Biomedicine in Africa – an anthropology of law, organization, science and technology

This research program examines how the science and practice of biomedicine is shaped through its engagements in various African contexts. Sociologists and anthropologists of medicine have begun to open and scrutinize the black box of biomedicine through studies of laboratory and clinical life in the West. There has, however, been little scrutiny of biomedicine on the more difficult terrains of non-Western countries, which frequently are intertwined with humanitarian crises and complex emergencies involving refugees, wars, and epidemics. Our program, which focuses regionally on Ivory Coast, Kenya, Tanzania, Angola, and South Africa, aims to remedy this gap

This research program examines the making of biomedicine in Africa within the context of political and economic changes such as deregulation, privatization, decentralization, and the devolution of the nation-state in an era of globalizing markets and globalizing networks. These changes affect relations between the state, health care, civil society organizations, and capital – in Africa perhaps more than elsewhere. They give rise to new regimes of governance requiring stricter forms of standardization of medical procedures and new kinds of accountability and auditing, both of which are highly vulnerable to misuse and failure.

For this reason we are interested in demonstrating how the making of biomedicine in Africa is not only a scientific enterprise with political and economic dimensions, but also a legal enterprise. This legal dimension encompasses the juridical definition of responsibilities and entitlements in the area of public health and medical research as well as issues of intellectual property rights, health insurance, and the governing of human bodies through medical taxonomies.

We understand biomedicine as a circulating set of technologies, practices, and ideas that – as a by-product of prevention and healing – links individual bodies to the political order. We take Africa to be central for understanding global shifts in bodies and subjectivities as well as in social, political, and juridical forms precisely because the African continent is so marginalized in the global political economy and thus a site of intense conflict and experimentation.

Finally, by examining the making of biomedicine in Africa we also address epistemological issues arising at the intersections between the different forms of classification and ideas about the causation of bodily disorders and their remedies.

The program is comprised of ten individual research projects grouped along four thematic axes. The first axis concerns embodiments of biomedical technologies and focuses on shifts in biological and social reproduction. The second axis examines biomedicine’s intersections with traditional medicine and focuses on new forms of legal, organizational, and experimental practices that function as a means of translation between science, healing, herbs, ancestors, and spirits. The third axis focuses on biomedical taxonomies and governing bodies, paying special attention to how political subjectivities and populations are reconstituted through the deployment of biomedical forms of organization. The fourth axis concerns the experimental character of normal biomedical research and health interventions in zones of crisis and states of emergency as responses to life-threatening diseases and the failure of political states but also as newly emerging forms of “therapeutic domination”.

The term “traditional” should in one sense always be placed in quotations marks or inverted commas because its meaning can be understood only in relation to a particular discursive order. Colonialism made most African medical practices appear traditional, and genetic medicine currently makes most of conventional modern biomedicine appear traditional. We have for this reason abandoned the use of inverted commas or quotation marks in all such cases. Readers should be aware that we have done this not only for the term “traditional,” but for numerous other terms as well, for example, for “male” and “female.”

Biomedicine in Africa – an anthropology of law, organization, science and technology

Axis 1: Biomedical technologies and their embodiments

The first axis deals with issues of biological and social reproduction in Africa today. The central focus here is biomedical technologies that have in various ways become significant for how people in Africa imagine and enact the future. We have selected four exemplary technologies: (1) Antiretroviral therapy, which has become a powerful social operator in restoring individuals to health and allowing those being treated to envisage a future where having children, for instance, becomes a real possibility. (2) Biomedically supported understandings of sex and the evolving practices that have rendered both sex and gender malleable have made available a new range of gender identities in the African context. (3) Reproductive technologies ranging from contraception to fetal ultrasound are reshaping social relations as women gain access to increased control over their own reproductive health. (4) Particular forms of citizenship have been established through the deployment of international medical norms and practices that aim at standardizing populations and thereby making them accessible to biomedical interventions.

These four paradigmatic developments indicate a shift from the classical anthropological view of the body as blank slate onto which society inscribes its norms (e.g., through scarification, genital alteration, and body techniques) to a contemporary view in which biomedical technologies are seen as facilitating the simultaneous co-production of new embodiments and novel subjectivities. As possibilities change, the embodied subjectivities into which individuals are interpolated, mis-translated, or denied access to also shift.

In our studies, particular interest will be paid to the ways in which individuals become entangled – or do not become entangled – in medical technologies and to the biological, political, and economic factors that affect these entanglements. This will serve as an ethnographic lens for our examination of the translation of global technologies, practices, and ideas into local forms as well as the translation of local technologies, practices, and ideas into global forms. These practices of translation are framed and enabled through the mediation of various discursive structures, the most important of which are dominant cultural patterns and disputes, social movements, juridico-political controversies, the state, and trans-national institutions.

For this reason, we will focus on diverse legal mechanisms as well as the policies, protocols, and rhetorical strategies employed by state and non-state actors. This will also allow us to account for the way in which these global forms increasingly enter the private sphere, potentially enacting intimate forms of colonialism.

General questions on axis 1

How do medical technologies shape the identities available in the African context?
How are medical technologies drawn upon to create and fashion new selves in the African context?
How do these novel identities lead to changes in social and political relations?

Biomedicine in Africa – an anthropology of law, organization, science and technology

Axis 2: The intersections of biomedicine and traditional medicine

The second axis deals with the role of traditional therapies in the making of biomedicine in Africa as well as the influence of biomedicine on those therapies. The ethnographic studies focus on the ways in which traditional and modern medical practices intermingle, interfere, and interrupt one another in the circulation of medicines, practitioners, legal and ethical frameworks, and laboratory technologies.

Biomedicine has long confronted traditional medicine, perhaps most explicitly in the bodies of afflicted people seeking care, in therapy management groups that shape these healing trajectories, and in the expectations of treatment they embody. On this axis, we are interested in the effects of this sustained interaction. While the juxtaposition of traditional versus modern medicine was part of the discursive order of the colonial encounter, it has also provided a ground for rethinking the categories of traditional and modern medicine.

When new afflictions and new corresponding traditional therapies appear, they usually reflect radical changes in political, economic, social and ecological conditions, thereby challenging the entire classificatory system. In Africa today healers often attempt to treat biomedical disease entities, while national and international organizations invest in the professionalization of traditional practitioners and their integration within local health services. Traditional medicines and traditional practitioners have found ways to travel within national health-service delivery networks and global scientific networks. By focusing on the ways in which traditional medicines and experts travel, this research seeks to reveal how traditional medicine permeates the therapeutic landscape in Africa and beyond.

Through this line of questioning, we seek to challenge simple dichotomies that frame biomedicine as either dominating or liberating and traditional medicine as either an obstacle to development or a valuable object of cultural heritage. Rather our individual projects examine how political, bureaucratic, and scientific interests in traditional medicine in Africa provoke new forms of experimentation, new ethical regimes for research, and new technologies for care and distribution.

Ethnographies of these changes in the development, organization, and uses of medical knowledge provide insight into the ways in which Africa is central to contemporary biomedical knowledge and practice. They also raise questions about the relations between medicine and new forms of nationalism, regionalism, and globalism.

General questions of axis 2

How are the objectifications of traditional medicine by modern science instrumentalized by its practitioners, by biomedical actors, and by the state?
How do claims of universal validity enable traditional knowledge about bodies and medicines to circulate?
How are such claims constituted through the making of scientific “facts” about the efficacy of traditional medicines?
How does the work of medical science shape Africa and how is medical science in turn shaped by this work?

Biomedicine in Africa – an anthropology of law, organization, science and technology

Axis 3: Biomedical taxonomies and governing bodies

The third axis examines biomedicine as a form of biopolitics. From this perspective, biomedicine constitutes an armamentarium of political technologies that ensure the social order by governing bodies and by making populations accessible to intervention. The ethnographic studies contributing to this axis focus on biomedical practices, forms of organizing, and legal regimes that aim to enhance well-being by controlling disease and, by extension, the suffering body. They focus in particular on how these biomedical practices, forms of organizing, and legal regimes are transformed by their encounters with individual sufferers, afflicted populations, and institutional environments.

Biomedical criteria, standardized by international agencies such as the WHO, are the lens through which public health officials perceive and intervene in reality. As with all taxonomies, however, medical classifications structure reality and thus affect social processes. Epidemiological measures taken against communicable diseases, including new hygienic standards, vaccinations, or quarantine, can be implemented on entire populations to varying degrees of success. The same is true of attempts to implement routine medical follow-ups, for instance in mother-child care. These medical practices of standardization necessarily strive to control individual bodies and in the process work to embody nationhood. The deepening health crisis on the African continent and the hollowing out of local state capacity to deal with this crisis have expanded the scope of humanitarian and biomedical intervention. As a result, the continent is increasingly viewed through biomedical lenses.

Medical classifications are also instruments of normalization. Medical ideas of normality and the practices through which they are generated shape individuals’ experiences of health, disease, and the body. This process does not necessarily result in docile, disciplined populations. Indeed, unexpected, unruly subjectivities may arise that disrupt biomedical taxonomies: New identities and social relations that emerge around biomedical classifications and normalizations that have consequences beyond the field of health. These consequences are often unintentional, caused for example, by medical institutions seeking to manage a marginalized population. They can, however, also be intentional, for example, attempts at self-empowerment in which biomedical categories and practices are employed in the pursuit of other goals.

The issues addressed on this axis will be studied primarily within contexts in which all or most forms of medical care have collapsed as a result of conflict and war and in which completely new medical infrastructures must be constructed from scratch. In these circumstances various international, state, and non-state actors are called upon to provide medical services and to establish a basic infrastructure in the affected region. In order to achieve this, the agencies in charge first have to categorize individuals and groups of people. In doing so, they apply globally circulating medical, administrative, and juridical taxonomies and technologies. Of particular interest for axis 3 are the translations of these taxonomies and technologies into local contexts and the converse flow of information about these local adaptations back to the global centers of medical care.

General questions of axis 3

How does biomedical care frame new categories and groups?
How are new medical and biometrical technologies generated from the intention to control populations?
How do people re-appropriate biomedical taxonomies?
How are biomedical taxonomies negotiated between the people who implement them and those at the receiving end?

Biomedicine in Africa – an anthropology of law, organization, science and technology

Axis 4: Biomedical experimentation and health interventions

The fourth axis is primarily concerned with the research aspect of biomedicine, epidemiology, and pharmacology. As in other sciences, experiments in biomedicine are the central and standard form of knowledge production. The context of an experiment inevitably influences the process of experimentation, as is evident in the case of Randomized Clinical Trials (RCT) of herbal remedies in Africa. On a more dramatic level, humanitarian medical interventions can also be regarded as forms of experimentation that differ in specific ways from conventional forms of carefully controlled and demarcated scientific experiments. The same is true for experimentation with medical solutions for particularly devastating diseases, in which treatment and experiment tend to overlap to a greater extent than is usually the case. In the African context, humanitarian medical interventions are often interventions in crisis zones involving life-threatening diseases and epidemics (such as AIDS and malaria), in various kinds of disaster (such as drought, flooding, and famine), and in states of emergency caused by wars and the failure of political institutions. These extreme conditions force and enable health care institutions and professionals to rapidly develop strategies both nationally and internationally to contain the crises and their devastating consequences. The emergency approach gives rise to a new form of governmentality that can be glossed here as “experimentality”, in which new strategies are tested, research and policies are re-ordered, and provisional solutions are often transformed into robust forms of health care and “therapeutic domination”. Experimentation, however, presupposes a certain degree of standardization. In order to experiment, a number of factors have to be held constant. Crisis interventions therefore normally follow a blueprint that was previously used in similar conditions supplemented by the experience gained from past “lessons learned.” In an inversion of the classical modernist model – according to which evidence of efficacy permits intervention – in the newly arising scenarios exceptional intervention drives the need for evidence demonstrating that the intervention was effective and that important lessons have been learned for the next occasion.

General questions of axis 4

What factors are assumed to be constant and unchanging and therefore to permit the application of traveling models of humanitarian emergency interventions?
What are the dimensions that are experimented with?
What type of governance emerges as a result of the normalization of humanitarian intervention?
How does the work of medical science shape the conditions of crisis and states of emergency, and how in turn is it shaped by these conditions and states?