I had the pleasure of attending the recent conference of the German Anthropological Association (DGSKA) in Konstanz, which invited panels under an overarching theme of “The End of Negotiations?”. While there, I attended two panels which will be the focus of this blog:
The Contested Primacy of Neoliberal Thinking, convened by Janina Kehr and Stefan Leins,
Without alternatives?! Challenging political-economic dogmas in the field of health and healing, convened by Dominik Mattes and Claudia Lang, with a keynote from César Abadía-Barrero.
In her introduction to the „Without Alternatives“ panel, Claudia Lang noted how the structure and organisation of healthcare are largely contingent on prevailing political ideologies. But perceptions of personhood and modes of engagement in clinical encounters are also influenced by prevailing ethical frameworks. Medical anthropology has always been a fertile ground for delving into and unpicking both of these observations, which is exactly what this panel invited us to do, in a similar vein to the second panel of this report.
Several of the papers in the „Neoliberal Thinking“ panel were thereby able to shed light on the politics of healthcare by investigating how individuals engaged with ethical dilemmas. On the other hand, the papers in the „Without Alternatives“ panel did the opposite. These papers investigated how groups of people engaged in political campaigns that were undergirded by particular moralities of care and conceptualisations of what healthcare should look like. For example, César Abadía-Barrero spoke of his own experiences, having spent much of his career as an activist-scholar participating in political campaigns that directly contested neoliberal transformations of what he referred to as Colombian “epistemologies of care”, grounded in an ethics of „buen vivir“.
Neoliberal rationality as a puzzle, rather than an explanation: Commercial surrogacy
Rather than summarising all of the papers, I will now focus on one contribution from each panel, exploring it in more depth[1]. In the „Neoliberal Thinking“ panel, Veronika Siegl’s paper focused on commercial surrogacy in Ukraine. Like several of the other papers in this panel, Siegl demonstrated how neoliberal logics invade our daily lives and consciousnesses, becoming a part of how we work on our selves and our relationships, how we justify and make sense of our actions. Her fieldwork was with a German couple who travelled to Ukraine to pay a woman to act as a surrogate for them. When they arrived, they could not help but observe the obvious inequalities between themselves and the surrogate mother, creating an ethical dilemma for them. Was it ok for them to be doing what they were doing? How free was the mother to make the “choices” she was making? How informed was her consent? The answers to these questions seemed to hinge on the question of whether she was free or coerced. But far from the simple binary supposed by economic rationality, Siegl demonstrated how the imaginaries of freedom and coercion were themselves fragile truths that had to be worked at and constructed by the German couple.
Eventually, the man from the couple told Siegl that there was nothing wrong in what they were doing, because the Ukrainian mother had made a choice, electing to be paid for her labour. While this could simply be understood as a blandly neoliberal statement, the power of the ethnography lay in documenting the journey he had gone through to reach that rationale, as well as exposing its contingency and instability. He had begun by recognising the surrogate mother’s suffering and the circumstances restricting her choices. But then he also placed his apperception of her experience in the context of the couple’s own desires and the limitations to their own freedoms and capacities to achieve those desires. Thus Siegl did not use neoliberalism as an explanatory matrix to solve difficult ethnographic puzzles. (In fact I don’t recall if she used the word “neoliberal”). Instead, the German man’s eventual collapse into a logic of choice was itself the puzzle that required explanation.
The sociohistorical specificity of responses to global problems: Antimicrobial resistance
In the „Without Alternatives“ panel, I focus on Anthony Rizk’s paper on antimicrobial resistance in the fragmented healthcare system of Lebanon. Here, antimicrobial resistance was one threat among many to the Lebanese healthcare system. But Rizk demonstrated how it was a useful one to think with. Microbes are literally transmissive – of disease – but Rizk also elaborated how they were transgressive in the sense of crossing borders that people were trying to erect. Many Lebanese people blamed the influx of Syrian refugees for bringing in resistant bacteria. Thus the Lebanese appeared to conceive of the problem as a national one, and yet no concerted national action was taken. Hospitals developed internal policies with no co-ordination beyond their own walls.
The persistent transgression of borders by these microbes highlighted the fractured nature of Lebanese healthcare. Lebanese healthcare professionals recognised the problem and named it, telling Rizk, “there is no order”. And in the absence of order, they developed a moral economy of blame. These professionals felt that everyone else was making decisions driven only by profit, and took this perception as evidence that “healthcare has no conscience”. In this situation of amoral chaos they could not envision a clear path to a well-defined alternative. But this did not lead them to give up on alternatives. When Rizk asked one doctor to consider solutions to the problems in Lebanese healthcare, he replied, “Remove everything and start over again.” The lack of specificity here – it was not actually clear what the doctor was referring to when he suggested removing everything – suggests this may have been a facetious or throwaway comment. But it is no less interesting for providing some indication that Lebanese healthcare workers were thinking about alternatives, even if they struggled to imagine them in substantial detail.
Unlike Abadía-Barrero, Rizk’s informants were not actually part of a social movement or political campaign. But their discourse did revolve around national politics: the influx of Syrian refugees, the absence of “order”, the possibility of revolution. Rizk’s ethnography was so fascinating because it demonstrated how his friends and colleagues understood and reacted to antimicrobial resistance in these historically, geographically and politically specific circumstances.
Medical anthropology in neoliberal times
In 2012, the Group for Debates in Anthropological Theory considered whether the concept of neoliberalism had become an obstacle to anthropological understanding. Following the meeting, Venkatesan (Eriksen et al. 2015:911) noted that
suggesting that neoliberalism is at the bottom of the various ills besetting the poor and marginalized around the world does violence to the particular histories and structural and life conditions of particular places and peoples. If we already ‘know’ that the problem is neoliberalism… then we do not delve ethnographically and deeply into what might be going on in any given location, how things have changed, how people perceive they have changed, and their expectations and aspirations.
The danger Venkatesan is elucidating is of using neoliberalism as an easy answer to ethnographic conundrums. The papers in these two panels did not fall into the trap identified by Venkatesan. Instead, like the best of medical anthropology, these scholars uncovered political ideologies lurking in clinical spaces and relations and threw them up against conflicting logics. Thus when the people being studied reached conclusions that could be described as fitting with neoliberalism, as with Siegl’s study, the task of the ethnographer was to document and attempt to understand how and why they had reached those conclusions. When the people being studied contested neoliberal thinking through reference to some other “epistemology of care”, as with Abadía-Barrero’s paper, the task of the ethnographer was to describe what exactly it was that they were contesting, what neoliberalism meant to them in all its historical and cultural specificity.
We know that the clinical encounter has a unique ethical and affective charge. These papers demonstrated both of these dimensions, while using rich ethnographic detail to expose how political ideologies surround and infuse clinical dilemmas. Overall, I think these papers demonstrate that we are entering a new era of politically provocative medical anthropology, beyond technoscientific universalism, beyond (but not ignoring) biopolitics and beyond the aforementioned neoliberalism trap. We may not have the theory all laid out yet. But the ethnographies here were careful with detail, sensitive with subjects’ reasoning and insightful with tentative explanations.
[1] You can find the names and abstracts of all of the authors by clicking on the links above. If you would like to contact any of them, please email me and I will try to put you in touch.
Author
Piyush Pushkar is a psychiatrist in Manchester, England. He qualified from the University of Edinburgh in 2007 and has worked continuously in the NHS since then, except for 6 months working in Australia as an aeromedical retrieval doctor. He is currently undertaking a PhD project on the moral arguments of NHS activists at the University of Manchester. His research fellowship is funded by the Wellcome Trust. Email: piyushpushkar@doctors.org.uk; Twitter: @DrPiyushPushkar
Publications:
Piyush Pushkar (2019) NHS Activism: The Limits and Potentialities of a New Solidarity. In: Medical Anthropology 38:3, 239-252, DOI: 10.1080/01459740.2018.1532421
Louise J Tomkow, Cara Pippa Kang, Rebecca L Farrington, Ruth E Wiggans, Rebecca J Wilson, Piyush Pushkar, Maya C Tickell-Painter, Alice R Lee, Emily R Whitehouse, Nadia G Mahmood, Katie M Lawton, Ellen C Lee (2019) Healthcare access for asylum seekers and refugees in England: a mixed methods study exploring service users’ and health care professionals’ awareness. In: European Journal of Public Health, DOI: 10.1093/eurpub/ckz193
Bibliography
Eriksen, Thomas Hylland, James Laidlaw, Jonathan Mair, Keir Martin, and Soumhya Venkatesan. 2015. Debate: ‘The Concept of Neoliberalism Has Become an Obstacle to the Anthropological Understanding of the Twenty-First Century.’ In: Journal of the Royal Anthropological Institute 21(4):911–23.
