Über die Autorin bzw. den Autor

Marcia C. Inhorn is the William K. Lanman, Jr. Professor of Anthropology and International Affairs at Yale University. She is past president of the Society for Medical Anthropology and the author, most recently, of The New Arab Man: Emergent Masculinities, Technologies, and Islam in the Middle East.

Emily A. Wentzell is Assistant Professor of Anthropology at the University of Iowa.

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Medical Anthropology at the Intersections

DUKE UNIVERSITY PRESS

Contents

Acknowledgments..............................................................................................................................................................viiMARCIA C. INHORN AND EMILY A. WENTZELL Introduction: Medical Anthropology at the Intersections...............................................................................1ONE | EMILY MARTIN Grafting Together Medical Anthropology, Feminism, and Technoscience.......................................................................................23TWO | LYNN M. MORGAN Getting at Anthropology through Medical History: Notes on the Consumption of Chinese Embryos and Fetuses in the Western Imagination.....................41THREE | LAWRENCE COHEN Making Peasants Protestant and Other Projects: Medical Anthropology and Its Global Condition..........................................................65FOUR | DIDIER FASSIN That Obscure Object of Global Health....................................................................................................................95FIVE | ARTHUR KLEINMAN Medical Anthropology and Mental Health: Five Questions for the Next Fifty Years.......................................................................116SIX | MARGARET LOCK From Genetics to Postgenomics and the Discovery of the New Social Body...................................................................................129SEVEN | RAYNA RAPP AND FAYE GINSBURG Anthropology and the Study of Disability Worlds.........................................................................................163EIGHT | MERRILL SINGER Medical Anthropology and Public Policy: Using Research to Change the World from What It Is to What We Believe It Should Be............................183NINE | RICHARD PARKER Critical Intersections and Engagements: Gender, Sexuality, Health, and Rights in Medical Anthropology..................................................206Notes........................................................................................................................................................................239References...................................................................................................................................................................251Contributors.................................................................................................................................................................307Index........................................................................................................................................................................313

Chapter One

Grafting Together Medical Anthropology, Feminism, and Technoscience

Within the groves of anthropology, the many grafts between medical anthropology, feminism, and science and technology studies (STS) have borne a rich harvest. In this chapter I trace how some of these grafts came about through a historical framing of the ways my work added to and benefited from them, moving through a variety of field sites and problems, from reproduction, through HIV/AIDS, and into mental health. The topics addressed by medical anthropology were so central to the constitution of twentieth- and twenty-first-century society and culture that scholars working in feminist studies and STS were eager to address them—topics such as diverse ways of defining health, stratified access to medicine and clinics, and centralized knowledge about the health and mortality of populations, to name just a few. Medical anthropology offered scholars specialized knowledge of how to understand institutions and practices that lay at the heart of contemporary forms of power and subjectivity. In return, feminism and STS offered complementary ways to understand the topics that medical anthropologists were addressing. In particular, feminism offered a robust way of seeing how medical institutions and practices were embedded in race and gender differences rooted in the larger political economy; STS offered ways of examining the assumptions lying in the background of medical practices: such things as the experimental method, the ideal of objectivity, or the paths by which scientific knowledge is produced and changed.

The metaphor of "intersections" inspired the event behind this book because it captures some aspects of the comings and goings between medical anthropology, feminism, and technoscience. An "intersection," like a section of a road shared by two highways or a group of elements common to two sets, captures some of the developments I will sketch: it captures the sense of shared problems and shared goals among the disciplines. But I am also guided by the metaphor of a "graft" because, in the plant kingdom, a graft can lead to a new organism with higher yields and better quality. The rich contributions these three fields have made to each other have laid the groundwork for exciting "grafts" still to come. I gesture toward some of them in my conclusion.

Many of us who were trained in anthropology in the late 1960s and early 1970s were primed to engage with questions at the heart of medical anthropology, whether we knew it or not. Many of my peers' research projects dealt with questions of health and sickness, life and death, or technology and gender, inspired by the now classic writings of Edmund Leach (1964), Raymond Firth (1963), Meyer Fortes (1949), Mary Douglas (1991), Victor Turner (1967), Clifford Geertz (1973), or Claude Lévi-Strauss (1963)—even though only a minority of us would have said we were "medical anthropologists." We might not have worked in medical institutions or with trained specialists, but we often studied cosmological notions about life and death and ritual practices during birth, illness, and death wherever we did fieldwork.

For some of us, a path into a more specialized concern with the topics of medical anthropology became available during the 1970s. Despite my own lack of training, it seemed unexceptional to me that Navel Medical Research Unit No. 2 (NAMRU-2), which had moved to Taiwan years before in 1955, offered me a summer job to investigate hepatitis and other endemic diseases at the village level in Taiwan. Despite my own dismay over the war in Vietnam, NAMRU seemed like a neutral research enterprise devoted to public health measures that would reduce disease. Their explicit goal—to study infectious diseases of military significance in Asia—sounds much more ominous now. However, NAMRU support was invaluable to medical anthropology as a field, as evidenced by their support of Arthur Kleinman's early work in Taiwan.

I could not shed any light on the causes of Taiwan's hepatitis epidemic, but I did figure out why villagers would not accept measles vaccines, then available for no cost at every rural health clinic. Measles, it turned out, was regarded as a phase in the life cycle that served the beneficial purpose of letting out the polluting matter that everyone could not help having inside their bodies from passing through the "dirty" female birth canal. If you did not get rid of this pollution through the oozing pustules of measles, you would break out with it on your deathbed and be marked by dirty sores forever after in the next world. What should I do with this knowledge? If I suggested that the vaccine could have an adjuvant added to it so that it would produce a local pustule that people might accept as a substitute for a full course of measles, this might lead more rural people to get vaccinated. It turned out that the current version of the vaccine was just about to be withdrawn in the United States because of harmful side effects. I did not know how to negotiate this conundrum at the time because at this point, in the interactions between medical anthropology and social and cultural anthropology broadly speaking, it was acceptable to think of Western medicine (even when purveyed by the military) as a valuable resource that would benefit local populations (Ahern 1978). My understanding would crystallize later, as I describe below.

Feminism

A few years later many anthropologists were being led into the world of feminist and Marxist theory and history, and this engagement would firmly introduce issues of power, control, and class discrimination into the topics anthropologists studied, including medicine. For me this happened through the work of my colleagues at Johns Hopkins, especially Elizabeth Fee, Nancy Hartsock, David Harvey, and Donna Haraway. My memory of how my fledgling acquaintance with medical anthropology connected to feminist theory centers on a lightning bolt that struck in the early 1980s when Donna Haraway, returning for a visit to Hopkins from her position at UCSC, met with some colleagues for lunch at an outdoor café. In those days, although there were no laptops, there were slides, but, of course, in the restaurant we had no projector. We were sitting in a circle outdoors and as she chatted with us about writing Primate Visions, she passed around the slides one by one.

It was fascinating to hear her interpret these images, while all of us were peering closely at those little slides. The one that most struck me showed Jane Goodall when she was studying the chimpanzees in the Gombe, sitting on top of a hill, eating beans out of a can. Donna's commentary on that image joins the entire history of the Second World War to Goodall eating beans. The lightning strike was: here is the scientist, in the jungle, in nature, studying nature, making science out of nature, and with her is the emblem of an incredible, mighty material force in history. The history of industrial canning, developed to serve the needs of soldiers in war, was present right in the middle of Goodall's scientific work. That was like a beacon to me. How do you see those kinds of secret forces, both cultural and political economic, hidden in plain sight?

Donna showed how this image is representational but also contains an object that was keeping Jane Goodall alive. This was literally the "material-semiotic." Donna led us from thinking, "Oh, she is eating a can of canned beans" —the prosaic—to somehow realizing what you were really looking at. I think that this lightning bolt influenced everything I did afterward. Together with scholarship like Elizabeth Fee's on the gendered dynamics of the history of science and medicine, David Harvey's on concepts and practices concerning value in capitalist societies, and Nancy Hartsock's on the gendered assumptions behind American concepts of political power, my thinking about medical practices was altered: no longer would a campaign to introduce a vaccine seem innocent, nor would cultural beliefs be positioned as obstacles to progress. The vaccine itself now could stand in for the can of beans: Whose interests were being served by its deployment? On what historical developments did it depend? What forms of power did it buttress and what forms did it weaken?

I had already been doing interviews with women, reading through obstetrics and gynecology textbooks in different editions, and going to childbirth education classes in order to get some sort of handle on what was going on with women giving birth, including myself. These years (the mid-1980s) were at the beginning of this kind of work in anthropology. Susan Harding was working in Jerry Falwell's community in Virginia, Harriet Whitehead was working with the scientologists, and Lorna Rhodes was working in a psychiatric clinic. Since all of us were doing fieldwork in the Baltimore area, we met every couple of months on my row house's flat rooftop, just trying to figure out how in the world you do anthropological fieldwork in your own culture and what would make such work anthropological rather than sociological. That was the main issue we grappled with. In my head there were theorists such as Gayle Rubin (Rubin 1975) and Frederick Engels (Engels and Leacock 1972) speaking about reproduction on the one side, and the women in my fieldwork speaking about reproduction on the other. But what was I to do with this ethnographic material? It did not rush out and tell me its significance. Yet, somehow, Haraway's can of beans provided an image of the materiality of the forces of production right in the object, and I was led to think about reproduction as a form of production.

I began to hear in the language of the obstetrics textbooks that reproduction was a form of production. Reproduction was not literally the same kind of thing as production: there was not a manufactured material object like a can. But in a sense the woman's body was an analog to canned goods. It was overdetermined that the activity of birth would be seen and organized as a form of manufacturing production. Nobody—not even those of us going through it at the time—could hear that women giving birth were being held to standards of production, time management, efficiency, and all the rest. Close attention to the imagery in medical textbooks and to the language women used in describing their experiences of menstruation and menopause led me to see that there were assumptions about the necessity of producing valuable products (babies) that informed interactions between physicians and women. Menstruation was taken to be the failure of production and the casting off of the ruined debris of this failure; menopause was taken to be the breakdown of the bureaucratically organized hormonal system that governed bodily production. Like an aging and outmoded factory, the menopausal body and mind were literally described as senile.

As with any ethnographic project, this one revealed that many women actively contested the assumptions that dominated medical contexts. Women, especially working-class women, found other, less productivity-oriented ways of thinking about menstruation. Much to my surprise, when offered the hypothetical chance to eliminate menstruation with a magic wand, most women I interviewed said they would not take it. In spite of their many complaints about the mess, bother, pain, and distress of menstruating, they saw it as an important marker of being an adult woman and something they felt forged important linkages with other women. Some women found that special abilities were unleashed while they were menstruating—vivid dreaming or poetic writing, for example. This led me to speculate that a society organized along different principles might value menstruation in different ways (Martin 1987).

Other anthropologists, thinking along similar lines, were realizing that our assumptions about such apparently stigmatizing practices as seclusion in a menstrual hut might have been mistaken. Working among the Beng in Africa, Alma Gottleib wondered if women might relish the break from their daily routines and find pleasure in the long-simmering stews they had the leisure to cook while in menstrual seclusion (Buckley and Gottlieb 1988). And in medical anthropology proper, a number of vigorous voices that placed medical institutions and practices in the context of unevenly distributed material resources and gendered ideologies were beginning to have an impact on anthropological studies of reproduction. More broadly, political economic analyses of gender, culture, and practices concerning the body were emerging at this time (Comaroff 1985; Estroff 1985; Scheper-Hughes and Lock 1987). There had begun to be, not so much neighboring "groves" of scholars working in medical anthropology and feminism, as hybrid "graft" forms. On the one hand, the early faith in the virtues of progress that could be achieved by medical technologies was turning into a more subtle awareness of the ways medical knowledge itself entailed the imposition of control over the bodies and minds of women. On the other hand, it became clear that any anthropology of contemporary society worth its salt must include sites where medical knowledge was learned, practiced, and imposed. This led more and more anthropologists to find ways of studying medical contexts ethnographically in ways that could reveal the sometimes hidden forms of power they entailed.

Science and Technology Studies

Later, in the mid-1990s, the problem of how to do fieldwork in the United States was no longer an issue. So many young anthropologists had by then been doing fieldwork in the United States that there was confidence that this could be done. The problem had become how to position work on topics like HIV/AIDS that seemed to encompass more social sites than those associated with medicine or even health. A key moment was a School for American Research conference on anthropology and STS. Organized by Joe Dumit, Gary Downey, and Sharon Traweek, the conference fostered serious engagement about how feminism could be understood in the 1990s, after women's studies programs were widely established and after the language of gender and sexuality, the need for feminist classroom practices, and the imperative to combat sexist employment practices, among other things, were widely accepted and in practice. Our conclusion at this conference was that critical anthropology and critical science studies simply were feminist. We spoke of hybrid—but we might have said "graft"—feminist-social-cultural theories (Downey and Dumit 1997, 159). We assumed that all of our STS work would centrally engage with issues of gender and race and class and how they interrelated. Anthropological ethnographic work in the early 1990s brought together insights into how ideas about gender inflect all aspects of scientific culture, from the nature of matter to the organization of hospital birth (Davis-Floyd 1993; Traweek 1992).

Anthropologists in STS were not the only ones realizing that race, class, and gender work together, not just as separate vectors that could be separated and compared but as systematically related cultural understandings of how people are different and practices that keep them different. (Of course to these three invidious distinctions, we would now add disability, age, sexuality, and religion among others.) In 1991 Kimberle Crenshaw, acknowledging her debt to feminist writings of the 1980s, published her article in the Stanford Law Review, "Mapping the Margins: Intersectionality, Identity Politics, and Violence against Women of Color" (Crenshaw 1991). In the early 2000s Leith Mullings and others held a conference titled "Intersectionality and Health," in which anthropologists and public health scholars worked together (Schulz and Mullings 2006). And the UN Committee on the Elimination of Racial Discrimination published its General Recommendation No. 25 on "Gender Related Dimensions of Racial Discrimination." An understanding that invidious distinctions among different kinds of people rely on each other has been growing. "Intersectionality" lies at the heart of the third wave of feminism. But parenthetically I would insist that it is a wave that rode in on much earlier understandings of how inextricable all invidious distinctions are from each other. Perhaps a kinship image would work here. Second-wave feminism always found brotherhood in the civil rights movement as it had found sisterhood in earlier moments in the feminist struggle. Feminism was never an only child.

(Continues...)

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