Foucault (1990), (2007) and Biehl (2008)

Michel Foucault. (1990). The History of Sexuality. Part V. Right to Die and Power over Life.
The right of the sovereign was centered in taking the life, the right to let die or let live, but the west has seen a profound change in this right and now the right lies on the social body and its capacity to maintain and develop its life. There is a dual power over death and over life. Is not the sovereign who needs to be protected but the whole population needs to be defended. The work of the state, according to Foucault has an underlying principle “the tactics of battle –that one has to be capable of killing in order to go on living- has become the principle that defines the strategy of the states” (137). Power is exercised at the level of the biological existence of the population: a biopolitics of the population. And it has two aims: subjugation of bodies and control of populations. Foucault defines bio-power as “what brought life and its mechanisms into the realm of the explicit calculations and made knowledge-power an agent of transformation of human life” (143). There is a relation between the law, which operates through the norm, which are incorporated within power apparatuses with the aim to regulate population and, ultimately, to normalize society.

Michel Foucault. (2007). Security, Territory, Population. Some quick ideas taken from Chapters 1, 2, 5 and 9.
The main question that circulates through all Foucault’s work is how specific forms of power had been produced, contested, reproduced, applied and resisted in the history of the western world. Politics of stuggles and truth are at stake, especially mechanisms of power (disciplinary mechanisms, mechanisms of security, and juridico-legal mechanisms). Foucualt wants to show the correlation between juridico-legal, disciplinary and security mechanisms of power. More over, he focuses on the slow development of techniques of security and its relation with the control of populations conceive as multiplicities. There is a central relationship according to Foucault among security, territory and population. The sovereign power in the last 200 years changed in quality and it was needed to produce a different form of power not tied to controlling populations fixed in a state but in terms of probabilities and risks, in terms of the uncertainties of the event, in relation of the circulation of good and people. Security mechanisms came precisely to reduce the insecurity of the event (and of controlling the populations). And here Foucault clearly differentiates the distinction between disciplinary mechanisms with their centripetal forces that concentrate and enclose, and the security mechanisms with their centrifugal forces that “lets things happen” (freedom of circulation it’s a technology of power in itself). Finally, the discussion Foucault starts in relation to governmentality is so pioneering that after more than 30 years it is a “hot topic” nowadays. He is trying to think on the “art of government” and how it emerged in the western world and consolidated in the totalizaing institution of the state. The modern state has to control multiplicites that are constantly moving, this pastoral power is what charactaerize the modern forms of governmentality.

Joao Biehl. (2008) Will to Live. AIDS Thereapies and the Political of Survival. Princenton/Oxford: Princenton University Press.
AIDS in Brazil is a particular case of state formation, civil activism, political rights and access to health. In many cases NGO activism came together with state policy making, and with the emphasis on treatment access instead of prevention “political rights have moved toward biologically based rights” (2008). Many activists groups in order to change the political economy of AIDS became visible through lobbying and pushing for lawmaking. Brazilian State central role in reaching a wider population of people experiencing AIDS (33% of its total population have free public treatment provided by the state) was performed thanks to what Biehl calls as the “pharmaceuticalization of public health”. Which means the creation of state responses that some times contradicts the global political economy of pharmaceutics and their drug monopoly, a pharmaceutizalization of governance and citizentship. Brazil broke the patent of an AIDS drug and started to import a generic one from India. Still marginalized underclass people, even in Brazil, are not taken care and they have to make big efforts to receive treatment.

The book is centered in both macro (state and pharmaceuticals) and micro-levels (an NGO in Salvador) of analysis and a two-phase fieldwork on 1997 and 2001 which helped Biehl to re-consider the trajectories and struggles people experiencing AIDS had, especially people that left the NGO and were not considered for treatment because they were seen as homeless that could not assure their willingness to follow the treatment. But as Biehl shows, these people also had the will to live and their personal stories show that. The interconnections among AIDS, pharmaceuticals, global health initiatives, the state, social inequalities, social experience, and subjectivity were central to understand what’s going on in the crossroads between medicine, political activism, public health, state policy, science, charity and homelessness. But this is an open-ending story, big pharma companies are constantly lobbying in order to not lose their monopolist rights, and the Brazilian state under Lula’s government has move in a slightly different direction jeopardizing some of the state sovereignty in terms of biological and pharmaceuticals governance. Although in 2007 the state made the movement to stat buying to India generic forms of AIDS drugs. But still the state has a different standard for black or non-black population not only in regards to AIDS but also in relation to public allocation of resources.

What I take from these quick readings (I have to come back and read them more carefully)?
From Foucault: the historization of power mechanisms and the State, and, at the same time, the de-naturalization of power and the State and de-centralization of the State. Also the political intervention over populations as an object of study and political manipulation. The different types of illnesses that Foucault considers, and the forms of political intervention (lepra/isolation, quarantaine/encloser, free circulation/security), are all important to think the sorts of illnesses that are useful to develop the system in terms of security and biopolitics (infectious diseases and environmentals) but don't know how this would play if I use this analysis in the children's hospital I will work in relation to cancer and hereditary diseases... I should ask why these children are sick? In terms of population and probabilities, these children are a small population of rare types of diseases in comparison with the average because the hospital treat children from all over the country and even bordering countries such as Paraguay. I would probably find different interpretation of why these children are sick by the children, their families on the one hand, and the more scientific view from the different class of professionals on the other hand. The case of children with AIDS would also be interesting to analyze using a Foucaultian frame in relation to discplines and management of populations. Indeed, within the hospital the two mechanisms of power, disciplinar mechanisms and security mechanisms should be very present (in the way children and families can or cannot do certain things, but in the way families trangess certain order but professionals and nurses let them do it i.e. letting eat more than the children when the family lack resources).

From Biehl what I take is his approach: he goes from micro to macro leveles of analysis, from the experience of localized and situated real people, with their unique faces and trajectories, to the political economy of pharmaceutical multinationals with their lobbying powers of seduction and corruption, from the politics of public health in Brazil, especially in Salvador do Bahia, to the global debates in relation to AIDS and poverty, from the wide access to AIDS drugs from a free and public state to the activists and NGOs that pushed and lobbied to produce that form of state, and ultimately from the marginalized people outside any type of assistance or access to anything but who still have the will to live to the extreme social inequalities of Brazil today. And Biehl adds, when all this approach lacks of words, he puts images, so there are pictures taken by a friend and fotographer (Eskerod) in black and white that gives you a different close view to the lives of these people (which, in Foucault's terms, the people are the ones that are against the security mechanisms of the population because they refuse to be treated as population).

I think what is important from these readings in both Foucault and Biehl is the need to re-think the state. For instance, we talked with Jon about the different approach to the state in Negri (antagonism), Holloway, Zizek (in relation with the statist such as Lenin) in which the state is the exercise of the collective will. For Jon this is a sign of a post-hegemonical state where the state is immanent, for him neither power nor the state is at stake... I guess what is at stake is the affective "power" of the multitude, a power that is completely unexpected in its effects and consequences...

Another thing worth checking is the multiplicities of power that traverse and experiment the hospital, and how they contribute to the tensions within the abstract and general logic of biopower. My focus, in the same line with Biehl, would be the tensions between populations, statistics and the real people... putting always people first.

Farmer and Kim (1991), Castro and Farmer (2005), and Farmer (1999)

Farmer, Paul and Jim Jim Yong Kim. “Anthropology, Accountability and the Prevention of AIDS” The Journal of Sex Research 28.2 (May 1991): 203-221

Castro A and Paul Farmer. “Understanding and addressing AIDS- related stigma: from anthropological theory to clinical practice in Haiti” American Journal of Public Health. 95.1 (Jan 2005):53-59

Farmer, Paul. “Invisible Women: Class, Gender and HIV” Infections and Inequalities: The Modern Plagues Berkeley: University of California Press.

On this week we have texts that focus on HIV/AIDS and the different ways it has been associated with for instance Haitian people or with poor women across the world. In the fist article Farmer and Kim highlight the racist and inaccurate beliefs in the physical and social sciences in relation to the origin of AIDS. For many years the common assumption was that AIDS was introduced as a foreign invasion from Haiti to USA. The specific targets of those assumptions were Haitians because many researchers and specialists had put their explanatory believes in the conviction that Haiti was the cradle of AIDS. This belief, based on racist and discriminatory notions, was then proven wrong, but the consequences of it have lasting effects in how Haitian were (mis)treated in the USA. For a real prevention of AIDS, Farmer and Kim suggest, issues of AIDS-related discrimination to Haitian had to be unpacked and re-considered. The authors conclude with five projects regarding the “ethical considerations in anthropological research on AIDS”: 1) to explain why AIDS is becoming an illness of the disadvantaged? Why so many Afro American and Hispanics have AIDS in comparison with other groups? (Which political economy is producing this type of outcome?); 2) a cultural critique to different socio-cultural responses to AIDS and how stigma works differently in Haiti or in USA; 3) to witness and to honor the memory of individuals who have died from AIDS, and of communities affected by AIDS and stigma; 4) to counteract false and irresponsible misinformation, fear and racism; and 5) to show the effects of this misinformation and work as “cultural-activist” not only “to the AIDS pandemic, but to the epidemic of discrimination that has risen in the wake of HIV” (1991: 219).

In the second article, Castro and Farmer move one step further and focus on AIDS-related stigma in Haiti from both anthropological and clinical approaches. For the authors stigma and discrimination is a form of Human Rights violation. Stigma/discrimination is built under relations of power, dominance, hegemony and oppression but is too constantly resisted. AIDS-related stigma is produced by the social formation of structural violence, forces that include racism, sexism, political violence, poverty and other inequalities rooted in historical-economical processes that shape the circulation and results of HIV/AIDS. The authors show that although still within processes of medicalization, there are two completely different forms of approaching people’s experiences with AIDS: one that I would call as “re-medicalization but with good faith”, what Castro and Farmer propose in this article (to support people with AIDS with HAART (highly active antiretroviral therapy), which creates a “virtuous social circle”; and, what I would call as “re-medicalization with bad faith” (expropriation of people’s own experience), which creates a “vicious social circle.” For Castro and Farmer, “only a biosocial framework drawing on both qualitative and quantitative methods can hope to assess the epidemiological, social and economic impact of both the epidemic and responses to it” (2005: 57).

In the third article, Paul Farmer highlights the fatal connection between women, poverty and AIDS around the world, a connection that is almost invisible in the public and scientific perception. First, AIDS was considered a disease of men, but since the beginning they were affected and especially poor, young, women. From the 1990s in the so-called developing world more women than men became infected with HIV. For Farmer, the experience these women have “is a result of structural violence: neither culture nor pure individual will is at fault; rather, historically given (and often economically driven) processes and forces conspire to constrain individual agency” (79). Poor women were, and are, silenced from public discussion; indeed, they have been unheard. These women suffer the “triple curse” of objectification, institutionalized powerlessness, and blame for their condition. For Farmer, some of the myths and mystification that are part of poor women with AIDS’s lives is what he calls as the “exaggeration of personal agency”, and he adds, “There is nothing wrong with underlining personal agency, but there is something unfair about using personal responsibility as a basis for assigning blame while simultaneously denying those who are being blamed the opportunity to exert agency in their lives” (84). Efforts to change this situation should be oriented to empower poor women, and this means to find ways to let them gain control over their own lives.

Coutinho (2003) y Azogue (1993). Chagas. Brazil y Bolivia.

Comments on
Coutinho, Marilia. 2003. “Tropical Medicine in Brazil: The Case of Chagas Disease,” in Diego Armus (ed.), Disease in the History of Modern Latin America. Durham: Duke University Press.

Azogue, E. “Women and congenital Chagas; disease in Santa Cruz, Bolivia: epidemiological and sociocultural aspects” Social Science and Medicine. 37 (1993): 503-511.

Coutinho.
Chagas, as a condition that affects humans “only when their living conditions become so degraded that they are similar to those of the natural reservoirs” (76) is the focus of this work. Here, Coutinho wants to understand the social determinants of transmission of this “disease of poverty”, which is carried by an estimated of 18 million people in Latin America, with 25% of the total population at “risk”. Perhaps the specific form in which Chagas is transmitted via an insect that defecate feces infected with a parasite which penetrate the human host through the wound and get into the bloodstream makes this disease more “repulsive”. By 1909 “neither parasite nor bug nor disease was known before Carlos Chagas” (77) discovered it. The beginning of the 20th century saw the emergence of a particular branch of medicine: “tropical medicine” not only in the colonies of the imperial powers but also in countries such as Brazil. (There was a distinction between the “insect vector theory” in the tropical diseases from the metropolitan infectious diseases.) The Tropicalista School in Brazil was involved with development and social justice, they “opposed slavery and openly rejected the tropical degeneration thesis that was popular in Europe in those days” (79). They have a political agenda of national development and self-reliance in relation to health care. Chagas had a lot of opposition within and outside Brazil. After his death the disease was forgotten and research stopped, although the disease was spreading throughout the continent. In Jujuy, Argentina with some overlap Salvador Mazza also conducted many research and found the etiology and with the help of Cecilio Romaña discovered the specific diagnostic marker of the acute phase, a conspicuous eye infection. They promoted a radical change in the conditions of living for people at risk and the fumigation (burning if was possible and feasible) of rural houses. In Brazil with the military coup the d’état in 1964 almost all the parasitological research was ruined and researchers dismissed and fired. The main reason of the disease, poverty and poor housing and life conditions, was never attacked by any government neither in Brazil nor in Argentina.

Azogue.
The main points of this article is how regions where Chagas disease is endemic (tropical and sub-tropical regions and in the valleys) develop into “risk areas” for women migrating from non-endemic regions, and the need to produce proper strategies for the control of this non-vectorial type of transmission of Chagas disease. This congenital transmission in the second generation is the focus of this article.

Diego Armus (2003) Tango, Gender, and Tuberculosis in Buenos Aires, 1900-1940.

Diego Armus. 2003. Tango, Gender, and Tuberculosis in Buenos Aires, 1900-1940. In Diego Armus (ed.), Disease in the History of Modern Latin America. Durham: Duke University Press.

In Argentina, between 1870 and 1950 tuberculosis was one of the main causes of death (though still prevalent in marginal populations such as indigenous people). In this article, Armus focuses in three lines that collide in the first half of 20-century Buenos Aires. He follows the development of Tango, of gender relations and the growth of Tuberculosis in order to show how they not only were entangled but how one was used to think the other. For instance, when waves of immigrants came to Buenos Aires, a city that in 1930 had almost 2.5M people, the relationship between the elites and the newcomers was in many aspects very tense and, thus, it was portrayed in the media and in Tango lyrics. Tensions between the center and the neighborhoods (one of the key spaces of social integration and argentinization according to Armus) of the city (still important today) started to arise when the elites felt threatened by the mass of immigrants slowly but steadily enclosing the center. In this context, metaphorical associations connected TB as a romantic disease of refined and sensible people with gender anxieties. Although most men died of TB than women, women were more visible in the media and literature as having TB than men (men were associated with syphilis). Anxieties that were showing signs of a society with a relatively high social mobility, in which the barrio “becomes the emotional geography of the poor” (106), but in which women were sanctioned for their movement from the barrio to the center. TB was imagined as a disease of excess (of passions, consumption) in a context in which people were over-exploited and worked in very poor working conditions. In these circumstances the figure of la costurerita appeared in the Tango lyrics. She represented the consumptives who contracted TB because of excess of work and difficulties but who did not leave behind the barrio, “the costureritas are protagonists of a journey fed by the desires and dreams of rapid social ascent, which can also end up in tuberculosis” (111).
The other figure Armus brings is the milonguita, a character that kicked off with the explosion of Tango with the help of the mass media through radio, movies and newspapers. Women were the subject (and object?) of Tangos such as “Don’t leave your neighborhood”, which started to portray how women became artists, coperas or queridas. Armus says, “Whatever their status, all these women had bet on a life away from the domestic barrio ideal. Their choice for a more autonomous life led many men to see them as a threat to the ruling gender order” (114).
Ultimately, comparing the milonguita (or milonguerita) with costurerita provides Armus a powerful approach to gender and power issues in the formation of the Argentina “multicultural” nation because it helps to show male fears and the struggles that men and women had when they tried to achieve social mobility within the Argentinean society.

Green (2004) An Ethnography of Nonadherence: Culture, Poverty and Tuberculosis in Urban Bolivia

Green. 2004. An Ethnography of Nonadherence: Culture, Poverty and Tuberculosis in Urban Bolivia. Culture, Medicine and Psychiatry 28: 401-425.
Working with five patients on a clinic in a suburb neighborhood in La Paz, Bolivia Green tries to understand how Aymara people (before the very radical changes brought by Evo Morales) although confident of biomedical diagnosis and treatment of Tuberculosis could not keep up with the long treatment due to structural poverty and lack of government aid. Normally a TB treatment would take up to 6-8 months with the first 2 having to go everyday to the hospital for the medicines. In the last decades a specific form of treatment arise, a short-course directly observed therapy (DOTS) in which patients must be present every day for as long as 4 to 6 weeks (then would be once every week) in order to take their pills. TB is the first cause of death in adults in Latin America, but in Bolivia within indigenous people the rate is 5 to 8 times higher than the national average. Nonadherence is considered when a patient doesn’t or can’t finish his or her treatment. At least four causes explain the widespread of TB, the correlation with HIV/AIDS, the relation between TB and adverse social conditions, the rise of drug resistant and multi-drug resistant traits due to nonadherence to treatment, and the incessant risk of contagion of inadequately treated patients. These four causes are enhanced by four more common factors: the blaming on the patient; the patient’s psychological structure; demographic factors such as gender, sex or income; and cultural and linguistic differences produced by the lack of knowledge about the local culture. Citing Farmer, Green considers that the “structural violence” is what can explicate how “poor adherence within an ethnically marginal group is often better explained by economic or political constraints than by folk-cultural constraints” (403). Some of this socio-economic-political constrains are “structural variables such as geographic and temporal availability of health care, hidden costs of treatment, and quality of available care” (404). The informants have to make a big effort to go everyday to the clinic to receive the medication, sometimes they could not afford to pay the bus so they would walk for 1 or 2 hours each way to the clinic and back home. They also have difficulties to keep up their job if they have one, or to look for one if they were unemployed, because going to the clinic would take a big chunk of time (they would be waiting and waiting for a whole morning). So when they could not carry on with the treatment for any reason (always very logical) then they were afraid of the reprimands by the doctors and social workers who would treat them, sometimes, discriminatorily. If social workers would complain that patient are putting their life in risk, patients would say that they need to support their families and can’t afford not to work. Although patients do feel sometimes that guilty for having “abandoned” treatment and this further complicate the decision to go back to the TB control program. All the patients were using both traditional and biomedical medicine, and they all agree that for TB biomedicine was better suited to cure it instead of the palliative treatment provided by traditional healers. I think this article is interesting to see how patients were using multiple forms of care and cure, and although they wanted to be treated by biomedicine for curing TB, they could not keep up with the treatment due to structural constrains such as hidden costs of the treatment (transport and additional costs such as X-Rays) and professional discrimination against Aymara population.

Rubel and Moore (2001) The contribution of Medical Anthropology to a Comparative Study of Culture: Susto and Tuberculosis

Rubel and Moore. 2001. The contribution of Medical Anthropology to a Comparative Study of Culture: Susto and Tuberculosis. Medical Anthropology Quarterly 15(4):440-454.

In this article the authors want to re-think different approach to the study of both susto and tuberculosis via cross-cultural comparisons. They’ve found three types of cross-cultural comparisons, one that compares different groups sharing the same region, another that compares within a society, and a third one that find worldwide comparisons. In relation to susto, or the state of being asustado, they’ve found that “among Latin America’s indigenous peoples” (a little bit too over-encompassing) susto appears when an essence is “thought to be captive because the patient, wittingly or not, has offended the spirit guardians of earth, a river, a pond, the forest, or collectivities of animals, birds, or fish” (442). I think that this explanation excludes other forms of susto according to indigenous peoples in which certain forms of witchcraft or even torture can trigger it. For the authors, in the case of non-indigenous peoples the cause of susto is a fright. In both cases the therapeutic effort is concentrated in returning the spirit essence to the body. In any case, the authors concluded that susto should be considered more as a syndrome caused by profound stress and with a high rate of mortality.
In relation to Tuberculosis the authors (with the help of more researchers) developed a study in which they could compare variations among gender, gender roles, and health knowledge in a single society (Mexico). They’ve found that, in comparison with the widespread symptoms of susto, tuberculosis is a very confined condition. The common symptoms are constant cough, bloody sputum, night sweats, weight loss, and fatigue. The research they’ve conducted was designed to understand how working-class Mexicans understand and react to respiratory disease. They wanted to understand people’s knowledge of the disease, they defined knowledge as “understanding of the causes, implications, and treatments of respiratory conditions that result from everyday experience with them, regardless of their biomedical acceptability” (446). They used “humoral” characteristics because they’ve found that in Mexico “hot and cold humoral dichotomy” is still very important to explain ill conditions. What I do not understand of this study is that at the beginning they’ve found that humoral characteristics were important and they used them in the surveys, and then in their conclusions they say that “these working-class Mexicans do, indeed, share a humoral model of respiratory health conditions” (447), but wasn’t this what they exactly went to look for!? Another conclusion they’ve made is that women have a stronger understanding of respiratory conditions through humoral qualities than men. I don’t quite understand the need to made so many surveys to come up with conclusions that were already included in the hypothesis. Perhaps they could have done more qualitative studies and come up with new information and not information they already pre-filtered.

Green (1999). Fear as a Way of Life.

Laura Green. 1999. Fear as a Way of Life. Mayan Widows in Rural Guatemala. New York: Columbia University Press.

In an environment of violence, fear and impunity the Guatemalan Mayan sense of collectivity and community, and the social connections among people, when completely destroyed and demolished, had to be constantly rebuild. In this book, Green tries to understand and represent the contradictions and (im)possibilities that Maya widows and orphans who survived the military and guerrilla violence, especially the (para)military destruction of hundreds of rural Maya communities, mass-massacre of at least 80.000 people (mostly men), face in their everyday life.

In a constantly shifting social landscape filled and formed with violence and impunity, fear could be considered as a logic response, some sort of tactic according to Green, by which Maya widows embody the memory of their lost husbands, cousins, parents, uncles, brothers and (re)create affirmative actions in their realities of suffering and oppression when now they have to become “mothers and fathers” at once. In a context of structural violence, when humiliation and fear, denial of dignity and integrity are over-present forms of micro-social processes of domination, when local communities are traversed by relationships of victim-witness-victimizer between neighbors and even family members are shaping the intricate forms of political and micro-social violence. One of the main forms of dominance and destruction created by the Guatemalan army was to use Maya boys as foot soldiers and local men as civil patrollers and military commissioners for surveillance and often for murdering, digging deeper fissures in family and community social relations. Maya women have to work to sustain their families, organize themselves and re-territorialize forms of political and community action when working in the milpas, something that before was usually done by men, producing corn in the same land in which the ancestors had cultivated and worked and harvested it. Here, the psychological, emotional, social and spiritual connection that Maya people have with their land is something worth noting. The massive destruction of hundred of rural communities not only killed and displaced thousands of people but also helped to augment the concentration of land and the exclusion of Maya people from their own lands. But this is a long process in which non-Maya Ladinos have used force, torture and the disappearance of Maya men for their own political and economical interests: forces of structural inequalities and political violence created a deadly cocktail. As Green says, “War, trauma, Christianity, loss of land, loss of control over their labor, poverty, and the introduction of farming crops and modern institutions have influenced who the Mayas are today” (52) and each generation have to confront the causes and conditions of their Mayaness.

And fear, when becomes chronic, when inscribed in the body and the collective imagination, when is the referee of power, it grows and grows and becomes a way of life: a meta-narrative of people living in a constant macro and micro “state of exception” when injustice is the rule. And this endless state of violence cannot and should not be taken in any abstract way, these are specific forms of fear and (in)visible violence which concretely traversed people’s lives in this capitalist neo-colonial Guatemala (with a huge portion of violence produced by the same state). Fear turns into the very nature of interactions and relations among people in rural communities (and perhaps in all the country). For Greeen one of the main “quality” of fear is its power to produce a sense of doubt in our own perception of reality: a self-censorship that internalize and anestheticize fear when situations of fear are constantly being repeated. Moreover, when people are living under constant surveillance and scrutiny by the military forces surrounding the Maya villages and the inner Maya people working for the army is not easy to felt overwhelmed by the (in)capacity to be in a continuous state of alertness.

The internalization of war and the militarization of everyday life in the context of Guatemala, some sort of “militarization of the mind” (Martin-Baro 1990), was a consequence of the continuous and very visible presence of soldiers and paramilitary personnel all over the country. So one relation between silent, fear and secrecy could be that silence can work as a survival tactic, but on the other hand, silencing is a brutal mechanism of control imposed through fear. When fear is a constant state in everyday life how can people act and react to it? Thus, silence via terror is not only psychological and individual but also collective and social as well. Added to this the fact that these women were transformed from wives to widows aggravating their suffering, and their need for economic, social and emotional support. With fear to return to their own villages and the kin ties completely destroyed and transformed many women and children left their villages as inner displaced within Guatemala or went to exile in Mexico in order to overcome their fear and suffering and re-start their lives economically, socially and politically renovating their network of support. These women live in a “chronic state of emotional, physical, spiritual, and social distress” (112), thus, I agree with Green that considering their organic disorders and their “folk illnesses” as manifestations of “clinical syndromes” or “culture-bound” illnesses is to “dehistoricize and dehumanize the lived experiences of the women” (112).

Green criticizes certain assumptions within anthropology, particularly how embodiment and the body are taken for granted in many theorizations when trying to understand everyday forms of violence. For Green, an analysis of the relation between violence and embodiment clearly shows the incapacity to split experience and cultural representation, and also reveals how power, gender and history work via “embodied subjectivity” and “concrete bodily activity.” Green considers that the body “is both a sociological and historical phenomenon, and knowledge is gained though the senses and sensory immersion in the natural and supernatural world” (114). This particular definition emphasizes embodiment as the territory in which human beings struggle beyond its usual consideration as a metaphor of human action or a mere text. What these women had and felted and experienced was connected with their emotional memory and bodily pain, their ill conditions had an obvious political causation. And when the women were meeting together and discussing about their common condition certain forms of community of pain and healing were being developed. For Green naming their suffering as illness had powerful results, “[it] created spaces for struggle while giving bodily shape to the image the women have of themselves as widows. Memory and pain served as a source for regenerating community and identity and for political consciousness” (117). The body in “itself” was the center of political demonstration due to women’s bodies were indeed the physical representation of the violence against the Maya population.

What I take from this book is a couple of things. I will have to come back often to issues of fear and other strong embodied emotions when dealing with children's end of life, family members and medical professionals for my dissertation. Also I will have to consider the role of the state as provider and mediator of services for terminally ill children. So in many ways Green's book would be useful to think on how to approach these issues. The situation is totally different because these women's fear comes from other sources, the state was the main producer of violence, death and fear; whereas in Argentina fear, anxieties and distress is mainly produced by the awareness of children's dying process. But still I think I will have to re-consider very closely if fear does not transform as a way of life for these people and what's the role of the state promoting or precluding those feelings and emotions of fear in children and their families.

Briggs (2003) Stories in the Time of Cholera: Racial Profiling During a Medical Nightmare.

Briggs, Charles. 2003. Stories in the Time of Cholera: Racial Profiling During a Medical Nightmare. Berkeley: University of Berkeley Press.

This book is about social imaginary and social inequality. It is also about the modern projects of creating different kinds of citizens. For Briggs, the creation of denigrating images, its circulation and consumption shapes public perceptions and the creation of public policy. He situates these tensions between the social production of sanitary citizens (capable of understanding modern medicine and providing self-care) and unsanitary subjects (inept to self-care and/or understand medicine) such as the Warao indigenous people in Venezuela as the struggle for appropriating or denying basic social and political rights. In this line he is very close to Paul Farmer’s approach. Briggs considers that the associations between Cholera and poverty and cultural difference facilitate the legitimacy of social inequality in each place. Thus, to think about disease and inequality without blaming the others creates the need for practicing health and social sciences on the “basis of a shared sense of responsibility and justice” (xviii).

Like Chagas, Cholera is considered a “disease of poverty”, in which certain forms of orientalism produce associations with pre-modernity and superstitions, although many epidemiologists think it is indeed a modern disease. For instance, if you one considers that national-states in Latin America have been attacked by, and shaped their practices because of, international monetary organizations such as IMF or World Bank in the 1980s and 1990s (and before in the 1970s helping with money dictatorships) and the involvement of US and other rich nations in Latin America supporting military governments, one could conclude that these other forces have “modernized” (in a narrow sense of producing more and more unsanitary subjects and less and less sanitary citizens) and help to produce the conditions that create cholera. Another problem is the creation of images of dirtiness and primitiveness of these other people that lack hygiene and “modern habits”.

The images of the cholera were mainly produced by a knowledge highly medicalized by biomedical professionals, and disseminated by the media with almost no criticism to the types of images and stereotypes they (re)produce. There was a big contrast, according to Briggs, between the medical personnel in situ trying to keep indigenous and criollos alive, and the governmental anti-cholera campaign that was hegemonizing the information and were portraying the general image that the situation was under control. In these circumstances, a general racialization of death as “local” (cholera was always there) and “natural” (for the indigenous people) phenomenon was produced using narratives of modernity, science and hygiene (or lack of). So the information produced to the middle-class urban population was under strict governmental control and has a direct aim: to blame indigenous for their fault in contracting cholera.

For Briggs, a process of racializing and spatializing cholera was developed although it contradicts in itself when not only indigenous people but also criollos became affected. But the media rarely criticized the official discourse in relation to cholera, and when they did so, when they create what Briggs calls as “intertextual gap” and criticized the government, they implicitly assumed the rhetoric that racialized and spatialized cholera. Moreover, both physicians and media believed that indigenous people were incapable of understanding biomedical concepts or appropriating of hygienic practices according to their own perspective. The ultimate effect of the governmental and media message was a meta-communicative message: “if you die it is your fault”. In the same line that with the Peruvian case, Venezuela did only attack the symptoms but never embarked in attacking the structural causes: access to potable water and waste disposal, medical care and education, and reducing social inequality. 1991 and 1992 were critical years to the indigenous people, and specifically to their claims for land, human rights, and access to medical care so these struggles were overlapped with the cholera crisis and thus created an explosive situation in Delta Orinoco. Ultimately, the cholera crisis deepened the social and racial inequalities of the region.

I am trying to think on the double side of poverty-disease. It is a tricky exercise. On the one hand, people get sick because they “are” poor, and this means because they have an unequal “access” (this is a neutral word) to drinkable and potable water, to sewage systems, to education, to health services, to different part of the state. And then, on the other hand, people are poor because they “are” sick? This is the main corollary of neo-liberal policies at the regional, national and transnational levels. Briggs and Cueto show how cholera was stigmatized, racialized and spatialized in a very particular way. So one can assume that for many parts of the “society” (or whatever we may call it) the association is first, they are sick, second they are poor. All these types of stereotypes such as “they are filthy”, “they eat raw fish” (very different from sushi, that’s is cool), “they do not have any kind of hygienic habits”, are constantly (re)produced in the mass media and in the self-prophetical discourses of middle and upper classes that are (re)assured they are not like them, these others. But how are we going to take this knowledge, and act upon it? In both sides of the equation, poverty=disease, or disease=poverty people are actively engaging with these struggles over meaning, values, practices and actions. Said that, I still do not know how to work and produce a critique to this. Of course, showing these contradictions can help to see how the logic of disease=poverty is manipulated to cover up what we all know, that poverty=disease. But still, if we say so, we are somehow playing the game we do not want to play, which is to give a passive role to the subaltern (or whatever we may call it) that can only criticize this depiction of their reality but not actively produce a different space where to destroy and overcome these two logics.

Cueto (2003). Stigma and Blame during an Epidemic. Cholera in Peru, 1991.

Cueto, Marcos. 2003. Stigma and Blame during an Epidemic. Cholera in Peru, 1991. In Diego Armus (ed.) Disease in the History of Modern Latin America. Durham: Duke University Press.

Looking at epidemics in specific societies can lead to understand social production of inequalities or can lead to reinforce them through strategic uses of blaming-the-sick rhetoric. Something like this happened with the Cholera in Peru in 1991 when “inner forces” (Sendero Luminoso) and “outer forces” (World Bank, IMF) put Peru under major sets of “crisis”: economic, political violence, collapse of public services, reduction of the state under neo-liberal policies, etc. One thing that underscores this article is the political manipulation and masking of the key role of (poor or inexistent) water and sewage systems that made possible the epidemics of Cholera (and the individualization of the problem), the fight that health workers made to the disease, and the general and governmental perceptions and images that emerged during and after the epidemic and the after effects in the general public health.

When Cholera started to spread in some parts of the country, the first reaction was to develop radical measures that would control the Cholera (ban of fish, veggies, fruits, raw, and canned food, then quarantines of Peruvian passengers in international airports, etc.). In the first months Cholera had a different impact in the urban, rural, highlands or Amazon areas according to the distinct access (or not) to (un)contaminated water (safe drinking water was unequally accessible: in rural areas only 22%, in cities 67%, and in shantytowns 24% of the population). Although diarrheal diseases was always present, and even though Peru had the 3rd highest rate of infant mortality mainly caused by these types of diseases, the extension of the Cholera epidemic was immense. And it came in the “worst moment”, when hyperinflation, political violence and terrorism (both military and guerrilla were terrorists killing and disappearing thousands of people) were devastating the country (although one would be inclined to think that Cholera came because of the social conditions).

At this juncture Dr. Vidal, the Peruvian minister of Health at that time, started a campaign to change the behavior and perceptions of common people, he follow WHO indications and implemented oral rehydration therapy and wide use of antibiotics to help patients in the overcrowded public hospital of Peru. During the epidemics Peruvian researchers found out that the literature in relation to treatment to severe cases of Cholera was wrong and they developed low-cost effective treatments using saline solutions. Another thing that happened was that people went massively to the public and free hospitals in contrast with the 1980s when a movement of de-centralization of public health, with the influence of primary health care movement, was de-hospitalizing public health. But much criticism arose to Dr. Vidal’s policies and he eventually quitted his job. Fujimori denied that eating raw fish could lead to Cholera and the government changed its campaign focusing on the individual behavior, especially poor individual behavior, for the government and media the equation was clear filthiness + poor areas (slums) = Cholera. This, indeed, masked the deeper? real? causes of the problem, that unequal access to water & sewage & health services = Cholera. It became a self-fulfilling prophecy, because the majority of the people that died from Cholera came from the slums and the lower classes of the urban spectrum, this should lead to conclude that it is their fault, and they are the causes of Cholera. In fact, as Naomi Klein suggests with her “shock doctrine”, Cholera reinforced the neoliberal trend, and Charles Briggs also implies that Cholera stigmatization was instrumental in further marginalizing of the poorest inhabitants of the cities. The final note to highlight is that after the epidemics many Peruvians “realized that taking care of the sick was an individual and family responsibility and expected less from the state” (285), and if this is true it means that the neoliberal policies and the idolaters of the shrinking of the state have won.

Rebhun (1994) Swallowing frogs: Anger and Illness in Northeast Brazil

Rebhun, LA. 1994. Swallowing Frogs: Anger and Illness in Northeast Brazil. Medical Anthropology Quarterly 8(4):360-382. Conceptual Development in Medical Anthropology: A Tribute to M. Margaret Clark. (Dec., 1994).

Women in Northeast Brazil employ the term "swallowing frogs" to explain from their own perspective what happened when hatred, frustration, anger and strong (negative) emotions are trapped or suppressed by social forces and cannot be exteriorized. These women are traversed by very distressful situations, and their anguish is allegedly “canalized” via folk illnesses that somatize distress such as evil-eye sickness, nerves, or susto. In this context we have a whole description of boiling machines under pressure, which are almost to explode. There is a tension between what these women feel (anger, anguish, anxiety, envy, etc.) and what others are expecting them to (properly) express at a social level (self-sacrifice, generosity, love). Because, if they don’t control their negative emotions not only they would be physically hurt but also socially devaluated. These are “embodiments of distress in which body symptom and psychological experience are one and the same” (361); so to say that someone is having susto is to imply that this person has both symptoms and a distressful psychosocial situation (something that usually is not so emphasized).

In a way, what we have seen before with susto is also happening here, the idea that people are catching up with, and there is a gap between, cultural expectation and personal experience. One thing that Rebhun remarks that I did not find in the other text is the “use” of these “folk illnesses,” some women may use them for their own propose, perhaps not even consciously; the author says, “Because of embedded moral discourses, emotional folk medical syndromes cab become powerful tactics in the struggle to control and manipulate friends, neighbors, and family members” (361).

One important question Rebhun makes, after showing that these illnesses can be considered in many different ways according to the region and socio-cultural contexts in which we locate the analysis, is “what do these diagnoses mean, how are they interrelated, and how do they fit into the micropolitics of power in families and local communities?” (364). For her, the question of whether, when and how get sick is very important, because naming someone as having “susto” or “evil-eye” is moral judgment (the same happen with biomedicine) about the situation and condition of the sufferer, especially in terms of gender, men and women would feel and express their emotion in very different ways according to each society. For instance, women and men would feel very different emotions and causes of their emotions, Rebhun says, “people encounter many reasons to feel these, from the anguish of frequent bereavement, to the frustrating humiliations of trying to get basic services from an uncaring government bureaucracy, to the injustices of poverty, to the many betrayals perpetrated by those who are supposed to love one another” (364).

Therefore, as we can see these emotions are not so easy to categorize, and the limits between “sickness”, “morality”, “emotion”, and “social condition” are blurry and difficult to separate, and so “Emotional life becomes a series of battles over interpretation and consequences of moral behavior” (365). What is clear here that there is a micro-politics of “swallowing frogs”, of silencing strong emotions for not causing familiar and social problems, but ultimately is producing physical and psycho-social instability, but there is always as a background a latent explosion of uncontrollable anger and fury. Rebhun concludes that through all theses “folk illnesses” in Northeast Brazilian women and men “discuss their traumas, weaknesses, and victimization, and negotiate social relations” (375). I can see Rebhun's main points and the contradictions she is trying to highlight between pure organicistic and scientific vision of "culture-bound" syndromes and her more complex approximation to social and emotional aspects of everyday experience that are self- and alter-categorized as illnesses. I prefer her approach, which is more sensible to the social fabrics of suffering, emotions and illness than others that are more centered in identifying etiologies, diagnoses and treatments but seems far of understanding what’s really going on people’s hearts and minds.

Mysyk (1998) Susto: An Illness of the Poor.

Mysyk, Avis. 1998. Susto: An Illness of the Poor. Dialectical Anthropology. 23(2): 187-202.

In Latin America the “folk illness” commonly known as “susto”, also called as “pasmo”, “espanto” and “perdida de la sombra” can be defined as “soul (or vital force) loss through magical fright”. The associated symptoms are usually: listlessness, weakness, loss of appetite, lost of interest in personal appearance, restlessness during sleep, and often more acute symptoms such as fever, vomiting, and diarrhea and may even cause death. The basic pattern to treat susto was to recognize the event that caused the fright, to search and find the lost soul (vital force) and eventually its re-appropriation into the body. Mysyk find three common explanations for susto, which were reciprocally exclusive: physiological (hypoglycemia), psychological (hysterical-anxiety disorder), and social (incapability to live up to social relations).

The main goal of this article is to reconsider who suffers and why. Mysyk wants to highlights the relationship between susto and class situation, which according to him has been almost ignored. He traces the Nahua explanation of loss of the vital force or tonalli, which could be lost or harmed by witchcraft. Then he refers to Rubel who finds that susto occurs in social situations which people sense as stressful, situations that are intracultural and intrasocietal, stressful situations that depend on the significance of each particular task and the failure to achieve it in each society, and therefore individual’s personality, his/her health status, and society are all implicated in the production of susto. Then, O’Nell found two types of fright: a “rationalized” connected with nonhumans, which has a slow symptomatology and the “precipitating” connected with humans, which has a fast symptomatology, and the author identifies a symbolic reflection of the “victim’s” stress pattern.

But for Mysyk, it is not clear if O’Nell consulted with the “victims” if there is actually a symbolic relation between the frightening event and the stress patterns. One could say that poor people and low class conditions are traversed by violence and constant forms of fear (Green would call it “fear as everyday life”), so the question is way certain people in these types of conditions develop susto? For Mysyk is clear that class position and cultural marginality and social mobility are central in the explanation of susto. But “susto” is embedded in a continuum from indigenous people that treat it with indigenous healers to ladinos that see it only as a term (this is what Mysyk says) that refers to intestinal parasites and which are treated with biomedical medicine. He then says that susto is “symbolical statement of an individual’s position in the community, whether self- or other-perceived” (195) and it implies different “message” depending the class position and social mobility; for instance, in case of mestizos in Bolivia the symbolic statement is their “downward mobility”.

For Mysik the corollary is that susto is the result of social conditions that turn unmanageable by the poor people, mainly poor peasants and landless laborers. What strikes my attention is that Mysyk is fast to dismiss explanations centered in role stress to put his explanation of class position but I still cannot understand what he means by class position. It seems that structural-functional ideas of (mis)adaptation are brought into the discussion without explicitly referred to them.

Weller et al. (2002) Regional Variation in Latino Descriptions of Susto

Susan Weller et al. 2002. Regional Variation in Latino Descriptions of Susto. Culture, Medicine and Psychiatry 26:449-472.

In the literature Susto is considered to be cause by a frightening event (specific in time) involving another person, an animal, a spirit, or a situation. It can cause either a displace of “an immaterial substance, an essence” (Rubel et al. 1984: 8, cited in Weller et al. 2002: 449) from the “body” that would cause the “victim” to become ill, but in other cases (which they don’t consider so much) susto can be caused not by a subtraction of vital force but by addition of vital force, in this case by an introduction of a spirit into the body (something very frequent in shamanic societies in which the shaman has to make certain rituals to expel the intruder). In the literature it was also common to find susto associated with a higher risk of anemia and parasitic infections, and overall a higher mortality rate. The key point when considering the “frightening event” is that it has a negative effect in interpersonal relationships. Stop here. A brief note: can we be very sure that the event that causes susto has an effect in interpersonal relationship? Could it not be also a cause in itself? In the classic anthropological literature in the Chaco region, for instance with Toba people, in many cases the (negative) interpersonal relationships were the cause of conflicts, that would eventually lead to people making harm one another via shamans and so loosing one of their many souls, and therefore causing susto. So here the effect is susto and the cause is the change in social relationships not the other way around.

But Weller et al do not consider this. They cite Logan (1979) who refers to competency for resources as a cause for sorcery, and the need for a healer to cure this “supernatural” causes of frightening, but then during their own research they give less weight in their analysis. They consider more the situation in which the “essence” is lost, and there is a subtraction of vital force. Their focus is more on “community descriptions of susto”. And they center their research in three “communities”, one in Guatemala, another in Mexico (although Guadalajara is not precisely a small community, it’s a 3M city), and the last in a small town in Texas, US. They develop a 127-question questionnaire. Another brief note: Why so many question? Who would answer them? The interesting thing about their inclusion criteria is that people have to know and believe in the existence of susto. In the US they chose people self-identified as having Mexican descent, and I wonder why? Non-Mexican people cannot have susto?
In only one point the researchers mentioned non-traditional, they put it as “more contemporary”, causes such as use of drugs in Mexico. But besides this there is still a big divide between “culture-bounded” syndrome such as susto, and “more contemporary” types of illness, it seems that susto is seen as a traditional believe that people somatized but it is not actually “true”. I wonder which would be the difference in approaching and understanding susto if researchers would actually know, believe, perceive, and experience it?

Nelson (1999). A finger in the wound.

Diane Nelson. 1999. A finger in the wound. Body politics in Quincentennial Guatemala. Berkeley: University of Berkeley Press.

Chapter 1 Intro:
Nelson uses the metaphor of a wounded body politics, and a finger that deepen the wound in a still postcolonial and post-civil war Guatemala with multiple sub-divisions and tensions en carne viva. In the introduction she set up her journey through a highly complex and very frequently re-visited social landscape: ethnic relationships, nationalism and the state, gender violence, modernity vs. tradition, and racism just to mention some. But she manages to give new insights and a fresh look to what was going on in Guatemala at the late 1980s and beginning of 1990s. Nelson says that her book is not only “an ethnography of the state as it emerged from thirty years of civil war and military dictatorship” (4), but also is an ethnography of the emerging Maya’s and Ladino’s identities that are intricately related with the reconfiguration of the nation-state as a producer of articulations between modernity and tradition, nation and ethnicity. Nelson tries to grasp the articulations that cause, and are the condition of, Quincentennial Guatemala as a moment of danger and fear. Following Hall she defines articulation as “a relation, a joining that creates new identifications and social formations” (2). She also defines Quincentennial Guatemala as the “sickening fear, the fierce exhilaration, and the doggedly persistent hope of these intricately articulated emergings” (4).

An important thing worth to remember is that Nelson is analyzing a process, and she reminds us that 20 years ago (in 2009 this means 30 years ago) “Maya” in Guatemala was either part of Archeological knowledge, something of the distant past; or when referring to linguistic difference; or when government were making tourism promotion. However, for 1992 it was clear that Maya people were following a deep reorganization through indigenous activism with pan-indigenous goals (to move beyond the local ethnic differences). But Nelson is aware that identity should not be seen as “easily taken” or “willfully discarded” (5), instead identification occurs through the small buildup of slight effects of “orthopedic change”, and she takes orthopedic in a Foucaultian way, is an endless recurrence of sites of power that are historically overdetermined, and through “unconscious investments and resistances” (5). Nelson ultimate aim in this book is to show how ethnic, gender and nation-state identities are reciprocally produced, and those they do not exist outside their relationship to each other.

History as Catastrophe: First of all, between 1978 and 1984 an estimated 70.000 people (mostly indigenous) were killed, 40.000 disappeared, and more than one million (1M out of 8M, to compare with Canada would be if 4.25M would have to escaped) flee the country during the civil war. The military contra-insurgency literally wiped out hundred of indigenous villages in the highlands and created a political economy of violence that was loaded with feelings of fantasy and paranoia.

Because Nelson focus is indigenous activists, she made the distinction that themselves do between “cultural rights groups” and “popular” sector with a more classic leftist and Marxist class orientation. She focuses only in the first group because she considers the latter organizations underestimate the power of race and racism and she will concentrate in organizations that focus on linguistic, education and development issues. But she always has in mind the inter-relationship between Maya organizations and the Ladinos reactions, and how they in turn are forced to think critically of their own identity. Both identities are embedded in myriads of meanings and stereotypes; Indian is sometimes coded as female, others as child. Therefore, the Quincentennial Guatemala is a strange site for ladino identification because it recognized it’s own body politics as wounded. But also is central here the role of the state, a schizophrenic state, that on the one hand tried to wipe out or force assimilation Maya indigenous people but on the other used them as tourist resource and workers. This double bind in Batesonian terms of love and hate is what characterizes the relation between Guatemala’s state and Maya organizations.

Nelson relies in the idea of “body image”, how a subject represents his/her own body, other bodies, and how other people represent the subject’s body to talk about the wounded body politics, because the body image is required to manage any prosthetic. But she is also concern with multiple dimensions of popular culture such as pleasure and laughter and therefore jokes, movies, fashion, and science fiction would be central. Her approach to these issues is using a “methodology of fluidarity”, a “practice and analytics that combine solidarity –being partial to, as in the side of, the people I work with- with an acknowledgement of how partial, how incomplete, my knowledge and politics have to be” (31).

Chapter 3: State Fetishism and the Piñata Effect.
Nelson says, “Although most agree that the Guatemalan state is politically exclusive, ethnically discriminatory, and economically monopolistic, it may be precisely because of this insecurity, this tenuousness, that the state is also open in some ways” (84). This is what she calls the “Piñata Effect”: the idea that if you shake it, you’ll take the sweets. This attraction and repulsion to the State not only from the Maya’s but ladino’s (and other minority groups) point of view create multiple tensions, desires, and jokes. One central notion here is that the nation-state is in ruins. Perhaps because ladinos now are recognizing that are not an homogenous category (there are struggle between which ladinos will control the state apparatus). Or, perhaps, because class is interpenetrated with ethnicity and so what was a given now it is not any more. In any case, Maya are becoming cultural stronger but ladinos feel cultural weaker, and so it is projected an identity crisis onto the nation-state. But at the same time the process has produced a certain denaturalization of the relation ladino-national identity-control of the state: now ladino’s identity is a problem. Before culture was a sign of Maya’s powerless but now that they are organized culture made them more fashionable (and relatively more powerful), whereas, in contrast, ladino’s identity become more problematic.

There is the image of the ruin, the state is in ruins, the ladino’s identity is in ruin, Guatemala lives for and of the (Mayas) ruins; all this fueled by the sense that the state has no legitimacy after decades of military and civil elite government (with no clear line between both) and under constant suspicious of being a bunch of corrupted and ignorant people. Indeed, the state was a military state, and by the 1980s the counterinsurgency had affected directly or indirectly almost all Guatemalan families. During 1985 and 1996 many things remained the same (violence and assassinations were still happening) but others started to change. In 1996 there was the Peace Accords and the feeling of “democratic spring”, although Guatemala kept being a militarized state (the Army still today holds an enormous economical, political and legal power). Nelson also considers Chatterjee’s idea that the colonies were the first places in which the metropolis tried modernity, and she shows how in Guatemala the highlands were a “modern laboratory” in which model villages as state policy reterritorialized the indigenous villages in order to gain a better control and particular forms of governmentality in the “counterinsurgency war”. But in this process, Nelson also shows how the “new” army was the only state institution that really understood indigenous issues (trying to transform the womanized Maya into masculine bodies in the army, using Maya symbolism, etc.).

The “state” is neither different from the “civil society” but not the same, there is a complex intricate relation of interpenetration in which state policies tried to fix in a double way of stabilizing (homogenizing, erasing and dominating) and repairing Maya culture (Maya language unification and approval of new laws protecting indigenous rights). These paradoxes, Nelson asks, can be grasped with the idea of state fetishism? And what about the idea of “piñata effect”? For Nelson it represents the contradict sense of hitting the state for being corrupt, racist, and responsible of ethnocide and at the same time waiting to gain the power and resources that are magically projected onto the state. Both Maya and ladino relations in the topography of the state are overdetermined by what Zizek calls “ideological fantasy” (I made a typo, that now I’ve found interesting to consider, I typed indeological fantasy), a sort of dreamwork process through which social relations take contingent forms. The tension between “Maya” and “ladinos,” as heterogeneous as they may be, was also centered in terms of modernity and tradition. The visible emergence of Maya organizations made clear that national and ethnic identities, and modern and traditional claims, are not given but subject to struggles and contestations. Things changed and Maya organizations started to adopt the symbols of modernity while at the same time contested ladinos’ use of Maya images, especially gender uses of Maya women, for their own particular interest.

Chapter 6: Bodies that splatter.
There is certainly a battlefield of the allegedly integrated national ethnicity of mestizaje shaped by the elites’ racializing and womaining discourses and practices that interconnect nation, gender, race, ethnicity, class, sexuality as reciprocally constitutive. The tortured and wounded and massacred splattered bodies are polysemic and mean differently according to each specific body and the particular audience (for the army is an enemy that in 40.000 times had to be disappeared, for the Maya is a sign of injustice and impunity), and this also means that Guatemala as an ethnic-nation is split (“a nation that is not one”). The body politics of Guatemala also splatter because it is in constant malfunction, ladinos, mestizos, and Maya are mutually constituted as others, the political production of difference is what makes splattered bodies and what can help us to understand some of the national fixations with the Maya as woman and ladino as man (woman as the “universal donor” to the blood politics of mestizaje). For Nelson, this fixated claim that in Guatemala everyone is mestizo, and because of this the racialized body does not count and only culture counts, creates the belief produced by elites and ladinos that “because we are all racially mestizo, then we can escape racism” (240). But instead this shows the fragile instability in which ethnic and racial categories are built in Guatemala in which a ladino is anxious to be taken as an Indian and where ladino elites are trained to “see” (through some kind of false consciousness) the difference between Indian and white bodies while at the same time hide that they may actually be mestizos.

Chapter 9: Global Biopolitical Economy
Maya are a source of all kinds of labor and forms of cultural and material production that depend on the state regulation and on contingent articulation of identifications, which Nelson calls “prosthetic dependence on gendered bodies” (350), and she describes the way gender and sexuality are linked with a body politics as a biopolitical economy. But a third-world biopolitical economy, with a wounded and incomplete body politics, it is also a source of inner and outer conflicts. For instance, Maya culture was considered as an obstacle to the development of Guatemala in both left and right narratives (its backwardness and its incapability for revolution). But the same Maya culture helped Guatemala to organize its participation in the global economy after 1985. And Guatemala was not the only Latin America country that during the 1980s and 1990s was object of IMF and World Bank neoliberal policies intended to “adjust” and modenize the pre-modern and traditional nation reducing the state (and leaving it open to the penetration of international policies) but at the same time re-producing culture as a “productive resource” when tourism became the main industry (fueled by the same images of pre-modernity and tradition that were supposed to be erased). Here Nelson brings again the idea of prosthetic, this medium that inter-connects different bodies politics images: between Maya and ladino, women and men, poor and rich, modernity and tradition, which all work inseparably together.

But ultimately, Indian women as the concentration of indianness are key to both the national and international biopolitical economy. They are working in many cases in unpaid jobs and supporting their families, speaking out in the peace process (in which Rigoberta Menchu is only one of them), they are pushing to reconsider machismo within Maya organizations, but they are also the images that attract tourists who would look for them when traveling to Guatemala. But now that the constant articulations of identities made the state and Maya organization reformulate themselves and one to another, now that Maya identity is powerfully shaped by the state and vice versa, still many more contradictions are being inscribed and explode in more prosthetic relationality because these bodies politics are gendered, racialized, imagined, and fantasized in vulnerable and incomplete fluid ways.

After this overview I think I don’t find much to criticize or even to problematize Nelson’s work because it is a very fresh and rich study with a broad aim and profound intrincacies. She is conscious of her own gringa position and she takes a political and epistemological stand on the side of the heterogeneous Maya collective, and especially on the Maya women. Her emphasis on the relational aspects of history and bodies politics the need to see the interconnections and mutual influences between gender, race, ethnicity, nation, sexuality, modern and traditional discourses and practices, and national discourses of mestizaje is what I found very interesting about her book. The only question I have is now, in 2009, ten years after she wrote her book, how cynical (disbelieve in politics) and/or pragmatic (believe in micro-politics) Maya women and men, Maya organizations have become in relation to the spaces of maneuverability within their own organizations, with the state, and with international agencies? How much pragmatic cynicism or cynical pragmatism is part of our everyday experience as citizens of the modern states in which more or less all feel that talking about, acting upon, and producing a practice in relation to our inequalities and inner divisions is like putting a finger in the wound?

Ayora-Diaz (2000) Imagining Authenticity in the Local Medicines of Chiapas, Mexico

Ayora-Diaz (2000). Imagining Authenticity in the Local Medicines of Chiapas, Mexico. Critique of Anthropology. 20(2): 173-190.
One important thing when considering other forms of healing not-biomedical such as the so-called “local medicines” is how people think about them, which symbolical and material efficacy it has for producers and users, and more importantly in this case what non-indigenous people directly related with indigenous people such as a NGO’s workers and other “foreigners” (such as tourists) may view them. In San Cristóbal de las Casas (Chiapas) there is an overlapping and intricate situation in which travelers and tourists embodying a “tourist gaze” (the idea of bracketing everyday life) come to be in contact with indigenous populations who are consumed as exotic and, in so doing, tropes of “community”, “solidarity” and “harmony with nature” are filtered through nostalgic views that divide “them” as “authentic” and “us” as “artificial”. So in this context authenticity plays a key role in how others see indigenous people (and how indigenous people portray themselves). Hybrid forms in local practices are considered politically incorrect, a break in their “cultural intimacy.” The author identifies two strategies that operate to protect the local sense of cultural intimacy: the establishment of the parameters that legitimize local ‘indigenous’ medicines, and the institutionalized confinement of religious medical practice to the museum and the past. The particular site of Chiapas is relevant to think on multiple forms of healing because there is a multiplicity of practices, practitioners and users beyond biomedicine, alternative and local medicines. Here is where the perception of authenticity plays a big role. Because users have to rank these heterogeneous forms of medicine according to their authenticity or lack of. In some places there is even certain tolerance from the biomedicine to local healers, for instance, in Comitán there are three Tojolabal-speaking healers working in the hospital (although “cosmopolitan doctors” –this is how the author refers to biomedical doctors– look down on them and call them as witches). There is also an Organization of Indigenous Healers (OIH) that tries to keep some power over their public image but it is in constant struggle with the “rational” legitimacy of the “cosmopolitan healers”. Still the problem is how local healers are portrayed through a romanticized and nostalgic view of indigenous life by the ladinos and mestizos who work in the OIH, and how these views imply a lot of assumptions (healers belong to a community, communities deal through consensus, ownership of land is communal and so after consensus healers can receive a piece of land for growing their medicinal plants, a true indigenous healers should not be interested in receiving money, and local healers cure with plants) and consequences to who may be helped by the organization. The tension here is again about authenticity, more precisely how authenticity is conceived. For the OIH a “real indigenous healer” has to represent his community and his community has to choose him, which is not always the case. Ayora-Diaz shows that local healers within the OIH tend to portray their processes of gaining healing knowledge as a learning one, whereas healers outside the organization refuse this image saying that “Local medicines are a gift from God; not something one can learn from anyone” (182). More importantly, the OIH also produces the Museum of Maya Medicine, which tries to capture the real Indianness and “authentic” “modern traditional” medicine; these are according to Ayora-Diaz “hyper-real healers within a simulacrum of community and tradition” (185). Here authenticity and purity of knowledge has become commoditized, and local people have to play this game with foreigners in order to keep their own forms of hybridization. One of the richness of this text is that engage with multiple forms of perceiving and acting upon the use of “cosmopolitan” and “local” medicines. Only at the end he mentions how tzeltal healer combine local and cosmopolitan medicines to heal sooner. And I think the author could have thought a little bit more about the local use of the wide palette of choices and this combination and hybridity. He only focuses on how biomedical and local healers negotiate ideas of authenticity for local healing knowledge but he could have added how their also negotiating ideas of authenticity for the “cosmopolitan” medicine.

Low (1987) The medicalization of healing cults in Latin America.

Setha Low (1987). The medicalization of healing cults in Latin America.
Low’s article “The medicaliation of healing cults” should have added a subtitle: “and the sacralization of biomedical doctors” “in Latin America” (and the medicalization of healing and demedicalization of medicine). This is precisely the dialectic and complex relation Low is trying to get at when considering the history/stories of two very influential doctors, Dr. Moreno Cañas in Costa Rica and Dr. Hernandez in Venezuela. On the one hand these two Doctors have things in common: upper class origin, went to Europe to study, return to work in the country, and help the poor giving health care for free. They engaged in social reforms, were seen as doctors-heroes due to their medical accomplishments, and after death allegedly returned in spiritual form to keep healing the one in need and so became the center of veneration and devotion as saints. Low says, “As the technological ‘magic’ of medical practice challenges religious healing’s claim to miraculous power, the number of lay, quasi-religious healing cults increases, sacralizing medical symbols by placing them within religious contexts” (137). Each of these doctors have a tragic death, Moreno Cañas was assassinated by a former patient and Dr Hernandez was hit by a car when was going to look for medicines for one of his patients. In both cases shortly after their death espiritismo cult began to spread (with spiritual mediums contacting the spirits of these doctors) and more people made promises to these doctors and ask for healing while their images were spread with the use of all sorts of representations. For Low three types of meaning were attached to these two doctors: 1) meanings derived from the folk Catholic form and the symbolism of the cult, 2) meanings derived from the specific symbolism of the doctors’ medical career (medical technology and symbols of modernity), and 3) meanings derived from the cultural medicalization in which professional doctors replaced folk healers, orthodox Catholic saints and virgins as the focus of cult veneration. Low concludes that the secularization of traditional symbols of religious healing is what is at stake when considering these two doctors and the ways they have influenced social changes and popular forms of healing. But I have to say that these doctors could also be seen as a subaltern appropriation of their powerful status as professional healers and members of the elites.

Afterthoughts: I think in this text and in the next one (Finkler 1994) a discussion on what is modernity is missing. And I think one should discuss this question because it underlines authors' ideas of "science" and "religion" and what is to be (or not to be) modern. The reader could find useful my post on Chakravarty's Habitations of Modernity.

Finkler (1994). Sacred Healing and Biomedicine compared

Kaja Finkler (1994) Sacred Healing and Biomedicine compared.
In this article the author contrasts two healing systems, the “Sacred Healing” system with the “Biomedical” system. And she does this comparison with the aim of highlighting both differences and similarities not only in the ways they diagnose and treat patients but also in how they engage with people’s experience of illness and healing. The main point Finkler made is that in the “sacred healing” what is at stake is the treatment techniques and the persona of the healer is less important (she is only a medium of a spirit) whereas in the biomedical encounter the persona (and the need of assuring patient’s compliance) is important because the treatment itself is more uncertain. The first distinction Finkler suggests between these two systems is that one is secular (biomedicine) and the other sacred (sacred healing) and one wonder if her use of “sacred” permit or preclude understanding of this phenomenon. It is “sacred” because it is health care system and it is associated with a religious movement and lacks what medicine has (professional system, made by trained professionals, and legitimated by the state). Furthermore, these two systems have an epistemological difference (although people use them in many cases at once judging their success by the their treatment effects).
One central point in this analysis is that sacred healers are usually women (and though not mentioned biomedical professionals are usually men) who have experienced sickness before, have been cured with spiritism and then became healers themselves with the help of spirit protectors. The gender issue is not considered in Finkler’s analysis but I think should be highlighted more. One of main difference that I’ve found compelling is how different both systems consider the role of the “patient”. In biomedicine, it has a passive role in relation with the doctor constant pursue of finding right diagnosis and treatments, needs to comply (“adhere” is the usual term) with the treatment and is seen in isolation as an individual (usually as at the physiological level). In “sacred healing”, in contrast, patients are active and engage in their own healing processes trying to re-organize themselves and their families lives although the diagnosis in itself is less relevant. Finkler even says that a certain “passive catharsis” occur when “the healer tells the patient what the patient is experiencing, eliminating the need for patients active verbalization of their discomfort” (182). The healing processes in both cases are dissimilar: in biomedicine the physician uses his clinical judgments to change the image of the body (for instance, change diet under the physician’s perception of patient’s obesity) whereas in the sacred medicine the engagement with the “community of sufferers” work as support and produce a change in the experience of the body in itself. And there is another difference in that doctors tried to situate the cause of the malady chronologically and in a specific site of the body, whereas the sacred healers is expected to know what the patient is having since she already suffered similar conditions and because the spirit helping her “knows everything” as usually tells patients. There are other differences too, the sacred healing is supposed to be a progressive reordering of person existence, a gradual transformation of his/her life and of their families (many men after the healing quit drinking, or abusing their wives and kids), in fact they are changing the social relation in which patients live emphasizing in the congregation as part of the cure. Whereas biomedicine, instead, treats individuals’ bodies but fails to transform peoples’ lives.
One problem that I see in this article is certain essentialization of both sides. It is clear the analytical distinction the author made between both systems, but we keep thinking what else is going on between the sacred healers and the doctors. Finkler mentioned that patients were seeking for cure in both systems but then she does not say anything or bring more lights to these more pluralistic use of the patients of both types of healing.

Good (1994)

Good, Byron. 1994. “Illness Representations in Medical Anthropology: A Reading in the Field” in Medicine, Rationality and Experience. An Anthropological Perspective. Cambridge: Cambridge University Press. Chapter 2.
In this chapter, Byron Good is trying to map the different approaches within medical anthropology in the last decades. Indeed, medical anthropology as an inheritor of colonial knowledge-power has been criticized from within and without over the types of cultural representations the discipline has created when portraying “the Other.” The anthropological analysis has shown that western biomedicine is one medical system among others in competition. It has also criticized the medical profession’s Enlightenment assertion that lack of knowledge and maladaptation are the causes of illness. One problem in medical anthropology as sub-discipline is that often anthropologists are at once critics and committed participants of the heterogeneous biomedical enterprise. One central question in this regard for Good, which I consider important too, is how we situate our analysis of cultural representations of illness, “encoded in popular or folk therapeutic traditions or in individual understandings and practices, in relation to the truth claims of biomedicine” (28). How we consider the authority of biomedical science is key to how we relate as anthropologists with those with whom we work. Following Kleinman’s definition, Good asks to what extent “disease” is different from “illness”? But I ask myself, using the distinction disease (biological), illness (personal) and sickness (social) aren’t we taking for granted the biomedical notions of body and causality that put first the biological causation and then the non-biological? The current debates concerning illness representations show four schools of thoughts: the empiricist tradition, the cognitive approach, the interpretative approach and the “critical” medical approach. The first approach was centered in understanding “cultural beliefs” in relation with illness, to modify “irrational (sick) behavior” and to decrease risk factors and obey medical treatments. But that approach was very much “mentalistic” in its emphasis in understanding what makes people ill but not focusing on the actual biological and physical problems associated with people’s illnesses. They just considered “culture” as “belief”. There was a profound separation between folk beliefs and biomedical scientific knowledge (knowledge would eventually correct inappropriate popular beliefs). The second approach was more centered in cognitive processes, the ethnotheories of illness and health. These studies tried to understand particular cultural segments of people’s lives in relation with ways of dealing/comprehending diagnosis, treatment and prognosis in specific cultural ways. But again, illness representations were understood in mentalistic terms detached from “embodied knowledge”, affect, and socio-historical forces that shape illness meanings. The third approach, the meaning-centered tradition considers the biomedical system as a cultural system. They put the relation between culture and illness as the core of the analysis but in a different way, they consider disease not as an entity but as an explanatory model. Explanatory in the way that disease is only understandable through interpretative activities, because “interpretations of the nature of an illness always bear the history of the discourse that shapes its interpretation, and are always contested in settings of local power relations” (53). So the embodied experience, how illness is experienced and represented within different cultural systems is what should be analyzed. The fourth approach, the “critical” applied medical anthropology, tries to grasp the political and economical forces that shape illness experience and influence biomedicine itself. So for instance, forms of suffering developed from class relations may be defined as illness, medicalized, “constructed as dehistoricized objects-in-themselves” (57). Therefore, hunger or poverty are often medicalized and individualized when the social causes of them are invisibilized and unproblematized. Thus central in this approach is a critical unmasking of the social fabric of these conditions and the dominant interests. But Good, coming from the third type of approach, is quick to show that each approach has its weakness. Biomedicine is not only mystification and masking, and using a “critical” name does not make any approach more crucial than others. But the biomedical enterprise is more complex, is a site of hope and despair, desire and hatred, it is a right and an obligation, so the human actions in relation to its power deserve a deep understanding, especially if we want to produce knowledge and actions that would democratize its access and reduce its abuses of power.
I agree with Good that medical anthropologists are in-between this field of great tensions, they analyze and participate at the same time in the phenomenon they try to understand. And it is not only this idea of dual-loyalty (to biomedicine and to patients/family/social circle) what is at the center of medical anthropology practice, but also the possibility of co-construction of the anthropological knowledge/practice. Besides the anecdotal discussion between clinical or critical medical anthropology, the real discussion is how our knowledge can be useful for the people that are suffering and which strategy we should develop in order to help them better.

Paul Farmer (2003).

Paul Farmer (2003). “Rethinking Health and Human Rights” in Pathologies of Power. Berkeley: University of California Press.
In this chapter Paul Farmer is trying to show how the same definition of human rights (HR) is open to contestation and discussion when considering it in a narrow or wide way. He takes the case of Russian prisoners in the attested prisons after the collapse of the USSR in which prisoners (under illegal long pre-trial detentions) are dying of TB in spite of having access to medication. Farmer shows that many social, economic and legal factors are interplaying to produce this sickly situation for the prisoners. Prisoners are first held in overcrowded jails, then in TB colonies, and are receiving old medication that does not do anything to the resistant type of TB they are experiencing. So for Farmer HR should be considered as economic and social rights, prisoners in Russia in TB colonies, having developed multidrug-resistant tuberculosis (MDRTB) are untreatable in such conditions. But many international HR organizations of wealthy donor nations using the logic of cost-effectiveness say they cannot give the right medication (not resistant) because they are too expensive for developing countries. But this argument of cost-effectiveness fails to consider that the majority of the drugs use in the treatment is old and so off-patented. Farmer shows that in poor countries such as Peru or Haiti MDRTB can indeed be cured. He also highlights that public health and access to medical care are social and economic rights. In other words, in order to understand violence inflicted over individuals we need to consider the deep-rooted structural violence that caused it and its relation with HR, according to Farmer, we need to develop a pragmatic solidarity. One problem I see, that Famer is very aware is the divergence between HR discourses and declarations at the international and national levels of jurisdization and the real experiences in which people live and the facts they face on everyday basis. If HR are not seen narrowly, if they are seen as economic and social rights the contradiction between HR discourse and real life is even more pronounced. So inequalities in health are difficult to reconcile because the same state that violates social, economic and civil rights creating wider inequalities is eager to cover these same violations. Many HR organizations are also very tied to economic, social and state powers. So the “pragmatic solidarity” is not only to denounce these violations but also to actually help the sufferers moving beyond the “blaming the victim” discourse. There is a need for moving beyond the analysis to find useful strategies for the poor and in need. Is to move from “who did what to whom, and when?” to “what is to be done?” Farmer suggests that in order to find strategies that would really work they need to put a new agenda of health and human rights, and make health and healing the symbolic core of the agenda. So in a way is to “medicalize the human rights” and Farmer considers this because he saw it can work, for instance with the Russian prisoners when the debate started to be a medical debate and not a legal or prison reform debate, the situation for the prisoners, the need to control the epidemic and to cure the prisoners started to change. And in doing so the sick and abused need to be listened and be part of the solutions. Finally I think one important issue is to re-consider the role of the state. States that legitimate growing inequalities and are urged to do more but are the same time are dispossessed (or portraying they are) of the means to alleviate these inequalities, basically the social and economic rights of the poor. I overall think that this chapter is showing the contradictions that HR organizations and researchers/activists have when trying to help to reduce the social inequalities. They are working within the frame of the state but trying to criticize and resolve some of the damage produced by the same state. So I agree with Farmer that we need to move beyond a narrow consideration of HR to a broader one in which economic and social rights of the poor are included. And a pragmatic strategy is needed if one wants not to reproduce what is not working and to find solutions that work for the people that need them. Sometimes considering "the poor" as a category seems over-simplifying but I do see his approach, with his loing experience in the field, as valuable and worth thinking.

Seanlon, Tomkins, Lynch, Scanlon (1998)

Seanlon, Tomkins, Lynch, Scanlon (1998). Street Children in Latin America.
The authors of this review try to look at the problematic children living in the streets face in Latin America. They follow the UNICEF’s (1986) definition of “street based” children and “home based” children meaning ones that live all the time in the street and ones that stay on the street during the day and return home at night. Other tried to find other definitions, but the UNICEF’s one was thought having Latin America in mind where up to 90% of the children have some sort of contact with the family (whereas in places like India this does not happen). The problematic of street children is enormous, some sources consider between 30 and 170 million street children in the world. Many intricate factors collide to “produce” street children, being the main one in my opinion the unequal distribution of wealth, the authors mention among others: land reform, population growth, drought, rural to urban migration, economic recession, unemployment, poverty, and violence. So these are economic, political, social and legal factors combined with lack of material and symbolical resources at the social and family levels (with histories of physical, emotional and psychological violence). Of course, these children have all kind of problems, they face physical, mental, sexual, and social violence, often leading to trauma, marginalization and assassination by death squads (most famously in Rio de Janeiro in the 1980s but still happening in all Latin America). So the problem needs a multidimensional approach, many actors such as Governmental agencies and Non-governmental organizations, and the street children themselves need to “intervene” and find creative ways beyond “rehabilitation” or victimization of the children. Some suggested solutions are to re-integrate children with their families, but this needs a reconsideration of the family as a system and ongoing support for many years to sustain the program. In Brazil the street children have started a movement (Movement of Street Children) that has pushed for new legislation and visibilization within Brazilian society. The authors show the supposedly contradiction that although Brazil has the more progressive legislation and a strong street children movement, violence, human rights abuses against children and impunity of the aggressors are still very high. But this leads me to think if violence and street children are not “functional” to the Brazilian society with its hyper-exclusion and hyper-concentration of wealth and because of this aggressors are “functional” too the overall system?

Armus (2003)

Diego Armus (2003). Disease in the Historiography of Modern Latin America.
In this introduction to the book, Diego Armus maps three (some times overlapping) currents in the historical analysis of diseases in modern Latin America: a new history of medicine, the history of public health, and the sociocultural history of disease. He highlights, and I agree with him, that these attempts to try to make historical sense of any given disease are a risky approach: “given the fact that human well-being and ill-being cannot be fully captured through the lens of a single disease” (16). But given that disease is an “elusive entity” that at the same time is biological, meaning-seeking, has a medical intellectual and institutional history, it’s a site for public policy, a feature of social role and individual identity, has cultural values, and a central component of doctor-patient relationship, given that disease is all this, there is also the recognition that “disease dos not exist until we have agreed that it does, by perceiving, naming, and responding to it” (1). Still one important point made by Armus is that diseases cannot be investigated outside their societal context. Armus wants to frame the articles of this book within three approaches (new history of medicine, the history of public health, and the sociocultural history of disease) having in mind the socio-political features of epidemics, the expansion of public health policies in relation with outer influential powers and state-formation processes, and finally, the cultural use of disease.
(I) In terms of the new history of medicine, Armus considers that now historians are less inclined to look at the biographies of the “big men” in the history of medicine, the “pioneers”, and instead they analyze how medicine work as an irregular process in tension with socio-cultural and political contexts in which doctors are immersed, and where certain doctors, institutions and treatments made their way to be more visible and successful while others. And this process of visibility/invisibility success/failure within medicine has to be analyzed in all its complexity to grasp the social and political dimensions of epidemics. Before the modern bacteriology the blame of epidemics was put on urban conditions that allowed the enemy (microorganisms) to grow and which forced intrusive and violent interventions. But according to Armus there is distinction between, on the one hand, more or less visible diseases and, on the other hand, countryside or urban settings, and these tensions influence the way public opinion and elites consciousness would consider specific diseases as epidemic or not (independently of the large or small impact on the population, for instance syphilis or leprosy were seen as epidemics whereas TB or malaria not having the latter more impact than the former). Armus reminds us that “the project of sanitizing the countryside or at least combating one of its endemic diseases ignited efforts to launch social policies and facilitated state expansion, the centralization of power, and nation building” (8).
(II) The history of public health has, however, another approach: it focuses on the political, economic and social dimensions of health institutions. Health problems faced by individuals and social groups and the political interventions to maintain or reinstate collective health are considered in this approach. A key factor here is the differential availability of public health resources at regional levels within Latin America and how different national projects have dissimilar impacts according to different regions. Another important issue is the interrelationship between external influential powers and nation-building processes. Although medical professionals were aware of what was going on in Europe and North America, they were in need to find specific solutions for specific problems often very different than of Europe or North America. Certain diseases such as Chagas were particular of Latin America but other such as malaria or yellow fever were politically constructed through an inter-national site of production/reception/transfer of expertise and practices in which international agencies such as Rockefeller Foundation played a big role in the region. These tensions between national and international medical groups were “complex, at times involving subordination, cooptation, alliance, pragmatism, conflict, or mutual adaptation” (10).
(III) The third approach, the sociocultural historical dimension of disease, considers the “socio-political or socio-demographic dimensions of a particular disease, medical professionalization processes, welfare and social control instruments and institutions, and the state’s role in building health infrastructure” (5). This considers the medical discourse of illness and the metaphorical use of disease. In terms of psychiatric medical power these studies focus on empirical information that highlights both the “instrumental and controlling aspects” of psychiatry and the “humanitarian and liberating” options in relation to mental health. Thus mental health is a space that goes beyond psychiatric power and incorporates public hygiene, mental institutions, utopian seek for collective moral development, and the history of nation-formation and state-formation.
The three approaches regard medicine as an “uncertain and contested terrain where the biomedical is shaped as much by human subjectivity as by objective facts” (6). And in doing so, they emphasize the importance of individual and collective “hygiene” as a “civilizing” project promoted (and often imposed) not only from above but also strongly supported from below. There is a tension in here between the medical enterprise and the ability and capacities of the sick to negotiate and even challenge the medical power. Therefore, three issues are important to highlight: 1) “public health interventions and medical practices can be resisted, accepted, or demanded according to local, cultural, social, political, and disease-specific contexts”; 2) these tensions should be considered in a short and long run to look at how medical practices are incorporated in specific instances but in the long process within people’s everyday life; and 3) focusing on the historical agency of the sick, not considering as a merely passive objects of medical practices and knowledge but as highly implicated in the processes in which they are the object of intervention.
I think that considering this article as an introduction of a book on the historiagraphy of epidemics in Latin America Armus makes a good work trying to synthesize the different approaches historians have developed when dealing with issues of illness and health but sometimes there is too much overlapping in the distinctions he is trying to make. If he is trying to make the point that diseases cannot be studied outside their specific societal context, and this context is surely contested and resisted at the same time maybe there is no other option than to have an overlapped analysis, but perhaps it would have been more useful to consider the specific role of say the nation-state or the medical professionalization in a more analytical way in order to shed more clear light to these issues.