Science, Medicine, and Anthropology
The fantastic papers in this symposium cover a wide diversity of topics, from the fallout of dementia on kinship relationships, to exchanges with Gods, to the self-administering of make-up, to medical research. So how do we know we are all talking about the same thing? One of the strengths of anthropology is the way we stretch concepts, test them in new contexts to see how far they can reach. But one of the pitfalls is that in doing this we extend the meaning of the concept so far that it becomes meaningless. So we need to look after, dare I say ‘care’, for our concepts. And doing so means recognising their limits.
These papers are brought together by the shared use of the concept of care. But given the very different practices, relationships, and values they describe in the name of care, it is important to ask just what conceptual work care is doing for us. Are we stretching it too far? Might other concepts capture what we are talking about with more precision? What concepts are articulated by our interlocutors in the field, and how might these differ from anthropological concepts of care in subtle ways?
Hannah, for example, talks about care in relation to that now rather old-fashioned medical anthropology concept ‘healing’. This made me wonder what difference it makes to talk about care rather than healing in this context. Might we actually want to keep both concepts in play? For example, people ‘care’ for their gods, and in doing so they also get ‘healed’?
Like Hannah, Bridget discusses practices of ‘self-care’. But where in Hannah’s paper, self-care is juxtaposed with healing, in Bridget’s paper self-care is juxtaposed with ‘coping’. Again, the question for me is what difference it makes to use either of these words, what specific work is ‘care’ doing here that ‘coping’ is not?
Sandalia talks about the added ‘care’ that participants in medical research get, by comparison with the routine care that is possible in an under-resourced health system. When the doctor tells Sandalia that they offer ‘quality care’, what exactly does he mean? Here, the counterpart to care is not healing, but resources. Again and again Sandalia poignantly returns to the list of things that were present or absent in the public hospital and the research clinic and dispensary. Is the presence of those things care itself, is it evidence of care, or the infrastructure that makes care possible? Might a distinction between care and infrastructure be useful? Making these distinctions is precisely what enables our concepts to do productive work.
So what do we agree on?
1. Many of the papers approached care through the idiom of exchange. Care, the papers showed, is a mode of transaction. Transaction can both be intangible – we care about something or someone when we recognise their needs – and tangible – we care for someone or something when we respond to those needs. Several papers also emphasised the reciprocal nature of care. For example, Lilian describes how for those who care for people with dementia, to give care without receiving recognition in return is to experience simultaneously the gradual loss of a loved one, and of the person that one is in that relationship.
There are further parallels with the conceptual moves made by economic anthropologists. Hannah, for example, picks up on Marcel Mauss’s theory of the gift in order to contest the assumption that care is an essentially altruistic act. She shows that people care for their Gods, but in doing so get a return, in terms of their own capacity to become closer both to the divine and to their own true nature. Last, in Sandalia’s paper, medicine is recognised by people as care when certain material resources are present, undermining any romantic notion that care might be opposed to technology. By focusing on transactions and relationships, the papers collectively put to bed any notion that care is synonymous with altruism, or that it might be opposed to self-interest, to monetary exchange or to materiality.
2. By focusing on the transactional qualities of care, the symposium papers showed that any discussion about care is inherently moralistic. It is difficult, if not impossible, for people to talk about care, without implicitly invoking a normative moral code. Of course we are as guilty of this as the people we study. When we ask – as the title of this symposium does – ‘who cares’ we are already implicitly suggesting that caring is a good thing, that people should care, and that not caring is bad.
People’s claims to care often also involve insinuations that other people are not caring. Medical scientists compare their research studies to the failure of the public hospital to administer care; Bridget’s informants compare the care they feel they get from her to the formal health care providers who they feel don’t care.
In unpacking the moral assumptions that underpin our discussions about care, we might ask ‘is care always good?’ Bridget’s piece, raises this question when she describes how family members who seek to stop people living with trich from hair pulling misunderstand the condition and can set back recovery. Here care seems to fall short because it involves a mis-recognition of needs. This raises the question of whether we locate care in the intentions that mobilise action, or in its effects, and shows that caring about people and caring for people may not always align.
3. Asking ‘is care good’ inevitably leads us to questions of good for what or for whom? Hannah’s account of exchanges with Gods raised the question of how we might further explore dynamics of care in relationships with non-humans. Sandalia’s focus on the stuff of care made me wonder what it meant to care about or for medical infrastructure. Lilian’s paper is in some ways the most conventional account of care as a transaction between two persons. Only, the overwhelming experience of those who give care within these relationships is that they are not caring for a person at all, or at least not the person they once thought they were in a relationship with. All the papers pointed towards the ways in which the object of care defines to a great extent the parameters of what we recognise as care.
4. As demanded by the title of this symposium, the papers also explored in different ways the identity of the caring subject. Many of the papers made implicit or explicit distinctions between informal care practices, usually taking place between kin, and professional care practices. For example, Bridget talks about the yearning that people with trich have for some kind of professional care – in this case medical care – which ends up being met by hairdressers rather than doctors. This raised an interesting question of what is distinctive about professional care – what it can provide that other kinds of care cannot. Sometimes do we yearn for more impersonal, more commodified forms of care, because it provides some kind of formal or public recognition of the legitimacy of suffering?
In Lilian’s paper, meanwhile, we encounter people who care for family members because they are kin, but increasingly find themselves taking on a role more akin to that of the professional ‘carer’. Indeed, the very fact they refer to themselves as ‘carers’ attests to this, and distinguishes the kind of care work they do from the everyday forms of care that is routinely given between kin. Lilian astutely identifies the difference as one of reciprocity and recognition. People who care for family members with dementia must continue to care for them even when their own needs are not recognised in return. Again, we return to care as a kind of exchange.
5. What needs to be put in place for ‘good’ care to be possible? This is where I think Sandalia’s comparison of the resources available for care in the public hospital where she worked and the vaccine trial she observed are important. When we ask what sustains care, or what makes care possible, we also need to attend to material resources, in a really practical way. We often think about care as something that is additional to the technical work of medicine. For example people like Claire Wendland and Julie Livingstone have written about the way that, despite the lack of resources, nurses in hospitals in Botswana or Malawi are still able to care for their patients. Care, in these accounts, appears as something that can be done without resources. Sandalia, by contrast, shows that care requires physical infrastructure.
Why do we talk about care?
Care, I have suggested, is a dangerous term – its conceptual fluidity can lead to over-use, and the depletion of meaning. The participants in this symposium resisted that fate by holding close to the ethnographic worlds in which questions of care were first raised for them. In doing so, they never lost sight of the stakes that people have in ideas and acts of care. Care matters.
But the term’s conceptual elasticity may also underpin its utility. It was precisely because the care framing allowed us to explore comparisons across contexts that might otherwise have been classified separately as religion, kinship, medicine, or the body, that new ideas emerged. If there is a concept to help us break down the sub-disciplinary silos of anthropology, this is it. Care connects, in more ways than one.
Alice Street is Senior Lecturer and Chancellors Fellow in the School of Social and Political Science at the University of Edinburgh. Her research focuses on the material politics of global health, with a focus on Papua New Guinea and South India. Her book, Biomedicine in an Unstable Place: Infrastructure and Personhood in a Papua New Guinean Hospital was published by Duke University Press in October, 2014.