An Anthropology of Biomedicine

MARGARET LOCK is Professor Emerita at McGill University, Montreal, Canada, Dept. of Social Studies of Medicine and Dept. of Anthropology. She is a Fellow of the Royal Society of Canada, Officier de L'Ordre national du Québec, Officer of the Order of Canada, and an elected Member of the American Academy of Arts and Sciences. Author and/or co-editor of 18 books and over 220 articles, Lock is a medical anthropologist whose work focuses on embodiment, comparative epistemologies of medical knowledge, and the global impact of biomedical technologies. VINH-KIM NGUYEN is Professor at the Graduate Institute of International and Development Studies in Geneva, Switzerland and at the University of Montreal, Canada. He is also Chair of Anthropology and Global Health at the Collège d'Études mondiales in Paris. He is a medical anthropologist and practicing physician who practices in infectious diseases and emergency care and has worked on the frontlines of global health efforts particularly in West Africa since 1994.

Acknowledgements xiii

Introduction 1

The Argument 1

Interwoven Themes 2

Improving Global Health: The Challenge 4

Biomedicine as Technology 5

Does Culture Exist? 7

A word About Ethnography 10

Section 1

1 Biomedical Technologies in Practice 15

Technological Mastery of the Natural world and Human Development 16

Technology and Boundary Crossings 17

Biomedicine as Technology: Some Implications 19

Technologies of Bodily Governance 21

Technologies of the Self 24

The Power of Biological Reductionism 25

Techno/Biologicals 26

2 The Normal Body 29

Cholera in the Nineteenth Century 30

Representing the Natural Order 31

Truth to Nature 32

The Natural Body 34

A Numerical Approach 35

Other Natures 36

Interpreting the Body 38

How Normal Became Possible 39

When Normal Does not Exist 42

Problems with Assessing Normal 43

Pathologizing the ‘Normal’ 46

Limitations to Biomedical ‘Objectivity’ 48

Better than Well? 49

3 Anthropologies of Medicine 51

The Body Social 51

Contextualizing Medical Knowledge 53

Medical Pluralism 55

The Modernization of ‘Traditional’ Medicine 56

Medical Hybridization 57

Biodiversity and Indigenous Medical Knowledge 58

Self‐medication 59

A Short History of Medicalization 60

Opposition to Medicalization 62

The Social Construction of Illness and Disease and Beyond 64

The Politics of Medicalization 68

Beyond Medicalization? 71

In Pursuit of Health 71

In Summary 74

Section 2

4 Colonial Disease and Biological Commensurability 79

An Anthropological Perspective on Global Biomedicine 79

Biomedicine as a Tool of Empire 81

Acclimatization and Racial Difference 82

Colonial Epidemics: Microbial Theories Prove their Worth 83

Fear of Biomedicine 85

Microbiology as a Global Standard 87

Infertility and Childbirth as Critical Events 89

Birthing in the Belgian Congo 90

A Global Practice of Fertility Control 91

Intimate Colonialism: The Biomedicalization of Domesticity 92

Biomedicine, Evangelism and Consciousness 93

The Biological Standardization of Hunger 94

The Colonial Discovery of Malnutrition 95

Albumin as Surplus 97

The Biologization of Salvation 98

In Summary 100

5 Grounds for Comparison: Biology and Human Experiments 103

The Laboratory as the Site of Comparison 103

The Colonial Laboratory 104

Experimental Bodies 106

Rise of the Clinical Trial 107

Taming Chance 109

The Alchemy of the Randomized Controlled Trial 110

The Problem of Generalizability 110

Medical Standardization and Contested Evidence 112

Anthropological Perspectives on Clinical Trials: The West African Ebola Epidemic 114

‘Jiki’: A Clinical trial Amidst the Ebola Epidemic 116

Context of the Clinical Trial 117

Globalizing Clinical Research 118

What Should Count as Evidence? 120

Economies of Blood 121

Experimental Communities: Social Relations 122

In Summary 124

6 The Right Population 127

The Origins of Population as a ‘Problem’ 129

Addressing the ‘Problem’ of Population 130

Improving the Stock of Nations 131

Contraceptive Technologies and Family Planning 133

Indian Family Planning – meeting Quotas 135

Increasing Fertility with Contraceptive use 139

The One‐child Policy 140

Biomedical Technology and sex Selection 145

Contextualizing Sex Selection: India and ‘Family Balancing’ 146

Contextualizing Sex Selection: Disappeared Girls in China 148

Sex Selection in a Global Context 151

Ghost Children, Little Emperors, Burgeoning Elders 153

Reproducing Nationalism 155

In Summary 157

Section 3

7 Who Owns the Body? 161

Commodification of Human Biological Material 162

Objects of Worth and their Alienation 164

The Wealth of Inalienable Goods 164

A Bioeconomy of Human Biological Materials 165

Who Owns the Body? 167

Gifting Life 168

Commodification of Eggs and Sperm 169

Medical Tourism 171

Immortalized Cell Lines 171

The Exotic Other 174

Biological Databases 177

Concluding Comments 182

8 The Social Life of Human Organs 185

Bioavailability – Who Becomes a Donor? 186

The Biopolitics of Organ Transplants 187

A Shortage of Organs 190

Inventing a New Death 192

The Good‐as‐dead 194

Struggling for National Consensus 197

A Rapacious Need for Organs 199

The Social Life of Human Organs 200

When Resources are in short Supply 204

Liminal Lives 206

Does the Body Belong to God? 207

Altruism, Entitlement and Commodification 209

9 Making Kinship: Infertility and Assisted Reproduction 213

Assisted Reproductive Technologies 214

Problematizing Infertility Figures 215

From Underfertility to Overfertility 216

Reproducing Culture 222

Assisted Reproduction in the United States 224

Assisted Reproduction in Egypt 227

Assisted Reproduction in Israel 230

ART and the Reproduction of Normalcy 234

Global Hubs of Conception 237

Section 4

10 The Sociotechnical Self 241

The Biological Boundary Between Self and Other 241

The Sociotechnical Self 242

Technologies of the Self 243

Technologies of the Self in Biomedicine 244

The Unconscious as Technology of the Self 245

The Discovery of an Unconscious Self 246

­Unlocking the Pathogenic Secret 247

The Pathogenic Secret as a Mode of Subjection 248

The Making of Posttraumatic Stress Disorder 248

The Practitioner‐self 251

Producing the Self Through Talking Technologies: Technologies of Health Promotion 252

Technologies of Empowerment 253

Technologies of Self‐help 254

Confessional Technologies 255

The Globalization of the Unconscious 257

Beyond Freud to the Neurosciences 259

The Psychiatric Self 259

Psychopharmaceuticals 260

Addiction and the Lie 263

Conclusion 264

11 Genes as Embodied Risk 265

From Hazard to Embodied Risk 266

From Generation to Rewriting Life 267

Genomic Hype 269

Geneticization 271

Genetic Testing and Human Contingency 272

Genetic Citizenship and Future Promise in America 275

Biosociality and the Affiliation of Genes 276

Community‐based Participatory Research 277

Genetic Information and Hybrid Causality 277

Genetic Testing in the Era of Personalized Medicine 279

Genetic Screening 280

Screening as a Collective Endeavour 282

Race and Genetic Testing 284

Preimplantation Genetic Diagnosis 286

Is a Neo‐Eugenics Looming on the Horizon? 287

12 Global Health 291

What is Global Health, and How is it Different from International Health? 292

Metrics and the Global Clinic 296

Botswana’s Cancer Ward 297

Leukaemia in the Indian Ocean 298

Value in Global Health: A Global Market for Diagnostics and Drugs 300

When Markets don’t Work 301

Medical Humanitarianism and ‘Philanthrocapitalism’ 303

Regimes of Anticipation in Global Health: Epidemics Fast and Slow 304

An Anthropology of Preparedness 305

The Politics of Anticipation 307

Conclusion 309

Section 5

13 From Local to Situated Biologies 313

The End of Menstruation 314

Local Biologies 319

Kuru and Endocannibalism 320

Racism and Birth Weight 323

Agent Orange and Foetal Abnormalities in Vietnam 324

An Abundance of Local Biologies 326

Local Biology and the Erosion of Universal Bodies 328

Rethinking Biology in the Midst of Life’s Complexity 329

Is Biology Real? 330

In Summary 332

14 Of Microbes and Humans 335

The Microbial Arms Race 337

Warfare and Iraqibacter 339

Debates About the Origin of HIV 340

From Versus to Commensals: Microbiomes and Metagenomes 345

The Human Ecosystem 346

15 Genomics, Epigenomics and Uncertain Futures 349

Divining the Contemporary 349

Amassing and Systematizing DNA 350

The APOE Gene and Alzheimer’s Disease 351

Genetic Testing for Late‐onset Alzheimer’s Disease 353

Interpretations of Risk Estimates 355

Dethroning the Gene? 356

Eclipse of the Genotype–phenotype Dogma 357

Does a Programme for Life Exist? 358

Learning (Again) to Live with Uncertainty 359

Epigenetics: Overtaking Genetic Determinism 360

From Epigenesis to Epigenetics 361

Molecular Epigenetics and the Reactive Genome 362

Miniaturization of the Environment 364

Embedded Bodies 365

Epigenetics and the Womb 366

Food as Environment 367

Social Deprivation 367

Ageing and Epigenetics 368

From Causality to Contingency 368

16 Molecularizing Racial Difference 371

Molecular Biology and Racial Politics 375

The Molecularization of Race 377

Bioethnic Conscription 377

Racialized Allelic Variation 379

Mexican Genomics 380

Discordant Genomic Knowledge 381

Commodifying ‘Race’ and Ancestry 382

Looping Effects 383

Epilogue 385

Notes 389

Bibliography 467

Index 529