Secondary Infections

When I first began my fieldwork, and began the process of grappling with influenza viruses and the various experts who study and track them, I lamented the difficulties of doing research on global phenomena. The 2009 H1N1 pandemic not only mutated faster than I could write about it, but the boundaries of my subject matter were notoriously difficult to delineate. Where did one go to study a pandemic? When did it begin or end? And how could I possible incorporate everything I observed or experienced into a cohesive ethnographic narrative? In the end, I decided that the virus was the key to unlocking the puzzle of how to study pandemics. All I had to do was let it mutate my thinking and writing and research methods. The Viral Network was the result.

Happily, the insightful and provocative comments collected here have further infected my thinking. Reading through these careful reviews from some of my favorite scholars and colleagues has led me to see my original project and its scope, its successes and failures, from a few new vantage points. And for that, I’m grateful both to them and to Somatosphere for inviting me to take part in the book forum.

To begin, Lyle Fearnley is absolutely right to suggest that perhaps we focus too much on the laboratory. My own work bridges the fields of anthropology and science & technology studies (STS) and it is difficult, after over a decade of delving into STS and the history and philosophy of science, not to be contaminated by the concept of the lab. Fearnley compares this lab mania with the factory obsession of Marxist political economy. The comparison is an apt one. He provocatively asks, “But what if our anthropological models of scientific knowledge production no longer treated the laboratory as the essential organ of science, as if laboratories were the vertebrae that hold up the entire body of knowledge?” What if?

For a start, I’m not sure that one can ever fully ignore the lab — especially since “the lab” has now become a metaphor for any space in which science is practiced. After all, where isn’t the lab these days? Fearnley suggests that, ultimately, the superorganism of Global Public Health is confined to the space of the laboratory. I don’t think that’s true. I spent a bit of time in the actual, physical space of a virology lab, but quite a bit more time outside of it. Yet where ever I went — U.S. CDC meeting rooms, conferences, fresh chicken stalls, public health offices — there it was. I was never fully outside of the lab. But I do agree with Fearnley in that global health does best — or is healthiest in terms of its capacity to function — inside the institutional spaces from which it emerges and reemerges during times of international health crises. And one of those spaces is, and will continue to be, the laboratory.

And yet, why should the lab — by which I mean the products of the lab, lab thinking, or the concept of the lab — travel so well throughout the viral network of global health? Natalie Porter reminds us that a network is, at its core, an informational and material web. Knowledge about viruses travels along sticky trails already carved out by the viruses themselves. The flu virus, at least in part, spins its own webs. In many ways, the lab is the virus’s workshop as much as it is the virologist’s. It’s the constant interaction of people, places, and viruses that produces the silk threads of the web in the first place. The resultant viral network is, as Porter argues, very sticky. Porter writes, “Like viruses, the actors in this web do not really exist on their own, nor are they situated in any one place or time; rather they emerge, interact, mutate, and communicate at different sites and moments in the ever-expanding network.” People and things and ideas can, and often do, get trapped in tacky threads of knowledge and expertise and their movement is both aided and limited, to be sure.

But what are the limits of the viral network? Does everything become caught up in this gummy web of viral expertise? And what about the very real dangers of the flu to the communities most at risk (rural farmers, chicken stall workers, etc.)?

Katherine Mason’s review astutely points to one of the limits of my ethnographic research and the book itself. Porter wonders about “the affected communities” and “how their expertise figures into the viral network.” She argues convincingly that the narratives produced by the superorganism of global health completely co-opt or drown out the voices of the disenfranchised — people who are at the mercy of the institutional structures that global health is supported by and undergirds. Echoing Mason, Porter writes that we can and should “ask specific questions about how patients, farmers, funders, and state leaders also transmit information in the viral network, whether directly or through scientists’ discourses.” I take seriously Mason’s critique that the viral isn’t just about global networking or connection, but “also represents the pain and suffering that that connectivity can create.”

In a provocative continuation of my own usage of the superorganism, Mason writes that “the ‘superorganism’ of global health has a brain (the center) that exercises profound control over other organs (the periphery).” In other words, not all actors or experts are alike — some experts are more subject to the strict hierarchies of the global network itself. This is no doubt very true and very troubling. Mason suggests that the concept of pandemic humanity that global health helps to construct is a dangerous pipe dream. Death is very real; it’s not just a narrative that relies upon ungrounded fears of a once or future pandemic. The problem is, as Mason points out, that death does not come for everyone equally. It is more likely to affect those living in the most dire situations — as is seen in the continuing Ebola outbreak (or the continuing cholera outbreak in Haiti for that matter). Mason effectively argues that tracking power would work just as well as tracking viruses in terms of epidemiological forecasting. Epidemiological models, as she suggests, simply mirror what we already know: that the “global” poor will die faster and in greater numbers than the “Western” rich.

Since the book’s publication, and throughout the Ebola epidemic, I’ve been thinking a lot more about how expertise is created and then functions within global health and how “local knowledge” factors into policy planning and decisions. One of global health’s biggest problems centers around the issue of “culture.” Medical anthropology has largely infiltrated public health in so far as epidemiologists and other experts working in places like the WHO and MSF understand that they need to be aware of and take “local cultures” into consideration. They also understand that local knowledge is important to a successful global health response. However, “global” health is a patchwork of “national” and “local” actors anyway. All experts, without exception, come into any outbreak situation carrying their own institutional “cultures” with them. Epidemiology isn’t practiced alike everywhere — even though the terms, protocols, and “facts” are all the same. Knowledge about what to do and what to prioritize are different between, say, the U.S. CDC and the European CDC. It’s not just the disenfranchised voices that are being lost, co-opted, or misinterpreted. In the cacophony that is global health in a crisis, whose voices should matter the most?

To trouble this even further, Carlo Caduff suggests that the problem may originate in equating expertise with reason, as if rationality were the only true path to knowledge. Expertise, Caduff argues, is always about the future — you need expertise to predict events, not necessarily to tell you about what already happened. Or rather, those working in global health only care about what happened if it is useful in the present moment in relationship to deciding upon a future course of action. Global health knows in order to plan to do. In this way, global health is truly viral. As Caduff points out, the virus is excess; it cannot be contained or predicted. Thus global health is doomed to be as ever-shifting and incapable of understanding itself as a virus is. And this is to say nothing of its capacity to accurately predict the course of future viruses. (Unless, like Mason suggests, global analysts simply do away with their models and pay more attention to the real-time movements of poverty and the dynamics of economic and political power.) Experts, in Caduff’s view, traffic in pure fiction. They have to — since the future is always fictive.

Adia Benton’s response also asks us to think about time in epidemiology, but in terms of its uses. She suggests that “accounting for temporality in ethnographic studies of epidemics also means engaging in deep study of timing, sequencing, tempo, and synchronization, among other things.” Timing is, as Benton argues, a tool of power. Indeed, in my time observing global health is action, timing can be not just an enemy (in terms of the speed of response and lives saved), but a weapon. A delay in sending requested information or performing an action might signal resistance or act as a way to renegotiate the power dynamics at play; a speeding up might be a response to a delay and indicate that the message was heard. Benton asks us, echoing but going beyond Fabian, “how might an even more thickened conception of time and temporality — beyond loops of past-present-future — open up how expertise and knowledge about pandemic flu is produced and circulated, how viral networks constitute themselves?” It seems to me that this question is in concert with Caduff’s reflections on the future-oriented focus of expertise. I meant pathography to be a method capable of doing this work, of attending to time and space and power, and I hope that it will be useful to scholars doing similar work on global events.

In the end, what this exercise in responding to these thoughtful reviews has really shown me is that the idea of viral anthropology is already a concrete reality. The ideas and critiques here have already begun their mutations and recombinations. Their transformative effects will be hidden, but no doubt traceable, in everything I write on global health far into the still-fictive future.


Theresa MacPhail is a writer, journalist, and medical anthropologist. She is an assistant professor at Stevens Institute of Technology, where she teaches classes in science & technology studies, medical anthropology, and global health.

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