered. There were two teams from India: IIT Kharagpur and IIT Delhi, out of 101 teams from Asia.
The terrain is varied, uneven, and calls for new forms, perhaps of financing, but more importantly of new social organization for robust community public health and sense of citizenship and responsibility, from community clinics to five-star hospitals.
Despite the Kalyuga age, of which the Mahabharata is emblematic, there is energy and hope to be fostered and ignited. Life is always a counterforce to entropy and decay. The tales of the everyday are of intermediate structures and work practices, patient ‘accompaniers’,[note 23]A term introduced by Paul Farmer and Partners in Health for laypeople who help patients through the difficult regimes of HIV and tuberculosis treatments, originally used to prove to the World Health Organization that it was not true that it was ineffective and counterproductive to give state-of-the-art drugs to the poor in third world countries, as it was thought that they would not be able to comply with treatment regimes and would cause the spread of drug-resistant viral and bacterial strains.
and patient advocates; of training health care physicians, nurses, and biomedical scientists and engineers to think about robust communities as their metrics; and of the peopling of technologies themselves as networks of care, compassion, and mutual responsibility (Fischer 2013).
Conclusion: Agni and atman (fire and breath/speech)
vakprabaddho hi samsarah
The world is bound up and held together (or kept awake)
with words (vak).
– Santiparvan 215.11 (the twelfth book of the Mahabharata)
When someone is angry with us,
The hearts duel and one abandons the relationship.
– (Jain) Navkar Mantra
[If] the gods of mythology do not sweat, smell or sneeze,
and the goddesses do not menstruate… . in folklore they do
-– A. K. Ramanujan, ‘When Mirrors are Windows’
Standing alone on the field of battle,
O Hussein, never shall I forget Hussein!
Showing no fear, the zibb-e-Azeem of Abu Abdillah
Ya Hussein! Ya Hussein! Ya Hussein!
– Inda Sinha, Animal’s People
Both biomedical developments on the ground in India and the anthropological literature analyzing those developments seem to have a new energy, not just to celebrate the new, but to draw attention to gaps and disconnects.
Affliction is the flickering of life, fever and fire. In Animal’s People’s Bhopal, there is firewalking on Ashura, as described in these three excerpts:
I can now hear the fire … hissing like some giant cobra stirred up and enraged.
a different kind of fire [than] that Somraj had breathed, which had scoured his lungs and taken away his singer’s breath. What must it have been like, that inferno? O who will speak now for the orphans? … who now will speak for the poor?
The marble balconies that surround the courtyard of fire are lined with women in dark robes. On this night most of them have pushed back their veils, their faces are lit from below, the flow softly rouges their cheeks watching with unblindfolded eyes… . as the seventy-one rode off to die. (Sinha 2007, 217, 219, 220; italics in the original)[note 24]Sinha interweaves the laments for the martyrs of Karabla and Bhopal.
The exothermic reaction and release of methyl isocyanate and other chemicals has turned the air, soil, and water toxic, and has burned out the poet-singer Somraj’s lungs. In Zafar and Farouq’s hunger strike against the pesticide company’s stonewalling, twenty years after the gas leak, the sun and their refusal of water burn their bodies inside and out.
In his essay ‘Just Words’, Arindam Chakrabarti (2014, 248) points out that speech ‘is fire, it burns and cooks’. It can also heal and repair. ‘This could be’, notes Chakrabarti (ibid., 250), ‘why actual sacrificial routines used to include a debate session’:
At the end of a satra or long sacrificial festival like the horse sacrifice (Aivamedha) that Yudhisthira performed after the war to cleanse himself of the sin of killing his kinsfolk, priests performing the roles of a reviler (apagara) and a praiser (abhigara) would come at the end, the former pointing out the failure and faults, and the latter the greatness and success of the sacrifice.
Das, like Chakrabarti, calls us to conversation, to the power of words to change the world, to nurture life, evident even in the title of Life and Words: Violence and the Descent into the Ordinary. Echoing Levinas (1969, 71), who writes, ‘We call justice, this face to face approach, in conversation’, Chakrabarti tells us it is ‘just words’ (words of justice), face-to-face words, that are responsive to the calls of others (‘Ya Hussein! Who will speak now for the orphans, for the poor?’), across the interfaces of biomedical expertise and ordinary life. These words are calling awake the ‘peopling of technologies’ (Fischer 2013) to care at the local community level, the ‘trying to search together’ (Chakrabarti 2014, 249) for public health and robust communities, the staying awake to the world (vakprabaddho hi samsarah).
– completed during the 10th annual HONK! festival
of activist street bands, Somerville, Massachusetts,
10–11 October 2015
About the author
Michael M. J. Fischer is Andrew W. Mellon Professor in the Humanities and Professor of Anthropology and Science and Technology Studies at the Massachusetts Institute of Technology, and Lecturer in the Department of Global Health and Social Medicine, Harvard Medical School. He is the author of several books including Iran: From Religious Dispute to Revolution (Harvard University Press, 1980), Anthropology as Cultural Critique: An Experimental Moment in the Human Sciences (with George Marcus, University of Chicago Press, 1986), Debating Muslims: Cultural Dialogues in Postmodernity and Tradition (with Mehdi Abedi, University of Wisconsin Press, 1990), Mute Dreams, Blind Owls, and Dispersed Knowledges: Persian Poesis in the Transnational Circuitry (Duke University Press, 2004), Anthropological Futures (Duke University Press, 2009), and the forthcoming Anthropology in the Meantime (Duke University Press).
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