Open Encyclopedia of Anthropology - Globalisation

Pandemics

Rebecca Tishler — Wed, 02 Mar 2022 17:15:36 +0000

Laboratory of Social Anthropology (CNRS-Collège de France-EHESS)

Initially published 2 Mar 2022

Abstract:

Pandemics tend to be defined as large epidemics, i.e. as sudden and widespread rises in disease incidence that occur over a very wide area, cross international boundaries, and affect a great number of people. However, this conventional definition neglects the fact that some diseases that reach a global scale, such as influenza or Severe Acute Respiratory Syndrome (SARS), are usually considered to be pandemics while other diseases that are similarly widespread, such as tuberculosis, are not. It is therefore necessary to investigate how scientific and medical knowledge led experts to frame only some pathogens as actually or potentially pandemic. The history of past pandemics shows the extension of both the human species and its parasitic microbes over the globe, foregrounding that humans and pathogens co-evolved and that immunity is as much a process as it is a state of being. As the Industrial Revolution and the rise of capitalism have accelerated environmental change and caused the emergence of new pathogenic microbes, the medical concept of ‘emerging infectious diseases’ was developed in the 1970s. It relied on the technical possibility to track microbes as they cross borders between species and territories, turning microbes into objects of surveillance under a logic of security and emergency. Preparing for and responding to pandemics has since transferred technologies of anticipation from civil defence to public health, and the collective management of uncertainty associated with pandemic preparedness and response redefined the publics of medical care. Social anthropology improves our understanding of these publics and processes by enlightening the entanglements between species, the co-infections between diseases, and the structural violence of inequalities that drive pandemics, particularly in the Global South. Studying pandemics as fundamentally social phenomena also allows anthropologists to investigate figures such as the prophetic expert or the virus hunter, who question the efficacy of science at a time when infectious diseases become more and more commonplace.

Introduction

The World Health Organization (WHO) has recently defined a pandemic as ‘the spread of an infectious disease over three continents’ (Doshi 2011). This definition was implemented to anticipate the emergence of influenza viruses by global warning systems, and to control their spread through public health measures in nation-states. Since December 2019, the WHO has faced a respiratory disease pandemic caused by the coronavirus SARS-CoV-2, and the number of victims has rapidly and dramatically increased despite strong measures such as population lockdowns and mass vaccination applied worldwide. Anthropologists have been engaged in this and previous pandemic emergencies on both applied and more theoretical levels, trying to understand which public health measures work best, what such measures mean for populations, what long-term conditions enable the emergence and severity of pandemics, and what pandemics themselves can teach us about the human condition (Abramowitz 2017; Higgins, Martin and Vesperi 2020).

Past pandemics have shown that an infectious disease does not just limit itself to a series of individual cases on human bodies but instead questions the very foundations of social life. Pandemic pathogens raise fears about the effects of human contact and contagion because they cross the boundaries of social groups, which tend to define people in terms of immunity as well as purity and even moral decency (Farmer 1992). Pandemics also show that the human species does not control its autonomous development in the domestication of nature, but is entangled with other species in unstable ecosystems. This makes pandemics one of the most pressing challenges for the human species, because they reveal the fragile conditions in which we co-evolve with microbes that can become pathogenic (Latour 2020). Investigating the human fabric of pandemics leads anthropologists not only to question how pandemics are configured as global threats but also to study how they emerge at the ecological scale of the planet.

Since anthropology studies the relations between humans and non-humans in local sites (Descola 2013), it can ask how these relations produce pandemics at a global scale, but also how some aspects of these relations are ignored or left aside through, for example, models of calculation and techniques of anticipation. How is an infectious disease configured as a pandemic, and can the notion be extended to non-infectious diseases? What kinds of vulnerabilities do pandemics reveal in the globalised infrastructures of human societies? How does the scale of ‘totality’ (pan-) that pandemics rely on transform what we understand society to be? Are societies defined by the immune protection of different human groups exposed to a disease?

This entry will describe four aspects of pandemics that have been covered in some depth by social anthropology. Pandemics expose vulnerabilities in global connections, they amplify existing social inequalities, they serve as horizons in that they force us to anticipate the future, and they foreground entanglements of relations between human and non-human species.

Vulnerabilities in global connections

The term ‘pandemic’ was first used to describe the effect of climate at the scale of the planet. In 1862, the British army doctor Robert Lawson invoked ‘pandemic waves’ to account for global fluctuations in the spread of infectious diseases by a mix of social, hygienic, and meteorological forces (Harrison 2016: 131). When the Ancient Greeks coined the term epidemic to describe how diseases moved from one body to another, they did not think that it could spread to the whole human species. The term pandemos was used by Plato for a vulgar and pathological form of love extended to all human bodies, in contrast to the intellectual love of ideas, and referred to self-government rather than to the government of the human species (Foucault 2005). Epidemics such as bubonic plague moved from the East to the West, following the movements of persons and commodities across burgeoning cities and spreading empires, and were most often interpreted as divine punishments (McNeill 1976). When humans, animals, and plants circulated massively between the Old World and the New World, smallpox and tuberculosis ravaged the Amerindian population while syphilis came to Europe (Crosby 1976). As epidemics were increasingly related to global trade, discussions on how to control the contagious transmission of diseases were linked to debates on how to regulate flows of commodities and persons (Delaporte 1986).

The development of microbiology as a laboratory science in the nineteenth century led to the replacement of climate as a vague causality for epidemics with a more precise causality: the infection of human bodies by invisible microbes. While Robert Koch discovered the bacteria causing tuberculosis and cholera in land fields and water sources, Louis Pasteur showed that pathogens could be modified in the laboratory and be used to cure diseases. Following Bruno Latour (1993), the strength of Pasteurian medicine, by contrast with public hygiene, was its capacity to displace relations between humans and microbes from the laboratory to another site, the countryside or the colonies. If pandemics are diseases of globalisation, the microbiological response to pandemics is the globalisation of the laboratory as a space where serums and vaccines are made to mitigate their effects (Latour 1983). Society itself was defined by the study of the mechanisms of immunity, separating good microbes from pathogens in their encounter with the human body. Thus, Emile Durkheim (1916) compared what it feels like to live and think in a society to the inoculation of a small amount of pathogens through vaccines, since they allow the body to know what is proper and not proper under a collective form of memory (Esposito 2011). The organisation of public health relied on maps of distribution of infectious diseases and on access to vaccines and drugs, following the principle of solidarity between all participants of a social group.

The First World War confirmed the microbiological revolution while challenging it at the same time. The globalisation of war multiplied contacts between bodies but also standardised military forms of control, leading to the decrease of cholera or yellow fever by simple techniques of hygiene and social distancing. Yet new pandemics appeared with this accelerated form of globalisation. The influenza pandemic of 1918-1919 killed more humans than the war itself, and apparently caused diseases independently from social classes or climates (Crosby 1989). As the search for the microbe that caused it failed, despite the discovery of an associated bacteria by Richard Pfeiffer in Germany, no vaccine could be made (Honigsbaum 2020). While the influenza pandemic moved from America to Europe and Africa through the circulation of soldiers, pandemics of plague moved from Asia to Europe through steamship and railway, revealing the acceleration of global transportation by war and colonialism. The use of surgical masks against pneumonic plague in Manchuria in 1910 was extended to the United States against influenza in 1918, which shows that prophylactic measures could be invented against pathogens for which no vaccine or treatment was available or effective (Lynteris 2016).

It took a century after two global wars to redefine how we understand the relations between humans and microbes in the sociological notion of immunity. If ecosystems in which humans co-evolve with microbes are constantly changing, immunity must be remade by adapting treatments and vaccines to new pathogens and being attentive to their conditions of emergence. This was the foundation of the ecology of infectious diseases, a medical form of thinking illustrated by immunologist Frank Macfarlane Burnet in Australia and bacteriologist René Dubos in the United States, who argued that medical intervention should ‘run’ to keep nature in a state of balance (Anderson 2004). These two prophetic voices were confirmed with the emergence of new pathogens in the 1970s, such as Ebola or Lassa, which could spread rapidly through accelerated means of transportation. In 1996, microbiologist Joshua Lederberg declared,

we come then to social intelligence as our remaining option to counter the evolutionary drive of the microbial world. That intelligence must include a profound respect for the ecological factors that enhance our vulnerabilitity. From this perspective, we have never been more vulnerable (King 2002, 768).

Ledeberg encouraged biologists to ‘think from the microbe’s perspective’ and saw globalisation, with its increasingly rapid connections between distant points of the world, as multiplying opportunities for microbes to thrive. Latour, following the works of James Lovelock and Lynn Margulis, has described relations between humans and microbes through the concept of Gaia, a symbiotic entity conceived at the scale of the planet and its atmosphere. He asks how it is possible to reassemble the social in the ‘critical zones’ where pathogens signal disruptions and call for attention (Latour and Weibel 2020). Relations between humans and microbes, in that perspective, are sites of vulnerability which require local forms of investigation, rather than a rigid sociological definition of immunity as a kind of border.

Social inequalities, from local causes to global amplifications

If pandemics are caused by microbes spreading globally through human means of transportation, they are also caused by social inequalities, which they amplify. Epidemics are often ‘syndemics’, as the effects of one pathogenic microbe are added to other social factors of vulnerability, including other infections (Singer 2009). Unequal access to health care is caused by poverty, racism, hierarchy, discrimination, and violence, thus contributing to the emergence and spread of infectious diseases (Nguyen and Peschard 2003). Pandemics produce global inequalities and prejudices, between populations in the Global North who are often protected from these diseases by their governments, and populations in the Global South who are predominantly affected by them and tend to be depicted as the origins of emerging pathogens (Wald 2008). Anthropologists have questioned global health interventions by the WHO or the Bill and Melinda Gates Foundation for example, because when focusing on pandemic pathogens that they want to anticipate, mitigate, or eradicate, they tend to ignore or simplify the social distribution of pandemic pathogens. Here, microbiology must be connected to epidemiology, which studies the differential exposure to infectious diseases, and to social anthropology, which reflects patients’ vulnerabilities as well as feelings of suffering and injustice.

The virus causing AIDS (Acquired Immunodeficiency Syndrome), identified in the United States in 1981, spread to a slow pandemic, killing around 30 million people. While it first affected gay urban communities who could mobilise to promote research on medical treatments, it reached poor communities through sexual relations or blood transfusion with little access to a cure (Epstein 1996). Paul Farmer, as a physician and anthropologist, studied the transmission of infectious diseases in Haiti and the local idioms in which people made sense of their suffering, such as through accusations of sorcery. Refusing to oppose the cultural explanations rooted in belief and the biological causality of the microbe, Farmer followed narratives of illnesses in which AIDS occurred in long-term infections such as tuberculosis (Farmer 1999). For him, the global narrative of AIDS connected places where different and sometimes contradictory idioms to make sense of illness were used. ‘The AIDS pandemic is a striking reminder that even a village as “remote” as Do Kay is linked to a network that includes Port-au-Prince and Brooklyn: voodoo and chemotherapy, divination and serology, poverty and plenty’ (Farmer 1992, 8). Indeed, these different idioms can enter in tension when a migrant worker from Haiti arrives in New York with AIDS, and seeks medical treatment at hospitals while making sense of the disease in his own concepts.

The contradictions between idioms of illness produce what Paul Farmer calls a ‘geography of blame’, which traces pandemics to poor territories where they are considered to emerge. AIDS became a target of global health measures a few years after the Ebola virus was detected in Central Africa after 1976. This coincidence raised concerns that Ebola could infect North Americans, thus reinforcing security measures to control its spread on the African continent. Some anthropologists, such as João Biehl and Adryana Petryna, want social anthropology to enter into a critical dialogue with global health. They show that the technologies to detect pandemic emergencies predominantly as a security concern tend to forget the people who are affected and the narratives by which they make sense of their suffering. These aspects should play a role in the mitigation of pandemics:

Global health players can become impervious to critique as they identify emergencies, cite dire statistics, and act on their essential duty of promoting health in the name of “humanitarian reason” or as an instrument of economic development, diplomacy or national security (Petryna and Biehl 2013, 7)

In his ethnography of AIDS in South Africa, Didier Fassin (2007) analysed the accusations launched by president Thabo Mbeki that the disease was caused by poverty and not by a virus, and that treatments proposed by Northern countries were too costly and non-effective. These claims, portrayed as heresy in the language of global health, were accepted by many South African citizens because the context of the post-apartheid regime made sense of experiences of suffering and inequality. For Fassin, the national accusations of a president captured local experiences of disease in a long history of colonisation and racism, which became public with the Truth and Reconciliation Commission.

When they emerged in China in 1997 and 2003, H5N1 avian influenza and SARS (Severe Acute Respiratory Syndrome) were described as potentially the first pandemics of the twenty-first century, as they revealed the increasing connections between China and the global economy. They were also understood as epidemics of information, because a ‘viral network’ coordinated by the WHO followed the mutations of respiratory pathogens in real-time as they circulated from one country to another, which raised the question of how to distinguish true information from fake news in social networks (MacPhail 2014). Arthur Kleinman and others analysed these diseases with a biosocial approach of inequalities between humans faced with emerging pathogens. In the US, members of the Chinese diaspora were stigmatised by prejudices about wet markets as sites of contagion (Kleinman and Watson 2003). In Southeast Asia, small poultry breeders were replaced by big industrial farms which could implement biosecurity measures (Kleinman et al. 2008). While biological approaches in global health tend to correlate target and response, biosocial approaches take into account the local, national, and global scales that shape the context of the response.

A biosocial approach may question why some diseases are considered as pandemics while others are not, even if they also spread globally and are caused by social inequalities. Thus, obesity and diabetes have been described by global health authorities as epidemics because they followed the globalisation of sugar and Western modes of consumption. And yet they are not objects of mobilisation with the same urgency as infectious diseases, because they do not jump borders rapidly and cannot be expressed in the language of security. Moreover, their causes in the unequal distribution of food are more complicated to target with a standardised distribution of medical treatments (Moran-Thomas 2019; Sanabria 2016; Yates-Doerr 2015). While the origins of obesity and diabetes are apparently more complex than the emergence of a new pathogen, their outcomes are more difficult to model than infectious diseases. Beyond the opposition between biological and social causes of epidemics, anthropologists can thus ask how the notion of pandemics has become a tool to anticipate the future at a global level.

Horizons to anticipate the future

How are experts led to think that a disease will become a pandemic in the future, and how does this mode of reasoning affect relations between living beings? Pandemics have become one of the horizons to generalise a contingent event, resonating with other forms of anticipation in environmental knowledge, such as climate change or nuclear accidents. They are what Charles Briggs and Clara Mantini-Briggs called a ‘chronotope, a narrative device for connecting social, biological and spatial elements and ordering them in temporal sequences and interpretive frameworks’ (2003, 276). Thus cholera, one of mankind’s oldest diseases caused by a bacteria that spreads through water, was described by the WHO in 1961 as a pandemic, and retrospectively six pandemics of cholera were traced to Asia as its region of origin. When it reached Venezuela in the 1990s, the state, ruled by Hugo Chavez, tended to under-report cases to avoid quarantine, in such a way that the voices of the Warao people affected by cholera were unheard in the global discourse of pandemics. Such obstacles to making sense of pandemics have led global experts to anticipate them without relying exclusively or even heavily on national statistics but rather by involving populations in the imagination of pandemics as catastrophic events.

According to Andrew Lakoff, the emergence of infectious diseases in the 1970s has been framed in a new form of anticipation of the future. Infectious diseases such as tuberculosis or cholera were managed by public health experts in the last two centuries through techniques of prevention, based on the calculation of risks shaped by territory and the ability of distributing treatment. Infectious diseases after Ebola and AIDS were described by global health experts as ‘events’ whose probability cannot be calculated but whose catastrophic consequences can only be mitigated. Pandemics are now imagined through worst-case scenarios as events for which populations must be prepared, in order to contain panic when they do occur. Pandemic planning regulates the distribution of vaccines and treatments that are being stockpiled and secured to avoid looting. Pandemic preparedness is about creating a constant state of vigilance and readiness produced by techniques of anticipation of the future, such as exercises simulating an outbreak of smallpox in the New York City subway. ‘Preparedness envisions the future not to predict what is going to happen but to generate knowledge about the vulnerabilities in the present’ (Lakoff 2017, 23).

With Stephen Collier (2021), Lakoff has traced the history of techniques of preparedness in the US to the beginning of the Cold War, when civil defence experts identified vulnerabilities in ‘vital systems’, such as public transportation, the food industry, or banking systems, that could be targeted by a nuclear attack. These experts organised exercises or simulations to imagine such improbable events and mitigate their consequences. After the end of the Cold War, this style of reasoning was transferred from civil defence to national security in order to anticipate ‘generic threats’, a range of unpredictable events from terrorist attacks to hurricanes and floods. By shifting from national security to global health, pandemic preparedness has become one of the languages to think and act in a world struck by disasters, be they intentional or not, short-term or long-term, by simulating their effects rather than modifying their causes (Samimian-Darash 2009).

Carlo Caduff has studied how pandemic preparedness has transformed the work of microbiologists, particularly in the domain of influenza viruses. Because these viruses are constantly mutating, public health authorities have to anticipate new influenza viruses when a new strain replaces another, as in the cases of the 1918, 1957, and 1968 pandemics. When virologists study viral mutations in the lab, they have to bet which strain will become pandemic, leaving aside other strains considered as not ‘potentially pandemic’. This leads some of them to make what Caduff calls ‘prophetic claims’ by projecting previous pandemics into the future (2015, 7). When the H5N1 avian influenza virus emerged in Hong Kong in 1997, with a high lethality but a low transmissibility (12 persons were infected, out of whom 8 died), virologist Robert Webster warned of a pandemic more severe than the 1918 ‘Spanish Flu’ which had killed around 50 million people. These prophetic claims draw on apocalyptic images when they predict disasters at the global level. However, they are not promises of redemption but rather invitations to act in order to mitigate the disaster they announce. ‘At the core of pandemic prophecy is a particular prospect: destruction without purification, death without resurrection - in short, dystopia without utopia’ (Caduff 2015, 7).

Edwin Kilbourne, the founder of the department of microbiology at the Mount Sinai School of Medicine in New York City where Caduff did his fieldwork, promoted a policy of stockpiling vaccines for future flu pandemics with the motto: ‘better a vaccine without a pandemic than a pandemic without a vaccine’ (Caduff 2015, 61). The US Strategic National Stockpile also included masks and antivirals distributed during exercises to test for the allocation of scarce resources during a pandemic. These simulations of pandemics, based on scenarios similar to those used in novels or films, produce a sense of disaster imminence, and engage participants in a presumably realistic course of action. They blur the distinction between reality and fiction in such a way that a pandemic, when it happens, is taken as a simulation of the next one. Hence the 2009 H1N1 pandemic, which killed fewer persons than seasonal flu, could have led to a disengagement in preparedness, but the ‘lessons learned’ in stockpiling masks have been used, for better or worse, during the Covid-19 pandemic. In China, criticisms for the failure to control SARS in 2003 led public health authorities to take the H1N1 pandemic as an exercise, showing their ability to trace contacts and control its spread better than their US counterparts (Mason 2016).

Pandemic preparedness can be criticised as privileging the future over the present, calibrating faith and reason. Caduff analyses precautionary measures as a way to justify action by betting on the future in a competition between truth-claims about viral mutations where the most catastrophic claim wins over others. The logic of pandemic preparedness defers the present for a future that it indicates or signals. It is not regulated by the opposition between true and false, since no false signal can be criticised for failing to anticipate the pandemic.

The fact that this form of preparedness is causing too many signals can also be seen as a sign of its sensitivity: it actually constitutes a part of its functionality. The false alarm is a consequence of the exceptional vigilance that is considered necessary to prepare for the inevitable pandemic (Caduff 2015, 135).

This preference for the future in the logic of preparedness has produced new kinds of ‘publics’ (Prince 2019) in the neoliberal management of uncertainty. Vinh-Kim Nguyen (2010) has studied patient groups anticipating the end of the AIDS pandemic through their participation to clinical research projects. He shows that the possibility to treat HIV/AIDS with antivirals has led global health experts to collect narratives about living with the virus in West Africa, thus operating a triage between those who could receive treatments and those who could not. Although it has colonial antecedents, triage is in part a simulation technique of global health, since it defines priority populations for the administration of treatments in times of pandemics. These populations can become publics, in the sense that they are trained by NGOs and activists to argue reflectively. They institute forms of sovereignty below the nation-state, by referring to themselves as responsible subjects.

If Nguyen is critical of the social boundaries set up by exercises of triage because of the violence they institute, he is more positive about software simulations of pandemics that retrospectively track emerging viruses. These simulations reflect possibilities of social life. Based on pandemic scenarios, they calculate probabilities of new pandemics and imagine modes of ending existing ones, often through the problematic notion of ‘eradication’. Working as a health professional during the Ebola outbreak in West Africa in 2014, Nguyen testifies to the differences between slow epidemics such as AIDS and a fast epidemic such as Ebola: while the origins of HIV/AIDS were traced by phylogenetic analysis to a transmission from apes to humans in Central Africa in the 1920s amplified by human trade, the arrival of Ebola in West Africa by contact between bats and humans in a village in Guinea was much more difficult to prove. Anthropologists are called upon by biologists to speculate on the speed at which viruses travel across global infrastructures, and not only to understand cultural obstacles to public health measures. ‘In effect, an anthropology of infectious diseases must be attentive not only to the social drivers of biological emergence but also to the conditions which allow biological events to be detected and made tangible in situ’ (Nguyen 2019, 166). Participating in debates about the origins of pandemic viruses allows anthropologists to imagine alternative futures based on ethnographic knowledge, and thus question and improve techniques of preparedness.

Entangled relations between human and non-human species

Concepts such as ‘vital systems’ and ‘interspecies contacts’, which play a central role in pandemic preparedness, have led anthropologists to rethink social life not only as shared vulnerabilities in a human collective but also as changing webs of relations in which pathogens emerge. Pandemics are often caused by ‘zoonoses’, diseases transmitted across species by ‘spillover events’ (King 2002; Keck and Lynteris 2018). While some infectious diseases are transmitted by mosquitoes, such as malaria or dengue, and others by water, such as cholera, some pathogenic microbes circulate without symptoms among animals before spreading to humans, such as tuberculosis among badgers, coronaviruses among bats, or influenza among waterfowl. To describe these chains of transmission from ‘animal reservoirs’ to infectious outbreaks, the epidemiological concept of contact is not sufficient, because it presupposes that zoonotic emergence is a unique event. More ethnographic concepts are necessary, such as habit, proximity, and entanglement, to describe long-term relations that condition emergence (Brown and Kelly 2014; Nading 2014; Narat et al. 2017). How humans perceive and treat the animals they live with is a structural factor in the early detection of zoonoses, either in the use of apes and bats as bushmeat, or in the consumption of poultry and pigs as domesticated animals. New modes of human habitat have brought humans closer to mosquitoes and ticks carrying pathogens, whose behaviour has been modified by climate change. Under the concept of ‘One Health’, reframed and extended as ‘planetary health’, environmentalists, veterinarians, and physicians share information on relations between human and non-human animals to prepare for and fight against pandemics. If these associations are driven by demands of biosecurity, they can also be attentive to biodiversity, which increasingly appears as a protection against pathogenic emergence (Hinchliffe 2015).

Here again, the anticipation of an avian influenza pandemic has been a field of experimentation for virologists and anthropologists alike. The massive precautionary killings of poultry suspected of carrying influenza viruses has raised concern regarding the shared immunities that have been lost by the globalisation and commodification of the industrial chicken (Haraway 2007). In the Indonesian archipelago, the dispersion of backyard poultry has led villagers to resist biosecurity measures, which can be related to the mode of existence of viruses as ‘clouds’ of information (Lowe 2010). In Vietnam, the massive vaccination of poultry promoted veterinarians as central actors in a national ‘war’ against influenza viruses, but raised suspicions about the advantages they offered to industrial farms (Porter 2019). In Hong Kong, unvaccinated chickens were placed as sentinels at the entrance of poultry farms, while birdwatchers monitored the health of wild birds (Keck 2020). In mainland China, the recent scaling up of industrial breeding remained compatible with small poultry farms mixing wild and domestic birds (Fearnley 2020). The global scale of a pandemic affecting humans has led anthropologists to study the different scales at which humans perceive the movements of birds, from farms to markets and migratory flyways.

When they are seen from the perspectives of animal reservoirs in which they mutate, emerging pathogens such as influenza viruses and coronaviruses are not only warning signals of future pandemics but also signs of communication between species in disrupted ecosystems. Christos Lynteris (2019) has proposed to take seriously the idea that pandemics should be understood not only as extending epidemics globally but also as reminding of the potential extinction of the human species. While humanity has caused the ‘sixth extinction’ by its impact on other species’ conditions of life, the multiplication of zoonoses in the recent decades has led many observers to interpret pandemics as a ‘revenge of nature’—a popular idea quite different from René Dubos’s evolutionary race between nature and humanity. When pandemics reveal the vulnerabilities of infrastructures of social life, leading to the massive interruption of human activity to stop contagion, they question more generally the claim to autonomy which separates humans from other species. ‘The pandemic is imagined as striking not simply human populations – or even the human species as a whole – but rather at the heart of humanity as a project for mastery’ (Lynteris 2019, 9). Pandemic preparedness can thus be interpreted as a way in which humanity confronts alterity in the process of domesticating nature, either focusing on spillover events on the side of animals or superspreader events on the side of humans. This reversal of apocalyptic time is compared by Lynteris to mythological narratives in Amazonian societies, where humans have been separated from animals by an original conflict which serves to explain the diversity of species (2019).

While the figure of the prophet can be mobilised to understand how experts of pandemics make truth-claims about the future, the figure of the shaman can explain how scientists manipulate past relations between humans, animals, and microbes in new forms of ritual practices. The regular sampling of animals to check if they have potentially pandemic pathogens turns them into allies for global health: if a virus is declared the enemy of humankind, birds or bats carrying this virus offer biologists the possibility to ‘take the enemy’s point of view’ (Viveiros de Castro 1992). While biosecurity interventions separate subjects of care from sacrificial victims when they cull animals or conduct triage, the attention to biodiversity as a limitation of pandemic risks produces more inclusive forms of surveillance and monitoring. Borders between species and territories have become sites of intense production of knowledge under the horizon of future pandemics. The border between China and Russia was a site of rehabilitation of the knowledge of marmot hunters at the time of the pneumonic plague (Lynteris 2016), and the border between China and Hong Kong was constantly monitored by birdwatchers to prevent outbreaks of avian influenza (Keck 2020). Pandemic preparedness has transformed natural sites into reservoirs of signs of the future perceived by ‘virus hunters’, who can read microbial mutations to describe continuities and discontinuities between populations and between species.

Conclusion

Pandemics are among the main drivers of the globalisation of knowledge, as they lead experts to follow a pathogen at the scale of the planet and recommend measures to control it. As such, they have had complex and often contradictory impacts on human-animal relations, global social policy, belief in the efficacy of science, and visions of planetary solidarity. Lessons from the past show that pandemics start and end with environmental changes, but they do not provide models on how to anticipate the next pandemic. The technological capacity to detect potentially pandemic pathogens at their early start and to raise alarm has led global authorities to manage pandemics as security issues by targeting microbes as enemies. But the unfolding of a pandemic as a long-term process reveals an entanglement of relations between social groups, non-pathogenic microbes, and animal species that does not follow the logic of eradication, which requires cleaning animal reservoirs and distributing medical treatment. By reaching the scale of the planet, the notion of pandemics can reduce the work of science to globalised networks of surveillance, or enlarge the understanding of diseases to the complex web of causes that interlaces different forms of trouble, from remembering past illnesses to detecting future pathogens, often producing violence and inequality. Social anthropology can contribute to the redefinition of solidarity at the time of pandemics, because it stands at the borders crossed by pathogens between species, territories, and populations. It can usefully ask what kind of experience and knowledge is produced at these borders, how such knowledge travels, and how it can be translated to speak to everyone. Pandemic preparedness could thus become a new language to think about a disrupted planet and fragile environments.

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Note on contributor

Frédéric Keck is a Senior Researcher at the Laboratory of Social Anthropology (CNRS-Collège de France-EHESS). After working on the history of social anthropology and contemporary biopolitical questions raised by avian influenza, he was the head of the research department of the musée du quai Branly between 2014 and 2018.

Frédéric Keck, Laboratoire d’anthropologie sociale, 52 rue Cardinal Lemoine, 75005 Paris. frederic.keck@cnrs.fr

Monsters

Rebecca Tishler — Fri, 15 Oct 2021 15:54:41 +0000

Yasmine Musharbash

Initially published 15 Oct 2021

http://doi.org/10.29164/21monsters

Abstract:

Monsters are not only key protagonists in myths, legends, fairy tales, fiction, and films; they also haunt cellars, cyberspace, and crossroads. Based on encounters with monsters in their fieldsites, anthropologists define monsters as inherently social entities but with a defiant relationship to order. This entry showcases that monsters haunt humans in culturally distinct ways. Emphasising the comparative potential of monsters, it highlights the ways in which their study reveals much about what monsters are, about society, and about time and space. Anthropology has made key contributions to the study of monsters: from the meticulous documentation of local monsters in early ethnographies, via regional theoretical frameworks and a gradual increase in singular works concerned with individual types of monsters, to recent comparative monster anthropology. Anthropology continues to have much to offer to those interested in monsters, especially in these times of planetary crises, disasters, catastrophes, ruination, and their accompanying rise of monsters.

Introduction

We are living in a time of monsters. As the planet is ravaged by climate change, pandemics sweep across the globe, fires and floods consume entire regions, extinction rates rise exponentially, and waste clogs up the environment, globalised media and popular culture conjure up new monsters at breakneck speed. There is a contemporary profusion of monsters, which far exceeds the recent renaissance of vampires and zombies in variation and volume (think anything from the re-emergence of dragons, via new creatures of the deep, to the abundance of creatures hunted in assorted monster-hunter movies, books, and TV series). This explosion of new monsters into popular culture serves well to highlight their capacity to colonise the human imagination in times of crisis. There is something infectious in this far beyond pop culture. Anthropology, certainly, is being swept up in the momentum: attention to monsters as monsters is steadily proliferating in twenty-first century anthropology.

Interestingly, though, while it was not until recently that the term ‘monster’ entered the anthropological canon (Mikkelsen 2020: 6), the ethnographic record has been teeming with creatures that can be subsumed under the umbrella term ‘monster’ since its earliest beginnings. This entry showcases what anthropology can contribute to general concerns with an interest in monsters. It first draws on ethnography to contour a broad definition of what monsters are. The entry then illuminates different trends in anthropological engagements with beings that can broadly be defined as monsters across the ethnographic record. Lastly, it identifies the promises that a new engagement with the category of monsters in anthropology carries both for anthropology itself and for others interested in monsters and their meanings. Overall, this entry shows that monsters are exemplary agents which convey the weight of radical sociocultural transformation and change. At the same time, anthropology is a treasure trove showcasing that monsters are much else besides.

Monsters are key actors in myths, legends, fairy tales, fiction, and films, but they also haunt cellars, cyberspace, and crossroads. Anthropologists are concerned with monsters because they frequently encounter them in their fieldsites, via stories told by interlocutors, by observing social action relating to or caused by them, or by sharing experiences of being haunted. These monsters thus possess agency in spades, which distinguishes them from their fictional pop culture cousins. While the primary characteristic of fictional monsters is being metaphors, anthropologists, as Michael Dylan Foster puts it, work ‘with monsters productively not (only) as metaphors or reflections of human imaginings but as real actors capable of changing society and culture, and capable also of being changed’ (2020: 213).

Monsters are also wily. They not only unsettle the orders of the people they haunt, they also easily escape the confines of any definition you might try to catch them in. What exactly they are, what exactly they do, what exactly they mean—the answers always crucially depend on the people they haunt, anthropology tells us. This entry therefore proposes a broad anthropological understanding of monsters as non-human social actors who are other-than-the norm, always contingent on the humans they haunt, the times and the places in which they operate, and with a profound awareness of social rules, taxonomies, and classificatory schema that they then subvert—including, naturally, this very definition. Why then, you may ask, try and define them at all? As Geir Henning Presterudstuen and I put it, ‘it allows us to gather, contrast, and compare (ethnographies of) a great variety of different beings that otherwise would not be considered in the same conceptual space’ (2020a: 2). In addition, employing the term ‘monster’ in anthropology opens up avenues of communication between anthropology and interdisciplinary monster studies—a young but rapidly growing field spanning literature, media, film, cultural and gender studies, history, geography, and psychology, among others.^[1] An anthropology of monsters thus enhances not only comparisons between different types of entities (say, fictional monsters and social ones) but also deepens cross-engagement with the theorisations that accompany such different monsters, respectively.

This entry offers an overview of what an anthropology of monsters has to offer. It does so in two distinct parts. The first is concerned with ethnographically contouring the details of the aforementioned monster definition with a focus on four topics central to anthropology: the monstrous body, monsters and place, monsters and time, and monsters as social beings. This first part emulates Jeffrey Jerome Cohen (a medievalist widely acknowledged as a founding father of interdisciplinary monster studies), who offered ‘a set of breakable postulates’ (1996: 4) in lieu of a fixed definition. It emphasises that monsters’ very trait of habitually disrupting categories, undermining taxonomies, and violating order makes them ‘a walking anthropology’, as Rupert Stasch puts it (2014: 196), which is why monsters ‘compel us to rethink the parameters, methods, and objectives of anthropological inquiry’, according to Foster (2020: 213).

The second part ponders the utility of the general term ‘monster’ in anthropology by looking back and re-examining some past studies through the lens of monster as a category. It also highlights the benefits of employing the broad category of monster in this current time, by exploring key directions of contemporary anthropological analyses of monsters, focussing in particular on monsters and alterity, monsters and environmental crises, and monsters and change.

The conclusion reflects on anthropology’s main contribution to the interdisciplinary study of monsters: insights arising out of ethnographic explorations of the intimate entanglements between monsters and the humans they haunt.

Contouring the anthropological definition of monsters

What do a dwarf, an octopus so large it could cover an entire village, an invisible sorceress, a water leopard, a zombie, and a ghost have in common? From an anthropological point of view, the one commonality they share is that they all violate order: one is too small, one too large, the next one is there but invisible, another exists in an element it does not belong in, one lives when it is dead, and the last is neither dead nor alive.

As Stephen Asma, a philosopher and eminent historian of monsters formulated it, ‘monsters, from Aristotle’s time to the present, always disrupt neat categories of taxonomy’ (2009: 125). Looking at this anthropologically means that monsters are not a pre-existing category of phenomena that share this feature, but that this feature is what makes a phenomenon a monster. Monstrous bodies have in common that they disrupt taxonomies, and as any anthropologist will tell you, taxonomic systems are socio-culturally distinct. Any particular monstrous body, as a taxonomic disruption, is equally socio-culturally distinct. Put simply, only if people classify, say, animals and humans as distinct categories can a monster take a shape by disrupting this taxonomy.^[2] That is to say, their very bodies place monsters in the realm of culture, as they depend on subverting the taxonomic schema of the people they haunt. Monstrous bodies are ‘always impossible; they always cross un-crossable categories’ (Musharbash & Presterudstuen 2020a: 4); yet, importantly, they always do so in culturally legible ways. The monstrous body is fantastic, especially if we consider ‘fantastic’ in its original Greek meaning, where phantastikós signifies that which is imaginable as opposed to imaginary (see also Musharbash 2014a: 8-11).

There are a number of ways in which monsters embody taxonomic transgression.^[3] Hybridity is one, and early monsters are exemplary of this; so much so that David Wengrow (2014), who explores monsters from the Bronze to the Iron Age, calls them ‘composites’. Their bodies are literal assemblages: the head of one animal, wings from another, a body from a third. Examples of early hybrid monsters with which we are still familiar include griffins, sphinxes, and centaurs. A multitude of other kinds of hybrids across any number of taxonomic categories, of course, is not just conceivable but is recorded across the anthropological record.

Transgressing states of animation is another way for monsters to disrupt taxonomies. The most prominent among these are the states of being dead or alive: ghosts, spirits, zombies, vampires, and more fall into this category. Monstrousness in these cases hails from being neither dead nor alive, or being both, dead and alive. The anthropological literature records ghosts and spirits across the globe (see, among many others, Blanes & Santo 2013, Bubandt 2012, Mills 1995), and note that neither zombies nor vampires are in any way limited to popular culture. While the contemporary cinematic zombie’s genealogy is commonly related back to the Haitian zombi, which in turn made the transatlantic journey from Africa to the Caribbean in the slave boats, other zombies never left Africa and proliferated there (see, amongst many others, Cannon 1942; Comaroff & Comaroff 2002; Niehaus 2005). Vampires—undead monsters who drink the blood of humans—appear across time and space in countless cultures (see Weiss 1998 and White 2000 for examples from Africa).

Other ways of taxonomic transgression are more fluid. One example of this are shapeshifters, creatures who are sometimes human, sometimes animal. Further significant aspects of the monstrous body are its size (often much larger or much smaller than the original category, such as dwarves or the giant octopus). Then, there are culturally specific markers of monstrosity which render a monstrous body unnatural, such as horns (on beings to whom they don’t ‘belong’), or long nails, hirsuteness, and so forth. Lastly, the monstrous body is often endowed with powers that far exceed what it should ‘naturally’ be capable of, including excessive speed and/or strength, the ability to become invisible or teleport, and so forth. These literal superpowers highlight the monster’s supernaturalness.

Next to embodiment, anthropologists take the physical presence (or, emplacement) of monsters to signify meaning in multiple ways. First and foremost, monsters as a rule are local, vernacular, and environmentally contingent. In other words, monsters are deeply emplaced. An illustrative example of this is summed up by Mathias Clasen:

We find different shape-shifters in different ecologies: a were-tiger in India and other Asian regions, a were-bear in North America, a were-leopard in Africa, a wereboar in Greece and Turkey, a were-crocodile in Indonesia and Africa, and so on (2012: 225).

To turn this on its head:

An Anito [an Indigenous Taiwanese malicious spirit] in Paris, Huldufólk [an Icelandic type of fey] in the Australian tropics, or a Minmin Light [central Australian luminoids] in LA would elicit either very different, or just as likely, no responses at all from humans there (Musharbash 2014a: 11).

Within their deep emplacement, however, monsters often are simultaneously ‘out of place’. As Stasch puts it, they are ‘physically present in the place but clashing with the ideas understood to go with it’ (2014: 211). This is why we often find monsters in the margins, at crossroads, in the dark, underground, under the bed, and so forth: they should not be there, so this is exactly where they are! This is also why indicator events that happen ‘out of place’—such as the flowering of a shrub out of season, the cry of a diurnal bird at night—indicate monstrous presence (see also Musharbash 2016, Turpin et al. 2013). Often, their presence ‘out of place’ signals danger, but this must not necessarily be so. Consider, firstly, that monsters can signal danger also by being exactly where they are expected to be, in naturally dangerous places. To give some examples from the aquatic realm: it is in the vicinity of rip currents and whirlpools that mermaids are said to dwell, the deepest and darkest waterholes are home to rainbow serpents, and a treacherous salt lake in Australia’s Western Desert is where ngayurnangalku (malevolent cannibal beings) haunt. Secondly, and demonstrating monsters’ cunning ability to escape too-tight definitions, they can also be exactly where they are meant to be and signal safety. For example, the vicinities of shrines and altars often are dwelling places of protective spirits, and the presence of milarrlpa (benevolent place-specific spirits) in Australia’s Tanami Desert is a sign of well-cared-for ancestral Country.

Perhaps even more complex than monsters’ relationship to place is their relationship to time, but here as well there are some distinct patterns as well as exceptions to the rule. Generally, monsters are deeply contingent on the temporal schema of the humans they haunt. For example, monsters tend to prefer nighttime over daytime to be active in contexts where this inverts the temporality of human sociality. This way of monsters ‘being in time’ can be expanded from a day/night cycle, to annual cycles and seasons, and on to epochs. In other words, monsters find their niches in each society’s temporal schema, so that the presence of certain monsters, say, at night, in spring, during the full moon, has a dual effect: emphasising the monstrousness of the monster and simultaneously re-enforcing the meaningfulness of temporal schemata.

For anthropologists, this means that it becomes possible to look comparatively at different temporal schemata through the times when monsters haunt. This is possible not only on daily or seasonal cycles, but also by looking at deep understandings of time. For example, if people have a time before the beginning of history, monsters may or may not hail from there. If people live in an unchanging and eternal ‘everywhen’, monsters may or may not be part of this, and so forth. Much as temporal ontologies differ, so do the ways in which monsters integrate or subvert the temporal ontologies within which they haunt. The point here is that no matter how monsters relate to time, that relationship always reveals something about a society’s temporality (and, in the process, helps define monsters).

Another way to investigate the relationship between monsters and time is to explore how monsters change across time. This is a major trope in monster studies, where often fears and monsters are related to each other, and a common argument is that as societal fears change, so do monsters (see, amongst many others, Asma 2009 and Pool 2011). Such diachronic work is rarer in anthropology, but where it exists, it presents exciting insights into temporality as much as into monsters, as for example Foster’s (2009, 2012) work on Japanese yōkai (supernatural beings) across time.

The monster, says Cohen ‘is born as an embodiment of a certain cultural moment’ (1996: 2), and—once translated into anthropology—this is probably the primary way in which anthropology relates monsters and temporality. Anthropologists recurrently highlight how monsters are expressive of profound socio-cultural change. In anthropological analyses, monsters seem to herald change in ‘the times’ and pinpoint the consequences of this change through changing themselves. For example, Katie Glaskin (2018) investigates cultural change among Bardi and Jawi people in the Kimberley region of Western Australia through analysing the fading of complexity among spirit beings, showing how the knowledge about spirit beings becoming less differentiated is intricately linked to Bardi and Jawi experiences of colonialism and capitalism. On the other side of the world, Paul Manning (2005) critically engages with capitalism through tracing the transformations of tommyknockers (gnome-like creatures who dwell in mines) as they migrate with the miners from the Cornish mines to the US. Rupert Stasch (2016) investigates social ruptures experienced by Korowai people in Indonesian Papua through the movement of their dead to the ‘big city’, and Nils Bubandt (2008) explores the repercussions of violent communal clashes in North Maluku, Indonesia, through the emergence of traumatised ghosts.

Parallel to the particular ways in which monsters are embodied, emplaced, and temporally contingent, they act both in accordance with and by rupturing the social norms of the people they haunt. Haunting, in the anthropological literature, is not necessarily loaded with negative connotations. In this vein, this entry uses the verb ‘to haunt’ as a catchall phrase to capture the manifold ways in which monsters are inherently social (even when they are anti-social). I have argued that anthropologists understand monsters as social actors deeply embedded in the cultural fabric ‘not least because they are intimately familiar with their interlocutors’ responses to the presence of monsters’ (2014a: 6). This entry singles out two types of response to exemplify anthropological understandings of monsters as social beings: the variety of emotions engendered by them, and examples of the kind of social practices performed in the presence of monsters.

Against popular understandings, the emotions that monsters elicit when encountered by anthropologists in the field far exceed fear. It is true, many monsters are terrifying: they can frighten, hurt, and potentially kill people—think only of the bunyip, which lurks in deep black pools in the River Murray in southeastern Australia, and is known to drown people in the river’s depths; or, the windigo of Algonquian-speaking First Nations, whose greed and selfishness propels its cannibalistic blood thirst. But not all monsters terrify humans. Many monsters are more ambivalent—think Cornish tommyknockers or Islandic huldufólk, for example, who may warn people about imminent dangers, play tricks on them, or lure them away from their kin, but for a while only. Others, again, are protective; many emplaced spirits, for example, are conduits between people, ancestors, and land, and their presence steeps the living in a sense of wellbeing and safety.

In turn, humans react to the presence of ‘their’ monsters in culturally specific ways, be they embodied or ritualised. These are practically limitless, but include actions and practices such as flight, avoidance, greeting, calling out, singing, leaving gifts, chanting, keeping lights on at night, bowing, specific hand gestures, turning the body, hurling abuse at them, brandishing fire sticks, fighting them, and so forth. The specific social practices humans engage in response to ‘their’ monsters can be read as a mirror that reflects back to the observer who people are and what haunts them.

Monsters across the anthropological record

From its earliest beginnings, the anthropological record has been populated by beings that fit into the definition of monsters put forward in this entry. However, how monsters were included differs across time. The different ways can broadly be classified into four distinct (if at times overlapping) trends, the first three of which did not employ the term monster. In the foundational phase of anthropology, during the late nineteenth and early twentieth century, anthropologists meticulously described multitudes of local monsters (as per the entry’s definition) and included them in their ethnographies. They soon began to focus on fewer monsters (broadly defined), such as malicious spirits, analysing them and their presence in more sustained manners. This lead to regional paradigms, such as the anthropology of witchcraft.

Over the last three decades of the twentieth century, anthropology saw a gradual increase of works that concentrate on single, specific monsters (not labelled thus) outside of well-established regional paradigms. This included, for example, ghosts, the devil, and aliens. Over the past decade, works emerged that employ the term ‘monster’ strategically, quite possibly in response to the ways in which the new century is permeated by monstrousness.

By providing an overview of key ethnographic examples from each trend, this entry highlights the enduring presence of monsters in anthropology as well as some of the different kinds of frameworks within which they have been conceptualised. In tandem, these trends underscore the meaningfulness of monsters as an analytic category and they provide a path towards more fully grasping the great contemporary importance of the concept.

There is nary a classical anthropological work that does not include descriptions of local monsters; they are teeming across the pages of The golden bough (Frazer 1890) and populate many an ethnography that followed. Look at ethnographies by early anthropologists, and you will find mulukuausi, deadly flying witches; an octopus so large it could ‘cover an entire village with its body; its arms […] thick as coco-nut trees’; and ‘big, live stones, which lie in wait for sailing canoes, run after them, jump up and smash them to pieces’ (all in Papua New Guinea’s Trobriand Islands, as described in Malinowski 1922: 76, 234-5, 241). Across the sea, in the Andaman Island, there are lau, spirits who eat the flesh of the dead, may cause illness or death, are considered to be more dangerous to strangers than locals, but can also be friends with magic users (Radcliffe-Brown 1922: 136-9). And up in the Arctic, Inuit are haunted by the kalopaling, a ‘fabulous being’ that appears like a human in a feathered outfit but lives under the sea and can capsize ships; the uissuit, a ‘strange people that live in the sea. They are dwarfs and are frequently seen’; and the tornit, a people who shared the land with the Inuit many years ago, ‘much taller than the Inuit [with] very long legs and arms. Almost all of them were blear eyed. They were extremely strong’ (all in Boas 1964: 212-3, 226-8).

These examples are but the tip of the iceberg of a veritable cornucopia of monsters in early ethnographies—except that early anthropologists did not employ the term ‘monster’ as a category for these creatures. Even though they were not collated under any umbrella term, they were as matter-of-factly included in early ethnographies as were descriptions of local climate, fauna, flora, kinship, or ritual. As an example, consider how Edward E. Evans-Pritchard (1956), a leading British social anthropologist, includes beings who easily fall under the broad definition of monsters in his note on the ways in which the Azande of north-central Africa categorised their totems (emblematic species with which different social groups identify) in the early half of the twentieth century. Evans-Pritchard lists the totems by category: first, named ones (based on mammals, birds, reptiles, and crustaceans) followed by an unnamed category which he describes as ‘creatures [that] may be supposed not to exist, though the experiences they stand for are, or may be, actual’ (1956: 108). These creatures include a crested water snake called ngambue, a rainbow snake called wangu, the moma ima, which is a water leopard, and the gumba, which is an entity known as thunder-beast (1956: 108.). The point to note is that the inclusion of monsters as totems is not what Evens-Pritchard finds striking, but rather that there are no plant totems. In other words, monsters were taken as a given. Their presence, or, minimally, people’s belief in them, was not an issue early anthropologists grappled with. The concern rather was with ‘where’ in an ethnography and in analysis they belonged. In this vein, Bronislaw Malinowski (dubbed the founding father of participant observation, anthropology’s core method), when mentioning deadly flying witches called mulukuausi in a paper about spirits of the dead, explains:

But all these data really belong to the chapter about sorcery and evil magic, and have only been mentioned here, where the mulukuausi interest us, as especially connected with the dead (1916: 357).

The foundational phase of anthropology is thus characterised by expansive inclusion and meticulous description of multitudes of local monsters—and, an implicit and sometimes explicit understanding of monsters and humans cohabiting the worlds studied. Early anthropology’s preoccupation with ‘discovering’ the ‘Native’s point of view’ meant that how people made sense of monsters was at stake, not the fact that monsters existed in the fieldsites visited by anthropologists.^[4]

The expansive inclusion of all beings retrospectively catchable under the broad definition of ‘monster’ is countered by the development of regional theoretical paradigms. A number of anthropologists soon focused on one regionally salient ‘monster’ (never called that), leading to more sustained analyses of these respective monsters and the developments of specific theoretical frameworks. An illustrative example is witchcraft as an anthropological topic where it relates to more-than-human witches—either known or unknown persons endowed with superhuman and magical powers.^[5] Such witches may be able to fly, become invisible, kill with magic, and more. They can be wholly evil or are protectors, and are often embroiled in local misfortunes on a wide scale, from making a person slip to being entangled in disasters from pandemics to natural catastrophes (for an overview, see Moro 2017).

As anthropologists increasingly focused on witches, they often abandoned other local monsters. However, this allowed them to develop in-depth, complex, influential, and lasting theoretical engagements. Take two prominent works in the field of African witchcraft studies, for example, by Evans-Pritchard (1937) and Peter Geschiere (2013). The counterpoint to the time-depth is that these engagements are regionally distinct. So distinct, in fact, that anthropologists working on witchcraft in Africa and anthropologists working on witchcraft in Melanesia had progressively less and less to say to each other (Patterson 1974)—and even less to discuss with anthropologists who were focussing on monsters other than witches (say, malicious spirits or ghosts, two other monsters responsible for vast bodies of anthropological work). Stasch sums up the effect of this process of specialisation on the studies of monsters in anthropology by affirming that ‘in anthropology, scholarship on monsters has been quite dispersed, despite the existence of a strong tradition of work on witchcraft and many excellent accounts of other monsters in specific settings’ (2014: 195).

Revisiting such regional paradigms with an understanding of their protagonists as monsters impels new conversations that open up fascinating comparative possibilities, and in return offer ethnographically rich, fine-grained analyses of specific monsters.

A gradual but distinct shift took place in ethnographies from the later twentieth century onwards, towards beings that fall under the monster definition given here. While rarely theorised as monsters, these beings are employed as a lens through which to explore sociocultural aspects of inequality, gender, and race in contexts of imperialism, colonialism, capitalism, and extractivism. Among countless others, examples of this development include studies of aliens in the US (Lepselter 2016), demons in Sri Lanka (Kapferer 1983), ghosts in Indonesia (Bubandt 2012), spirits (Blanes & Santo 2013) and the wildman (Forth 2008) across the world, yōkai in Japan (Foster 2015), and zombies in Africa (Comaroff & Comaroff 2002). These works do not form a canon as other regional paradigms do. However, if gathered together as works which share in common that they are dealing with monsters in one shape or form, they become a productive source displaying the rich and nuanced comparative potential of monsters in anthropology. This can be analysed in a multitude of ways, exemplified in the following by a focus on ethnographies of monsters and alterity (from the Latin word alter, for otherness).

In anthropology, perhaps the best-known monsters of alterity roam in South America, where they have generated many fascinating analyses, not least since Michael Taussig’s seminal work, The devil and commodity fetishism in South America (1980). Here, Taussig analyses how displaced peasants in Columbian sugar cane plantations and Bolivian tin mines make sense of the injustices of capitalist exploitation through worshipping a devil figure known as el Tío. Almost forty years later, Anders Burman (2018) took this vein of analysis of monsters as alterity the furthest in his study of the kharisiri, a monster haunting the Indigenous populations in the Bolivian Andes. The kharisiri looks like a white man, said to have its roots in either Spanish soldiers and/or friars, and steals the kidney fat of locals. He shows how not just the monster and the ‘white man’ (standing in for colonialism), but also the anthropologist as well as anthropology as a discipline, can be said to share four characteristics: ‘(1) they are ‘strange’; (2) they are powerful (relatively speaking); (3) they are exploitative; and (4) the resources they extract are used in “strange” contexts’ (Burman 2018: 52). Other analyses of the kharisiri play on the roots of the monster and capitalism trope, but then examine how it extends itself to acute contemporary issues, for example, racial violence (see, among many others, Canessa 2000).

The Ecuadorian and Peruvian counterpart to the kharisiri is the pishtaco (Weismantel 2001), another body-fat-stealing monster. Its evil exploits epitomise gender, race, and class alterity perfectly: a white male figure, with church, military, and business associations, who steals the kidney fat of local people. The equivalent of kidney fat (life, power) in the Andes seems to be blood in parts of Africa, where monsters of alterity take the form of white vampires who steal the blood of locals. Much as in South America, the genealogy of these monsters goes back to the roots of colonialism, so much so that Luise White (2000) speaks of ‘colonial bloodsucking’ in her analyses of countless examples of stories about Africans being slaughtered (or kept in pits) for their blood to be used for the treatment of anaemic diseases. Contemporary forms of these vampires continue to haunt and steal blood (life, power) in contemporary guises (see, amongst many others, Weiss 1998).

In Indonesia, seventeenth-century Portuguese soldiers, transmogrified into animal-like wild-but-Western giants, continue to haunt locals in ways that uncannily speak to the Anthropocene (Bubandt 2019). In Malaysia, the jenuing, who existed as evil female spirits with maggots in their hair, are now driving logging trucks (Rothstein 2020). Their transition perfectly encapsulates how monsters not just embody alterity, but can also and with ease change over to the Other’s side. The same is true of kurdaitcha in central Australia. They are pre-colonial monsters—human-like but endowed with supernatural strength and speed and driven by a lust to kill—who are said to have cohabited in the desert with humans since time immemorial. Today, however, they are allied with non-Indigenous Australians. This allows them to pursue their life’s desire of killing Aboriginal people even more successfully than before (Musharbash 2014b).

The most recent developments in anthropology concerned with monsters build on previous, more comparative work to employ the term ‘monster’ strategically. Some anthropologists now theorise a vast multitude of beings as monsters. Presterudstuen and I (2014, 2020b) call this new field ‘monster anthropology’. Bringing together interdisciplinary theorisations about monsters and ethnographic material about all manner of creatures, beings, and other-than-humans, we propose that employing the umbrella term ‘monster’ drastically increases anthropology’s comparative possibilities in areas that were previously investigated in either geographic or analytical isolation (Musharbash 2014a: 15). This approach aims to bridge the conceptual gap between monsters encountered in the field (by locals and/or anthropologists) and interdisciplinary monster studies. It demonstrates that theoretical debates in interdisciplinary monster studies can very productively inform anthropological understandings of monsters, up to a point: the nub lies in the tension between empirical experiences of monsters and understandings of monsters as fictional or part of folklore (see especially Musharbash 2014a). In turn, the empirical experiences of ‘living with monsters’ are the primary contribution anthropology can make to interdisciplinary monster studies (for narrative ethnographies vividly capturing various ways of living with monsters across the globe, see contributions in Musharbash and Gershon forthcoming).

A parallel development is taking place at the interface between anthropology and Science and Technology Studies (STS): Anna Tsing et al.’s volume, Arts of living on a damaged planet (2017) draws on monsters and ghosts to grapple with how to understand local repercussions of the Anthropocene. They put forward that monsters lend themselves ideally to readings of what ails the planet, as they ‘have a double meaning: on the one hand, they help us pay attention to ancient chimeric entanglements; on the other, they point us toward the monstrosities of modern Man’ (Swanson et al. 2017: M2.). Scholars in this tradition make a categorical distinction between monsters on the one hand and ghosts on the other, and employ monsters in analyses of different forms of embodiments while ghosts serve to explore how people relate to place (their ‘emplacements’).^[6] As Heather Anne Swanson et al. put it: ‘ghosts […] help us read life’s enmeshment in landscapes, monsters point us toward life’s symbiotic entanglements across bodies’ (2017: M2). Their approach highlights the fruitfulness of making monsters central to anthropological investigations into change and transformation, generally, and the crises of the Anthropocene most specifically.

It is no accident that monsters are resurging in anthropology as the Anthropocene reveals its force, and planetary crises in a multitude of shapes and forms reach all points of the Earth. As climate change worsens and its effects brutally impact the lives of people across the planet, monsters come to the fore of anthropological analyses as monsters. Monsters seem to jump at the new opportunities granted and wreak havoc in new but always culturally legible ways—even if what they say is that there is no legibility to what is happening. Their acts can be almost trivial, like minis, spirits living in the treetops around a temple in Tamil Nadu, India, who refused to catch the rice balls thrown up to them during an annual festival (Arumugam 2020) in a response to environmental degradation, or like ghosts starting to haunt differently as cyclones become more destructive (Presterudstuen 2020). Yet even these small monstrous acts poignantly illuminate what it means to live in crisis. They can become quotidian, just as the never-ending series of disasters may be, or they can be momentous and apocalyptic.

The ways in which monsters change, not just allegiance but in all manner of ways, has been identified by Presterudstuen and I (2020a) as a crucially salient aspect of what they are. We suggest six axes along which to analyse monster change and transformation, namely: examining the ways in which new monsters emerge (e.g., Frankenstein’s monster, during the Industrial Revolution); investigating how monsters adapt to new circumstances (for example, how new infrastructure like electricity may repel some monsters and draw new ones nearer); how monsters might be appropriated (say, by capital, or the settler-colonial state); the ways in which monsters can amalgamate (like the Algonquian windigo, who acquired more werewolfish features as French-Canadian voyageurs started intermingling with local Indigenous people), as well as their extinction (which often goes hand-in-hand with missionisation) and, of course, monster succession.

We also argue that analytical attention to how monsters change may provide anthropologists with perceptive insights into crises that occupy the lives and minds of the people they study. As long as monsters play central roles in their humans’ struggles in dealing with all kinds of catastrophes—from new infrastructures and species extinction to neo-colonialism, environmental degradation, and climate change—the anthropological study of monsters is likely to grow in the years to come.

Conclusion

Anthropology, more than any other discipline, deals with monsters who are part and parcel of social life: the monsters that anthropologists encounter in their fieldsites do not only appear in myths and rituals but shape people’s daily lives. Monsters turn out to live with the people they haunt: they know them, their systems, rules, and orders, their problems and their crises. The lives of local monsters and ‘their’ people are thus deeply, intricately, and intimately entangled. The fact that, until recently, anthropology did not use the category ‘monster’ to class all the beings that can be captured by the definition given in this entry is triply significant: it pinpoints something of a turning point, as it goes against the grain of most arguments in anthropology by highlighting that it is not a multitude of local concepts we need at this point, but also perhaps big, universal ones. In the case of monsters, at least, using such a broad category is productive, as it deepens our understandings by comparatively including all sorts of ethnographic material under a general banner of monster studies. Lastly, it seems this new category of monster in anthropology gels well with the times and carries much promise, as monsters abound in this unceasingly globalised world visited by endless strings of crises. The study of past and present monsters promises novel insights not only into them, but into the ways in which different peoples deal differently with what haunts them. Taking seriously the capacities that monsters have—of hybridity, transgression, adaptation, and shape-shifting, among many others—will be instructive also for investigations into human imaginations of and the potential to deal with change and transformation. This entry has foregrounded global environmental, colonial, and economic crises as examples, and it forecasts that anthropology will never cease to find new monsters. Just consider the rise of digital monsters (see Asimos), or, the rocketed popularity of Amabie, a Japanese yōkai that serves as a protector from COVID-19 (Springwood 2020). From there, it is not far to considering that cyborgs, robots, bioengineered beings, androids, ghosts of post-industrial ruins, and nuclear and plague zombies are in the process of leaving science fiction and becoming part and parcel of everyday life. Tackling them and the next wave of monsters that will surely follow will be easier when it is possible to draw on broad comparative material—from across time and comparatively across the planet—as well as bringing together ethnographic expertise with other disciplines studying monsters.

Acknowledgments

I would like to thank the anonymous reviewers and Felix Stein for their wonderful in-depth engagement with the first draft of this entry. Their comments, queries, and reflections have helped immensely in reworking this piece.

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Note on contributor

Yasmine Musharbash is a Senior Lecturer in the School of Archaeology & Anthropology at the Australian National University. Since the 1990s, she has been conducting participant observation-based research with Warlpiri people in Central Australia. She is the author of Yuendumu everyday (2008) and of a number of co-edited volumes, including Monster anthropology in Australasia and beyond (with G.H. Presterudstuen, 2014), Monster anthropology: ethnographic explorations of transforming social worlds through monsters (with G.H. Presterudstuen, 2020), and Living with monsters (forthcoming, with Ilana Gershon).

[1] Jeffrey Jerome Cohen’s (1996) Monster culture (seven theses) is generally accepted as the foundational work.

[2] This might be a key reason why anthropologists tend not to talk about monsters in ethnographic contexts where animals and humans are counterparts of each other (parts of Amazonia, for example).

[3] The ‘fantastic’ embodiment is what sets monsters apart from Mary Douglas’s (1966) classic taxonomic transgression example of dirt as ‘matter out of place’.

[4] For an eminent critique of the ‘Native’s point of view’, see Clifford Geertz (1974).

[5] The most renowned example in anthropology of all-too-human witches is Jeanne Favret-Saada’s (1980) Deadly words.

[6] While this separation of ghosts from monsters galvanises the fertile literature on haunting, from Derrida’s ‘hauntology’ to Avery Gordon’s (2008) Ghostly matters, it does less for theorising monsters themselves.

Medical pluralism

Rebecca Tishler — Thu, 17 Jun 2021 18:37:25 +0000

Venera Khalikova

Chinese University of Hong Kong

Initially published 17 Jun 2021

http://doi.org/10.29164/21medplural

Abstract:

Medical pluralism describes the availability of different medical approaches, treatments, and institutions that people can use while pursuing health: for example, combining biomedicine with so-called traditional medicine or alternative medicine. If we look closely at how people deal with illness, navigating between home remedies, evidence-based medicines, religious healing, and other alternatives, we can notice that some degree of medical pluralism is present in every contemporary society. As a concept, medical pluralism lies at the heart of the discipline of medical anthropology, which owes its birth to the study of non-Western medical traditions and their encounters with biomedicine. This entry describes the history of debates in the scholarship on medical pluralism, the search for an appropriate terminology, and current theoretical and methodological developments. In the 1960–1980s, many studies were focused on patients and their strategies of choosing a ‘medical system’ from a plurality of options. In the 1980–1990s, the notions of medical systems and medical traditions came under severe criticism for their inability to describe how medical thought and practice change over time, often being too eclectic to fit single systems or traditions. As a result, anthropologists began investigating patient-doctor negotiations of treatment, their diverse health ideologies, as well as the role of political-economic factors in shaping the hierarchies of medical practice. Additionally, scholars began examining the processes of state regulation and institutionalisation of medical traditions (for example, as ‘complementary and alternative medicine’ [CAM] in Europe and North America). This opened the field of medical anthropology to new debates, terminology, and geographical horizons that are trying to account for the pluralist nature of medicine in the twenty-first century. Transnational migration, the Internet, the rise of alternative medical industries, and the global flow of medical goods and knowledge all serve as catalysts for ever-more pluralistic health-seeking practices and ideologies.

Introduction

Medical pluralism describes the availability of different approaches, treatments, and institutions that people use to maintain health or treat illness. Most commonly, medical pluralism entails the use of Western medicine (or ‘biomedicine’) and what is variously termed as ‘traditional medicine’ and ‘alternative medicine’. For example, cancer patients might complement chemotherapy with acupuncture and religious healing; or women who want to get pregnant might combine hormonal treatment with home remedies and Yoga. Scholars of medical pluralism have used different terms such as traditional, indigenous, folk, local, or alternative medicine, but since they all imply distinction from biomedicine, this entry will refer to them as ‘nonbiomedical’ practices.

As a theoretical framework, medical pluralism was developed in the second half of the twentieth century to examine local medical traditions in their diversity, co-existence, and competition, especially with biomedicine. These studies were central to the establishing of the field of medical anthropology. In the context of today’s globalisation, medical pluralism retains its analytical importance, especially in the examination of people’s search for alternative cures locally and transnationally, the growing consumer market of ‘holistic’, ‘traditional’, and ‘natural’ treatments, and the attempts of many countries to incorporate alternative treatments into national healthcare.

While early anthropologists used to focus on local medical traditions in non-Western societies, contemporary scholars examine the place of plural medicine in all societies, including Europe and North America. This shift expanded the scope and terminology with which we describe medical pluralism, for example, by including ‘integrative medicine’ or ‘alternative and complementary medicine’ (or, ‘CAM’). Although there are differences in the usage of these terms, broadly speaking, integrative medicine means that one medical provider offers both biomedicine and nonbiomedical elements as part of a holistic treatment course, while CAM refers to procedures outside biomedicine.

Anthropological studies examine nonbiomedical practices from multiple perspectives, illuminating the role of patients, doctors, markets, and governments in shaping them. As this entry will show, medical pluralism as a concept enables analyses of medicine beyond the dualism of Western/non-Western, modern/traditional, or local/global, by showing how all medical knowledge and practice, be that biomedicine or some regional tradition, is inherently plural, ever-changing, and culturally porous. Such realisation was a result of scholarly debates that problematised the concepts of a medical ‘system’, ‘tradition’, and ‘pluralism’ themselves, as explained in the first section of this entry. The entry then describes the studies of how medical pluralism is influenced and regulated by the state, followed by the studies of medical pluralism in relation to the discourses on modernity, science, and efficacy; gender; and globalisation.^[1]

Medical ‘system,’ ‘tradition,’ and ‘pluralism’

Anthropological interest in non-Western medicine dates to the early twentieth century when W.H.R. Rivers (1924) proposed that medicine should be treated as a separate system of knowledge. However, it was only in the 1950s that medical systems began emerging as a focus of anthropological studies. Although the term ‘medical pluralism’ had not yet been introduced, scholars like George Foster (1953) showed the importance of accounting for the impact of colonial and global processes on local medicine, which can result in the eclecticism of medical concepts and therapies as practiced in people’s everyday lives.

The studies of medical pluralism proper began in the late 1970s–early 1980s, when anthropologists launched a comparative study of Asian medicine, exemplified by an influential volume, Asian medical systems (1976), edited by Charles Leslie. The title and content of this volume, as well as the definition of medical pluralism as ‘differentially designed and conceived medical systems’ in a single society (Janzen 1978: xviii), show that a central concept in these studies was ‘system’ (see also Kleinman 1978; Leslie 1978, 1980; Press 1980). In line with how anthropologists studied kinship systems or religious systems, medical anthropologists sought to understand and classify heterogeneous medical knowledge and practice as holistic ‘systems’. This often entailed the assumption that each medical system is characterised by unique epistemology, disease etiology (origins and causes of diseases), and corresponding diagnostic and healing methods. For example, Unani medicine, which is a Greco-Arabic tradition practised in contemporary South and Central Asia, is a medical system because it has an elaborate understanding of body and bodily processes as affected by four humors (elements) which need to be maintained in certain balance to avoid sickness. If a person falls sick, a trained Unani specialist can employ a variety of techniques to identify the type of abnormality in the balance of humors and prescribe a treatment to restore a healthy humoral state.

In attempts to classify medical systems, scholars used various criteria. Some took a geographical scale to make a distinction between local systems (folk medicine), regional systems (like Unani medicine or traditional Chinese medicine), and cosmopolitan medicine (Dunn 1976). Others used disease etiology, proposing that all medical systems are either ‘personalistic’, when a disease is explained as a result of a purposeful action of a human, god, or other actors, and ‘naturalistic’, when a disease is thought to be caused by non-personal forces such as weather or humors (Foster 1976). Other scholars chose writing as a criterion to distinguish ‘little-tradition medicine’ that did not have written accounts from the ‘great-tradition medicine’ that was based on medical texts (Leslie 1976; Obeyesekere 1976, borrowing from Redfield 1956).

However, the attempt to present medical knowledge as consisting of independent, ‘differentially designed and conceived’ systems was quickly recognised as problematic because it downplayed important mutual developments and influences: for example, so-called folk medicine can borrow ideas and methods from regional medicine like Ayurveda, which itself can be influenced by other regional medicines and cosmopolitan biomedicine. Similar problems arise when medical pluralism is defined through the notion of ‘tradition’, for example, as ‘the coexistence in a single society of divergent medical traditions’ (Durkin-Longley 1984: 867). Without critical reflection, the term ‘tradition’ can inadvertently present medical knowledge and practices as something continuous and unchanged since ancient times. In reality, medical ‘traditions’ are ever-changing and quickly respond to socioeconomic processes, which makes them just as modern as biomedicine. Moreover, the idea of ‘divergent traditions’ can be overly reductionist because it presents medical knowledge and practices as belonging to distinct, separable entities uniform throughout large culture areas, while in fact they are often intertwined, heterogeneous, and varied.

It is therefore not surprising that medical anthropologists have struggled to define medical pluralism itself. How can we write about a plurality of traditions, if traditions are themselves plural? To address this problem, scholars have emphasised that medical ‘systems’ and ‘traditions’ are to be understood as analytical constructs, not as real separable areas of medical knowledge with apparent internal homogeneity and rigid boundaries (Nordstrom 1988; Waxler-Morrison 1988). It has also been argued that the idea of distinct ‘systems’ or ‘traditions’ is divorced from how patients and even doctors themselves understand and use various medicines (Khalikova 2020; Naraindas, Quack & Sax 2014; Mukharji 2016). For example, Marc Nichter documented how healers in South India provided a unique blend of therapies and medicines tailored to patients’ pockets and preferences (Nichter 1980). This phenomenon of mixing and blending different medical approaches is sometimes termed ‘medical syncretism’ (see Baer 2011: 419).

Beside medical syncretism, scholars have experimented with other analytical conceptualisations such as eclecticism and hybridity (Brooks, Cerulli & Sheldon 2020) to highlight how seemingly distinct medical traditions can be practiced in eclectic and entangled ways, where every doctor-patient encounter entails a negotiation of diverse medical ideas and treatments resulting in a unique outcome to the extent of unrecognisable amalgamation. Other scholars prefer the notion of the ‘therapeutic itineraries’, i.e., ‘precise pathways taken by patients’, as well as their reasons for choosing and staying with chosen treatment courses (Orr 2012). Yet other anthropologists use the term ‘medical diversity’ to describe mixtures, borrowings, and intersections of various therapeutic ideas, methods, and attitudes (Krause, Alex & Parkin 2012).

All these examples highlight that the studies of medical pluralism quickly pushed anthropologists to examine how medicine is practiced. Even before postmodern critiques of the notion of culture as a bounded entity, and before the emergence of theoretical frameworks that emphasised practice and agency, some medical anthropologists had already began examining medicine as it unfolds in practice: in doctor-patient relations and patient’s health-seeking strategies. Studies of the ‘hierarchy of medical resort’ (Romanucci-Ross 1969), for example, questioned when and why people choose one therapeutic option over another: Do people ‘shop around’, seeking multiple therapies for a single disease, or do they use different therapies for different kinds of illness? Do patients use various treatments simultaneously or sequentially? As a result of studying such questions, scholars demonstrated the importance of cultural, medical, and socioeconomic factors that lead to various scenarios. People’s choices can depend on a disease type, its folk interpretations, patients’ social status, their worldview, available information, as well as the cost and accessibility of treatment (Gould 1965; Beals 1976).

Another line of studies utilised decision-making models—a term borrowed from cognitive anthropology. These models embody a concern with how people choose a treatment, rather than what they choose and in which order (Garro 1998; Janzen 1978; Young 1981). The emphasis is on cognitive aspects of health-seeking behaviour, conversations about medical options, and the pragmatic aspects of decision-making. For example, people often make medical decisions by consulting their relatives or accepting what is given to them by senior family members: parents choose treatments for children, husbands for wives, and adults for elderly parents. This centrality of kinship in medical pluralism was an important finding of the studies of therapeutic decision-making (Janzen 1978; 1987).

Another milestone in the theorisation of medical pluralism was the recognition that it is present in Western societies too. While traditional medicine was initially mostly studied in non-Western and postcolonial societies in contrast to a single ‘cosmopolitan medicine’, scholars soon demonstrated that even in seemingly homogenous or developed societies like the US, medicine is pluralistic by nature (Leslie & Young 1992; Kleinman 1980). If we look closely at how people deal with illness, alternating between biomedical drugs or home remedies, psychotherapy or religious healing, osteopathy or chiropractic, and other alternatives (Naraindas 2006; Zhang 2007), we can see that medical pluralism is present in every contemporary society. Moreover, biomedicine itself is pluralistic: its practitioners ascribe to various conceptions of health and illness, healthcare services differ significantly, including across the private and public sectors, and established and experimental biomedical treatments co-exist and compete with one another.

Thus, rather than juxtaposing Western and non-Western therapies (as was done by Rivers in the early twentieth century), medical anthropologists since the 1970–1980s have been interested in both differences as well as similarities between biomedicine and other medical approaches. Medical pluralism thus provided an important framework that broke away from a reductionist dichotomy of biomedicine versus ethnomedicine, or the West versus the rest. From this perspective, biomedicine could be studied as yet another tradition, one of many options that patients around the world use.

However, biomedicine is not a neutral option at par with other medicines. Scholars of medical pluralism have highlighted its hierarchical nature: nonbiomedical traditions often occupy a subordinate position to hegemonic biomedicine in terms of social prestige, education, employment opportunities, and funding (Baer 1989, 2011). For example, biomedical doctors often secure higher salaries and social respect than alternative medical providers (but not always, see Kim 2009). Critical medical anthropologists have argued that the spread of biomedicine across the world is premised on coercive factors, including the colonial past and biomedicine’s alignment with the state power, rather than on ‘natural development’ or medical superiority of biomedicine (Lock & Nguyen 2010; Young 1981).

Nevertheless, contrary to the logic of modernisers who argue for biomedicine’s technological advantage, local therapies did not die out. Why not? Some scholars suggested that this had to do with people’s dissatisfaction with biomedicine and perceptions that traditional medicine is better suited for local illnesses, safer and does not produce side-effects (Farquhar 1994: 19; Lock 1980: 259). Other scholars emphasised the doctors’ perspectives: alternative and biomedical practitioners occupy different medical niches and catered to distinct clientele (Waxler-Morrison 1988; Leslie 1992).

The above-mentioned questions and answers were shaped by the fact that most theoretical work on medical pluralism was based in colonial and postcolonial contexts. Colonialism had a colossal impact on scholars’ interpretations of local medical knowledge and practice. Both in public health policies and writings of early medical anthropologists, a frequently idealised Western medicine was conceived of as a yardstick against which other healing practices should be evaluated. Today, scholars are increasingly critical about the dichotomies of ‘Western’ and ‘Eastern’ medicine, ‘modern’ and ‘traditional’ medicine, or even ‘science’ and ‘belief’. Moreover, contemporary medical anthropologists pay attention to the hierarchies that exist among nonbiomedical systems and within biomedicine itself.

Nevertheless, the residue of such dichotomies can still be found in the academic literature and in public discourse, where the new terms of ‘complementary and alternative medicine’ may unwittingly reinforce the subjugated place of nonbiomedical knowledge and practice. Often the subjugated place results from the lack of legitimation of nonbiomedical therapies by the state. How and why the state regulates medical pluralism is, therefore, another prominent area of scholarly inquiry. Studies that focus on global political economic inequalities often do so to disentangle the multiplicities and hierarchies of medical practice, especially as influenced by state ideologies and transnational markets.

The state

Today, most governments take an active role in regulating medical pluralism: they can either ban alternative medicine as ‘quackery’ and ‘pseudoscience’, provide ways to integrate it partially into biomedical infrastructure, or provide it with full support as a standalone institution (Adams & Li 2008; Berger 2013; Kloos 2013; Lock 1990; Scheid 2002). How do governments make such decisions? Why are some medical traditions denied legitimation while others are promoted? What is at stake when a nonbiomedical tradition is officially recognised? What kind of transformations occur in its ontology and epistemology after its legitimation and institutionalisation? What are the implications for practitioners, patients, and society in general? These are some central questions raised in the studies that investigate the relations between medical pluralism and the state.

A government’s support for nonbiomedical treatments can be a strategic move to conform to international directives, especially after the 1970–1980s, when the World Health Organization (WHO) promoted the integration of traditional therapies as ‘a means of accessing gaps in service provision’ (Hampshire & Owusu 2013: 247-8). ‘Filling the gap’ is a common trope in official rhetoric in countries with large rural populations where biomedical services and institutions are limited. Here a standardised, regulated alternative medicine is presented as a necessary means to achieve a common good. However, more critically, the recognition of alternative medicine can also be seen as the government’s failure to provide accessible and affordable biomedical care, pushing people to rely on services of ‘a large, unregulated, unqualified medical cadre of practitioners’, as argued by some scholars in the case of India (Sheehan 2009: 138). Similarly, in post-Soviet Cuba, the government partially incorporated traditional herbal medicine into the healthcare system as a strategy to disguise massive shortages in biomedical pharmaceuticals after the decline in supply from countries of the socialist block (Brotherton 2012: 46).

In multicultural contexts, the legitimation of alternative medicine can be also taken as the government’s responsibility to satisfy popular demand. Often associated with migrant populations, plural and ‘culturally sensitive medicine’ is at times demanded as citizens’ rights. Some scholars have pointed out the importance of providing non-discriminatory medical services to migrants, especially to those who may not share a biomedical model of health and disease (Chavez 2003). Others go as far as to argue that integrating nonbiomedical healing should be a goal for modern democratic governments as that would recognize the rights and identities of minority groups. For example, the official healthcare system in Israel includes many alternative medical modalities, but not Arab herbal medicine, indicating that the cultural preferences of the Arab minority may remain undermined (Keshet & Popper-Giveon 2013).

An important insight from the literature on the state shows that governments are selective about the degree of legitimacy and support they provide to medical traditions. Thus, medical pluralism can become a mechanism for and the end product of carefully planned and instituted government efforts for managing population and economy. For example, by analysing the New Order government of Indonesia under President Suharto, Steve Ferzacca (2002) proposes to understand medical pluralism as a form of state rule. Ferzacca demonstrates how the Indonesian government manipulated the plurality of medical practices by recognising and promoting only those that fit into the overarching ideology of ‘development’.

Another example of selective legitimation of nonbiomedical knowledge and practice is demonstrated by Helen Lambert (2012). She highlights how medical pluralism is characterised by the ‘hierarchies of legitimacy’ when the government grants support to Ayurveda, Yoga and other text-based medical systems, while the practitioners of local traditions, like bonesetters in India, remain at the ‘margins of government legitimation’, even though they are seen as experts in their local communities.

This is important, because to nonbiomedical doctors, official recognition brings visibility, further societal acceptance, and legal employment (Blaikie 2016). Once a medical tradition is granted official status, its practitioners can demand higher salaries, better facilities, funding, and more opportunities. In contrast, healers who are left outside government legitimation face the danger of losing community respect, losing clientele, and gradually disappearing (Hampshire & Owusu 2013; Kleinman 1980). At the same time, Linda Connor (2004) argues that state legitimation does not necessarily affect people’s medical preferences: in an ethnographic study of residents of Australian suburbs, she demonstrates that people often choose nonbiomedical treatments outside the official healthcare settings for their perceived effectiveness and imagined ‘natural’ qualities in contrast to pharmaceutical drugs.

A related outcome of the professionalisation of traditional medicine is the marginalisation of women’s knowledge. In Ghana, Kate Hampshire and Samuel Owusu (2013) have observed that the government’s efforts to ‘professionalise’ traditional healing have led to the dominance of male practitioners who had means and connections to become ‘professional’ doctors. In contrast, women lacked those means, which created a context for a potential loss of their traditional knowledge, particularly concerning children’s illness.

However, even officially sanctioned and integrated medical traditions face many challenges, including the problem of ‘translation’, when the state, biomedical healthcare, or the market appropriate local medical knowledge by ignoring, undermining, or transforming its value system (Bode 2008; Cho 2000; Craig 2012; Janes 1995; Saks 2008). For example, due to ideological pressures from the Chinese government, certain procedures of Tibetan medicine have been pushed to the periphery of practice as being ‘religious’ and ‘unscientific’ (Adams, Schrempf & Craig 2010). In a similar way, in India, bhūtavidyā — one of the eight branches of Ayurveda, which deals with non-human entities — has been discounted by many contemporary Ayurvedic patients and doctors (Naraindas 2014: 112-3; Hardiman 2009).

Even if institutionalisation does not result in a distortion of meaning and repertoire of traditional medicine, it nevertheless transforms flexible healing practices into coherent units of standardised therapies, imposing therapeutic normativity and orthopraxy. This means that only select medical texts, ideas, and procedures along with their ‘correct’ interpretations get to be included in medical education and training; doctors must follow these normative ways of doing medicine if they wish to remain in institutional settings. For example, the institutionalisation of traditional Chinese medicine in the 1950s was accompanied by measures to ‘define, delimit, name, and “purify”’ select practices to comply with the communist ideology (Farquhar 1994: 14-5). Also, the professionalisation of traditional medicine affects how medical knowledge is transmitted and learned. While traditional medical knowledge is often passed through apprenticeship from a teacher to one or several students, state involvement often brings the introduction of a college system, which may break a vertical structure of teacher-student and elder-younger relations (Farquhar 1994: 15; Smith & Wujastyk 2008: 7).

As various political and social actors have high stakes in promoting a particular medical ideology, medical anthropologists have been careful to show the existence of heterogeneous powers within governments as well as rival groups of citizens, their competing claims about medical traditions, and various ideological positions embedded in those claims (Khan 2006). For example, because of the co-constituted relations between Western imperialism and biomedicine, the ‘revival’ of ‘indigenous’ medical systems is often embedded in anti-colonialist and nationalist discourses (Langford 2002). In other words, postcolonial states articulate their aim to recuperate local medicine as a sign of liberation from structures of colonial rule. This goal becomes particularly complex in the countries with more than one nonbiomedical system, through which nationalist ideologies can be activated (Alter 2015; Khalikova 2018).

Modernity, science, and efficacy

Discourses on nationalism and national medicine are often interlaced with debates about modernity (Croizier 1968; Khan 2006). An important insight from this literature is the problematisation of the terms ‘traditional’ and ‘modern’. While twentieth century anthropologists tended not to look at nonbiomedical practice as already modern, by the end of the century, scholars began exploring ways in which the modern and the traditional were co-constructed and fluid.

Based on her research on three medical traditions in Bolivia—cosmopolitan medicine, indigenous Aymara medicine, and home remedies—Libbet Crandon-Malamud (1991) introduced the notion of 'medical ideologies' to show that when people say something about their illness, they are also saying something about themselves and making statements about political and economic realities (1986: 463; 1991: ix, 31). Consequently, people’s beliefs and debates about therapeutic authenticity, efficacy, and legitimacy of a medical tradition can explain a lot about a society in a local and global context.

In many parts of the world—but especially in postcolonial countries struggling with the cultural and political legacies of colonialism—doctors and patients attempt to reconfigure traditional medicine through the notions of modernity, science, and technological progress. Medical practitioners often employ ideologies of both modernity and tradition, in response to demands and expectations from patients, government policies, and other actors. The same holds true for the notion of science. For example, Vincanne Adams has documented how practitioners of Tibetan medicine in China have to use the language of science in order to conform to the science-oriented ideologies of the communist state, while maintaining that Tibetan medicine is efficacious and scientific in its ‘own’ way (i.e., not measurable by biomedical standards). Thereby, they satisfy the aspirations of the local population for culturally appropriate therapy and demands of the international market for a ‘unique’ Tibetan medicine (2002b: 213).

But why do patients seek alternative medicine? Does it work? The problem of efficacy has been important in the study of medical pluralism since its conception (Leslie 1980), but anthropologists still lack a consensus about what ‘efficacy’ means and how it should be analysed (Waldram 2000). If we take efficacy to be a statistically measurable capacity of a drug to produce a desired relief, then in general scholars of medical pluralism tend to avoid making claims about whether or not alternative treatments are efficacious (Ecks 2013: 12; Langford 2002: 200). Instead, scholars have been more interested in understanding the ‘perceived’ efficacy by bringing attention to the feelings, subjective experiences, and views of patients and doctors as they rationalise their use of alternative medicine (Poltorak 2013).

Patients often ‘shop around’, alternating between therapeutic options, until they find what works for them. Here, the concern may be not about whether alternative medicine brings measurable therapeutic relief or not, but what kind of effects it produces. For example, in India many people insist that nonbiomedical treatments such as Ayurveda and homeopathy work but do so gradually and therefore are mild on the body, while biomedicine provides immediate relief but has numerous side-effects (Langford 2002). In other words, both alternative medicine and biomedicine can be seen as efficacious, but in different ways. In North America, patients who are dissatisfied with biomedicine turn to alternative medicine because it is seen as instilling a sense of ‘safety, comfort and well-being’ by appealing to nature, wholeness, and harmony, providing treatments in pleasant surroundings, whereas biomedicine is criticised ‘for its failure to engage the personal and cultural dimensions of suffering’, and for involving ‘painful, disorienting, and disturbing treatments aimed not at comfort but biological efficacy’ (Kirmayer 2014, 38-9). Such juxtaposition of alternative medicine as warm and personal, while biomedicine may be cold and institutional, frames many cultural discourses about how and why different treatments work.

Probing the questions of efficacy of alternative medicine even further, Sienna Craig argues that the very question ‘Does a medicine work?’ is a fabrication of a hegemonic, clinical perspective; instead, one needs to ask, ‘What makes a medicine “work”? How are such assertions made, by whom, and to what ends?’ (2012: 4). Craig argues that the question of efficacy serves as a mechanism for ‘translating’ nonbiomedical knowledge into the language of biomedicine and science, which is itself an outcome of global governance of medicine (such as by the WHO) and neoliberalism. In other words, scholars highlight that the efficacy of biomedicine is embedded in its social and economic power. This means that efficacy is not a neutral objective category, but something that needs to be interrogated with regard to what counts as evidence and who gets to define it.

As reminded by Margaret Lock and Mark Nichter, social claims of efficacy can have actual impact on patient’s health, since the ‘attributions of efficacy, however determined, and be they positive or negative, influence treatment expectations and thus effectiveness in their own right’ (2002: 21). Therefore, anthropological studies often explore various truth claims, the semantics and language of efficacy: how efficacy is spoken about in local terms, how it is invoked by patients and doctors themselves, and how various ideas about efficacy can influence the health outcomes. This includes negative health outcomes too, when claims of the efficacy of alternative treatments can create an atmosphere of distrust towards established biomedical treatments (such as vaccines). Hence, it is important to recognise that the existence of plural medical options can cause confusion and be detrimental to people’s health: while shopping around for a therapy that appears right to them, patients may delay using medicines with proven effects.

Gender

For most of the twentieth century, the studies of medical pluralism contained only scattered references to women—for example, as primary users of alternative medicine or as traditional healers. Today, there is a growing body of literature that critically addresses gender and gender ideologies in the context of medical pluralism (Cameron 2010; Fjeld & Hofer 2011; Flesch 2010; Menjívar 2002; Schrempf 2011; Selby 2005; Zhang 2007). A related area of scholarship is focused on reproduction, traditional birth attendants, and the issues of gender equity in pluralistic medical settings, particularly within the institutions of intercultural medicine in Latin America.

Many medical traditions such as Tibetan medicine, traditional Chinese medicine, Ayurveda, Unani, and biomedicine used to be the spheres where female doctors, teachers, and authors of medical texts were absent or rare (but see Fjeld & Hofer 2011). In the twenty-first century the situation has started to change, and more women have become practitioners of these previously male-dominated medical traditions. Yet this can also create new inequalities. For example, by examining an increase in female practitioners of Ayurveda in Nepal, Mary Cameron (2010) argues that the ‘feminization of Ayurveda’ has been entangled with the official marginalisation of Ayurveda in the context of biomedicine-dominated healthcare system. In other words, a positive change, such as the increased acceptance of women as alternative practitioners, is negated by the loss of prestige of Ayurveda in Nepal (although this is not the case in India). Another problem is that the increase of female practitioners in alternative medicine can reinforce the stereotypes of women’s ‘innate’ ability to heal and their proximity to nature, as documented in Hannah Flesch’s work (2010) on female students studying Acupuncture and Oriental Medicine in the US. Thus, these studies illuminate that the discourses on alternative/traditional medicine are often gendered.

Other scholars have shown how nonbiomedical health-related practices can be linked to ideas of masculinity and socio-political ideologies. By examining traditional male wrestlers in India, Joseph Alter (1992) has discovered that their practices of celibacy, self-control, and dietary regimens are linked to their unique interpretations of modernity, masculinity, and nationhood. While many Indian citizens conceive of biomedicine as a link to modernity and good health, traditional wrestlers engage with nonbiomedical practices to strengthen a national physique and achieve culturally appropriate masculinity by countering the harmful impact of Western consumerism and sexual liberation.

Globalisation

The studies of medical pluralism and globalisation emerged in the early 2000s in an attempt to make sense of medical practices in the face of transnational migration, medical tourism, the global flow of alternative pharmaceuticals, the spread of the Internet, and other processes that have problematised national and cultural boundaries, creating avenues for the global exchange of local and ‘new age’ medical knowledge (Lock & Nichter 2002; Krause 2008; Wujastyk & Smith 2008; Hampshire & Owusu 2012). Certainly, transcultural connections were forged intensively during the colonial era and even earlier; however, the close interconnectedness of the world is a relatively recent phenomenon, which both allows and compels people to render their therapeutic itineraries ever more diverse and geographically dispersed. This complexity has compelled scholars to rethink the concept of medical pluralism as no longer confined to a single society but as spanning national borders (Raffaetà et al. 2017). Rather than being limited by medical options within a certain locality, contemporary health-seekers can avail of pluralistic medical approaches, experts, and institutions by crossing borders physically and virtually.

On the one hand, nonbiomedical practices are taken outside their place of origin, as exemplified by the popularity of German anthroposophic medicine in Brazil, the proliferation of Yoga centres outside India, or the spread of acupuncture outside East Asia (Alter 2005; Kim 2009; Wujastyk & Smith 2008). Unlike many twentieth century studies of the influences between the ‘core’ and the ‘periphery’ (as per World Systems Theory), contemporary scholars explore South-South and other global connections: for example, the incorporation of traditional Chinese medicine into pluralistic medicine in Tanzania (Hsu 2002; Langwick 2010). Additionally, there is an emerging literature on the impact of new communication technologies on plural medicine (Hampshire & Owusu 2012; Krause 2008). Such research addresses ‘telemedicine’, self-help Internet blogs, email consultations with overseas nonbiomedical doctors, and other technologies (for example, digital apps on meditation and Yoga) that have significantly shaped the ways in which medical pluralism is conceived and practiced.

At the same time, patients themselves travel around the world in the search of nonbiomedical treatments. Here, some scholars distinguish medical tourism, associated with biomedical treatment, from health tourism or wellness tourism associated with traditional and alternative medicine (Reddy & Qadeer 2010: 69; also Smith & Wujastyk 2008: 2-3). For example, health-seeking tourists may travel to India in pursuit of ‘authentic’ Ayurvedic therapy, Yoga, or spiritual healing (Langford 2002; Spitzer 2009).

Therapeutic trajectories of migrants in host countries is also a particularly fast-growing area of research, especially because migrants carry different medical ideologies and attitudes that might raise concerns in the sphere of public health, health policy, and public discourses (Andrews et al. 2013; Cant & Sharma 1999; Chavez 2003; Green et al. 2006; Krause 2008). Some of these studies examine how minority groups seek satisfactory treatment in biomedicine-dominated contexts. For example, Tracy Andrews and others (2013) examine how adult Hispanic migrants in the US make therapeutic decisions for their children in a pluralistic healthcare setting that includes both biomedical providers and famous Mexican healers in the vicinity. Many studies emphasise that migrants resort to alternative practitioners, particularly from their community, because of language difficulties, cultural preferences, a search for a specific herbal or spiritual treatment, or fear of being looked down on by biomedical practitioners (Green et al. 2006, Andrew et al. 2013; Lock 1980: 260; Chavez 2003: 201, 219). These challenges can motivate migrants to postpone immediate care and instead make trips to their countries of origin to receive medical treatment. Therefore, medical anthropologists often point out the importance of providing non-discriminatory medical services to migrants, especially to those who may not share a biomedical model of health and disease, and advocate for health policies of ‘integrative’ and ‘culturally-sensitive’ healthcare (Green et al. 2006; Chavez 2003).

In addition to the focus on patients, scholars of globalised healthcare also investigate the transnational mobilities of medical practitioners and material objects. ‘Traditional’ medicines, healing crystals, talismans, and other paraphernalia, which are not exchanged through formal channels of commerce, often follow along the lines of an informal economy of transnational connections (Hampshire & Owusu 2012; Krause 2008; Menjívar 2002). Kristine Krause (2008) provides an example of ‘transnational therapy networks’ that connect Ghanaian migrants in London, their relatives and friends in other European counties, and traditional healers in Ghana who may ‘directly deliver their products’ to owners of Afro-shops in the UK. In these transnational channels, money, drugs, and prayers are sent between members of the African diaspora in Europe and their friends and suppliers in the countries of origin.

Inspired by the work of Arjun Appadurai (1988) and other scholars of materiality, medical anthropologists have expanded their inquiries of medicine as knowledge and practice to the examination of physicality and the ‘agentive properties’ of medical objects: pills, intake forms, ultrasound prints, medical charts, stethoscopes, syringes, and other equipment are not passive objects but active agents in clinical interactions, as they can influence people’s behaviour, compel action, communicate, instil fear or trust, and even heal. For example, contemporary alternative doctors frequently adopt material objects from other medical traditions, especially from biomedicine: in India, some patients who visit an Ayurvedic doctor demand to be examined by a stethoscope, believing that a touch of a stethoscope has a curative outcome (Nichter 1980). Thus, a stethoscope is not a silent object in a doctor’s room but an agent that speaks, calls for action, and brings confidence.

Such studies of materiality provide the crucial insight that medical pluralism is often unmarked: sometimes neither doctors nor patients see their encounters as pluralistic. As shown in Stacey Langwick’s work in Tanzania, a ‘traditional’ healer may routinely use a syringe and ask to bring an X-ray from biomedical hospitals. The presence of ‘modern’ medical technologies can ‘challenge the self-evidence of boundaries between traditional and modern medicine’ (2008: 429).

Unlike the above research on unauthorised, informal transnational flows of medicines, there is a new scholarship on the commercial flow of ‘alternative’ pharmaceuticals and the operations of alternative industries beyond national borders. Building on previous studies of marketisation of alternative medicine in domestic contexts (Adams 2002a; Banerjee 2009; Bode 2008; Craig 2011, 2012; Kim 2009), this scholarship highlights the transformations under the pressures of a global neoliberal economy, when many nonbiomedical practices can no longer be dismissed as local, marginal, or alternative traditions. It makes the case for recognising them as transnational, mainstream, innovative, and profit-driven industries (Kloos 2017; Kloos et al. 2020; Pordié & Gaudillière 2014; Pordié & Hardon 2015).

Conclusion

Developed in the 1970s–1980s, the concept of medical pluralism offered novel ways of understanding diverse medical practices and their relations with biomedicine. It went beyond the early twentieth century descriptions of indigenous healing beliefs and was a crucial concept for establishing the field of medical anthropology. By attempting to overcome the dualistic representation of Western/modern and non-Western/traditional medicine, scholars of medical pluralism demonstrated that the diversity of medical ideas, approaches, experts, and institutions exists in every complex society, even in the West. Rather than merely focusing on health and healing, medical pluralism highlights the heterogeneity, multiplicity, and competition that permeate medical thought and practice. Although many scholars have challenged the notion of ‘pluralism’ and suggested replacing it with other terms such as eclecticism or diversity, medical pluralism remains a valuable framework.

Many anthropologists have come to criticise the ideas of medical ‘systems’ and medical ‘traditions’ as being overly rigid, even essentialising. Instead, they moved towards the exploration of doctor-patient negotiations, paying attention to whether different actors see therapies as pluralistic, what therapeutic plurality means, who benefits from their promotion, and what kind of inequalities exist between various categories of medicine. Most prominent examples of such inequalities include the hegemonic position of biomedicine supported by science discourses due to which nonbiomedical knowledge and practices are dubbed ‘alternative’ and ‘complementary’, if not entirely fake.

However, the studies of medical pluralism also show that, paradoxically, traditional and alternative medical practices did not disappear under the dominance of biomedicine. Although sometimes lacking official support, they are widely sought out around the world not only by rural populations but also by consumers with wealth and power. The analyses of pluralism as resulting from medical tourism, the spread of the Internet, and the pharmaceuticalisation of indigenous therapies have become important areas of study. This scholarship acknowledges that multiple actors such as medical providers, tourists and migrants, corporations, national leaders, and other categories of citizens—all have their own stake in various medical traditions. Therefore, instead of a narrow focus on colonial and postcolonial situations, researchers explore ‘new’ (Cant & Sharma 1999) and ‘transnational’ (Raffaetà et al. 2017) forms of medical pluralism. The pressing need to account for local and global media, migration, and the rapid growth of medical and other technologies have also forced scholars to change their methods. They moved from studying health practices in a single community to ‘following’ people, objects, and ideas across borders (as per Marcus 1995), showing that people’s therapeutic options have become truly transnational and even more pluralistic. The intensified pluralism is also visible if we account for the ‘virtual’ field in which both biomedicine and nonbiomedical healing is increasingly offered. As a result, scholars have also moved from the descriptions of nonbiomedical practices as small, local, low-cost, marginal alternative traditions to recognising them as large, profit-driven, and mainstream ‘industries’ that occupy substantial market segments domestically, while also rapidly expanding globally. All of this demonstrates that medical pluralism does not just remain an important feature of modern life, but that it is constantly changing in form and content.

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Note on contributor

Venera R. Khalikova is a cultural anthropologist and Lecturer at the Chinese University of Hong Kong. She received her PhD from the University of Pittsburgh. Her previous work on medical pluralism and the politics of Ayurveda in North India have appeared in Medical Anthropology, Asian Medicine, and Food, Culture, and Society. Her current interests include the study of migration, race, and gender among Indians in Hong Kong.

Dr Venera R. Khalikova, Department of Anthropology, Chinese University of Hong Kong, NAH 322, Shatin, N.T., Hong Kong. venera.khalikova@cuhk.edu.hk

[1] For additional reviews of this concept in anthropology as well as sociology and history, readers can consult texts by Hans Baer (2011); Sarah Cant & Ursula Sharma (1999), Waltraud Ernst (2002), and Roberta Raffaetà et al. (2017).

Neoliberalism

Rebecca Tishler — Mon, 26 Oct 2020 20:02:25 +0000

Natalie Morningstar

University of Cambridge

Initially published 26 Oct 2020

http://doi.org/10.29164/20neolib

Abstract:

‘Neoliberalism’ is a widely used term that travelled from economic philosophy into policymaking, and from policymaking into critical social scientific discourse in the late twentieth century. It refers to a form of capitalism ascendant since the 1970s but informed by post-war economic philosophical ideas. In practice, it is characterised by the retrenchment of the welfare state and an increased role of the state in preserving market competition. Anthropologists have critically engaged with neoliberalism. They have at times used the word as a neutral description of an economic doctrine or set of related policies, and at others as a normative description of their negative effects. This entry starts by exploring the benefits and drawbacks of two different ways of theorising neoliberalism. First, it examines contributions that have treated neoliberalism as a world system, and the influence of Marxist concepts on this approach. Second, this entry presents work that frames neoliberalism less as a unified system and more as a flexible mode of governing, and the influence of the work of Michel Foucault on this body of literature. Third, it addresses how the intersections between these two approaches have been productive for anthropologists. In order to demonstrate as much, this entry highlights insights about the effects of neoliberalism on the state and on labour. It concludes by setting out ongoing debates about the use of neoliberalism and related concepts proposed to think critically about contemporary capitalism.

Introduction

As an economic philosophical movement, neoliberalism refers to the form of liberalism resurgent after the Second World War. Its contemporary use was consolidated by the inaugural 1947 gathering of the Mont Pèlerin Society, organised by Friedrich Hayek, and attended by prominent economists and thinkers such as Milton Friedman, George Stigler, and Karl Popper (Harvey 2007, Coleman 2013, Mirowski & Plehwe 2015, Slobodian 2018). While there was disagreement amongst attendees about the precise form that this ‘new’ liberalism should take, most were critical of the rise of the welfare state and Keynesian economic doctrine, which encouraged state intervention and spending to boost economic growth (Slobodian 2018: 6). These approaches had gained momentum in response to the Great Depression and declining faith in classical liberalism, which relied on the assumption that the market was capable of regulating itself, a conceit troubled by economic crisis (Coleman 2013: 82).

Those committed to Hayek’s vision felt that to avoid repeating historical failures, a different relationship between state and market should be engineered. Unlike in classical liberalism, the market would be treated not as a natural and separate sphere but ‘as the principle, form, and model’ for the state (Foucault 2010: 117). Like Keynesians, neoliberal thinkers supported state intervention, but with the purpose of preserving market competition, which was thought to index a healthy liberal democracy (Lemke 2001: 193). This new liberalism was thought to be the road to a stable post-war international economic order: in theory, it recognised the necessity of state intervention without compromising individual liberty (Slobodian 2018: 128).

The economic ideals put forth by early proponents of neoliberalism were consciously taken up by policymakers and states in the 1970s and 1980s in response to ‘stagflation’, a period of high inflation and unemployment. These variants of neoliberal policymaking were tailor-made to different social settings, but they tended to protect individual liberty and private property rights, encourage free trade, involve a decline in social provisions, and increase the political influence of the private and financial sectors (Harvey 2007: 3; Gershon 2011: 538). Margaret Thatcher, Ronald Reagan, Augusto Pinochet, and Deng Xioaping are frequently cited as neoliberal policymakers par excellence (Harvey 2007). Yet where these policies and policymakers were dubbed ‘neoliberal’, it was most often by critics using the term negatively and normatively (Boas & Gans-Morse 2009). These critics often argued the above policy shifts were the root causes of various patterned and detrimental social effects in the late twentieth century. The results of the policies born of neoliberal reform that these critics highlighted include rising inequality, a decline in welfare support, heightened labour precarity, a power shift toward financial institutions, increasingly speculative financial practices, and a punitive displacement of social responsibility from the state onto the citizen-subject (Harvey 2007; Wacquant 2008, 2009; Standing 2011, 2012).

This normative use of the concept of neoliberalism quickly gained traction in the social sciences. Throughout the late twentieth century, and particularly in the early twenty-first, anthropologists used the term to critique the dominance of market-led policymaking and the decline in social welfare (Kipnis 2007: 383). These critics saw the policy consensus of the 70s and 80s as sufficiently successful that it had come to influence everyday life on a global scale. By the turn of the century, for many of these anthropologists, neoliberalism was aptly described as a ‘new world order’ (Comaroff & Comaroff 2000: 291). Such theorists were frequently influenced by Marxist concepts, and often focused on neoliberalism as a political economic structure or ideology. Others argued that neoliberalism was best understood not as a unified political economic or cultural system, but as a flexible mode of governing (Ong 2007). The latter theorists frequently made use of the work of Michel Foucault—particularly his work on governmentality and the subject—to examine the ways in which neoliberal policies can produce unexpected outcomes.

While the distinction between Marxist and Foucauldian approaches is important, it should be noted that it is rare to find anthropologists of neoliberalism that are not indebted to the insights of both thinkers. Most anthropologists mentioned do not strictly belong to one school or another, but instead they tend to draw on a combination of Marxist, Foucauldian, and other concepts. Indeed, while there have been various categorizations of the anthropological literature on neoliberalism that distinguish between Marxist and Foucauldian approaches (Kipnis 2007, Ferguson 2010), others distinguish between approaches to neoliberalism as culture versus system, even where both draw on Marxist concepts (Hilgers 2011), or offer the work of other theorists, like Bourdieu, as an alternative (Wacquant 2010). Nevertheless, the first two sections of this entry discuss Marxist and Foucauldian approaches separately. The third section then explores how the intersections between these two approaches have yielded some of anthropology’s most distinctive contributions to the analysis of neoliberalism. Examining two areas in particular—the state and labour—this entry explores a key anthropological insight: while neoliberal logics often seem overly dominant, they never manage to govern people’s lives fully. The entry concludes with a discussion of enduring disagreements regarding the usefulness of neoliberalism in anthropology, as well as the benefits of considering related critical theories of contemporary capitalism.

Neoliberalism as world system

The rise of neoliberal reform at the end of the twentieth century coincided with seismic geopolitical and intellectual shifts. The fall of the Berlin Wall, and the spread of liberal democracy and market capitalism, meant that for many, the modernist ideological battles of the twentieth century were replaced with a sense of all-encompassing governance. This shift was encapsulated most famously—and controversially—by Francis Fukuyama’s declaration, in 1992, of the ‘end of history’ and liberalism as the final stage of social progress. Around this time, there was also a proliferation of ethnographies of globalization (e.g. Appadurai 1990, Hannerz 1996 [cited in Ortner 2011]) and ‘the capitalist world system’ (Marcus 1995: 97). This body of work sought to produce social analysis ‘sensitive to its context of historical political economy’ (Marcus 1986: 167), to situate diverse ‘lifeworlds’ in the ‘world system’ that may by turns facilitate and constrain them (Marcus 1995: 98). This work demonstrated that ‘local’ experiences of everything from family life to religious beliefs to labour could be understood in terms of ‘global’ political economic systems like capitalism (Marcus 1995). As Marcus argued, the ‘world system’ thesis ‘developed explicitly within genres of Marxist anthropology’ (1995: 97). Like Marxism, it was devoted to the idea that political and economic forces and events constrain our interlocutors’ thoughts and actions in a structured sense.

However, in the 1990s and early 2000s, neoliberalism came to replace ‘globalization’ as the most relevant ‘world system’ within which to understand a variety of ethnographic cases. This was not just a shift in terminology. Increasingly, anthropologists became pessimistic about the exclusionary effects of globalization and capitalism in their fieldsites around the world (Ortner 2011). Neoliberalism was the word used to critically spotlight these effects. Often, in doing so, these theorists made use of a variety of Marxist tools and concepts. Some of these anthropologists focused on neoliberalism as a policy project with material effects, especially the accumulation of wealth in the upper class. Others framed it as a culture, or set of ideological values and discourses.

Geographer David Harvey is perhaps the most vocal proponent of a class-based theorisation of neoliberalism. For Harvey (2007, 2016), neoliberalism is a globally-dominant policy project designed to intensify the accumulation of wealth in the upper class. It is characterised primarily by ‘deregulation, privatization, and withdrawal of the state from many areas of social provision’ (Harvey 2007: 3). This policy project draws on a number of discourses and values, which echo those of significance to the neoliberal architects and engineers discussed above: for instance, the ‘assumption that individual freedoms are guaranteed by freedom of the market’ (Harvey 2007: 7). Yet at base, it is best understood as a practical political tool for wealth accumulation. As Harvey notes, the ‘increasing social inequality’ is observable in national income distribution. After neoliberal reform in the US, for instance, ‘the ratio of the median compensation of workers to the salaries of CEOs increased from just over 30 to 1 in 1970 to nearly 500 to 1 by 2000’ (Harvey 2007: 16).

Anthropologists of neoliberalism have turned to their fieldsites to demonstrate how neoliberal values and policies marginalise vulnerable populations along class lines. The work of Loïc Wacquant (2012) is exemplary. While Wacquant is also influenced by other thinkers—especially Pierre Bourdieu’s work on bureaucracy and the state—he is indebted to the Marxist theorisation of neoliberalism as a form of class struggle, or what he calls a ‘revolution from above’ (2010: 211). Wacquant’s work focuses on issues of class and race for the urban poor in the US and France (2008), as well as on the relationship between the neoliberal retrenchment of the welfare state and mass incarceration (2009, 2010). Like Harvey, Wacquant argues that neoliberalism works to the disadvantage of ‘those trapped at the bottom of the polarizing class structure’, often with particularly severe consequences for those who also suffer racial injustice (2009: xv). He pays attention to what Harvey would also identify as key features of neoliberal reform: ‘the social and urban retrenchment of the state’ and ‘the imposition of precarious wage labor’ (Wacquant 2009: vx) in increasingly underserviced urban neighbourhoods (Wacquant 2008: 25). Building on Harvey, he argues that the retrenchment of social welfare is only one-half of the neoliberal picture. It isn’t just that the urban poor have suffered decades of decreasing social and labour security, but also that the carceral system has been mobilised to discipline and contain those suffering the worst effects of social insecurity (2010: 216).

Other anthropologists have turned their attention to the role of neoliberal values and discourses accompanying the rising material inequality discussed above. The work of Jean and John Comaroff (1999, 2000) is a case in point. For these anthropologists, neoliberalism is best understood as a global ‘culture’, a patterned way of relating to oneself and others that draws on both ‘ideology and practice’ (Comaroff & Comaroff 2000: 305). Based on ethnographic research in South Africa at the turn of the twentieth century, they demonstrate how increasing labour precarity as a result of neoliberal reform was accompanied by a marked rise in anxiety about the illegitimate accumulation of wealth. The latter manifested in what they call ‘occult economies’, systems of exchange that deploy ‘magical means for material ends’ to gain access to wealth as if by ‘enchantment’ (1999: 279). Their ethnographic examples are diverse, ranging from witchcraft accusations, to pyramid schemes, ritual killings, and the illicit sale of body parts, observed in Africa, Latin American, the United States, Eastern Europe, and Asia. According to the authors, all involve efforts to ‘multiply available techniques of producing value, fair or foul’ (2000: 316) and to isolate causes for the uneven distribution of resources. The Comaroffs thus see these as instances of a global backlash against a contradiction at the heart of neoliberal capitalism: ‘the culture of neoliberalism’ (2000: 304) relies on a newly positive moral value attached to speculation, gambling, and risk, and with it comes a sense that inordinate sums of wealth can be accumulated without effort. Yet for many, this belief is at odds with real material inequality. Neoliberalism thus ‘appears both to include and to marginalize in unanticipated ways’ (Comaroff & Comaroff 2000: 298). Occult economies, then, can be understood as expressions of both hope in and disappointment with the promises of neoliberal capitalism.

Despite their differences in approach, there are important convergences across the aforementioned analyses of neoliberalism. All share the conviction that neoliberalism is the dominant world system. Along with other Marxist critics of neoliberalism (e.g. Brenner & Theodore 2002), they frame it as the root of systemic forms of global inequality, which are thought to be less the result of individual choice or responsibility than of a fundamentally unequal distribution of political power and resources (Hilgers 2011, see also Harvey 2007: 16). If Harvey and Wacquant focus on the material and institutional effects of neoliberalism as a political economic project, the Comaroffs focus on the relationship between material inequality and the beliefs and values that accompany neoliberal reform. In both cases, the influence of Marxism is clear: the power of political economic structures and institutions is linked to the dominance of certain ideological beliefs and values, and both are seen to have global reach. What this body of work is particularly good at, then, is situating a range of ethnographic examples within a set of predictable forces, events, and constraints which are often presumed to chiefly oppress citizen-subjects. Nevertheless, what should also emerge from the aforementioned body of work is that neoliberalism can play an expansive explanatory role. Some anthropologists thus began to question whether neoliberalism was as coherent and constraining a system as the above analyses sometimes imply. To do so, many turned to the work of Michel Foucault.

Neoliberalism as mode of governing

Foucault’s work has been compelling for anthropologists of neoliberalism who have sought to capture nuances they see as missing from the world system approach. One of the key concepts that appears in Foucauldian approaches to neoliberalism is governmentality. Governmentality, for Foucault, is a double-edged concept. It refers to both the rationalities and to the practical techniques used to guide the conduct of oneself and of others (Lemke 2001: 201). Governmentality is the process through which influence is exerted over political subjects, which are not just oppressed ‘docile bodies’ but also reflective selves, who may be aware of and participate in being governed (Lemke 2001: 203). Crucially, both governmentality and the subject are unstable concepts that depend on one another; different techniques of governmentality produce different kinds of subjects. Anthropologists have therefore been attracted to Foucault’s theory of governmentality and the subject because they make space for contingency. Rather than presuppose a single political economic structure, or a field of class-based struggle, within which to understand a variety of ethnographic examples, Foucauldian analysis leaves the specific characteristics and effects of government open-ended. As a result, Foucauldian approaches tend to treat neoliberalism not as a system or structure but as a set of context-specific practices that are vulnerable to recapture by different political projects and actors. Foucauldian theorists often emphasise that neoliberalism does not explain everything, that it does not look the same everywhere, and that not all subjects respond to it in expected ways.

Those who have relied on the concept of governmentality frequently focus on how neoliberal policies can paradoxically make space for non-neoliberal ideals and outcomes. James Ferguson’s work on anti-poverty programs in Southern Africa (2007, 2015) demonstrates this clearly. Ferguson focuses on the South African Basic Income Grant (BIG), a universal direct payment granted to all South Africans to alleviate the most severe effects of poverty and labour insecurity. At first glance, Ferguson points out, we might be inclined to see this type of assistance as appealing to ‘recognizably neoliberal elements’, such as ‘the valorization of market efficiency, individual choice, and autonomy; themes of entrepreneurship; and skepticism about the state as a service provider’ (2010: 174). But upon closer inspection, one discovers that these direct payments are also ‘pro-poor’ (Ferguson 2010: 174). What emerges in this case, then, is that basic income grants are one of several instances in which ideals ‘we can readily identify as neoliberal are being put to work in the service of apparently pro-poor and pro-welfare political arguments’ (Ferguson 2010: 176). Approaching neoliberalism as a flexible mode of governing thus allows one to appreciate how ‘devices of government that were invented to serve one purpose have often enough ended up […] being harnessed to another’ (Ferguson 2010: 174).

If Ferguson demonstrates how neoliberalism can aid and abet non-neoliberal policies and values, other Foucauldian anthropologists of neoliberalism have pointed to instances in which neoliberalism collides with explicitly non-neoliberal policy projects to contradictory effect. A key instance of this is Stephen Collier’s (2011) work on neoliberal reform in Soviet and post-Soviet Russia. Collier is critical of the assumption that neoliberal doctrine ‘is opposed to social welfare and to the public ends of government’ (2011: 1). To correct this, he examines the surprising alignment between neoliberal reform and Soviet socialism. He finds that contrary to expectation, neoliberal policymakers were not ‘blind to the need for social protection’ (2011: 3), nor did they attempt to retrench the social state. Rather, neoliberal reform was mobilised to retain ‘the social welfare norms established by Soviet socialism’ (2011: 3). Collier examines how neoliberal policies were applied to durable Soviet infrastructure—comprised of pipes, homes, urban centres, bureaucratic and budgetary practices—all of which endured and were extended through neoliberal reform. He is careful to qualify that his work is not ‘an apologia for neoliberalism’ (2011: 249). Instead, he draws on Foucault’s theory of governmentality to emphasise the in-built ‘flexibility of many elements of neoliberal reforms’ (2011: 248) often overlooked in critical approaches to neoliberalism. In this sense, Collier joins a group of scholars who have examined how neoliberal reform has intersected with communism and socialism to produce ‘exceptions’ (Ong 2006) to neoliberalism as we know it.

Still other anthropologists have framed neoliberalism as a process of subject formation to point to the ways in which subjects might meet neoliberal modes of governing with a variety of responses, ranging from resistance, to compliance, to indifference. As they demonstrate, even as a subject might be incited to uphold one neoliberal value, he or she might also participate in reproducing other decidedly non-neoliberal beliefs and practices. This is evident in Andrew Kipnis’s work on discourse about suzhi, or ‘human quality’, in China (2007: 383). As Kipnis notes, suzhi is an important political concept mobilised for a variety of purposes, ranging from justifying educational reforms to legitimising the authority of political figures (2007: 388). It is used to denote features of a person ‘that result from both nature and nurture’, such as dress and educational attainment, and that designate their worthiness as political subjects (Kipnis 2007: 388). As anthropologists of China have argued, one area in which the effects of suzhi are particularly evident is in the pressure placed on parents to raise high-quality children in a competitive educational market (Anagnost 2004, Kuan 2015). From one perspective, then, suzhi discourse seems to be a clear instance of an effort to produce ‘responsible and governable but alienated neoliberal subjects’, with the ‘hyper-disciplined, over-achieving only child’ being a prime example of this (Kipnis 2007: 386). However, as Kipnis argues, closer attention to suzhi discourse demonstrates that it draws on other non-neoliberal schools of thought, including nationalism, Marxism, and Confucianism (2007: 395). Moreover, suzhi discourse has come to have a certain linguistic authoritarianism about it, so that ‘improving the suzhi of the Chinese population’ became a ‘sacred slogan’ beyond reproach (Kipnis 2007: 393). Yet people often use the language of suzhi disingenuously, as political cover, to soften or occlude unpopular opinions while making public expression possible (Kipnis 2007: 393). Two important conclusions follow: suzhi is a mode of governing that overlaps with aspects of neoliberalism as we conventionally think about it, but which also captures other political and philosophical projects (Kipnis 2007: 394). Moreover, neither discourse about suzhi nor neoliberal values exert complete influence over citizen-subjects, who might draw on one or both disingenuously.

As the above examples attest, Foucauldian approaches to neoliberalism have allowed anthropologists to suspend assumptions about what the world system looks like in order to better examine its unanticipated effects on governance and the political subject. On the whole, then, these authors have a different vision of how to engage critically with neoliberalism. Unlike the Marxist critics discussed earlier, Foucauldian critics tend to be less interested in decrying or generalising the deficiencies of neoliberalism than in probing its context-specific inconsistencies, gaps, and contradictions for alternatives (Ferguson 2011). Neither is more or less anthropological, or more or less critical, but they have different strengths and rely on different assumptions. If world system approaches to neoliberalism are good at contextualising diverse ethnographic examples in systemic political economic and ideological frameworks, Foucauldian approaches try not to assume there is a fixed context within which to understand ethnographic cases, and are therefore sometimes better at asking where neoliberal policies and values can incorporate contradictions. However, many compelling contributions to the anthropology of neoliberalism have drawn on aspects of both Marxist and Foucauldian theory, as the next section demonstrates.

Ethnographies of the state and labour

While many of the above anthropologists have profited from leading with either Marxist or Foucauldian theory, it is common to find scholars drawing on a mix of the concepts discussed, often in conjunction with the work of other thinkers. Though they have faced criticism, as discussed in the final section, these accounts are generative in that they balance the recognition that neoliberalism can be flexible along with the striking, patterned inequalities that have been entrenched in the wake of neoliberal reform. Many of these contributions have married Foucault’s concepts of governmentality and subjectivity with a Marxist reading of class. In so doing they have enhanced our understanding of everyday political subjects’ experience of the state and labour. These examples are hardly exhaustive. Anthropologists have also offered generative accounts of the impact of neoliberal reform on areas as diverse as gender (Schild 2000), kinship (Shever 2008), gentrification (Potuoğlu-Cook 2006, Herzfeld 2010), forms of self-management (Urciuoli 2008), voluntarism and affect (Muehlebach 2012), and the division between the public and private spheres (Bear 2011, 2015). However, the following examples are particularly helpful for demonstrating the usefulness of setting Marxist and Foucauldian concepts in conversation.

Philip Bourgois’ and Jeffrey Schonberg’s (2009) Righteous dopefiend is a clear example of where class and subjectivity can be used in consort to understand the effects of neoliberal reform. Based on more than a decade of fieldwork with homeless individuals who inject drugs in San Francisco, the book situates drug addiction in the context of the gentrification of the housing market, the decline of stable wage labour, and the retreat of social services (Bourgois & Schonberg 2009: 16). They offer an account of their interlocutors’ troubled relationships with their families and the state, which, in the absence of a social safety net, increasingly takes the shape of a network of temporary healthcare providers and members of law enforcement. The book sets forth the claim that substance abuse is thus at once ‘structural and personal’ (Bourgois & Schonberg 2009: 16). To demonstrate this, Bourgois and Schonberg draw on a class-concept written about by Marx: the lumpen proletariat. The lumpen proletariat, for Marx, are ‘the historical fall-out of large-scale, long-term transformations in the organization of the economy’ (18). Bourgois and Schonberg suggest that we can understand becoming ‘lumpenized’ as an experience of becoming a type of marginalised subject (2009: 19). In so doing, they bring a different emphasis to their reading of Foucault than those authors discussed in the previous section. To bridge between Marx and Foucault, they also draw on Pierre Bourdieu’s work to argue that the state is better understood as a shifting network of institutions and actors, rather than a network of elite actors operating in their own class-based interests. Their argument would thus be unorthodox for those who consider the world system and governmentality approaches as at odds. Yet allowing these concepts to speak to one another enables the authors to show how neoliberal reforms have meant that the state is more harshly disciplinary on the poor, in ways that aggravate class-based and race-based distinctions. Though not completely constraining, processes of subject formation emerge as more punitive for classes deemed unworthy of personal and political concern.

Anthropologists have also drawn on theories of class and governmentality to examine the effects of neoliberal reform on the labour market. Aihwa Ong’s work is canonical. Like other Foucauldian anthropologists, Ong approaches neoliberalism less as a coherent ideology or structure than as a novel mode of governing that relies heavily on technical expertise, efficiency, and individual responsibility (2007: 3). Crucially, then, neoliberalism is a highly ‘mobile technology’, or rational tool, of governance and can operate in conjunction with other non-neoliberal policies, techniques, and ideals (2007: 3). To demonstrate as much, Ong trains her ethnographic eye on labour and citizenship in the Asia-Pacific region, in which ‘neoliberalism itself is not the general characteristic of technologies of governing’ (2007: 3). She echoes Collier’s observation that neoliberal reform has therefore had unanticipated effects, such as the preservation of social state infrastructure. Yet she also demonstrates that neoliberalism can produce exclusions. By redrawing the lines of who counts as valuable citizens and workers, it ‘marks out excludable subjects who are denied protections’ and ‘the benefits of capitalist development’ (Ong 2007: 6, 4). One clear example of this is the ethnicised and class-based divides that are thrown into relief by the outsourcing of knowledge-based jobs from American to Asian markets. As Ong notes, ‘labour arbitrage involves shifting well-paying jobs across borders’, delinking traits associated with the American middle-class and ‘reterritorializing such features in skilled actors’ in, for instance, Asia’s burgeoning urban knowledge hubs (2007: 157, 158). Meanwhile the ascendant middle- and upper-classes targeted to take up these jobs rely on ‘foreign domestic workers’ often confined to conditions of ‘neoslavery’ (196). Populations deemed to be comprised of valuable labourers are thereby conferred the rights and protections previously granted by citizenship, even as devalued labouring populations are left increasingly vulnerable. Ong thus draws on the concepts of governmentality and the subject, as well as class, to demonstrate how neoliberalism might intersect with explicitly non-neoliberal ideals and policies, even as it also throws into relief the patterned inequalities of ‘global capitalism’ (2007: 7).

After neoliberalism?

By this point, it should be clear that anthropologists have theorised neoliberalism in a variety of ways. Precisely because neoliberalism has been so analytically productive, it has also been subject to intense debate. Written between the lines of the approaches discussed above are often more fundamental theoretical assumptions about the nature of political power and the purpose of social analysis. This final section therefore traces recent debates regarding the on-going usefulness of neoliberalism, as well as the merits of alternative concepts proposed to critique contemporary capitalism.

Most critics of the anthropological uses of neoliberalism have raised concerns that the concept is both nonspecific and also explains too much. The target of critique in these debates is often the world system approach. Like the concepts 'world system', or 'modernity', some argue neoliberalism has occasionally functioned as ‘a sloppy synonym for capitalism itself, or as a kind of shorthand for the world economy and its inequalities’ (Ferguson 2010: 171). One of the key issues Collier (2012) sees is that analysts sometimes assume that a given world system exists at the outset, so that they at once conjure and prove the system they seek to defend as an analytic framework. In other words, it is because neoliberalism is theorised in ways that are often more ‘prescriptive’ than ‘descriptive’ that it is vulnerable to imprecision (Ganti 2014). Proponents have responded by arguing that when carefully executed, the world system approach can have descriptive power: it can account for the patterned effects of neoliberal reform without overlooking nuances and exceptions (Brenner et al. 2010). And though the world system approach has received the brunt of criticism, Foucauldian governmentality approaches have also been critiqued. For some, this is because the concept of governmentality can be used in ways that are expansive enough to echo the world system approach (Collier 2012: 193). For others, the issue is that neoliberal governmentality is conceptually nebulous. As Wacquant (2012) argues, if neoliberalism is framed as mobile and capable of undergoing mutations, it is difficult to pin down, and can seem to exist ‘everywhere and nowhere at the same time’ (70). Regardless of differences of conviction, what is at stake in these debates is both whether anthropologists are accurately describing our interlocutors’ experience of political power, and whether their critical tools are empirically rigorous.

Doubts about the analytic usefulness of neoliberalism have yielded a variety of responses. Some have attempted to tease apart the various ‘uses’ (Ferguson 2010) or ‘approaches’ (Hilgers 2011) to neoliberalism to provide conceptual clarity. Others have proposed that we do away with neoliberalism altogether, as it has become so expansive that its meaning is no longer clear and its uses contradictory (e.g. Laidlaw & Mair in Eriksen et al. 2015: 912, 917). Indeed, even contributors sympathetic to the on-going relevance of neoliberalism have raised concerns about its usefulness (Ferguson 2010: 171; Comaroff 2011: 142). Those who continue to use it do so because they feel there are patterned phenomena to which it can be said to refer, and because they are committed to a moral and political project invested in the reduction of inequality and a reinvigoration of collectivist ideals (Eriksen & Martin in Eriksen et al. 2015: 914, 920). Others point to the importance of neoliberalism as a tool for comparison (Ganti 2014: 100). These disagreements may come down to ideological differences, even where one or the other side presents itself as more empirically rigorous or critically sharp (Venkatesan in Eriksen et al. 2015: 911).

Though many insist that any pronouncement of the death knell of neoliberalism is at best premature (Harvey 2009, Peck et al. 2012, Aalbers 2013), alternative terms have been proposed to critique contemporary capitalism. Nikolas Rose (1993) has insisted that ‘advanced liberalism’ is a better description of the patterns often described as neoliberal. For Rose, ‘advanced liberalism’ refers to the consummation of neoliberal principles through the governance of autonomous subjects by a network of experts, one that is less a new form of liberalism than an accelerated instance of liberalism’s classic principles (see also Rose et al. 2006). For Elizabeth Povinelli (2011), the 2008 recession has given way to a novel period she calls ‘late liberalism’. If neoliberalism is ‘a series of struggles across an uneven social terrain’ that produces forms of life and death exclusion, ‘late liberalism’ refers to the more specific ‘shape that liberal governmentality has taken as it responds to a series of legitimacy crises in the wake of anticolonial, new social movements, and new Islamic movements’ (Povinelli 2011: 17, 25). Others have focused less on the relationship between neoliberalism and liberalism, and more on the changes neoliberal reform has brought about in the relationship between markets and bureaucratic institutions. Marilyn Strathern (2000) and Cris Shore and Susan Wright (1999), for instance, have argued that one of the hallmarks of neoliberal restructuring has been a rapid increase in ‘audit culture’: bureaucratic mechanisms for measuring social progress, profit, and efficiency. Consequently, institutions—like universities—are increasingly treated more like corporations than public resources (Shore 2010).

Conclusion

Neoliberalism is a concept with multiple faces. It can refer to economic and philosophical ideals, policy projects, and the effects of either of the former. Anthropologists have drawn on Marxist theory to frame neoliberalism as a political economic or ideological world system within which we can understand diverse ethnographic cases. For those inspired by Foucault, neoliberalism is best understood as a flexible mode of governing with unexpected effects. Along the way, the intersection between these two camps has yielded significant insight into interlocutors’ experience of the state and labour, as well as productive disagreement on the appropriate relationship between empiricism and critique. Some of the most generative contributions anthropologists have made to the literature on neoliberalism have accounted for both the patterned inequalities neoliberal reform exacerbates, and the flexibility of neoliberal policies and ideals. If neoliberalism has at times been a messy term, it has also been immensely productive and has allowed anthropologists to participate in an interdisciplinary and public debate about how best to describe, engage with, and critique our contemporary political and economic moment.

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Fukuyama, F. 1992. The end of history and the last man. London: Penguin.

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Note on contributor

Natalie Morningstar is an anthropologist with an interest in social movements, capitalism, and political economic transition. She has conducted research on art, activism, and collectivist social organization in post-recession Dublin. Her future research examines the rise of ethnonationalism and populism, and the putative crisis of trust in Euro-American liberal democracies.

Department of Social Anthropology, Free School Lane, Cambridge CB2 3RF, United Kingdom. ncm40@cam.ac.uk

Global health

Felix Stein — Thu, 20 Jun 2019 20:40:13 +0000

Emily Yates-Doerr Kenneth Maes

Oregon State University and the University of Amsterdam; Oregon State University

Initially published 20 Jun 2019

http://doi.org/10.29164/19ghealth

Abstract:

Global health is a field of expertise that has emerged at the turn of the twenty-first century alongside changing disease profiles, health technologies, and governance structures. This entry provides an overview of the historical conditions that have given rise to the field. It illustrates the new political and financial transformations that have made global health 'global', in contrast to earlier work on international, world, or tropical health. It also charts new undertandings of wellness and disease, which have been shaped by global pandemics including HIV, the increase in non-communicable illnesses, and the recent concern for planetary sustainability. While anthropologists have played a central role in global health since its inception, the fields of anthropology and global health also operate in an 'awkward relation' (Strathern 1987) with one another. In the second part of the entry, we overview how anthropologists work within, against, and in-between the expertise of other global health practitioners. We suggest that insofar as the field of global health is emergent, so too are the ways that anthropologists engage with it.

Introduction: An awkward relation

Throughout the twentieth century, ‘global health’ was an uncommon term. The terms ‘world health’ or ‘international health’ were commonly used instead to discuss expansive supra-national health concerns, from epidemic diseases to political relations and financing. ‘Global health’ emerged to draw attention to the global connectedness of diseases and of the people and institutions that govern and respond to them, driven by the spread of new technologies that facilitate rapid global transit, exchange, and communication.

Global health has become codified as a field of expertise over the new millennium, and today the term is used widely. Global health centres exist at most major academic and health-focused institutes. The World Health Organization now issues a global health agenda^[1] and compiles its health-related statistics in a database called the Global Health Observatory.^[2] Numerous publications advance ‘global health science’. For example, the journal Global Public Health launched in 2006, and the medical journal The Lancet initiated a publication devoted entirely to global health in 2012. International conferences organised around the theme of global health draw thousands of professional and academic participants each year and news outlets commonly have global health sections as part of their broader health reporting.

As global health has exploded onto the scene of health scholarship, the field of anthropology has responded by taking it up as a set of practices within which to engage as well as a concept to study critically and ethnographically. Many anthropology departments now participate in multidisciplinary undergraduate and graduate programs focused on global health, and university partnerships between centres for global health and anthropology departments are common. Academic presses such as Duke University’s Critical Global Health series also connect the fields and several anthropologists have published review articles, readers, textbooks, and edited volumes on global health (e.g. Nichter 2008; Janes & Corbett 2009; Singer & Erickson 2013; Biehl & Petryna 2013; Adams & Biehl 2016; Brown & Closser 2018). Moreover, numerous meetings convened in recent years explore the rapidly transforming theories, policies, and practices produced through the intersections of these fields (e.g. de Klerk 2015).

Anthropologists have found diverse ways to engage with global health, and they have witnessed important frictions between the methods, orientations, and interests of different scholars and practitioners in these overlapping fields. In this sense, anthropology and global health are in ‘awkward relation’ to each other (Strathern 1987). This is to say that tensions arise when two differently-oriented and internally diverse fields meet and occasionally merge, and that the coming together of the fields will not be seamless. This entry will review the alternative orientations and praxes that have emerged in global health and anthropology’s intersections, and illustrate how this heterogeneity can be both productive and disruptive to efforts to address health problems around the world.

The entry is divided into two parts. The first shows that global health’s formations are both expansive and emergent. Its sprawling systems and organization of stakeholders include an exceedingly complex and dispersed set of interactions between microbes, carcinogens, billionaire donors, government officials, medical and pharmaceutical corporations, NGO workers, health care professionals, and publics. Moreover, the priorities, methods, and impacts of these multiple actors are rapidly transforming. That said, ‘rapid transformation’ is also a discursive strategy of some powerful players in the field of global health, and attention to the field’s historical formation shows that much of what is presented as ‘new’ echoes colonial-era patterns of consolidating wealth, exacerbating global inequality, and monitoring sickness and health for the sake of empire and/or corporate profit (Packard 2016; Trouillot 2003).

The second part of the entry shows that anthropologists over the past two decades have held a variety of dynamic positions in relation to the field of Global Health. It focuses on three positions, reviewing how anthropologists have worked within, against, and in-between dominant global health interests.

Emergent transformations in global health

1. Responding ‘globally’

‘Global health’ has emerged in policy and development spaces that were, until recently, organised around ‘international’, ‘world’, or even ‘tropical’ public health concerns (Brown et al. 2006). It operates as both a collection or assemblage of individuals, organizations, and nation-states and as a discourse about health that travels beyond these institutions. The term has become so commonplace in public discourse that it may be easy to overlook that it is an invented, historically specific concept, which organises the world by prioritising some set of values over others (eg. charity over political justice, moral universalism over cultural specificity, global citizenship over Indigenous sovereignty, etc.) (Butt 2002).

Much anthropological work on the topic unpacks how global health has been constituted as a ‘global’ domain. It emphasises that the category ‘global’ is not an objective summation of all places in the world; rather, places and things that are considered to be global are produced out of specific historical and cultural milieus (Law 2004; Tsing 2000). And though ‘global’ purports to represent the entire world, the category often reinforces exclusions and absences. Current anthropological engagement and concern with global health can thus be seen as a continuation of anthropology’s awkward relation with state-making projects; indeed, medical anthropology itself has a root in the enlistment of anthropologists into twentieth century international health development projects (e.g., Foster 1976).

However, as Nolwazi Mkhwanazi (2016) points out, global health does not adhere to a single origin story. Doing global health well, she insists, entails searching out and listening to the stories that are often systematically erased alongside those which are commonplace. For example, the widespread interest in sexually transmitted disease and sexual violence in Africa on the part of global health organizations may foreclose attention to the fact that, for many, sex remains a source of thoroughly healthy pleasure (Hendriks & Spronk 2017). Or, the global health agenda focused on ‘maternal health’ may unfairly burden women with the responsibility for reproduction while silencing the experiences of domestic and caring fathers (Han 2009, Powis 2019). It is important to keep the power of stories in mind when reading the common histories of the field. Whether the explanation offered for the rise of global health focuses on transitioning disease profiles, changing governance structures, or something else entirely, it must be understood in terms of its narrative effect, which creates and reinforces the thing it purports to simply describe (Mattingly & Garro 2001).

One powerful story about the ascendance of global health emphasises the acceleration of contagions and potential pandemics whose vectors of transmission do not adhere to national boundaries (Caduff 2014). These epidemics involve viruses such as the human immunodeficiency virus (HIV), swine flu, or Ebola; bacteria such as tuberculosis or cholera; protozoa like the ones that cause malaria; and agents whose mechanisms of infection are not well understood. Many experts have responded to fears about the spread of illness by linking global health to national security. For example, the U.S.-based Centers for Disease Control (CDC) describes the basis for its commitment to global health as follows:

Disease knows no borders. In today’s interconnected world diseases can spread from an isolated, rural village to any major city in as little as 36 hours. The U.S. cannot protect its borders and the health of its citizens without addressing diseases elsewhere in the world. (2018)

The case made by the CDC and numerous other health agencies is that ‘local’ health and illness programs must be simultaneously global in outlook, since global monitoring is good for the nation. Of particular concern are countries or regions that health professionals frequently characterise as ‘resource-poor’.^[3]Global experts often positioned these countries as the containers of diseases – or people with diseases – which might, potentially, spread beyond their borders (Brada 2011). Experts typically talk about diseases moving from south to north or east to west. It is important to note, however, that many countries deemed ‘poor’ by the global health community are, in fact, resource-abundant and their apparent poverty is the result of Euro-American colonial expansion and extraction (Benton 2014) as well as on-going, deliberate efforts to maintain income and health inequalities on the part of exploitative global elites (Vasquez 2018).

In addition to categorising disease patterns and technologies, the ‘global’ of global health also references new structures of governance. The meteoric rise of global health in the past two decades speaks to the crucial role of non-governmental actors, including corporate and philanthropic foundations, in shaping health services today (McGoey et al. 2011; Nguyen 2005; Rottenburg 2009). The World Health Organization, founded in 1948, and the Latin American Health Organization, founded in 1902, once coordinated public and international health concerns among their ‘member states’. Now organizations headquartered in the Global North such as the Bill and Melinda Gates Foundation or Save the Children serve as ‘uneven partners’ of impoverished countries in the project of making health globally accessible (Crane 2010). Yet while the ‘single story’ of global health emphasises the emergence of non-state actors and disappearance of the state, other stories make clear that non-state actors were historical drivers of ‘international’ health, and that the involvement of the state remains central and on-going in global health practices today (Quirke & Gaudillière 2008; Vaughan 2007).

One especially common origin story of global health locates its roots in the strategic responses to the devastating effects of twentieth century HIV. In the US and Western Europe, infected people and their allies and advocates successfully pressured their governments to make therapeutic drugs more widely accessible in the 1980s and 1990s. Meanwhile, antiretroviral drugs (ARVs) and therapies remained prohibitively expensive for many people dying outside these countries, particularly in Sub-Saharan Africa, Brazil, and India. In fact, many health experts even argued against treating AIDS outside of Euro-America, framing prevention and treatment strategies as mutually exclusive, and arguing that AIDS should be prevented but not treated (Moyer 2015).

Grassroots movements connecting diverse global communities were instrumental in challenging the denial of ARVs to people outside the West. Activists demonstrated that successful treatment and high adherence rates were possible in resource-restricted settings and they leveraged pharmaceutical companies to make generic drugs available worldwide (Avirgan 2005). They also convinced donors to pay for the delivery of treatment and care, bringing foundations and non-governmental entities into the conversation. Bill Clinton, as President of the United States, initially supported Western pharmaceutical companies’ attempts to protect their patents on antiretroviral drugs abroad. In 1999, under pressure from global AIDS activists and members of the Congressional Black Caucus, Clinton announced that the United States government would not pressure sub-Saharan African countries to give up their rights to import or produce cheaper, generic ARVs (Messac & Prabhu 2013). In the early 2000s, the newly formed Clinton Foundation brokered a reciprocal investment/production deal between governments and generic drug producers in Africa and India. This was broadly described as a ‘win-win’, with profits made by drug companies and needy government purchasers securing drastic price reductions (Biehl 2006; see also Allen 2006; Erikson 2016).

The Clinton Foundation’s involvement in ARVs set the stage for other philanthropic organizations to join the emergent global health movement. In 2001, Amir Attaran and Jeffrey Sachs published an influential article in The Lancet, proposing a new funding structure dedicated to controlling the world’s three greatest infectious killers (Attaran & Sachs 2001). Later that year, leaders of the world’s eight largest economies launched the Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria. While the goal of universalising access to treatment has not been met, the Global Fund helped galvanise a massive increase in health financing that connected diverse non-state actors, including civil society groups, in the project of health governance. Speaking of health as ‘global’ and not ‘international’ was, in this sense, a strategic move to bring together actors whose interests extended beyond the wellbeing and security of single nations.

In addition to its unfolding against the backdrop of a worldwide mobilization against HIV, twenty-first century Global Health has also emerged as a response to the devastating global effects of structural adjustment programs, which dominated the international development agenda during the 1980s and 1990s. The World Bank and the International Monetary Fund had offered loans to low-income countries in exchange for various fiscal reforms. Some of the most crippling reforms involved government reductions in health care spending, leading to poorer quality and often non-existent public health care (Pfeiffer & Chapman 2010). During this period, the deregulation of global, transnational corporations led to the accumulation of massive wealth in the hands of the few, while also contributing to large-scale environmental degradation through resource extraction and the promotion of white middle/upper class consumption habits. Much of the work of global health today aims at righting the wrongs done by a previous era of experts who created widespread health inequity and illness in the name of global development. We explore how this is playing out further in the section below.

2. Transitions in ‘health’

Just as the ‘global’ in global health is emergent and under negotiation, so too is ‘health’. In the current era, it is often difficult to tease apart health as a biological condition of well-being from health as a risk factor, indicator, or proxy for development (Adams & Pigg 2005; Harper 2014). Global health professionals routinely use ‘health’ strategically, to reference both an immediate physiological state and a value-laden future aspiration. The following example of how health and health policy professionals are re-purposing the term ‘health’ illustrates the conceptual fluidity of the term.

‘“Health” has had its day’, Julio Frenk – then Dean of Public Health at Harvard University – declared at a 2013 conference held at the Institute of Health Metrics and Evaluation (IHME), an institute endowed by the Bill and Melinda Gates Foundation which has carried out much of its work under the banner of global health. Frenk was describing what he saw as a decline in the previous era of biomedicine, which had oriented public health toward body-focused and individual indicators for health such as maternal mortality, child morbidity, or average life expectancy. In its place was growing health-related interest in global development.

For Frenk, and many others at the IHME conference, this transition was linked to the Millennium Development Goals (MDGs). As Frenk explained, the assembly of these first UN development goals (in effect from 2000-2015) had been a small affair. Over three days, a relatively small number of politicians and policy experts had come up with eight global goals, giving themselves a 15-year window to meet them. Three MDGs (Goals 4, 5 & 6)^[4]were unquestionably related to biomedicine, seeking to reduce disease and mortality and to enhance health. Yet the goals also promoted a framework for thinking of health as a matter of global economic progress and planning. ‘No one expected the MDGs to be such a success’, Frenk told his audience. Crucially, the ‘success’ he referred to came about not because the MDG targets were achieved (most countries’ attempts to meet them fell far short) but because they significantly changed the conversation and influenced health funding allocations by channelling funding toward the elimination of specific, targeted diseases such as HIV and malaria (see also Hardon & Blume 2005). The merging of health and economic development can be seen clearly in MGD Goal 1, which coupled the eradication of extreme poverty and the eradication of hunger, bringing the experience of bodily suffering squarely into dialogue with economic concerns.

As the UN committee settled on ‘sustainability’ as the theme for their second set of development goals (named the Sustainable Development Goals or SDGs), health further shifted from being primarily a human body-based quality (i.e. the experience of wellness) to being a proxy for economic growth and development. While body-based health concerns such as morbidity and mortality remain key aspects of the SDGs, these operate alongside ‘health’ concerns of gross domestic product, human capital, and environmental sustainability. This result was not the contraction or disappearance of ‘health’ as Frenk had originally declared but rather its expansion: linking health tightly to global development makes health relevant far beyond biomedicine’s traditional focus on the individual body.

Changing disease pathways and illness profiles also fuel transformations in the conceptual underpinnings of twenty-first century health. New antibiotic technologies and the development of the field of nutrition in the early twentieth century ushered in major demographic population shifts. Today, people around the world are living longer and dying more commonly of non-infectious, chronic, and comorbid illnesses than in the past. Complementing conversations that aim to control contagion and limit the spread of illness vectors are conversations about ‘lifespan’ concerns, including metabolic disorders, tobacco prevention, mental health, and cognitive decline (Cousins 2015; Kalofonos 2010; Solomon 2016; Reubi 2012; Davis 2018). Aging, once a given part of life, is becoming a medical condition that is financially lucrative for the health industry precisely because it is not curable (Manderson & Smith-Morris 2010; Danely 2019).

Rising temperatures and sea levels also shape the manifestation of afflictions such as diabetes and kidney disease (Nading 2016; Moran-Thomas 2019). Hygiene has likewise extended beyond the discourse of personal medicine, which often exacerbates racism and sexism by blaming and shaming individuals for system-wide failures (Briggs & Mantini-Briggs 2003; Saldaña-Tejada 2017). It now encompass ‘dirty’ atmospheric airstreams and construction technologies and their related – and still racially and gender-stratified – afflictions (Kenner 2013; Whitmarsh 2008). Concern about the immediate effects of microbial infection broadens to slower disasters, such as absorption of carcinogens or heavy metals. Illness, once defined as a feeling of being sick and suffering, has come to encompass that which accumulates in the body all but unnoticed, as in the case where the victim of a heart attack ‘suffers’ without longterm awareness of the disease. In many conditions of chronic illness, health may not pertain to patient perception but to diagnostic capacity and the anticipation of a future manifestation of illness yet to come (Lynch & Cohn 2016; Weaver & Mendenhall 2014). At the inception of the SDGs, The Lancet released a report on planetary health which expanded the concept of illness even further by drawing climate change, microbial environments, water security, and ecosystem diversity into global health’s terrain (Horton & Lo 2015).

The question of which – or whose – health is targeted by global health institutions has been a central concern for anthropologists (see Yates-Doerr 2018). As discussed further below, global health institutions have been widely critiqued for transforming culturally sensitive and locally attuned responses to complex diseases into ‘magic bullet’, short-term solutions. The field of global health has frequently ignored or devalued structural underpinnings of health and disease including access to food, employment, and high-quality primary health care (Closser 2010; Maes & Kalofonos 2013; Maes 2017). Yet in some important ways, the emergent focus on sustainable development among many key actors in global health may be helping to link health to structures of poverty, the violence of colonialism and deregulated capitalism, and climate vulnerabilities. Some suggest that on-going shifts in global health resonate with the social justice spirit of the Alma Ata Declaration of 1978, in which societal concerns for primary care were strengthened (Fee & Brown 2015). Exemplifying these shifts are movements to expand universal health care and ensure basic income. However, anthropologists caution that optimism about how these movements are unfolding should be tempered (Prince 2017; Berliner & Kenworthy 2017). There is clear empirical support for concern, for instance, that the cash transfer programs championed by behavioural economists and the World Bank may unfairly burden marginalised women’s lives or that turning health into a measure of poverty may have a dangerous ‘hidden cost’, by upholding gendered and racist inequalities (Cookson 2018).

The Global Burden of Disease (GBD) study, commissioned by the World Bank in 1990, did much to make global health a household term by quantifying the economic cost of more than 100 diseases across eight world regions. This study gave diverse and previously incommensurate illnesses a measurable standard through which they could be compared. The Lancet editor Richard Horton noted at a conference at the IHME celebrating the twenty-year anniversary of the study that ‘before the GBD there was not a science of health metrics’. Today, econometrics is central to global health, which makes use of disability adjusted life-years (DALYs), quality adjusted life-years (QALYs), and inequality measures called Gini Coefficients to transform diverse kinds of health into a single health metric to be defined by big data computing technologies. ‘Big data’ has brought health to policies previously focused on development while giving global health a decidedly economic flavour (Adams 2016; Yates-Doerr 2014).

At the GBD retrospective there was widespread celebration of the large number of lives saved by statistical analysis and its related ‘evidence-based policy’ (Adams 2013; Fan & Uretsky 2017). Several in attendance argued that the GBD study was a clarion call for investing more in health information systems. A speaker on an all-male panel noted that if the global community really ‘wanted nurses to save lives, we’d arm them with data collection tools’. This sentiment that data collection is more important than on-the-ground care is popular in many global health circles, whose participants seek distance from intimate patient-centred care practices and strive to improve health through the aggregation and analysis of (presumably neutral) data. A book celebrating one of the GBD’s founders is titled Epic measures: one doctor: seven billion patients, implying that better health data will have universal, global benefits. But data are not value-free, as those who study their assembly have shown (Geissler et al. 2016; Beisel & Schneider 2012; Sanabria 2016; Kelly 2012; Biruk 2018). Cultural and political orientations shape which questions are asked and how they are investigated. Framing health problems in some ways over others, in turn, shapes their solutions. For example, if the global increase in diabetes is framed as a biomedical problem, treatment strategies will address medication and diets; if it is framed as a problem of unjust food systems, responses may seek to bolster community-based food sovereignty and hold predatory food corporations to account (Carney et al.2019).

Sometimes anthropologists and global health practitioners may agree on how health problems and their solutions are constructed, finding each other at points of convergence and adding synergistically to the others’ perspectives. However, the person-centred, participant-observation, and ethnographic methods of much anthropological research are frequently at odds with the metric-centred methods of global health. Anthropologists and global health professionals may additionally take different positions with regard to their critique of colonialism or their embrace (or not) of capitalism, and they very often have differently imagined end-goals when carrying out research and subsequent interventions. The result is an awkward relation between the fields. In the next section, we address the different and dynamic positions that anthropologists hold in relation to the field of global health.

Anthropological engagements with global health

Anthropological engagement with global health can be characterised more by its diversity than by any uniform mode of relating. However, three broad positions of anthropologists with regard to global health can be identified: working within, in-between, and against other global health professionals. Additionally, the idea of an ‘awkward relation’ between anthropology and global health emphasises that different positions can be held by the same actor even while positions are in tension (see also Vernooij 2017).

1. Working within

While the field of medicine pre-dates anthropology by millennia, anthropologists have been centrally engaged in global health for as long as ‘global health’ has been recognised as a field. Some key anthropologists are well-known public health figures, such as the World Bank’s former Director Jim Yong Kim and his long-time collaborator Paul Farmer, co-founders of the NGO Partners in Health, which seeks to simultaneously treat individual illness and address the structural violence that devastates poor communities (2004). Kim and Farmer have been among several prominent anthropologists involved in the formulation and execution of health policies and intervention projects. As such, they are positioned to make a powerful case to the global health community to target the cultures of elite privilege that enable systemic health inequities in addition to – or even instead of – the cultures and behaviours of impoverished people when designing health projects (but see Shaffer 2018).

Other global health anthropologists hold valuable positions on the ground – often with little public visibility – where they work to improve local acceptability of global interventions or ensure projects are run in ways that matter to the people whose lives they are intended to shape (de Klerk 2013; Pell et al. 2019). Anthropological methods are embraced by several global health projects, which have found ethnography, and qualitative research more generally, crucial to their long-term success (Campbell 2011).

This work can be perspective-driven, addressing questions such as: what are local beliefs about vaccinations (Larson et al. 2016; Closser et al. 2016), food supplementations (Trapp 2016), microbiocides used in STD prevention (Pool et al. 2010), or regionally specific understandings of health, wellness, illness, or dying more generally? Their work can also be practice-driven, with anthropologists seeking to learn about how people receive vaccinations so as to make vaccination campaigns more effective (Sullivan 2017), to help experts design dietary interventions to better respond to people’s needs (Warin & Zivkovic 2019), or to impact midwifery policy to bring locally-accepted techniques for childbirth into public health systems (Kennedy et al. 2018; Berry 2010).

The anthropological project of ‘working within’ global health can entail the work of transforming how both experimental trials and their resultant interventions are carried out. Hardon and Pool, for example, call for ‘strategic collaboration’, in which anthropologists team up with biomedical allies to break the hegemony of many existing global health technologies (2016). One strategic collaboration entails multi-authored research projects drawing together experts from a range of regions and disciplines. For example, the book Second chances: surviving AIDS in Uganda, was based on collaborative writing between African and Western scholars to encourage global health’s polyvocality (Whyte 2014). Another example is the Ebola Response Anthropology Network, which formed in response to the 2013-2015 Ebola pandemic, and which aims to enable social scientists and outbreak control teams working for NGOs and governmental and international agencies to interact and engage in more appropriate and effective practices of containment of the epidemic and care for those affected.^[5]

Anthropologists have also noted that for all the talk of its global reach, ‘global health’ remains an English word with British colonial histories – as seen clearly in the outsized presence of global health institutions in former British colonies (and a less active presence in Latin America and China) and in the absence or looseness of regulations that exist for clinical trials and medical experimentation outside of Euro-America (Petryna 2009; Cerón 2011), clinical medical-tourism (Wendland 2012), and family planning policies that continue colonial-era practices of population control (Kuumba 2001).

At the same time, to foreclose global health as an inevitably colonialist project risks another erasure given that scholars located in the so-called Global South have been busy using – while simultaneously remaking – global health’s infrastructures in powerful ways (Brijnath and Antoniades 2018; Lasco & Curato 2019; de-Graft Aikins et al. 2010; Mishra 2013). Anthropologists Michael Tan^[6]and Gideon Lasco^[7], for example, each write a popular editorial column for the Philippines Daily Inquirer, amplifying while also repositioning the sciences of global health. Much like medical anthropologists today operate in the shadow of colonial history while also marking a departure from this history through their critiques of colonialism, so too might anthropologists work from within the apparatus of global health to initiate decolonial transformations in how global health work unfolds today (see Benton, Sangaramoorthy & Kalofonos 2017).

2. Working against

Anthropologists also hold themselves at a distance from global health, critiquing its frequently reductive myopic strategies for ‘doing good’. Rather than leverage capitalist-bound structures that often dominate global health care delivery systems, these anthropologists seek to refuse – or at least destabilise – these pathways for action. This emergent domain of ‘Critical Global Health’ (Adams & Biehl 2016) or ‘Critical Health Ethnography’ (Storeng & Mishra 2014) has vocalised a powerful challenge to how the activities of global health exacerbate deeply entrenched social and political-economic hierarchies. For example, in different ways, Liisa Maalki (2015), Miriam Ticktin (2011), and Elizabeth Dunn (2012) demonstrate how humanitarian calls for charity and compassion individualise suffering and occlude the political and structural determinants of suffering, undermining substantive challenges to capitalism and biomedicine. Numerous anthropologists similarly draw attention to how global health locks its participants into cycles of emergency and crisis which ignore – and thereby perpetuate – deep structural violences and their inequities (Benton 2015; Redfield 2013).

The global health inclination to ‘scale up’ treatment interventions has also received sustained anthropological criticism. Anthropologists showed how the scale up of ARVs in sub-Saharan Africa (Pfeiffer & Chapman 2010) and the response to Haiti’s 2010 earthquake (Schuller 2012) undermined public healthcare systems, contributing to the rise of NGOs and privatised care and leading to immiseration and intensified suffering. Yates-Doerr has critiqued the movement to ‘scale up nutrition’, pointing out that pathways that shape eating and satiety differ from those shaping pathogenic or viral infection, which tend to dominate global health frameworks of biosecurity. This work argues against the common global health paradigm of ‘one health’, which treats health as a singular global entity, by highlighting the diversity in forms of health and forms of health-care that matter in people’s lives (Yates-Doerr 2015a; Yates-Doerr 2015b).

Many involved in Critical Global Health see informed critique as a means of improving the lives of people throughout the globe, yet their critiques also unsettle the very language of ‘improvement’ (Li 2017; Wendland, Erikson & Sullivan 2016). Global health is frequently driven by a call for immediate response to urgent or imminent health crises. By contrast, a critical global health anthropology is likely to frame this as a discursive tactic that too often privileges the scalable, magic-bullet solutions that consistently fail as they move from theory to practice (Erikson 2012; Storeng & Béhague 2017). Here, anthropologists refuse global health’s logics by asking for patience, locality, and slowness (Adams, Burke & Whitmarsh 2014), and even radical inaction. These are posed as difficult but necessary tactics for refusing the capitalist logic of relentless innovation that drives many global health projects, and as a way to transform deep historical inequalities.

3. Working in-between

A final mode of relating involves the work of moving in-between different communities of practice. Anthropologists who study the unfolding of global health programs frequently serve as cultural brokers who mediate between experts and the people affected by experts’ visions for global health. Taking a biographical approach that tracks how health technologies transform as they are implemented, these anthropologists foreground that health practices have ‘social lives’ (Whyte, Geest & Hardon 2002), or what Ramah McKay (2018a) has called ‘afterlives’ in reference to how medical projects live on after official experts withdraw.

Anthropologists who move in between ‘everyday’ and ‘expert’ sites might find themselves translating information held by global health experts into an idiom understood by those whom experts hope to reach. They might also work in the other direction to bring knowledge gained through long-term, grounded engagement with everyday life to spaces of global expertise so as to improve health experts’ practices of design and dissemination. They might also do both (Vernooij et al. 2016; Manderson 1998; Hardin 2018). Moving in-between registers of practice can help to illuminate the expertise that lies in the so-called every day – for example, in the every day practices of community health workers who often refashion projects as they roll them out (Nading 2013; Maes 2014; Kalofonos 2014; Swartz & Colvin 2014) – while also showing how policy spaces are guided by their own cultures (Napier et al. 2017; Taylor 2003; Yates-Doerr 2018).

Global health anthropologists frequently find (or place) themselves amid controversies and disjunctures: spaces where conflicting normativities arise. One technique entails the explicit study of ethical disjuncture. For example, Jenna Grant unpacks the presumed universality of experimental research ethics by illustrating how different logics of ‘the good’ compete in an HIV pre-exposure prophylaxis trial (2016). Anthropologists who work with policy makers even as they study policy-making practices routinely draw attention to the frictions and even failures that happen when policy agendas are taken up in everyday life. In doing so, anthropologists do not simply emphasise the need to adjust interventions and pedagogies to be site-specific, but urge policy makers to learn to account for this adaptiveness in the design of their policies. The goal here is not to further Global Health in its own terms, but to illuminate the shortcomings or successes of its strategies.

Conclusion

At a 2009 Yale-based conference organised to celebrate fifty years of medical anthropology, Didier Fassin noted in a keynote lecture that ‘the obscure object of global health’ had rarely been problematised (2013: 96). Anthropologists would soon redress this. In fact, that very year an annual review on ‘Anthropology and global health’ (Janes & Corbett 2009) overviewed the work of more than 100 anthropologists engaged in a critical analysis of the globalization of bioscience. His lecture has served as a call for anthropology to critically unpack globality (asking, for whom is global health global?) as well as the need to open up the black box of ‘health’. Farmer, Kleinman, and Kim, in a similar vein, have pointed to how global health has existed as a collection of problems rather than a discipline (2013: xiii). And McKay (2018b) describes teaching global health as a ‘critical entanglement’, in the sense that anthropologists frequently critique global health interventions even as they use anthropological methods to participate in the work of global health.

This entry has suggested that global health and anthropology connect through an awkward relation. If global health is an ‘obscure object’ (Fassin 2013), so too is its anthropology. Indeed, one of the methodological approaches taken by anthropologists is to explicitly not know with confidence what is meant by global health but to instead follow, empirically, how global health is brought about in practices. As we’ve shown above, these practices include those of the anthropologists who work to shape, even as they might oppose, the terrain of the field.

While many economists and statisticians make use of the supposed objectivity of big data econometrics to make a strong claim to global health, Stacy Pigg (2013) notes that anthropologists might make a claim to global health themselves. That anthropologists use data that are typically not easily quantified – that anthropologists’ metrics are often lively and social (Verran 2001) – is, in fact, taken by many global health practitioners as a strength. The widespread failure of many global health projects has resulted in an appreciation and uptake of anthropological techniques in and beyond the centres of the field. The ‘awkward relations’ that are therein produced remain emergent and dynamic.

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Note on contributors

Emily Yates-Doerr is Assistant Professor at Oregon State University and the University of Amsterdam, where she holds a European Research Council Starting Grant for the project ‘Global future health: a multi-sited ethnography of an adaptive intervention’. She is the author of The weight of obesity: hunger and global health in postwar Guatemala (University of California Press, 2015). Follow her on Twitter at @eyatesd.

Emily Yates-Doerr, Faculty of Social and Behavioural Sciences, Universiteit van Amsterdam, Postbus 15509, 1001 NA Amsterdam, The Netherlands. e.j.f.yates-doerr@uva.nl

Kenneth Maes is Associate Professor at Oregon State University. He is carrying out collaborative research on the challenges and opportunities posed by community health work. He is the author of The lives of community health workers: local labor and global health in urban Ethiopia (Routledge, 2016).

Kenneth Maes, School of Language, Culture and Society, Oregon State University, 238 Waldo Hall, 2250 SW Jefferson Way, Corvallis OR 97331, United States. kenneth.maes@oregonstate.edu

[1] Available on-line: https://www.who.int/about/vision/global_health_agenda/en/

[2] Available on-line: https://www.who.int/gho/en/

[3] The terms ‘resource poor’ or ‘Global South’ have begun to take the place of earlier framings of ‘developing’ or ‘third world’. Each of these terms has problems (Fernholz 2016), reflecting the inherent difficulty of categorising diverse world regions through a shared ‘global’ agenda.

[4] Available on-line: https://www.un.org/millenniumgoals/bkgd.shtml

[5] Information can be found at http://www.ebola-anthropology.net/about-the-network/.

[6] https://opinion.inquirer.net/column/pinoy-kasi

[7] https://opinion.inquirer.net/byline/gideon-lasco

Sport

Felix Stein — Tue, 14 May 2019 12:33:54 +0000

Niko Besnier Susan Brownell

University of Amsterdam and University of Missouri-St. Louis

Initially published 14 May 2019

http://doi.org/10.29164/19sport

Abstract:

Activities that one can retrospectively label as ‘sport’ have probably been part of human beings’ repertoire for millennia, but sports as we know them today are the product of a modernity that arose from the late eighteenth century at the juncture of civil society, industrial capitalism, muscular Christianity, and the colonial expansion of North Atlantic states. Today, it is deeply intertwined with neoliberal capital, media technology, and neocolonial relations between the Global South and the Global North, as well as structures of inequality within nation-states in the Global North. Despite its neglect as an anthropological subject, sport under all its guises, from its effect on individual bodies to its spectacular manifestations in the rituals of mega-events, is a perfect object for an anthropological analysis inspired by ritual theory, exchange theory, feminist anthropology, and ethnographic approaches to globalization.

Sport in anthropology

All humans have probably engaged in sport-like activities since time immemorial, and today’s sports events and massive infrastructures are simply the latest permutation of a relationship amongst sport, spectacle, and political power that harks back to antiquity in the Greek Olympic Games, Roman gladiator games and chariot races, and Mesoamerican ball court games. Throughout the world and across the centuries, humans have engaged in rule-governed activities that exhibit certain features, the relative importance of which varies considerably across societies and contexts. These features include skill, physical exertion, sociality, pleasure, chance, theatricality, and competition. The task of surveying sport cross-culturally is hampered by the problem that the term ‘sport’ describes a category of activities that only coalesced in the West in the nineteenth century and was then carried around the globe by Western colonialism and imperialism and later globalization (Guttmann 1994). Many languages did not have a term with an equivalent semantic value until they borrowed it from a European language (Besnier, Brownell & Carter 2017: 3).

Today, the category is highly contested because being defined as a sport makes an activity eligible for official recognition by powerful international sports organizations; these organizations, in turn, defend the borders of their membership by constantly revising their definition of sport. The two international sports organizations with the broadest multi-sport representation and greatest global influence, the International Olympic Committee (IOC) and the General Association of International Sport Federations (SportAccord), emphasise that sport should be characterised first and foremost by competition, reflecting contemporary popular understandings in the West. For heuristic purposes, we follow this dominant usage here, while acknowledging that thinking of competition as central to sport may impose a Western view on activities that their local practitioners may understand differently.

Understanding competition as central to sport implies that sport is typically enacted in public events underpinned by complex social organization, with the events being the most visible part of the total phenomenon. Behind the scenes, however, there may be a great deal of sport-like non-competitive physical activity, such as athletes’ daily practice routines. In other contexts, such as the fitness practices that have become widespread throughout the world since the 1980s, competition may not be central to most practitioners, although these practices can potentially be codified into sports such as competitive aerobics. Moreover, even the concept of competition is not straightforward, since in some societies competitions are ‘fixed’ to conform to their social organizations. For example, ritualised footraces, archery, and wrestling reinforced the authority of kings among the ancient Egyptians, Sumerians, and Hittites (Scanlon 2012). In the 1950s, the Gahuku-Gama of the Eastern Highlands of Papua New Guinea played a sport loosely based on rugby to settle disputes, and the game ended in a draw when elders, watching from the sidelines, deemed the dispute solved (Read 1965: 190). In Afghanistan in the 1970s, khans (leaders) hosted buzkashi, a horseback game in which riders compete to seize the carcass of a dead goat and carry it to a goal; the scores were decided by debate, and often the most powerful khan won the debate (Azoy 2011). In games of cricket in the Trobriand Islands in the 1970s, the home team always won (Leach 1976).

Late-eighteenth- and nineteenth-century archaeologists had embraced sports as a hallmark feature of ‘Western civilization’ because of the prominent place that Greek games in ancient Olympia and Roman gladiator games in the Coliseum occupied in the archaeological record. But the attempt to arrive at a definition of sport is an anachronism influenced by the fact that the global reach of activities labelled as ‘sport’ today means that what counts or doesn’t count as such is laden with social, cultural, political, and economic repercussions that did not exist in previous epochs. Rather than seeking to establish an all-encompassing definition, anthropological approaches are attentive to the questions of when a particular activity qualifies or not as a sport, for whom, and to what end.

A heated debate amongst historians has centred on whether the keeping of records is found in any other historical or cultural contexts, or whether it defined modern sport (Guttmann 2004). Indeed, the use of the English term ‘sport’ to denote an athletic activity governed by rules of competition first appeared in the Oxford English Dictionary in the 1860s, almost simultaneously with the concept of the sports record (Mandell 1976). But the definition of ‘record’ has also proven to be problematic: there are multiple examples of individuals being ranked by their number of victories in such diverse cultural contexts as the ancient pan-Hellenic Games and weightlifting in nineteenth-century Edo Japan. In societies without standardised measurements or timekeeping, it was difficult or impossible to measure sports records in ways we take for granted today. Efforts at record-keeping and quantification for purposes of comparison may not be modern, but what is decidedly modern is the keeping of local, national, world, and other such records that reflect the bureaucratic structure of modern society since the nineteenth century.

Until recently, sport was a much more common topic of enquiry in history and sociology than in anthropology. In 1985, Kendall Blanchard and Alyce Cheska made the first attempt to define an anthropological approach to sport in The anthropology of sport: an introduction. They took a multiple subfield approach and ran through a list of archaeological, biological, and cultural theories and concepts that could be applied to sports. The cultural approach was functionalist, i.e. seeking to explain the existence of a feature in terms of the need it is supposed to meet, and did not have the benefit of the feminist, postmodern, and critical cultural studies that were then getting underway in the discipline, so the ideas presented in the book were quickly considered outdated. A pioneer sport ethnographer was Alan Klein, who documented baseball in the Dominican Republic (1991, 2014) and the U.S.–Mexico border (1997) as well as bodybuilding in Los Angeles (1993). By the twenty-first century, the number of ethnographically informed works on sport had increased significantly (for example, Carter 2011; Dyck 2012; Joo 2012; Kelly 2018; Laviolette 2011; Starn 2011; Thangaraj 2015).

One reason for the increase was that, more than ever before, sport plays an important role in people’s everyday lives as well as in economics and politics. Another was that sport operates on multiple scales, from intimate aspects of people’s lives to mega-events that bring together the entire world, such as the Olympic Games and the FIFA World Cup. Sport is therefore a particularly attractive field to ask how people’s local lives are intertwined with global processes, a question that stands at the centre of anthropology in the twenty-first century. It is also a productive lens through which anthropologists have studied other important questions about the nature of contemporary society and culture, such as the role of nationalism, changing norms of gender and sexuality, and the growing role that particular forms of capitalism play in our everyday activities.

The emergence of modern sport

In nineteenth-century Europe, many forms of sport-like activities preceded the emergence of modern sport. They had unwritten, locally specific rules and particular versions bore only a loose resemblance to others. In the 1840s, standardised ballgames emerged, primarily in elite British public schools, but for several decades their rules were unstable and they coexisted with the localised games of the working classes (Kitching 2015). By the 1880s, national sport associations had codified the rules of most sports as we know them today and two institutions – clubs and schools – quickly began carrying them around the world along with colonialism and imperialism. School sports became part and parcel of industrial capitalism as schools in Britain and Switzerland used them to attract the sons of the British old rank-based and new money-based elites. Club sports followed as the now-grown sons established them wherever they settled as they expanded their global industrial footprint (Lanfranchi & Taylor 2001).

Local sports were incorporated into local, national, regional, and international systems that imitated the layers of the political structures emerging at the same time. Modern sports took shape alongside the rise of the nation-state, incorporating rites of nationalism such as flag raising, anthem singing, and parades, as is still evident at many sporting events. National athletic unions that oversaw multiple sports appeared in the last third of the nineteenth century. Although the events they organised were new, they were legitimated by grounding them in a romanticised past, a process that Eric Hobsbawm and Terence Ranger (1983) call the ‘invention of tradition’. This was the case of the revival of the Olympic Games in 1896, which was fuelled by the idealization of classical Greece that had accompanied the rise of modern democracy.

Nationalism existed in an uneasy relationship with ethnicity. Folk sports that were standardised and incorporated into the emerging national structures – such as the national school system, the club or professional sport system – held a higher status and were carried abroad along with colonial and imperial projects. Non-Western sports and the sports of ethnic minorities in the West were at a disadvantage. In 1964 judo was the first sport of non-Western origin to enter the Olympic Games (it did not become an official sport until 1972): often hailed as a ‘traditional oriental’ sport, it was actually invented in the 1880s by combining principles of Western physical education with Japanese martial arts (Niehaus 2006). The Chinese martial art of wushu was not accepted onto the program for the Beijing 2008 Olympics despite the heavy pressure that the Chinese government exerted on the IOC (Brownell 2012a). For many ethnic sports, the price of exclusion from the international sport system is a concomitant exclusion from their national sport system, resulting in lack of funding, exclusion from school physical education, and the declining interest of younger generations. A few ethnically marked sports such as judo, wushu and Thai kickboxing (Muay Thai) have managed to thrive and spread internationally; others, such as traditional wrestling in Senegal and India, or kabaddi in India, have maintained a national fan base on account of their intense identification with national and ethnic identities (Hann 2018; Alter 1992, 2000). Generally, however, Western cultural imperialism has replaced local sports with sports of Western origin throughout the world.

The disseminators of nineteenth- and early twentieth-century British and North American sports were fervent adherents of muscular Christianity, a form of Protestantism that idealised athleticism, virility, and discipline. They also firmly believed in their own superiority as white men, and used sport to justify masculinism, nationalism, and colonialism (Mangan 1981). In the US sphere of influence, particularly East Asia, the Young Men’s Christian Association (YMCA), offered sports to young men (and to a lesser extent women) to convert them to Christianity (Gems 2006). Arguably, their more lasting contribution to world history was not the diffusion of Christianity but the diffusion of British and North American sports, particularly rugby, football, and cricket (spread by the British), and baseball and basketball (spread by North Americans).

Well into the twentieth century, sport was deeply entangled with European colonialism and American imperialism. The racist ideology that undergirded colonialism and slavery extended into sport and generated the enduring stereotype of the ‘natural athlete’ who possesses physical prowess adapted to his ‘savage’ existence, although this stereotype had its opponents among those who believed in the physical superiority of the ‘civilized’ white man (Brownell 2008). Anthropologists have long rejected that race is a biological category and demonstrated that race is a subjective interpretation of people’s superficial appearance, and these interpretations shape the reality of individuals being judged. Individuals may be naturally predisposed to certain forms of physical activity, but to say that entire groups are is nonsensical, because sports skills are the product of individual life histories shaped by social opportunities (Marks 2008: 395).

In schools, the military, and the police, colonisers taught sports to the colonised so as to instil in them what they considered civilised values. Later, however, sport became a conduit for decolonization as the colonised appropriated sport toward their own ends. In some cases, the desire of colonised people to beat the coloniser at their own game led to a national passion for a sport. In the Caribbean, cricket games became the stage for anti-colonial resistance against their British masters, as famously documented by Afro-Trinidadian intellectual C.L.R. James (2013). In other cases, the colonised adapted sports to their own social and cultural contexts. Such was the case with cricket in the Trobriand Islands off the coast of Papua New Guinea, made famous in Trobriand Cricket (Leach 1976), a documentary that has delighted many anthropology undergraduates worldwide over the decades with its scenes of several dozen players dancing in military formation to songs loaded with sexual innuendos.

Sport under capitalism and socialism

In the colonial metropoles, sport replicated the class hierarchies on which industrial capitalism was based. In Britain, public-school-educated elites were anxious to distinguish their sporting activities from the rough-and-tumble and morally suspect working-class ballgames. By the 1870s, the government had regulated the punishing industrial work schedules and workers could finally enjoy some free time, and blue-collar boys and men enthusiastically took up the newly codified sports, particularly football, encouraged by factory owners who saw an opportunity to distract them away from social unrest and improve their work ethics (Munting 2003). As football became popular among workers, public schools gradually abandoned it in favour of rugby.

Elites used arguments based on moral imperatives to justify the role of sport in maintaining the social divide: the amateur ideal maintained that athletes should be motivated by fair play and honour and not by material interests and was alleged (incorrectly) to have been inherited from ancient Greece (Young 1984). Amateur rules excluded members of the working classes, whose participation in sport often depended on skipping work. Late nineteenth-century Britain saw the eruption of conflict over ‘broken time’, namely compensation for time away from work to engage in sport. The IOC, which has regulated the Olympic Games from their revival in 1896, forbade Olympic athletes from openly receiving payment for competing until the late 1980s (Llewellyn & Gleaves 2016). Continental European and North American IOC members sometimes chafed at the rigidity of British members on this point.

In the twentieth century, as elite-level sport became increasingly commodified, social classes became polarised in a different way. In many professional sports, athletes now were largely of working-class or ethnic and racial minority (and later migrant) background, while team owners, managers, and other technocrats were overwhelmingly members of the elite classes. The class structure of sport thus reproduced that of nineteenth-century industrial capitalism, with athletes selling their labour for wages and capitalists owning the labourers, controlling contracts and setting wages. Only recently have court challenges and collective bargaining granted professional athletes greater control over their labour power. In the United States, most elite-level athletes have benefited from athletic scholarships to universities, where they are unremunerated despite generating huge revenues for the institutions (Gilbert 2016).

Even at the non-professional level, sport is deeply entangled in social-class politics. We owe the most systematic analysis of these dynamics to French sociologist Pierre Bourdieu (1984), who observed that members of the same social strata tend to gravitate towards the same kinds of sport and have little enthusiasm for (and sometimes despise) the sporting activities associated with other social classes, a process that he labelled ‘distinction’. Football in Britain and France, for example, appeals largely to the lower-middle and working classes, while elites prefer golf, tennis, and skiing. In some cases, these distinctions can be attributed to the resources required (e.g., for most people, skiing assumes the ability to travel, take time off work, and purchase expensive equipment), but in other cases material explanations are insufficient. Sport ‘choices’ thus have the effect of inscribing persons into a particular position in hierarchies of social class, race, ethnicity, gender, sexuality, and age.

In reaction to the class, gender, and ethnic distinctions that were already so deeply ingrained in ‘bourgeois’ sport in the early twentieth century, the Soviet Union, after its founding in 1917, attempted to develop an alternative socialist model of sport. Sport in the USSR was originally financed by industries and, after the 1950s, increasingly by the state, as the country began seeking sporting victories to demonstrate the superiority of socialism. State-supported athletes were derogatorily called ‘state shamateurs’ in the capitalist West for violating amateur rules, while socialist countries maintained that they were remunerated as soldiers, workers, or students. The West acquiesced in this fiction because international sports fields were one of the few meeting places where citizens of the communist and capitalist worlds could come together.

Socialist nations further demonstrated their commitment to equality in sport by organising sporting events that showcased ethnic minorities. The USSR organised the first Central Asian Games in 1920, which inspired China’s National Games of Minority Nationalities, held quadrennially from 1953 to the present, featuring sports associated with the 55 officially recognised non-Han nationalities. The relationship between sport and ethnic identity was a legacy of the continental European traditions of folklore and ethnology that predominated in Russia and China: traditional sports counted amongst the local customs (along with dances, rituals, and other practices) that scholars used to classify people into ethnic groups. However, these events clearly serve the assimilationist goals of the state (Liebold 2010).

In multicultural capitalist countries, indigenous minorities started using sports events as an identity-affirming political strategy in the 1970s. Indigenous peoples of Canada and the United States organised the first Arctic Winter Games in 1970 and the North American Indigenous Games in 1990. These competitions include both indigenous and global sports (Paraschak & Morgan 1997).

The neoliberal restructuring of sport

In the late twentieth century, the expanding global economy wiped out the socialist experiment (except for China, North Korea, and Cuba) and the inexorable increase of commercialization and professionalism compelled international sport organizations to eliminate the amateur rules. In many parts of the world, neoliberal economic policies privatised television channels, which found in the most popular sports a readily available and at-first inexpensive content with which to fill airtime. Corporate advertisers soon flocked to the new media platform, fuelling the escalation of television broadcasting rights fees. With it came an exponential rise in the wealth of elite clubs, sport federations, and top-level athletes and the dramatically uneven distribution of this wealth, as only a few sports are regularly televised and very few athletes earn enormous salaries. Corporate sponsorship of teams and events attracted multinational sources of capital into sports. Meanwhile, satellite television became commercial in 1982, bringing images of sporting glory to viewers in the Global South.

The wealth that today revolves around the most popular sports, such as football, rugby union, and basketball, has mobilised the yearning of ethnically and racially marginalised young men in the destitute urban settings of the Global North. In the inner cities of North America or the underprivileged suburbs of Western Europe, a career in sport was a way out of poverty. Very few actually made it, but ethnic and racial minorities came to numerically dominate some professional sports, such as basketball and American football in the United States, although the corporate structure of the sports continued to be dominated by wealthy white men.

More than a century has passed since racist evolutionary theories were abandoned in anthropology, yet in popular culture the hyper-visibility of non-white athletes continues to provoke searches for biological factors that supposedly explain sports skills in terms of race. Sometimes the biological argument about an innate athletic gift is twisted to argue that people of European descent are still superior in the ways that count. For example, Pacific Island and Māori male rugby players are said to be extremely successful players thanks to their ‘natural’ talent, but they are widely branded as undisciplined, unreliable, and unteachable (Hokowhitu 2004; Besnier 2015). Race-based arguments erase the fact that athletic prowess is the result of extraordinary personal efforts, and that young women and men of colour may be disproportionately represented in sports because other paths to mobility are closed to them.

Since the 1980s, clubs and teams of the most popular sports like football and basketball, now corporate entities, have been embroiled in a cutthroat competition for economic survival. They have recruited increasing numbers of players in the Global South. Concurrently, many economies in the former colonial world have collapsed as a result of the world’s turn to neoliberal economic policies, and entire countries have become emigrating societies. In this context, many young men, who have been particularly affected by shrinking labour markets, dedicate themselves to sport with the dream of signing a contract with the top teams they watch on satellite television (Besnier et al. 2018).

The transnational mobility of athletes has reconfigured the relationship between national identity and citizenship, as increasing numbers of athletes representing cities and nations are immigrants or children of immigrants. Some countries fast-track migrant athletes to citizenship, most blatantly oil-rich countries in the Persian Gulf, which have sometimes mounted teams consisting mostly of newly-minted citizens from the Global South while at the same time barring access to citizenship to low-level migrant workers who had toiled there for decades (Besnier, Brownell & Carter 2017: 219-22).

Sports have become a battleground of racial conflicts, in which some athletes have used their hyper-visibility to protest discrimination, as illustrated in the protests in the United States since 2017 by African-American football players who ‘took a knee’ during the national anthem to protest racial oppression. The decision of team owners in the National Football League to ban the practice as ‘unpatriotic’ served as a reminder that the world of professional and international sport is a system that reproduces racial and other hierarchies extant in society. Although athlete protests have stimulated public debate about race in the United States, there is little evidence that longstanding power structures have been reformed in response.

Sport, gender, and sex

In the West, most modern sports were a ‘male preserve’ at their inception and continued to be a last bastion of traditional masculinity (Dunning 1986). In the early modern Olympic Games, women competed in sports that did not challenge Western ideals of femininity, such as figure skating and archery, but it was not until 1928 that a few running events were added for women, and not until 1964 that the first team sport, volleyball, was added. In the United States, gender inequality was not addressed until the US Congress enacted in 1972 sweeping legislation known as ‘Title IX’, whose effect on sport was the requirement that women’s sports in schools and universities be allocated the same funding as men’s sports. In contrast, sport in China after the 1949 Revolution quickly became a path to upward mobility for peasant women and never was a male preserve (Brownell 1995).

Gender segregation is woven into the very fabric of modern sport. The common argument is that it ensures ‘fair’ competition, since men are thought to be stronger than women. However, there are sports in which women compete successfully with men, such as equestrian events, yet women were only allowed in an equestrian event at the 1952 Olympics. Men and women do not have to be separated by gender, as is evident in mixed-sex sports such as doubles in tennis or mixed-sex running relays. Women might also be competitive with men in some sports if they were divided by weight-class divisions rather than gender (Healy et al. 2014).

That the gender line is not just about fairness for female athletes is demonstrated by the fact that the world of sports has been a bastion of heterosexuality, characterised by strong homophobia, from the nineteenth century up to the present. It is ironic, because the Western all-male institutions meant to turn boys into men, such as public schools in Britain and the YMCA in the United States, tacitly encouraged surreptitious same-sex attractions that were forbidden in mainstream society (Gustav-Wrathall 1998). Still today, male professional sports and the international sports system display a homophobia that is in many ways more profound than that of mainstream society. Very few professional athletes have ‘come out’ of their own accord. This has prompted gay, lesbian, and transgender people to form their own associations and events, most prominently the Gay Games held every four years since 1982 (Symons 2010). Moreover, the clampdown on homosexuality has persisted even while rampant sexual abuse of both boys and girls has been endemic in sports and has been covered up by coaches and administrators, a reality that is only now undergoing widespread public examination. The most egregious example is the case of USA Gymnastics national team doctor Larry Nassar of Michigan State University, who was brought to justice in 2017–8 for assaulting hundreds of young female athletes over many years while the institutions turned a blind eye (Carr 2019). Taken as a whole, the history of sex, gender, and sexuality in modern sports reveals sport’s role in defending the gendered structures underpinning industrial capitalist society of the past century and a half, including a fundamental division between male and female, and compulsory heterosexuality.

The ongoing controversies over sex testing reveal the centrality of the gender paradigm in international sports up to the present. Sex testing dates back to the Cold War, when the International Association of Athletics Federations (IAAF) and the IOC instituted a visual exam and later a chromosome test for women on account of the suspicion that the communist block was fielding men masquerading as women in order to win medals. Political tensions were expressed in a gender idiom: questioning the sex of socialist women neutralised the political challenge posed by the gender equality in sport under socialism at a time when Western women were oppressed by the postwar cult of domesticity (Besnier, Brownell & Carter 2017: 129-34).

Sex testing has never exposed a man competing as a woman, but it has identified, often in the worst possible way, a small number of athletes who are intersex; that is, who exhibit non-normative combinations of biological markers of sex (e.g., chromosomes, hormones, genitalia). Most are individuals with Complete Androgen Insensitivity Syndrome, which heightens their testosterone level, although this has never been shown to confer an athletic advantage. Those who are targeted are frequently athletes from the Global South, the best-known case being Caster Semenya, a South African runner who had won world and Olympic championships. The historical realignment of suspicion from the Soviet block to the Global South suggests that global geopolitics plays a role in sex testing in sport despite its appearance as neutral science (Jordan-Young & Karkazis 2019).

Sport as cultural performance

Sports take on the role of defending fundamental structures of power by putting those structures on public display in embodied form. Such public events are typically organised by elites, who try to control what is put on display so that their social status remains unchallenged. Contextualised in the classic anthropological theory of the gift, sports events take on another dimension (Brownell & Besnier 2016). It is well-known that humans will go into deep debt to fund rituals and ceremonies. While this doesn’t make sense according to market economy logics, it is unproblematic in the context of a gift economy in which elites increase their prestige and strengthen alliances by organising extravagant events.

For example, buzkashi in Afghanistan was deeply embedded in a gendered world of men and their competition for reputation through extravagant displays of generosity in grand gatherings during which buzkashi was played (Azoy 2011). Because the gatherings required considerable volunteer labour, only a khan with a large network of kin and non-kin who owed him labour could pull off a buzkashi tournament. Similarly, summer Olympic Games would not be possible without the armies of volunteers who provide basic labour. More heads of state, CEOs of major corporations, billionaires, and celebrities attend Olympic Games than any other world event. There they lavishly entertain guests, display their influence, create relationships with new allies and partners, and seal deals with old ones. The dynamics of buzkashi festivals are found in the Olympics, but on a much grander scale, and critiques of the Olympics that only analyze them through market economic principles may be missing the point.

Sports events enthral audiences because they are cultural performances, namely condensed moments when participants consciously represent and evaluate values, roles, and societal institutions (Singer 1959; Turner 1982, 1988). The most widely-read example of such a cultural performance is Clifford Geertz’s (1972) interpretation of cockfighting in Bali in the late 50s, as ‘a story the Balinese tell themselves about themselves’. The metaphors he employed to illuminate the Balinese enthusiasm for cockfights are frequently applied to sports events: they are a mirror for society, an expression of a culture as a whole, and a story that we tell ourselves about ourselves.

Three important theorists of cultural performances, Max and Mary Gluckman and Victor Turner, debated whether a sports event could qualify as a secular ritual, a ritual-like behaviour not clearly associated with religious beliefs. They all concluded that sports do not qualify as rituals because they do not possess mystical or liminal qualities. However, subsequent scholars who conducted more research specifically on sports have found it enlightening to apply ritual theories to sports. In particular, they have emphasised that sports events may induce a sense of communitas, a sentiment of solidarity and shared humanity. Scholars have asserted that the World Cup and Olympics create an ‘upsurge of fellow feeling, an epidemic of communitas’ (Dayan & Katz 1992: 196) and ‘an enhanced consciousness of humankind’ (Giulianotti & Robertson 2004: 558; see also Roche 2000; Rothenbuhler 1988).

However, these scholars were based in sociology and media studies, while anthropologists were not part of this trend because, since the end of the 1980s, many have become critical of communitas as an overly optimistic concept that fails to recognise that not every participant and spectator is equally vested in the event. Who produces the performance and controls the symbols, whose agenda is served, and who is disadvantaged? Are common people being duped by the elites who organise big events? These questions would best be answered through ethnographic research, but to date there has been little ethnographic work on major sports events that has sought to understand the power relations between elite organisers, spectators, and athletes and their networks. Perhaps predictably, such work has tended to show that the on-the-ground reality is not a simple divide between exploiter and exploited, because major events involve a large number of social groups, the relationships between them are complex and under constant negotiation. Disadvantaged groups can benefit from the media spotlight by drawing public attention to their causes in a way that is not possible under normal circumstances (Klausen 1999; Brownell 2012b; Lindsay 2014).

The competition in sports means that the results are unpredictable, and so athletes worldwide deploy a wide range of practices designed to deal with uncertainty and fate, some derived from local cultural contexts, others derived from global flows, blurring the distinction amongst religion, magic, morality, gender, and bodily technique. Their practices include local magical practices (Gmelch 1978), revivalist religions such as Pentecostalism, which is increasingly popular amongst athletes from the Global South (Rial 2012; Guinness 2018; Kovač 2018), as well as sports techniques and training, the ideology of scientific professionalism, and sport psychology. In the national sport of wrestling in Senegal, wrestlers employ the services of marabouts, magico-religious specialists who prescribe potions, amulets, and rituals that merge Islamic and local cosmologies; but they combine the services of the marabouts with the hard training of an individualistic self and commercial sponsorship in the neoliberal mode (Hann 2018). Even when they emigrate to other countries to play professionally, indigenous New Zealand Māori rugby players call upon mana, the supernatural power that draws from their connection to kinship, spirits, and land (Calabrò 2014). Young men from upper-middle and upper-class families in exclusive rugby clubs in Buenos Aires participate in a Christian spiritual movement with the logo of a cross inside a rugby ball. Outside the door of some clubs stands a statuette brought back from the Our Lady of Rugby chapel in southwest France (Fuentes 2018).

Body enhancement and its limits

Sport has increasingly given us a glimpse into bodies of the future. The records for wheelchair athletes competing in track and road races are faster than those for runners on legs, but the clear separation between human and machine has enabled their segregation into their own divisions, such as the Paralympic Games. In 2015, the IAAF banned South African runner Oscar Pistorius, a lower-limb double amputee, from competing with the argument that the properties of the carbon-fiber prosthetic legs he wears gave him an unfair advantage, but he successfully sued and made it to the 400-metres semi-finals in the Rio 2016 Olympic Games. His case opened up entirely new ethical dilemmas, but since no other Paralympian has achieved his level of success, Pistorius must be credited with a great deal of talent, whatever advantage his prostheses might have given him.

However, new technologies may soon allow even average athletes to compete with top natural-limbed athletes. Gene doping, the non-therapeutic use of genetic enhancement to improve sports performance, does not yet exist, but genetic manipulation has produced ‘super-mice’ with superior strength and endurance. So far as we know this has not yet been tried on humans, but it was banned in 2003 as a preemptive strike by the World Anti-Doping Agency.

Clearly, the future holds novel technologies that will bring along increasingly complicated ethical dilemmas extending beyond the world of sports. Are we heading toward ‘transhuman athletes’ who have exceeded the bounds of normal human capabilities (Miah 2010)? All elite athletes exceed the bounds of normal capabilities—whether because they are taller or shorter than average, have large lung capacity, or any number of other physical traits. In the future, maybe it will become common practice for average humans to seek genetic and prosthetic enhancement in order to succeed in sports, careers, and life. Should this be prohibited? If defending class and gender lines occupied the greater part of the attention of administrators of international sport in the nineteenth and twentieth centuries, it may be that defending the line between what is ‘human’ and what is not will occupy them in the twenty-first century.

Conclusion: sport and scale

By the beginning of the twenty-first century, the wealth that revolved around sport, particularly the major international sports, had become so huge and its presence in popular culture so powerful that the longstanding tendency amongst academics, journalists, and many politicians to dismiss it as inconsequential began to change. Critics of sport mega-events, particularly the FIFA World Cup and Olympic Games, became increasingly vocal, countering rhetoric about the potential of sport to contribute to a better world by publicising violations of human rights common in the context of mega-events, such as mass evictions for construction, the silencing of dissidents, the exploitation of migrant workers, and the corruption by government officials and the leaders of sport organizations. ‘Social responsibility’ in sport became a keyword taken up by sport organizations in response to the critics.

Sport is somewhat unique in the repertoire of human activities in that it connects the intimacy of bodies, emotions, and personal projects to a global system of capital, world politics, and mega-spectacles. These connections operate on multiple fronts. For example, the collapse of economies in the Global South under pressure from neoliberal policies has destroyed labour markets, while the glamour of sport broadcast on satellite television fuel impossible dreams of sporting success among disenfranchised youth in these countries. Anthropologists are concerned to make sense of all the entanglements of the world in which we live, and sport distils them into clearer structures that can help us comprehend the complex whole.

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Notes

Some of Niko Besnier’s research discussed in this article received funding from the European Research Council under Grant Agreement 295769 for a project titled ‘Globalization, sport and the precarity of masculinity’ (www.global-sport.eu). Susan Brownell received funding for some of the research discussed here from International Studies and Programs and the College of Arts & Sciences at the University of Missouri-St. Louis.

Note on contributors

Niko Besnier is Professor of Cultural Anthropology at the University of Amsterdam. His books include On the edge of the global: modern anxieties in a Pacific island nation (2011) and Gossip and the everyday production of politics (2009). He is co-editor of Gender on the edge: transgender, gay, and other Pacific Islanders (2014) and Crisis, value, and hope: rethinking the economy (2014). In 2014–9, he was editor-in-chief of American Ethnologist.

Niko Besnier, Afdeling Antropologie, Universiteit van Amsterdam, Postbus 15509, 1001 NA Amsterdam, The Netherlands. n.besnier@uva.nl.

Susan Brownell is Professor of Anthropology at the University of Missouri-St. Louis. She is the author of Training the body for China: sports in the moral order of the People’s Republic (1995) and Beijing’s games: what the Olympics mean to China (2008), and is the editor of The 1904 Anthropology Days and Olympic Games: sport, race, and American imperialism (2008).

Susan Brownell, Department of Anthropology & Archaeology, 507 Clark Hall, One University Boulevard, St. Louis, MO 63121-4400, United States. sbrownell@umsl.edu.

Open Encyclopedia of Anthropology - Globalisation

Pandemics

Introduction

Vulnerabilities in global connections

Social inequalities, from local causes to global amplifications

Horizons to anticipate the future

Entangled relations between human and non-human species

Conclusion

References

Note on contributor

Monsters

Introduction

Contouring the anthropological definition of monsters

Monsters across the anthropological record

Conclusion

Acknowledgments

References

Note on contributor

Medical pluralism

Introduction

Medical ‘system,’ ‘tradition,’ and ‘pluralism’

The state

Modernity, science, and efficacy

Gender

Globalisation

Conclusion

References

Note on contributor

Neoliberalism

Introduction

Neoliberalism as world system

Neoliberalism as mode of governing

Ethnographies of the state and labour

After neoliberalism?

Conclusion

References

Note on contributor

Global health

Introduction: An awkward relation

Emergent transformations in global health

Anthropological engagements with global health

Conclusion

References

Note on contributors

Sport

Sport in anthropology

The emergence of modern sport

Sport under capitalism and socialism

The neoliberal restructuring of sport

Sport, gender, and sex

Sport as cultural performance

Body enhancement and its limits

Conclusion: sport and scale

Further reading

References

Notes

Note on contributors