With significant relevance to the Covid-19 pandemic, this paper contributes to emerging ‘aerographic’ research on the socio-materialities of air and breath, based on an in-depth empirical study of three hospital-based lung infection clinics treating people with cystic fibrosis. We begin by outlining the changing place of atmosphere in hospital design from the pre-antibiotic period and into the present. We then turn to the first of three aerographic themes where air becomes a matter of grasping and visualising otherwise invisible airborne infections. This includes imagining patients located within bodily spheres or ‘cloud bodies’, conceptually anchored in Irigaray’s thoughts on the ‘forgetting of the air’ and Sloterdijk’s immunitary ‘spherology’ of the body. Our second theme explores the material politics of air, air conditioning, window design, and the way competing ‘air regimes’ come into conflict with each other at the interface of buildings, bodies and the biotic. Our final theme attends to the ‘cost of air’, the aero-economic problem of atmospheric scarcity within modern high-rise, deep-density healthcare architectures.
Format: Journal
The Charm of Medicines
Even amongst biomedical scientists, medicines have an enigmatic air, for example in the way they are often referenced as ‘magic’ bullets. In reference to antimicrobials, ‘magic’ evokes both the power and potential super-power of such substances and their relations to our material and social realities. Moving this further, anthropologists Sjaak van der Geest and Susan Reynolds Whyte describe medicines as having ‘charm’, providing a concrete solution to ill- health, and an effect that can be separated from a therapeutic encounter. This distinguishes medicines from other forms of healing such as surgery, which cannot be separated from a surgeon.
Medicines are democratic and exoteric, they are ‘widely believed to contain the power of healing in themselves. Anyone who gains access to them can apply their power’ (Van der Geest & Whyte, 1989 p346). The authors extended this perspective to incorporate a wide range of places and spaces where medicines flow, are exchanged as commodities, are prescribed and consumed. They invoke an analytical framework of the ‘Social Lives of Medicines’, proposing that as things, medicines have biographies (S.R. Whyte et al., 2002). The authors trace the careers of medicines, often antimicrobial, and provide useful context for the ways in which these substances travel beyond the enclave of professional control and are made common. In drawing together a range of anthropological works, through which they illustrate how people in different settings, roles and industries, employ these substances for various endeavours, this volume is compelling in arguing that medicines should be understood beyond their capacity to cure (or poison).
The charm of pharmaceuticals, as concrete entities with wider symbolic, economic and political value, is a useful lens through which to consider how antimicrobial resistance may arise as well as how it may be tackled, especially in relation to the drivers of antimicrobial use. We can look at the value of antimicrobials for different actors in order to gain insights into the status quo, important to consider if intervention is to be undertaken, both to design effective interventions and to anticipate potential consequences beyond impact on AMR.
Development without Institutions
Sarah Pinto explores the emergence of so-called ‘informal providers’ of medicine and biomedical care in rural India. These providers are neither ‘formal’ nor ‘informal’, she argues, but instead “operate on the boundaries of legitimacy” (340). These ‘informal providers’ often fill the gaps where legitimate public health institutions have been too weakened to operate, and are informally sanctioned by the state because their operations are not regulated or denounced. These informal providers, Pinto writes, are actually “neither ‘quacks’ nor legitimate doctors”, but typically lay people who have self-trained, or been partially trained via a development scheme. They can “invent roles for themselves as medical authorities and representatives of development” (337) by claiming the authority of development and medical institutions. These claims go uncontested by legitimate institutions, who are aware of their work filling the gaps in communities with severely limited access to good health care.
In policy and development debates about ‘informal providers’ and their clients, though, informal providers are often characterized as rogue actors, both ‘irrational’ and exploitative, and clients are portrayed as uneducated and easily fooled. On the other hand ‘formal’ institutions are understood as modern, cosmopolitan; decidedly rational actors and purveyors of legitimate biomedical knowledge. In this way, what Pinto explains, is that despite on the ground evidence to the otherwise, formal and informal get defined in opposition to each other. Informal providers are “those against whom the educated and rational self is defined” (2004:356). The danger here is that we fail to understand the reasons why informal providers are trusted in the everyday lives of those who seek health care in environments with limited formal options, and likewise the institutional reasons they are propped up by governments and development organisations.
Anthropological Perspectives on Structural Adjustment and Public Health
Thirty years since its first public use in 1980, the phrase structural adjustment remains obscure for many anthropologists and public health workers. However, structural adjustment programs (SAPs) are the practical tools used by international financial institutions (IFIs) such as the International Monetary Fund (IMF) and the World Bank to promote the market fundamentalism that constitutes the core of neoliberalism. A robust debate continues on the impact of SAPs on national economies and public health. But the stories that anthropologists tell from the field overwhelmingly speak to a new intensity of immiseration produced by adjustment programs that have undermined public sector services for the poor. This review provides a brief history of structural adjustment, and then presents anthropological analyses of adjustment and public health. The first section reviews studies of health services and the second section examines literature that assesses broader social determinants of health influenced by adjustment.
Doctors, Borders, and Life in Crisis
The politics of life and death is explored from the perspective of Doctors Without Borders (Médecins sans frontières [MSF]), an activist nongovernmental organization explicitly founded to respond to health crises on a global scale. Following the work of Michel Foucault and Giorgio Agamben, I underline key intersections between MSF’s operations that express concern for human life in the midst of humanitarian disaster and the group’s self‐proclaimed ethic of engaged refusal. Adopting the analytic frame of biopolitics, I suggest that the actual practice of medical humanitarian organizations in crisis settings presents a fragmentary and uncertain form of such power, extended beyond stable sovereignty and deployed within a restricted temporal horizon.
Why India cannot plan its cities
Roy’s research troubles the easy binary between ‘formal’ and ‘informal’ that is often taken for granted within public health policy. Rather than take ‘informal’ and ‘formal’ as distinct and intrinsic categories, Roy shows how they enable one another. Informality, then, is better understood as a relation of power. The power and politics of the state – or an NGO or UN agency for example – is not contained to ‘formal’ channels, instead the ability of the ‘formal’ sphere to engage as it chooses often mobilizes informal processes and practices (Roy 2009:84), such as creative solutions to health, access to water or access to medicines. As Sarah Pinto has shown, many so-called informal health providers are indeed enabled because of lack of state resources to serve rural and marginal communities, and via a lack of denunciation of their activities. The ‘informal’ props up the ‘formal’, and is intrinsic to how the formal operates. Roy urges us to consider how the formal/informal binary obscures the modes and methods of informality as central to how the ‘formal’ operates.
Syndemics and the Bio-social Conception of Health
The syndemics model of health focuses on the biosocial complex, which consists of interacting, co-present, or sequential diseases and the social and environmental factors that promote and enhance the negative effects of disease interaction. This emergent approach to health conception and clinical practice reconfigures conventional historical understanding of diseases as distinct entities in nature, separate from other diseases and independent of the social contexts in which they are found. Rather, all of these factors tend to interact synergistically in various and consequential ways, having a substantial impact on the health of individuals and whole populations. Specifically, a syndemics approach examines why certain diseases cluster (ie, multiple diseases affecting individuals and groups); the pathways through which they interact biologically in individuals and within populations, and thereby multiply their overall disease burden, and the ways in which social environments, especially conditions of social inequality and injustice, contribute to disease clustering and interaction as well as to vulnerability. In this Series, the contributions of the syndemics approach for understanding both interacting chronic diseases in social context, and the implications of a syndemics orientation to the issue of health rights, are examined.
Syndemics and Public Health
The world of public health has undergone dramatic changes since the emergence of AIDS in the early 1980s. The appearance and global spread in recent years of wave after wave of new and renewed infectious diseases and their entwinement with each other and with the social conditions and biopsychological consequences of disparity, discrimination, and structural violence has produced a new significant threat to public health internationally. The term syndemic has been introduced recently by medical anthropologists to label the synergistic interaction of two or more coexistent diseases and resultant excess burden of disease. This article provides the fullest examination of this new concept to date, including a review of relevant new literature and recent research finds concerning coinfection and synergistic interaction of diseases and social conditions at the biological and population levels.
Reinventing Medical Anthropology
Responding to the narrow focus, medicalization, and inattention to political-economy within conventional medical anthropology, a growing number of researchers are participating in a significant restructuring of the subdiscipline. The paper examines several shortcomings of contemporary medical anthropology and, building on the work of the emergent critical trend, identifies key areas of theory and practice for furthering the critical realignment of medical anthropology.
Biocapital
Biocapital is a major theoretical contribution to science studies and political economy. Grounding his analysis in a multi-sited ethnography of genomic research and drug development marketplaces in the United States and India, Kaushik Sunder Rajan argues that contemporary biotechnologies such as genomics can only be understood in relation to the economic markets within which they emerge. Sunder Rajan conducted fieldwork in biotechnology labs and in small start-up companies in the United States (mostly in the San Francisco Bay area) and India (mainly in New Delhi, Hyderabad, and Bombay) over a five-year period spanning 1999 to 2004. He draws on his research with scientists, entrepreneurs, venture capitalists, and policymakers to compare drug development in the two countries, examining the practices and goals of research, the financing mechanisms, the relevant government regulations, and the hype and marketing surrounding promising new technologies. In the process, he illuminates the global flow of ideas, information, capital, and people connected to biotech initiatives.Sunder Rajan’s ethnography informs his theoretically sophisticated inquiry into how the contemporary world is shaped by the marriage of biotechnology and market forces, by what he calls technoscientific capitalism. Bringing Marxian theories of value into conversation with Foucaultian notions of biopolitics, he traces how the life sciences came to be significant producers of both economic and epistemic value in the late twentieth century and early twenty-first.
