Security, Disease, Commerce - Ideologies of Postcolonial Global Health - Nicholas B. King

Security, Disease, Commerce: Ideologies of Postcolonial Global Health Author(s): Nicholas B. King Source: Social Studies of Science, Vol.
32, No. 5/6 (Oct. - Dec., 2002), pp. 763-789 Published by: Sage Publications, Ltd. Stable URL: http://www.jstor.org/stable/3183054 . Accessed: 19/04/2013 05:59
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SSS
Technoscience SpecialIssue:Postcolonial
ABSTRACT Publichealthinthe United Statesand Western Europehas long been alliedwithnationalsecurity and international commerce. the 1990s,American During virologists and publichealthexperts on thishistorical capitalized association, arguing a threat that'emerging diseases'presented to American and economic political interests. Thispaper investigates whichI callthe 'emerging thesearguments, diseases and compares worldview', itto colonial-era and publichealth. ideologiesof medicine Threepoints of comparison are emphasized: of space and relative the mapping importance of territoriality; the increasing on information emphasis and commodity and the transition from of conversion exchangenetworks; and a 'civilizing metaphors to integration mission', and international development. colonialand Although postcolonial ideologiesof global healthremain deeplyintertwined, significant differences are becoming apparent. Keywords emerging diseases,exchange, information, networks, pharmaceuticals, publichealth
Security, Disease, Commerce: ofPostcolonial Ideologies GlobalHealth

Nicholas B. King
In April 2000, the Clinton administration, citingdomesticpoliticalpressure and awarenessof an emergent international health threat,formally designatedHIV/AIDS a threat to Americannationalsecurity. Earlierthat year, a National IntelligenceCouncil (NIC) estimateprojectedthat the disease would reduce human lifeexpectancy in Sub-SaharanAfricaby as much as 30 years,and kill as much as a quarterof its population.The reportpainted a grimpicturenot onlyof the future of HIV/AIDS, but of infectious disease in general,a 'nontraditional threat'whichit said would 'complicateUS and global security overthenext20 years... endanger US citizensat home and abroad,threaten US armedforcesdeployedoverseas, and exacerbatesocial and politicalinstability in keycountriesand regions in whichtheUnited Stateshas significant interests' [Noah & Fidas (2000): n.p.].l Described at the time as unprecedented, the announcementin fact codifiedin languagewhat had long been truein practice.Althoughoften characterized as an humanitarian activity, modernpublic health as practisedin theUnited Statesand otherWestern industrialized nationshas long been closely associated with the needs of national securityand internationalcommerce. The NIC estimate was partofa decade-longcampaign
SocialStudies ofScience 32/5-6(October-December 2002) 763-789 ? SSS andSAGE Publications Thousand OaksCA, New Delhi) (London, [0306-3127(200210/12)32:5-6;763-789;030429]
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capitalizingon this historic association. During the 1990s, American and defenceexperts arguedthat'emerging scientists, publichealthofficials international diseases' presenteda threatto Americannational security, the predevelopmentand global health. In doing so, theyrecapitulated healthpolicy.At the same vious century's dominantlogics of international world, about living in a globalizing time,theyexpressed Americananxieties in whichthe assumptionsand institutions of the Cold War era no longer of US seemed adequate to the task of ensuringthe safetyand interests citizens. the theAmericandiscourseon emerging diseases during By examining healthin the past decade, thispaper traces one ideologyof international to providea taxonomyof the postcolonialera. My aim is twofold:first, as well as theirrecomrisksthatWestern public healthexpertsidentified, to outlinesome mended interventions againstthose risks.Second, briefly of the continuities and discontinuities betweenthispostcolonialvision of health of international international health and colonial understandings that preceded it and, in many respects,provided its intellectualand foundations. For thepurposesofthispaper,I willuse theterm institutional 'postcolonial'to describewaysof seeingthatemergedduringan historical momentwhose defining characteristics included (but werenot limitedto) the revoltagainstthe formalcolonial orderthatfollowed19th-and 20thcenturyEuro-Americanexpansion, the end of the Cold War, and the transformations associatedwithglobalization.2 political-economic Background: The Commerce/Security/Disease Nexus
Public health, as conceived of and practisedin the United States and has primarily been a state WesternEurope duringthe past fivecenturies, of the and as such has been closelyconnectedto the protection activity, One of the key functions of public health has been to state's interests. perceivedas havingan externalorigin, protectits citizensagainstthreats infectiousdiseases carried across national borders. Public particularly and closelyallied withideologies of healthhas thus been 'international', and international commerce,since its earliestdays. nationalsecurity the One of the oldest and most widespreadpublic health strategies, quarantiningof people and goods suspected of harbouringinfectious in thePortofVeniceduring theplague epidemicsofthe disease, originated 14thcentury [Cipolla (1981); Markel (1997)]. For the nextfivecenturies, cordons (ringsof soldiersaround citiesto guard quarantinesand sanitary werewidelyused inWestern European and some againstdiseased fugitives) with Asian nations.While these measuresoftencame into directconflict more and free-market local economic interests during ideology generally, the 18th and 19th centuriesmercantilism providedthe impetusand, in forthe creationand extension manycases, the ideologicalunderpinnings, of public healthpracticesin Western Europe.3 in the healthof This period also saw the expansionof states'interests immediate borders,and thusthebirthof a broad populationsbeyondtheir
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discourseof, and institutions devotedto, international health.During the mid-1 9th century, epidemicsof cholera and plague in Turkeyand Egypt led European stateswithcommercial and colonial interests to push forthe creationof an international board of sanitary and quarantinecontrol.In 1851, 12 European nations held the firstof 14 InternationalSanitary Conferences,dedicated to standardizing quarantineregulationsinternaThese meetings, tionally. the last of whichwas held in 1938, established a templateforinternational cooperationin matters of health.Over the next hundredyears,a numberof similarcongressesand supra-national organizationswereestablished to addressinternational health,including thePanAmerican SanitaryBureau, founded in 1902 by the United States and severalLatin Americanrepublics;the Red Cross, foundedin 1863 to help wounded soldiers of any nation; and the Office International d'Hygiene Publique, headquarteredin Paris and concernedwith collectingand disinformation seminating on infectious diseases [Roemer(1994)]. While multilateral and non-governmental were still in organizations their infancy, international healthissuesweremostcommonly addressedin the contextof colonialism, wherethepracticaland ideologicalneeds ofthe colonizing powergoverned the ideologyofpublic health.Initially, assuring thehealthofEuropean soldiers,traders in hostileclimates and settlers was the priority, and strategiesof avoidance and separation the preferred methods.In time,thefocusshifted to thehealthofindigenous populations, primarily as a means of ensuringthe availability of a pool of productive labour. In either case, 'public health' served the interestsof colonial in local health(excepting powers,withimprovements male membersofthe labour force) a negligible and secondary side-effect [Arnold (1988a); Arnold (1993); Packard (1989)]. Despite its generaldisregardforindigenoushealth and largelyfutile in combating efforts infectious disease,Western medicineand publichealth were integral partsof the ideologyof empire.4 Europeans contrasted their own medicine and public health,symbolizing and modernity, rationality with putativelysuperstitious and primitiveindigenous medical beliefs, which they denigratedand sought to eliminate as part of the larger 'civilizingmission' of colonialism.The medical modernization of native via exportofWestern populations, medicaltheories and practices, was part of the 'ideology of colonial healing', that justifiedcolonialism as an humanitarian ultimately endeavour[Comaroff & Comaroff (1992): 222]. The United States followed a pattern similar to WesternEurope. Initially, public healthmeasuresfocusedon preventing the importation of infectious disease into the country. Use of isolationand quarantinewas widespread during the late 19th and early 20th centuries,a time of social and demographic significant change,urbanization, industrialization, in transportation, revolutions and immigration. As elsewhere, thismeasure oftenservedas 'a medical rationaleto isolateand stigmatize social groups reviledfor otherreasons', particularly immigrants and racial and ethnic minorities thatpersonified frightening social change [Markel (1997): 4]. Such was the case in 1900, whenhealthauthorities, fearing an epidemicof
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bubonicplague,cordonedoff the Chinatown district of San Francisco;and 25 years later when, in the most famous instance of nativistanxieties Mary Mallon determining public health policy, the Irish immigrant for25 yearson a popularlyknownas 'TyphoidMary' - was incarcerated small island near NewYork City [Kraut (1994): 78-104; Leavitt(1996)]. In the early20th century, as Americanbusinessessoughtnew markets trade abroad and thecountry soughtto establish military bases and control pressure routesin the Caribbean andWestern Pacific,therewas increasing for the United States to turn its attentionto public health outside its to borders.In the first two decades alone, the US Armylaunched efforts protectits occupyingforces fromyellow feverin Cuba, frommalaria, and dengue in the Philippines, and to bringmalaria and yellow dysentery feverunder controlin the building of the Panama Canal [Fee (1994): 239-40]. In 1942, US Surgeon General Thomas Parran created the Malaria Control in War Areas (MCWA) division of the Public Health Service to control the disease in army trainingareas in the Southern United States. During World War II, the MCWA expanded its proagency, grammes, and itsleadersconvincedParranto make it a permanent the CommunicableDisease Center- forerunner ofthe CentersforDisease Controland Prevention (CDC) [Etheridge (1992): 1-17]. Along withthe the US Armyand Rockefeller Foundation,the CDC would become the most responsiblefor protecting the health of public health institution and.commercial interests abroad. Americanmilitary This admittedly briefoverview of the history of public healthdemonstrates thatthereis significant precedentforboth the ideologicalconnecand economic tion between humanitarianconcerns, national security, of of these connectionsinto the institutions gain, and the sedimentation health.In the restof thispaper,I will statepublic healthand international argue that during the last decade of the 20th centurythis nexus of disease and commerceunderwent changes.I willfocus security, significant in particularon a set of documents produced by American scientists, national securityexperts, and public health officialsthat address the problem of 'emergingdiseases'. Before making these comparisons, a review of these documents and the discourse that they representis necessary. Emergence of a Worldview Uniof Health and Rockefeller On 1 May 1989, the National Institutes a term coined a on viruses', by versity co-sponsored conference 'emerging and immunologist itschair,virologist StephenS. Morse.5Amongthemore and public healthexperts, scientists than200 participants wereprominent includingRobert E. Shope, AlfredS. Evans, Frank Fenner and Donald Henderson. Morse and his colleague,Nobel prize-winning microbiologist in orderto discusstheir concerns convenedthemeeting JoshuaLederberg, such as the HIV, Ebola, about the appearanceofnew infectious organisms strains of resistant of antimicrobial and the development and hantaviruses,
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familiarones [Morse (1990); Morse (1991); Morse (1992); Lederberg (1988); Lederberg (1993)]. Over the course of the next decade, the anxietiesexpressed at this conferencewould be repeated widely by its attendees,eventually hardeninginto an orthodoxset of predictionsand recommendations that would later be picked up by a wider group that included otherscientists, prominent local and nationalpublic journalists, healthofficials, and, eventually, nationalsecurity experts. The emerging diseasesworldview would quickly come to dominate Americanunderstandings of international health.I call this a 'worldview' because the consensusthathas emergedduringthe last decade is, in every sense, a view of the world. It is tremendously flexible,allowinga wide variety of actorsto adopt it, mouldingsmall parts or emphasizing particular elements and downplayingothers to suit their own purposes. It furnishesthem with a consistent,self-contained ontologyof epidemic disease: its causes and consequences, its patterns and prospects, the constellation of risksthatit presents, and the mostappropriate methodsof preventing and managing those risks.It comes equipped with a moral economyand historicalnarrative, explaininghow and whywe findourselves in the situationthat we do now, identifying villains and heroes, ascribing blame for failures and credit for triumphs.Finally, it is a universalizing template for understanding the interactions between humans and the microbialworld:the rules and assumptions thatit lays out are presumedto be globallyapplicable.6 Three years afterthe 1989 conference,the National Academy of Science's Institute of Medicine (IOM) publishedthe most comprehensive and widely-cited statement of the emerging diseases worldview, Emerging Infections: Microbial Threats toHealthin theUnited States[Lederberg, Shope & Oaks (1992)]. The IOM report was authored by a distinguished committee of scholarsin virology, microbiology and public health,co-chairedby Lederbergand Yale University epidemiologist RobertE. Shope. It argued that Americans were no longer insulated from the diseases that they assumed had been relegatedto the developing world: As thehumanimmunodeficiency virus(HIV) pandemic surely should havetaught us, in thecontext ofinfectious diseases, there is nowhere in the worldfrom whichwe are remote and no one from whomwe are disconnected. some infectious Consequently, diseasesthatnow affect peopleinother parts oftheworld represent potential threats totheUnited States becauseofglobalinterdependence, modern transportation, trade, and changing social and cultural patterns. [Lederberg, Shope & Oaks
(1992): v]
Defining emergingdiseases as 'clinicallydistinctconditions whose incidence in humanshas increased' [ibid.: 34], the report noted thatratesof infectiousdiseases worldwidewere rising.New diseases were emerging intothehuman population,and old ones mutating into strains resistant to the drugsthathad previously eliminated or containedthem.
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fordisease emergence, responsible factors several identified The report a list which was in many ways a wholesale condemnationof the conurbaniDemographicchangessuch as migration, sequences of modernity. zation and populationgrowthcreatednew breedinggroundsfordisease. refugees. vulnerable Wars and economic crisesproduced immunologically substanceabuse and war,as sexual activity, Human behaviours, including resulting fromdam building, well as changes to the naturalenvironment and global warming, alteredthe vectorsalong whichdisease deforestation traveland commerce exposed spread. The accelerationof international new populations to diseases once thoughtto be contained in remote allowed and vectorcontrol immunization, locations.Inadequate sanitation, biologygave them whiletheirown evolutionary pathogensa new foothold, to the drugs and developresistance the capacityto mutateintonew forms that once killed them [condensed fromLederberg,Shope & and Oaks (1992): 34-112; see also Morse (1993b)]. To address this risk, the report recommendedthe expansion and in fourareas: epidemiofinancialsupportof public health infrastructure diseases and the emergence of outbreaksof infectious logical surveillance and basic researchin molecular biresistance;training of antimicrobial of vaccinesand therand development private and virology; public ology coordination betweenlocal, of and and the strengthening drugs; apeutic institutions. health public international and national The IOM reportbecame the centrepieceof a major public health theNIC, CDC, and the from It was followed reports by similar campaign.7 Council National and [CDC (1994); Science Technology Cabinet-level the New York Academy of of In 1995 meetings alone, CISET (1995)]. the Annual of IOM were Meeting Medicine and the 25th Anniversary the online journal, Emerging devoted to the topic; the CDC launched (WHO) established Diseases;and theWorldHealth Organization Infectious Diseases Surveillance a Division of Emergingand Other Communicable diseases a central ofemerging and control and Control,making prevention The following [WHO (1996); WHO (2000)]. part of its global strategy JournalofMedicine,the year, at the behest of the editorsof the Western American and theJournal ofthe Journal MedicalAssociation, Norwzegian ofthe 21 countries agreedto MedicalAssociation (7AMA), 36 medicaljournalsin devote all or part of theirissues to the problem of 'emergingand reforthis'global infectious diseases'.8In one of the lead editorials emerging of alarm at the sense growing themeissue' in JAMA, Lederbergcaptured their microbial adversaries: humans and between the struggle
as our remaining We come then to social intelligence option to counter must drives of the microbialworld.That intelligence the evolutionary include a profoundrespectfor the ecological factorsthat enhance our we have neverbeen more vulnervulnerability....From thisperspective, able. [Lederberg(1996): 244]
diseases campaignenjoyedclose ties to From the start,the emerging was coveredby scientific the mass media. The original 1989 conference
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weekliessuch as Bioscience, MedicalWorld News, and ScienceNews. It also attracted the attention of leadingAmericanscience journalists, including The New York Times'Lawrence K. Altman,and Newsday'sLaurie Garrett [Altman(1989); Garrett(1989)]. As the campaigngathered steam during the 1990s, it was aided by theircoverage of international outbreaksof exotic infectious diseases, includingEbola haemorrhagic feverin Zaire, pneumonicplague in India, a new strainof avian influenza in Southeast Asia, Bovine Spongiform in Western Encephalopathy (BSE) Europe, and theWestNile Virus in the Northeastern United States. The contributions ofGarrett and sciencejournalist RichardPrestonto theemerging diseases campaignwereessential.In October 1992, Preston's New Yorker magazine article,'Crisis in the Hot Zone' [Preston(1992)], introducedthe Americanpublic to the Ebola virus,a previously obscure pathogen. In rivetingprose, Preston described an outbreak of Ebola fever haemorrhagic of laboratory among a shipment at a primate monkeys quarantineunitmaintained by Hazelton ResearchProductsin late 1989.9 Preston concluded his account by noting that the 1992 IOM report consideredthe Reston episode to be a 'classic example' of disease emergence [Preston (1992): 80].1? Afterdetailingthe report'srecommendations,Preston drew explicitconnectionsbetweenEbola, HIV, and other viruses.Interviewing emerging Morse, Prestonasked whether an emerging virus'could wipe out our species'. Morse respondedby speculating on the of an aerosolizedformof HIV causing a pandemic of a hybrid possibility 'AIDS-flu': The humanpopulation is genetically diverse, and I have a hardtime imagining everyone getting wipedoutbya virus.... But ifone in three people on earthwerekilled- something likethe Black Death in the MiddleAges - the breakdown of social organization could be just as a species-threatening almost deadly, event. [Preston (1992): 81] Between 1992 and 1993, while a fellowat the Harvard School of Public Health,former National Public Radio and Newsday correspondent, Laurie Garrett,was conductingbasic researchfor a proposed book on emerging infectious diseases. Having previously coveredthe 1976 Swine Flu 'epidemicthatneverwas', as well as theHIV/AIDS pandemicin Africa and the United States,Garrett had longbeen interested in the science and international politicsofinfectious disease [Kinsella(1989): 225-411.11She was also familiar with the Ebola story, havingcoveredpossible bans on importation ofresearch monkeys as a resultoftheRestonoutbreak in early 1990 [Garrett (1990a); Garrett(1990b)]. Upon learning thatPrestonhad a contract withRandom House, she accelerated workon herbook so thatit would be released simultaneously. This provedto be a wise decision. In 1994, the publicationof The Coming Plague: NewlyEmerging Diseasesin a World Out ofBalance [Garrett(1994)] contemporaneously withPreston's The Hot Zone [Preston(1994)] gave it an improbably largeaudience.The two books were oftenreviewed together, withGarrett's receiving praise as the more substantial work.'2Garrettand Prestonensuredthat emerging
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the 1990s. In 1999, the news throughout diseases remainedfront-page Viruses and Preston'sThe Hot named Morse's Emerging American Scientist Zone as two of the '100 or so Books that Shaped a Centuryof Science' [Morrison& Morrison (1999)]. By any measure except its own expectahad effectively colonizedtheAmerdiseasesworldview tions,the emerging disease risk. of global infectious ican imagination Determiningexactlyhow and why the emergingdiseases worldview had such widespreadappeal is beyondthe scope of thispaper,but one of to the most prominent strategies employedby its backers was explicitly interassociate infectious diseases withAmericaneconomic and security ests.'3 Doing so allowed campaignersto make a case forfederalfunding but also to take advantage traditional healthinstitutions, not onlythrough of 'trickledown' fundingthroughthe Defense Department.This was a forpublichealthhad been shrewdpoliticalployin an era in whichfunding also a themost that, forthemoment, slashedrepeatedly. It was recognition and epidemiological were surveillance apparatuses laboratory sophisticated housed in the Defense Department's overseas medical research laboratories[Lederberg, Shope & Oaks (1992): 148-51]. halfof the 1990s, nationalsecurity expertshad begun to By the latter disease to thecampaignto convincethemthatinfectious respondpositively estimatehad termedit, a 'nontraditional was, as the nationalintelligence Two of the most threat' to American securityand economic interests. and emblematictextsof that campaign were Laurie Garrett's important 1996 Foreign article,'The Return of InfectiousDisease' [Garrett Affairs in GlobalHealth: America's VitalInterest (1996)], and a 1997 IOM report, Our Economy, andAdvancing Our National Our People, Enhancing Protecting Interests [IOM (1997)]. Together,theyestablisheda templateforlinking humanitarian concernwithenlightened self-interest.14 VitalInterest in Global Health was authoredby a group of America's the co-chair, were (threeof whom,including distinguished representatives from among the authors of the IOM report on emerginginfections), Federal agencies and non-governmental Americanuniversities, organizathe Rockefeller tions,and fundedby the IOM, the Carnegie Corporation, forEnvironmental Health ScienFoundation,and the National Institute the previousIOM report'selucidationof the riskof ces.'5 While following emergingdiseases closely,this reportwas notable for its invocationof betweendoIt argued that since 'distinctions global interconnectedness. healthproblemsare losing theirusefulnessand mestic and international often are misleading', the American polity should be concerned with 'global health',whichit definedas 'healthproblems,issues, and concerns or nationalboundaries, thattranscend maybe influenced by circumstances experiencesin other countries,and are best addressed by cooperative actionsand solutions'[IOM (1997): 1, 11]. The reportpainteda compellingpictureof global riskand response: there is an increasing theworld livelonger, As populations throughout a Thistrend mirrors concerns. ofhealth trend toward global commonality to prevent, forhealth and accessto newinterventions demand growing
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disease. The knowledge base required diagnose, and treat to meetthese fromexperiments needs is not onlyof a technical kind,deriving of butmustalso drawfrom researchers, theexperiences ofgovernments in and efficiently allocatingresourceseffectively to improvehuman health ... America has a vitalinterest and direct stakein thehealth of peoplearound theglobe, and ... this interest derives from both America's tradition of humanitarian and compelling long and enduring concern ofenlightened reasons self-interest. involvement canserve Ourconsidered to protect ourcitizens, enhance and advance oureconomy, US interests abroad... America mustengagein thefight forglobalhealth from its strongest basis:itspre-eminence in science and technology. US expertise in scienceand technology and its strength in biomedical, and clinical, health services research and development that has helped aretheengine powermanyof the advancesin humanhealthand well-being of this century. [IOM (1997): v-vi] For the rest of this paper, I would like to draw some comparisons betweenthe emerging diseasesworldview, as represented Vital byAmerica's Interest and selected other documents, and ideologies of international health duringthe colonial era. I should stresshere that in makingthis I do not intendto establishclear dichotomies comparison, or rigidperiodizations.Instead,I hope to map out some changesthatcharacterize thelast decade, and will likelyplay a role in the immediatefuture. I should also stressthat these ideologies are neitheruncontestednor infinitely negotiable.The emerging diseases worldview, like its colonial predecessors, is one local visionof international merely healthemanating from the Eastern United States; in practice, it will likely be deconstructed,contested, negotiatedand resistedin numeroussettings. Nevertheless, forthe time being,it has garneredan impressive arrayof adherents, and to date there have been few public critiquesor contrary voices.'6 For these reasons I think it is usefulto map out itscontours, and to inquireintoitsrelationship to the largely discredited discursive regimethatcame beforeit.
Territoriesand Networks (1): Information

Comparingthe colonial rhetoric of public healthwiththe emerging diseases worldview revealsa change in the way thatAmericansconceptualize space in international health.HistorianCharles Maier has arguedthatthe twentieth was century characterized by the 'emergence,ascendancy,and subsequentcrisis'of 'territoriality', whichhe definesas ... a boundedgeographical a basis formaterial space thatprovides and common resources, political power, allegiance ... [and] assuresa stablesense of community onlywhen'identity space' - the unitthat - is congruent provides thegeography ofallegiance with 'decision space'theturf thatseemsto assurephysical, economic, and cultural security. [Maier(2000): 816] Beginningin the 1860s, and facilitated by dramaticdevelopments in transportation and communication, European political entitiestried to
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create administratively cohesive and geographically bounded regimes. Gripped by an 'epistemeof separation','no cultureobsessed more about bordersthanthe one takingshape in themid-nineteenth century, insisting on national,racial,gender,and class lines' [Maier (2000): 819]. This was truenot onlyat home but also abroad: the colonialprojectwas not onlyan attemptto establisha political network, but also to export a vision of bounded geographic space worldwide. Maier arguesthatthisobsessiveproject, whichwas global in scope and fundamental to all of the political and economic transformations of the 20th century, began to dissolvein the 1960s. This dissolution was driven by politicalevents(most notablythe Americanretreat fromfinancing the Bretton Woods monetary regime,and the collapse of state socialismand planned economies) thatrenderedterritorial cohesion unimaginable;and by technological developments (the replacement of industrial by information technologies) thatrenderedit irrelevant as a resource. The end result was that 'the major politicaldivisionof our times [is] one that separates thosewho envisagetheirfuture prospectsbased in non-territorial markets or exchange of ideas from those who insist that territoriality can be reinvigorated once again as the basis foreconomic and politicalsecurity' [Maier (2000): 824]. One could scarcely find a better renderingof the twin impulses containedin the emerging diseases worldview, and of its continuities with from the regimeof colonialpublic health.Colonial-era and discontinuities public health was similarly marked by an obsession with exporting the evenifin practicethisideal was seldom European ideologyofterritoriality, achieved. Westernmedical theories identifiedparticularplaces (under miasmatic theory) or populations (under germ theory) as sources or of infection.Unhealthy(non-Western) reservoirs places or populations to healthy when the bordersbetween posed a threat (Western)individuals eitherby colonials in foreignlands, or by imthem were transgressed, of avoidhome countries.It relied on strategies migrants contaminating and establishment of sanitary cordons in orderto preance, segregation serveterritorial boundaries,isolating populationsfromone anothereither or control control ofborders(to guardagainstimmigrant through carriers) of populationsin colonizedterritories (to guardagainstthe contamination of colonial interlopers) [Anderson(1995); Ileto (1988)]. Like theirEuroto createwhat pean colleagues,Americanpublic healthofficials attempted - isolated Andersonhas called 'utopian medical micro-colonies' Warwick spaces in the colonial 'periphery'that mimickedthe social and spatial relations at the metropolitan 'centre' [Anderson(2002)]. The emergingdiseases worldview, worriedthat 'centres' mightbe while contaminated by 'peripheries',preservesthis ideal of territoriality one on a On the de-territorialization as simultaneously seizing response. of 20th19thand it recreates the hand, representational strategies early recenturypublic health, identifying particularnations as threatening the 'growing forexample,identifies of infection. The NIC report, servoirs of cross-border movements of people and produce' as ease and frequency
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one of the crucial 'mechanismsof entry'of pathogensinto the United States.It also preserves the ideal that,through of separation strategies and theUnited Statesand its allies can be biomedically containment, insulated - the postcolonialeconomicperiphery from those countries of 'developing nations'- identified as the source ofpotential and actual global pandemics such as HIV/AIDS, tuberculosis, WestNile Virus,Ebola and dengue [Noah & Fidas (2000): n.p.]. The obsession with boundaries - between races, - persists,as does the origin betweenclasses, and betweennation-states narrative thatlocates the ultimate source,or 'reservoir', of disease in other nations.This was illustrated duringthe 1990s by American fascination withtwo pathogensnamed afterthe Africanregionsin which theywere firstdiscovered,the Ebola and West Nile viruses,despite relatively few 17 cases in the United States. Alongside this pre-occupationwith boundaries is a second set of anxieties and solutions, envisioninga world in which the securityof territorial bordershas faded,to be replacedby one in whichvastnetworks are not onlyconduitsofinfection but also prophylactic tools.The emerging diseases worldviewidentifies globalizationas an irrepressible source of geographictransgression, renderingthe ideal of territoriality moot. As Garrettnotes in her Foreign Affairs article,'geographicsequestration was crucial in all postwar health planning,but diseases can no longer be expectedto remainin theircountry or regionof origin' [Garrett(1996): 69]. Recognizingthatphysicalsanitary cordons are impossiblein a putativelyborderlessworld, the emergingdiseases worldviewidealizes 'informational cordons',whichwould identify and manage risksbeforethey become epidemicsthatthreaten Americancitizensand interests. The 2001 CDC report thus argues that 'increased international engagementhas stimulated CDC to rethink itsinfectious disease priorities, keepingin mind that it is far more effective to help other countriescontrol or prevent dangerousdiseases at theirsource than tryto preventtheirimportation' [CDC (2001): 5; see also WHO (2000): 3]. Replacing the utopian medical micro-colony is an ideal of a utopian biomedicalmacro-colony, in whichglobal surveillance networks allow risks to be identified and managedquicklyand efficiently. While colonialanxiety revolved aroundfearsof contamination as certain(white,European,male) bodies moved intovulnerable places and faced novelcontaminating environments and (non-white,non-European, female) peoples, postcolonial revolves anxiety aroundthe contamination of space itself by mobile bodies and motileenvironments. This is not the horrorof matter(or bodies) out of place, which presupposed the identification of a place for matter; instead,it is the horror of places no longermattering, of a 'third-worlding' at home.'8 As the CDC's 2001 report, Protecting theNation'sHealthin an Era ofGlobalization puts it,the appearanceof dengueinTexas and malaria in New York duringthe late 1990s illustrated Americanvulnerability to diseases of the poor, but also 'remindsus that millionsof people live in tropicalareas wheremosquitoborne[sic]diseases like malariaand dengue are a factof everyday life' [CDC (2001): 11].
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severalareas in whichAmericanscienidentifies VitalInterest America's health: tificexpertisecould be deployed in the service of international management,biomedical and biotechnosurveillanceand information of pharmaceutand dissemination logical research,and the development ical products. Central to each of these projectsis the use of American and of information of global networks in the establishment technoscience betweenand treaties conductedthrough projects, exchange.'International' would be replacedby 'global' projects, states, amongsovereign cooperation organizaand non-governmental conductedby coalitionsofpublic,private in which networks would erectvastcommunications These coalitions tions. could be gathered,standardized,manipuepidemiologicalinformation managed and archived. lated,interpreted, inthe productionof verifiable also identifies America's VitalInterest to the prerequisite as a fundamental disease outbreaks formation regarding attainmentof global health. To this end, the report recommendsthe to detect,trackand intervene network of a global surveillance institution would allow This network around the world. of disease againstoutbreaks thatno ensuring disease, of outbreaks of local forthe rapid identification unnoticed. go would population the human incursionof microbes into of flexible teams of This would providethebasis forthe rapid deployment Centers for the from Americaninstitutions including biomedicalexperts of Health Institutes Disease Control and Prevention(CDC), N4ational - who would be availableto providediagnoses, (NIH), and theUS military the spread of and assistin measuresto containand prevent treatpatients, the disease. In addition,clinicalmaterialscould be collectedon site and sectors,in order in thepublic and private circulated amongexperts rapidly the specificpathogensand develop diagnosticand therto characterize notesthat,since the information apeutictools to combatthem.The report is both network a global surveillance necessaryto implement technology complexand expensive, to advance countries is how to helpdeveloping ... a specialchallenge The United ofinformation andcommunications. in fields their capacities in thisenterhas muchto offer thecorporate sector, States, particularly the US government, alongwithits To foster such involvement, prise. the world,mustensurethatthe regulatory, throughout counterparts investment to attract conditions private necessary and market legislative, services andinformation information technology, intelecommunications, arein place. [IOM (1997): 31] of would not be limitedto the identification management Information of the IOM the As development reportnotes, specificdisease outbreaks. and comvaccines and therapeuticsdepends upon efficiently effective it is trials. clinical data from Thus, and managing gathering prehensively is producedbe multiplied globally, essentialthatsitesin whichknowledge of thatknowledgefromthe developing and conduitsforthe transmission world(whichwas assumedto be thelocationin whichmostsuch outbreaks would occur) to the developedworldbe opened and maintained:
775
Medical research into the control of infectious diseasesis often not possible without collaboration between nations. Manypotentially threatmustbe studiedabroad eningdiseases,such as malariaand cholera, in whichthe diseasesare common. amongpopulations In the United of vaccines States, trials and drugsagainst suchdiseases wouldnotbe eventhough US citizens statistically havemuchto gainfrom feasible, resulting products. Testsofnew drugs and vaccines can also be undertakenmost cost-effectively in populations in whichdiseaseratesare high... in order to maintain thenecessary flow ofknowledge to prevent diseasesand savemoney, theUSA mustcontinue to invest in research collaboration with itspartners abroad.[IOM (1997): 32] In the emerging diseases worldview, Americaninstitutions would be both the natural leaders and the most prominentbeneficiaries of the creationof a global surveillance network.19 Thus the CDC plan - which, citing America's VitalInterest, arguesthat'promoting international cooperationto addressemerging infectious diseases is a naturalrole fortheUnited States,whose scientists and businessleadersare important membersofthe biomedical research and telecommunications communitiesthat provide the technicaland scientific underpinning forinfectious disease surveillance and control'[CDC (2001): 16] - identifies the improvement oflaboratory diagnostic facilities and surveillance networks as itsfirst twopriority areas. Its stated objective is to replace ad-hoc outbreak investigation with a formal,standardized virtualnetwork of data collectionand analysis. The CDC would be the source of the technology, standardsand expertise, creatingthe computermodels and risk-analysis software, refurnishing gional laboratories with'state of the art' diagnostics, and training foreign personnel througha series of InternationalEmerging InfectionsProgrammesin developingnations. In return, Americanresearchers would gatherinformation fromabroad not only on nascent epidemics,but also morebroadlyon the naturalhistory of infectious disease. In the postcolonialvisionof global health,then,riskscould no longer be prevented through the preservation of territoriality. Instead,theycould be managed in the de-territorialized networksin which information is collected,managed,assembledand disseminated. The familiar techniques of medical observationare multipliedglobally,and the monitoringof individual bodies in specific places augmented(and perhapsreplaced?)by the surveillance of the global populationin the de-territorialized space of informatics, telemedicine, databases and the internet. To be sure,information in public healthis hardly management a novel phenomenon,as targetedsurveillance of specificpopulationsand collection of epidemiologicalinformation have long been important aspects of public health practice [Coleman (1987)]. In an earlierera, information collectionwas a reactiveand specificmeasure,carriedout in responseto specific outbreaks or targetedat particularpopulations, especially the urban poor. In the emerging diseases worldview, surveillance is expanded fromspecificlocal activities of set durationinto an unlimited, unending, examinationof the global population, whose goal is the detection of abnormal distributions of epidemics of infectiousdisease before they
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In contrastto the panoptic institubecome publiclyvisible outbreaks.20 of a singleprisonor the clinic,whichis easilyidentified tionalsurveillance at all is imaginedto be everywhere, thissurveillance as coerciveor violent, a global clinic. times,producingdata availableto everyone: Territories and Networks (2): Exchange the productionand managementof diseases worldview, In the emerging thatensuredthe by a global system would be complemented information and consumptionof biomedical prodefficient production,distribution conInternational vaccines and otherpharmaceuticals. ucts, particularly - that focusedon vectorcontrol diseaseshad traditionally trolof infectious betweenhumansand nonofpathogens in thetransmission is, intervening it is diseases worldview, humans.While thisis stilla part of the emerging infectious in 'control' of future, the the that, assumption by overshadowed disease will be achieved throughworldwideconsumptionof biomedical technology. America'sVital Interest portraysthe protectionof global health as several obbut identifies withAmericaneconomic growth, synonymous of biomedicine. of business stacles to the smooth functioning the global in theability to invest and engagein global inequities Because ofstaggering introduction ofnew drugs the 'fortheforeseeable future, their production, on the pharmaand vaccines in developingcountrieswill be dependent in the United States and otherindustrial ceutical and vaccine industries marketforpharmaceutcountries' [IOM (1997): 36]. The international companies and inpharmaceutical withmultinational icals is bifurcated, dustrial producersin the USA and Europe (whichproduces 75 percentof all drugs exportedto developingnations) required'to pursue growthin as possible' [ibid.: 36]. However,these as aggressively markets emerging whose formarkets to developcommodities companieshave fewincentives They are also relative powerin theglobal economyis negligible. purchasing conventions and adherenceto international faced withunevenregulation and piracy. intellectual rights property regarding 'to make For thesereasons,globalhealthis dependentupon theability and feasibleforthe best ofAmericanscience,technology, it economically to addressmajor global healthproblemsand enable US industry industry ratherthan suffer losses, by that engagement'[IOM (1997): to profit, of The institution 36].21 The IOM reportrecommendsseveralstrategies. to allow countries purchase poor multi-tiered pricing schemes would envaccines at close to marginalproductioncosts, while simultaneously of The acceleration of scale. economies to exploit abling manufacturers standards of safety, regarding international synchronization regulatory and piracywould assurepharmaceutintellectual property qualitycontrol, markets fortheir ofwell-ordered products- and would ical manufacturers over intellectual rightsand the property forestall growingcontroversies nations [Noah & Fidas production of generic drugs by non-Western
777
(2000): n.p.]. Finally,the education and training of health professionals fromdevelopingnations in the methods of Westernbiomedical science 'would provideopportunities forUS medicalproductsand technologies to enterthe overseasmarkets'[IOM (1997): 45]. The integration of global public healthwiththe international pharmaceuticalindustry illustrates a second wayin whichthe idealizedrhetoric of - in thiscase, global networks the network of commodity exchange- is a centralcomponentof the emerging diseasesworldview. In thisview,health interventions take place in those real and virtualplaces where medical goods and servicesare exchangedbetweenindividuals, groups,institutions and organizations. Such places include the sites where drugs and other medical technologiesare bought and sold, eitherindividually or in bulk form;the virtualsites of international where resourcesare inmarkets, vested, prices negotiatedand determined,and futurestraded; and the global media,wherehumansuffering is transformed intoand exchangedas a commodity. It is instructive to look at one graphicrepresentation of the space envisionedin this imaginary. Figure 1, reproducedfromthe IOM report Orphansand Incentives [Harrison & Lederberg (1997): 12], illustrates a marketsegmentation strategy initiated by the Children's Vaccine Initiative (CVI) to encouragethe development of new pharmaceutical productsto address infectious diseases in developingnations.22 While the 1980s witnessed an explosionin vaccineresearch and development, driven in partby revolutions in themolecularsciencesand biotechnology, thetarget markets forthese productswere limitedprimarily to the industrialized nationsof NorthAmericaand Western Europe. As thisreport notes,two of the most significant disincentives to pharmaceutical development concernthe irregularityand unpredictability of the marketforvaccines and therapeutics. Demand forpharmaceutical productsis notoriously unpredictable, especiallywithregardto epidemic diseases. Because of the lengthy time and expense involved,manufacturers are loath to investin developmentof a productwhose demand cannotbe assured.23 In addition,even ifa reasonablylargemarket in termsofpopulationcan be assured (as, forexample,it can be fordiseases such as malariaand tuberculosis), those most likely to suffer from infectious diseasestendto have little social or economiccapital, and thusforman unappealingcustomer base. To addresstheseissues - or, as the IOM reportputs it, 'to bolsterthe competitiveness of such public healthproductsin industrial portfolios' the CVI adopted several strategies[Harrison & Lederberg (1997): 2]. Along withusingmanagement consultants to analysethe relevant markets and workingtowardsthe protectionof intellectual property and patent rights,they devised a plan to ensure that the global marketplacefor particularmedical productswould be stable and attractive. As the IOM reportnoted,thisconsistedof'earlyinterventions to make a givenmarket more attractive to investment, in effect creatingthat marketby limiting demand uncertainties and generating appealingeconomiesof scale' [ibid.: 35]. Under thisstrategy, countries are groupedaccordingto ability to pay
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forpharmaceutical products- in this case, vaccineswhose demand fluctuatesbetweendifferent geographic regions.Each groupis thenchargeda different rateforpharmaceutical sharethe products,in orderto efficiently risksand benefits of the unpredictable vaccinemarket. The ideologyof colonial public healthwas characterized in partby its preoccupationwith the transmission of medical knowledgebetweennation-states. historians of colonial medicineexaminedthe multiple Initially, waysin whichWestern medical theoriesand public healthpracticesfunctioned in a colonial contextas 'tools of empire' withwhich to subjugate local populations.Othershave studied the modes in whichWesternbiomedicinewas reconfigured or resistedin colonial contexts. More recently, some have begun to question the veracity of analyses that rely upon a model in whichknowledge is diffused from a (Western)'centre'to a (nonWestern)'periphery' .24 The emerging diseases worldview differs from the colonial in thatit is relatively unconcerned with the diffusion of knowledgefromcentre to and rather periphery, more concernedwithefficiently managingthe global circulation of medical products.Figure 1 presentsa worldmarkedless by the geography of place, than by the integration of locationsinto a global marketplace: not just a global clinic,but a global HMO. Connectionsbetween commodity exchange and international health are by no means historically novel.However,the emerging diseases worldview'semphasison innovative efficient production, and global distribution, consumptionof pharmaceuticalsis significant as a distinctively colonial in a sustainedAmericanfaith operation.Partaking in technological fixesand in contrast to the rhetoric ofprevious'global' healthstrategies such as the famous(ifineffectual) Alma-Atadeclaration of 1978 - it forecloses the consideration of social or structural remediesto international healthproblems.25 Instead,it establishes a framework in whichparticipation in global public health is conducted upon a terrainalready colonized by market relations and the logic of exchange.26 In the emergingdiseases worldview, participation in the global exchange of medical commoditiesis incumbentupon adherence to international standardsregarding regulation, pricing,piracy and intellectual While the specificcontent of these standardsmightgenerate property. - as it has in recentcontroversies controversy over pricingof HIV/AIDS drugs and productionof genericsin South Africa,India and Brazil - the ofstandardization prerequisite is already mapped out ahead oftime.Where colonialists anticipated eventual victory in the internationalconflict between competingmedical systems,the emergingdiseases worldview idealizes a smoothterrain of global capitalist exchange.27 From 'Civilizing Mission' to International Development This idealizationof exchangenetworks is part of a largerdiscourseon the integration of developingnations into world markets.It also providesa final point of comparison regardingdiscourses of humanitarianism in
780
analyScholarly diseases worldview. ideologyand the emerging colonialist have forthe mostpartfocusedon ses of public healthin colonial contexts or medical epistemologies the encounterbetween cultureswith different imaginedthemEuropean and Americancolonialists healthbeliefsystems. Western biomedicine betweenrational selvesto be part of a greatstruggle colonial public In theirimaginary, therapeutics. traditional and primitive mission',in which modernmedical healthwas part of a larger'civilizing backfreeing therapeutics, traditional science would drive out primitive colonialismas and legitimating thegripof irrationality ward societiesfrom humanitarian project. an ultimately of colonial medicinehas modifiedthis workin the history Revisionist First,it has critiquedthisideologyof colonialhealingby exposnarrative. mission', arguingthat this ing the violence at the heart of the 'civilizing involvedan oppressiveand often humanitarian enlightenment putatively to discipline brutalerasureof indigenoushealingpracticesin an attempt local populations.Second, it has critiquedthe binarylogic in which an a homogenous set of consistent 'Westernmedicine' confronts internally the coinstead to investigate beliefsand practices, preferring 'traditional' production of medicine and colonialism [Anderson (1998)].28 Finally, colonial public health as the site of a complirecentworkhas identified in a novel hybridof different medical oftenresulting cated negotiation, theoriesand practices[Lyons (1992); Cunningham& Andrews(1997)]. What these analyses share in common is the assumptionthat the between colonial situationis above all a scene of combat and negotiation Whateverone's differences. actors with incommensurableepistemological of the 'civilizingmission', there or consistency view of the authenticity seems to be broad agreementthat the colonial situationwas most procultures withdifferent betweendifferent markedby the encounter foundly practicesand beliefsystems. medical theories, By contrast,the emergingdiseases worldviewenvisionsa situation betweenincommensoveror negotiations markednot so muchby conflicts epistemologiesor belief systems,but ratherby more urably different in global over the relativeplace of stakeholders mundane disagreements missionis beingreplaced The ideologyofthe civilizing exchangenetworks. thegoal is no longerto bringmodern development; by one ofinternational them with cultures,but ratherto furnish Westernmedicine to primitive of to fosterthe integration Westernmedical technologiesin an effort underdevelopednations into the world capitalist economy [Anderson (2000): 235]. shares much in common withthe diseases worldview The emerging thatemergedin the postbroaderdiscourseof international development a professional WorldWar II period. Both emphasizethe need fortraining science in the and laboratory class in Westerndisciplines- epidemiology about the - in orderto produce knowledge economicsin thelatter former, interventions. developingworld and serve as the basis forhumanitarian into of non-Westerners and integration Both considerthe modernization
781
the world economyto be the most efficient vehicleforimprovements in qualityof life [Escobar (1988): 430-32]. this worldviewhas been promotedas a corrective Ironically, to the causal logic favouredby the Bretton Woods institutions duringthe Cold War. Internationaldevelopmentorganizationshave long assumed that improved healthnaturally followseconomicmodernization, and have thus prioritized investment in industrialand agricultural production[Garrett (1996): 69-71]. However, in its 1993 World Development Report, the World Bank argued that 'spending on health can be justified on purely economic grounds'. Identifying poor health as an obstacle to economic it recommendedthreestrategies development, to simultaneously produce betterhealth and economic development: implementing policies that encourage income gains among the poor, includingexpanded investment in education; redirection of government spendingfromspecialized clinical care to basic public health activities such as immunization, nutrition and controlof infectious diseases; and promotingcost-effective provisionof care and competition amonghealthserviceproviders [WorldBank (1993): 17]. Citing the growing 'financialand intellectual' influenceof theWorld Bank (whose 1996 loans forhealth were twice as large as WHO's total budgetforthatyear),America's VitalInterest similarly identifies poor health witheconomic underdevelopment, politicalinstability and global insecurity [IOM (1997): 42-43]. Otherreportscite a 'negativesynergy' between healthand development, in whichinfectious diseases contribute to labour shortages, absenteeism, tradedisruptions, reduced GNP, and the redirection of resourcesfromspendingon education,infrastructure and other social programmes, leadingeventually to politicaland economicinstability [Noah & Fidas (2000); Moodie & Taylor(2000)]. Westerninvestment in global health is thus justified by the need to foster continuedeconomicdevelopment and modernization. In thecontext of globalization, these concerns are smoothly interwoven withAmerican economicinterests and nationalsecurity. One reportcommissioned by the Council on Foreign Relations and Milbank Memorial Fund argued that 'defensiveimperialism'is necessarybecause 'in an increasingly interdependentglobal economy, thereis thepotential fordamage or stagnation to US economic interests whereill healthand otherfalling social indicators condemn a countryor regionto the "poverty trap" of high fertility and highmortality' [Kassalow (2001): n.p]. To be sure, this emphasis on developmentis hardlynovel, and indicates the persistence of a colonial 'transition narrative' whose assumed end-point is the modernization of non-Westernstates [Chakrabarty (1992): 4-8]. Yet the absence of questions of cultureand health belief systemsis striking. The emergingdiseases worldviewis silent in these matters,assuming that the conflictbetween 'Western' and 'traditional' health systemsis eitherover (with the formeras victor), or is wholly irrelevant to the projectof global public health.
782
Conclusion: Conversion and Integration Let me again stressthatmy reasonforsketching out thisparticular postcolonial visionis not to suggest thatcolonialagendas, strategies or practices are dead.29 Colonialand postcolonial ideologies are coincident and deeply entangled. My goal is instead to suggest thatthe objectsof - mostnotably criticism postcolonial theobsessive binarization ofcolonial logic- arebeingjoined, andperhaps superseded, bya form ofpower that in itsrhetoric, is pluralist integrative in its ambitions, and justas easily interwoven withthe concerns ofAmerican national security and global economic dominance & Negri(2000): 137-46].3? [Hardt and practices intobiomedical and moregenerally of 'primitive' science, into'modern' and doing. The postcolonial waysof knowing agendahas and doing is taken for and achieving biomedical ways ofknowing granted, 'globalhealth' depends uponintegrating localities intoglobalnetworks of and information Local populations obcommodity exchange. present or cultural staclesnot becauseof incommensurate belief systems differintothemodern ences,butbecauseofincomplete integration projects of totalsurveillance and seamless exchange. networks and exchange is attractive, The languageof integration, in thecontext ofan ideology that on particularly placessuchimportance moreegalitarian thanthat international development, becauseitseemsfar In fact,the projects of conversion and integration are of conversion. Information and commodity-exchange networks are mutually reinforcing. in practice, is achieved almostas a bya meansby whichconversion In thelogicofnetworking, itis notnecessary toeffect, product. byviolence ofanother's culture orworldview. It is orbyargument, thetransformation themin a seriesof specific necessary onlyto enlist exchanges: produce is small, these consume these Each exchange these data,learn skills, drugs. as a meansof enlistment intolarger and ultimately but serves networks, as SaskiaSassen intoa universalizing project [Latour (1993)]. Moreover, arenas: networks arefundamentally some (1991) has shown, inegalitarian or central thanothers, and somelocal points nodesare moreimportant their thando others. benefit morefrom operation criticisms ofWestern The network ideal also appearsto circumvent noted Anderson medicalparochialism. [(1998): 523] has disapprovingly ofmedicine, nota postcolonial that current scholarship represents history of medinationalist historians enclaveof implicitly but 'a disciplinary aboutWestern cine... [who]are morelikely to ask whatis distinctive than to lookfor in a particular orprotonational, medicine colonial, setting in anysetting'. medicine Western whatis colonial about Eschewing quesor practices are 'Western' or medical theories tionsofwhether particular diseasesworldview not,the emerging appearsto severthe tiesbetween abouttheemerging and colonialism. Whatis 'colonial' 'Western medicine' is not(oris notanylonger) itsdistinctive worldview diseases epistemology,
integration as its goal and its dominant metaphor.The universality of of indigenousmedical beliefsystems Colonialism'sgoal is conversion:
783
but rather its alliance withthe networking impulseofWesternmodernity [Giddens (1990)]. This postcolonial imaginaryis characterizednot so much by the overtexportof medical theories (thoughthisdoes doubtlessly occur as a matter of course), but rather by theintegration of localitiesinto the global circulation of information and commodities. If, as I have argued,expressions of power in the postcolonialera are both continuous and discontinuouswith those in the colonial era, this raises a question for the anthropology of resistance. If the emerging diseases worldview has set up particular agentsand agencies- theprovider of information, the consumer of pharmaceuticalproducts,the healthy, modern, productiveparticipantin the globalized economy - then what forms might resistance to theseagentsand agenciestake?Recentstudiesof colonial-eramedicine and public health have reviewedthe varied forms that resistance to religious and epistemologicalconversionhas taken. we might be attunedto theforms ofresistance Henceforth, availableunder a different mode of colonization:not the singularconversionof souls or ideals, but the unremitting conversion of universal exchange. Notes
The authorwould like to thankmembersof the HarvardUniversity Historyof Medicine Working Group,Warwick Anderson,threeanonymousreferees, and the Editorsof this special issue fortheirhelp. 1. This (unpaginated)report, issued as a National Intelligence Estimate,was commissioned by the US Departmentof State and National Security Council, and preparedby Lt Col Don Noah of theArmedForces Medical Intelligence Centerand George Fidas of the National Intelligence Council. On the Clintonannouncement, see Gellman (2000). 2. Throughoutthispaper, I use the hyphenated versionof the term'postcolonial'to a particular signify the retreat of the colonial geopoliticalorder), periodization (after and to distinguish it fromthatbody of theoretical literature thatfallsunderthe rubric of 'postcolonialtheory'or 'postcolonialcriticism'. I do not wish to claim thatwe are 'postcolonial'in the termsthatthesetheorists but to make rather understand, more prosaic observations the ideologyof international regarding healthin the aftermath of the demise of the colonial order.For the relationship betweenglobalization and the postcolonial,see: During (1998); Moore-Gilbert(1998); and Dirlik (1994). 3. But also note thatvaluationof unfettered freemarkets could also presentan obstacleto public healthmeasures [Porter(1994a): 5-8]. 4. Notable exceptions to thisfutility were the use of quinineprophylaxis and vaccination forsmallpox. 5. The conference, Viruses:The EvolutionofVirusesand Viral Disease', was 'Emerging held underthe auspices of the NIH's Fogarty International Centerand the Division of Microbiology and Infectious Diseases of the National Institute ofAllergy and Infectious Diseases. Details can be foundin Henig (1993): 12-20; Garrett(1994): 5-6; and Morse (1993a). 6. This universalizing was established tendency by some of Morse's earliest publications on the matter, in whichhe outlinedthe generalevolutionary biologyand epidemiology of viruses,whichhe termed'rules of viraltraffic' [Morse (1990); Morse (1991)]. It was established figuratively by popularizersof the worldview such as Laurie Garrett and RichardPreston,each of whose workfeatured extendedmetaphors of comparing global ecologyto an individualorganism's immunesystem[Garrett (1994); Preston(1994)].
784 7. 8. 9. 10. 11.
Social Studies of Science 32/5-6 In an interview publishedin April2001, JamesHughes, Directorof the CDC's Diseases (NCID), statedthatthe 'classic' IOM report National CenterforInfectious plan': McCarthy(2001). CDC emerging infections had 'helped shape the first of origincan be foundon page journalsand theircountries A listof the participating ofthe American MedicalAssociation. 1996 issue of theJ'ournal 246 of the 17 January of Four humansdevelopedantibodiesto the virusbut did not presentanysymptoms fever: Preston(1992). Ebola haemorrhagic In his foreword to Morse's editedcollection[Morse (1993c)], RichardM. Krause thatfailedto [(1993): xviii]invokesEbola alongsideSwine Flu as localized outbreaks spreadglobally. on Garrett can be foundin Kinsella (1989). Kinsella, Backgroundinformation critical of media coverageof HIV/AIDS, singlesout Garrett's otherwise ferociously world' as 'a model of how a on AIDS in America'sown third 'extraordinary reporting can be touchedby a story, yetmaintainenoughdistanceto be able to tellit' journalist [ibid.: 6]. Preston's criticized StephenMorse's reviewof the two books in PublicHealthReports dramatic, ifnot somewhat like a moviescriptwithoverly workforbeing 'written and identified of how people die of Ebola virusinfection', inaccurate, descriptions as the 'deeper and more substantive discussion' [Morse (1995)]. Garrett's is examinedmore comprehensively in mydoctoral The emerging diseases worldview dissertation: King (2001). VitalInterest Otherreports the recommendations ofAmerica's citingand reiterating includeNoah & Fidas (2000), CDC & ATSDR (2000), CDC (2001), and Moodie & Taylor(2000). I thankArthur me to thisreport. Kleinmanfordirecting of critical regarding voices engagingin the public conversation Amongthe minority emerging diseases,see: King (2001); Farmer(1999): 37-58; and Tomes (2000). cases of Ebola haemorrhagic fever There have to date been no reported symptomatic among humansin the United States.A 1989 outbreakat a primatequarantineunitin Between 1999 and 2001, there resultedin foursubclinicalinfections. Reston, Virginia, cases ofWestNile virushuman illnessin the United States, were 149 confirmed including18 deaths.During 2002, the virusappeared to have spread to a numberof the CDC new areas, and the numberof cases jumped.As thispaper was submitted, cases and 89 deathsin 32 statesand the Districtof reported1852 confirmed Columbia. Data availableat: http:llwww.cdc.govlncidodldvbidlwestnilelindex.htm a is undergoing even ifthe object of horror Mary Douglas' analysisis stillpertinent, see Douglas (1994 [1966]). processof reconfiguration: As one (unpaginated)studycommissioned by the Council on ForeignRelationsnoted, and thisin turnbenefits the the global system, "world healthimprovements strengthen of thatsystem':Kassalow United States as the dominantpowerand main supporter (2001): n.p. see Armstrong of surveillance in modernbiomedicine, For more on the centrality moregenerally, see Lyon (1994) and Bogard (1996). (1995). On surveillance As anotherreport[Moodie & Taylor(2000): 54-55] argued:
12.
13. 14. 15. 16. 17.
18. 19.
20. 21.
Pharmaceutical priorities. companiescannotbe blamed fortheircurrent to the market.... The They do whatbusinessestend to do - responding of the corporatecommunity mustbe sustainedwhilethe interests legitimate unstablecountries are addressed healthchallengesin poor and potentially to bridgethe needs ... thereis more thanenoughcreativity more effectively created of corporateactors,and opportunities of the poor, the requirements community. by the scientific in and Incentives 22. This IOM report,Orphans [Harrison& Lederberg(1997)], is the first conductedby the IOM's Forum on Emerging on workshops a seriesof reports betweenthe at collaboration and outlinesthe major issues facingattempts Infections, included in thisparticular The participants sectors. workshop public and private frnm American aca-dmic instituitons (6) variniis hranche of the UTS ntativ
r
Postcolonial Technoscience: King: Security,Disease, Comrnerce
785
23. 24. 25.
26.
27.
28. 29. 30.
Federal Government (5), local US healthdepartments (2), Americanand European Researchand Manufacturers pharmaceutical companies (9), and the Pharmaceutical of America(PhRMA). of a singlenew drugrequiredan average Accordingto one 1996 estimate, development of 15 yearsand $359-500 million[Harrison& Lederberg(1997): 24-25]. For an excellentearlyversionof a studythatillustrates the complexnatureof the relationship betweenbiomedicaland 'traditional' healingsystems, see Janzen(1978). Meetingin Alma-Atain 1978, theWHO called for'the attainment by all peoples of the worldby the year2000 of a level of healththatwill permitthemto lead a sociallyand economically productive life',via social equityand the universal of basic provision The fulltextof the Declarationis availableat http://www.who.intlhprl healthservices. archiveldocslalmaata. html In a discussionof commoditization as a universalizing process,Igor Kopytoff argues thatthereis 'a driveinherent in everyexchangesystem towardoptimum - the driveto extendthe fundamentally commoditization seductiveidea of exchangeto as manyitemsas the existing exchangetechnology will allow' [Kopytoff (1986): 72]. As Simon During has suggested, globalization and postcolonialism are distinguished by the differing stresses emphaseson timeand space: the former in 'de-historicization', whichmetanarratives are rejectedin favour of 'non-modern'relations to the past and future; whilethe latteremphasizes'de-territorialization', in whichgeographical is rejectedin favour determinism of an analysisof the fragmented but unified world of exchanges.Focusing on the latter system thus allows us to look at spaces of - to analyseless in termsof 'how some than contestsovertemporality exchangerather have been granted[or,we mightadd, rejected]fullaccess to modernity and others(the poorestand least powerful) have been "othered"and primitivized than in termsof how distancehas been reduced to forma global system witha sharedeconomy, a sharedset of technologies and an increasingly fluid,accessibleand exchangeablerepertoire of culturalmodes' [During (1998): 37]. This is part of a largerdebate on the utility of binaryoppositionsand grandnarratives within postcolonialtheory discussedmost clearlyin Hall (1996). In thisrespect,I agree with Warwick Anderson'splea that'we need to recognizethat the basic languageofWestern medicine,withits claims to universalism and modernity, has alwaysused, as it stilldoes, the vocabulary of empire' [Anderson(1998): 529]. As one reportsuccinctly argued,'worldhealthimprovements strengthen the global and thisin turnbenefits system, the United States as the dominantpowerand main of thatsystem'[Kassalow (2001): n.p.]. supporter
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Nicholas B. King is the J. Eliot RoyerPostdoctoral Fellow in the Historyof of California,San Francisco.He Health Sciences Program at the University
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and hisDoctoratein received hisMasters degree in MedicalAnthropology of Sciencefrom Harvard Hisresearch examines History University. emerging surveillance and information diseases,biological terrorism, and technology, the commodification of medicine. He has published on emerging diseases, tuberculosis, and biological terrorism, and is currently preparing a manuscript based on hisdoctoraldissertation, Infectious Disease in a World of Goods (Harvard, 2001). of Anthropology, Address:Department History and Social Medicine, University of California, San Francisco, 3333 California Street, Suite485, San Francisco, California 94143-0850,USA;fax:+1 415 476 6715; email: nbking@itsa.ucsf.edu.

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Security, Disease, Commerce: Ideologies of Postcolonial Global Health Author(s): Nicholas B. King Source: Social Studies of Science, Vol.

Security, Disease, Commerce: ofPostcolonial Ideologies GlobalHealth

Social Studies of Science 32/5-6

Postcolonial Technoscience: King. Security,Disease, Commerce

Social Studies of Science 32/5-6

Postcolonial Technoscience: King: Security,Disease, Commerce

Social Studies of Science 32/5-6

Postcolonial Technoscience: King: Security,Disease, Commerce

Social Studies of Science 32/5-6

Postcolonial Technoscience: King: Security,Disease, Commerce

Territoriesand Networks (1): Information

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Postcolonial Technoscience: King: Security,Disease, Commerce

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Postcolonial Technoscience: King: Security,Disease, Commerce

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Postcolonial Technoscience: King: Security,Disease, Commerce

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Postcolonial Technoscience: King: Security,Disease, Commerce

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Postcolonial Technoscience: King: Security,Disease, Commerce

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