what is life worth? exploring biomedical interventions, survival, and the politics of life

Rebecca MarslandDepartment of Social AnthropologyUniversity of Edinburgh

Ruth PrinceCentre of African Studies, Department of the History and Philosophy of ScienceUniversity of Cambridge

What Is Life Worth?Exploring Biomedical Interventions, Survival, and the Politics of Life

The cruel irony of history . . . is that as man learns how to increase humanwell-being through science, the number of persons who profit from thesegifts is fewer and fewer.—Kenneth L. Vaux, Will to Live, Will to Die, 1978

Health is the luxury of being able to fall ill and recover.—Georges Canguilhem, Knowledge of Life, 2008

Recent debates about technologies of “life”—medical technologies, such as ge-nomics, pharmaceutical innovations, and reproductive technologies—raise ques-tions about what it means to be human, and our relationship with biomedicine.The articles in this special focus section of Medical Anthropology Quarterly arefocused around the “value of life”—be it the economies shaped by biomedicalinterventions, the contestation of biological definitions of life, or studies whichchallenge the kind of person on which biomedicine is predicated. The collectionseeks to analyze critically the current fascination with biopolitics through empir-ical studies in sites where biomedical technology or techniques of self-care arenot easily accessible or realistic for everyone. Foucault’s work on the “care of theself,” and Nikolas Rose’s proposals about “contemporary biopolitics,” have influ-enced many recent studies in medical anthropology, but these do not fully resonatewith the sites in which we work. Underlying these concepts are practices that havemainly been available to elite groups in society—the “art of living” in ancientGreece was practiced by wealthy men, not women or slaves; and the technolo-gies of optimization and molecularization that Rose argues are at the center of a“contemporary biopolitics” not readily available to most people across the globe.These concepts take for granted an individualized ethos of care, and so we con-sider how this plays out in locations where alternative moralities shape interactionswith biopolitical regimes of care. Thus, we ask, where do the “edges” of biopoliticslie?

MEDICAL ANTHROPOLOGY QUARTERLY, Vol. 26, Issue 4, pp. 453–469, ISSN 0745-5194, online ISSN 1548-1387. C© 2012 by the American Anthropological Association. All rightsreserved. DOI: 10.1111/maq.12001

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We aim to explore the “in-between” spaces, the margins, the “edges” in whichcontemporary biopolitics meets other medical interventions, and are played outwithin—and indeed shape—particular moral economies. We ask what alternativeforms of “self-care” are available to those who share a “biological identity,” andhow important are these identities in contexts where poverty is still responsible forthe burden of illness? Indeed, to what extent is “self-care” even available as a tech-nique for those whose primary role is as carer for others, and in a context wherean alternative public morality to that of biomedicine is operating, or where peopleare simply struggling to get enough food to survive? If biomedical technologies of“optimization” are not available, are older techniques such as diet, spirituality, in-digenous medicines, and careful self-positioning within public networks of moralbehavior reoriented towards these new goals? Equally, how are local experts de-ploying the new ideas available within this “contemporary biopolitics” and usingthem to shape public debate? What forms of social triage—techniques of sortingand prioritizing—are developing in such contexts, and what are their consequences?For example, how do these emerging economies of care, treatment, health, and ill-ness relate to biological identities as well as to social distinctions such as class andgender, and with what consequences?

In summary, this special focus section aims to situate biomedical interventions—medicines, tests, counseling, care; the expertise and experts that practice them; andforms of triage—within particular socialities and moral economies, notions of healthand responses to sickness. Thus we ask questions concerning how and why peopleare drawing on biomedical technologies (or why they are unable or unwilling to doso)—and the consequences of these practices.

Our focus therefore is not so much on the power exercised through and on lifethrough biomedical interventions and technologies but on “life as such” (Fassin2009), that is, life as lived through both a body and a society. To work through theimplications of this, we have divided this introduction into three sections. The firstaddresses matters that we consider are left unaccounted for by biopolitics, the mostimportant of which is inequality. The second section begins to unpack ideas about“value,” notably the interest in extracting and commodifying the very substancesof life, and the moralities inherent in these activities. We end by asking how elsewe might conceptualize life, as more than just biology, by examining ideas aboutvitality, which conceives life as a plurality of activities that are in dialogue with theworld around us.

This special focus section begins with articles which address biopolitics, value,life, and living in Africa. The inspiration for the special focus section came from ourfield experiences in Kenya and Tanzania, where we found that contemporary ideasin medical anthropology—such as biosociality, biological citizenship, therapeuticcitizenship, and even the bio in biopower, did not quite work in our respectivesites. We wanted to extend these questions, and so we invited articles from otheranthropologists who work in other regions of the world to join us in a panel at theSociety for Medical Anthropology meeting in Yale, in September 2009. Our callfor articles brought together anthropologists working from Africa (Le Marcis) toSouth Asia (Staples) to Berlin (Guell) to North America (Christoffersen-Deb), andincludes an important essay by the medical anthropologist Christopher Davis.

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Biopower and Biopolitics

What are biopower and biopolitics? The terms are associated with Foucault and hisargument that in modern societies power is situated and exercised at the level oflife itself, that is, at the level of our biological existence. Biopower denotes powerover life, that which “brought life and its mechanisms into the explicit realm ofcalculations” (Foucault 1979:143); a field of more or less rationalized attempts tointervene on the vital characteristics of human existence. Foucault was interestedin the historical development of this form of power, from the 17th century, asthe sovereign states began to invest into “power to make live and let die ratherthan into make die and let live.” Much of his work traces the intimacy betweenknowledge and power in the development of scientific knowledge and rationality,the formation of institutions and professions. In doing so, he identified a bipolardiagram of power over life, one pole (working through medicine, family planning,public health, and disciplining of the self) focuses on the body, seeking to maximizeits forces and integrate it into efficient systems; the opposite pole focuses on thepopulation as the object of regulation and control (through the development ofstatistics and disciplines such as demography and epidemiology; see Rabinow andRose 2006:196). His interest was in how biopower transforms life and politics: whatit makes possible, which “truth” it speaks, how it establishes a “common sense,”and which strategies of intervention and modes of subjectification it delineates.

Scholars interested in (new) medical technologies and the possibilities of manipu-lating health that they introduce have taken up Foucault’s argument that biologicallife has become increasingly central to our social, political, and economic existence(Franklin 2000, 2005; Petersen and Bunton 1997; Rabinow 1999; Rose 2007). Anexample is Paul Rabinow and Nikolas Rose (2006), who diagnose “our biologicalcentury,” and the reach of biotechnology and biological rationalities into subjectiv-ities and somatic being, as well as into the economics and politics of contemporarysocieties. Rose seeks to map out the “space of contemporary biopolitics,” arguingthat biomedical interventions, and in particular those directed at stem cells and ge-netic material, are introducing important transformations into our ideas of life andour regimes of living. Life is now envisioned at the molecular level, and this makespossible the emergence of a “vital politics of life,” which strives to optimize life.New genetic futures are promised, in which life forms are improved, and diseaseprevention is of diminishing interest. This in turn creates new ways of governinghealthy conduct that draw people into an “ethopolitics” (the shaping of conductvia ethics—Rose 2007:27) and new genres of reasoning.

These biomedical technologies are also deeply intertwined with political econ-omy. Because scientific research into new forms of life and of medication is expen-sive, it requires long periods of investment, which comes increasingly from venturecapital provided to private corporations who also seek to raise funds on the stockmarket. These biotech companies do not merely “apply” or “market” scientificdiscoveries: the laboratory and the factory are intrinsically linked (Rose 2007:31).Here “life itself” gains market value—extending the market economy of health (cap-tured in terms such as bioeconomy, biovalue, and biocapital). A culture of promise,financial speculation, and hype informs the “promissory capital” driving the hopessurrounding biotechnology and its optimization of life (Sunder Rajan 2006).


Rose is strongest in his diagnosis of the “political rationalities of our present”and the effects of biomedical technologies on subjectivities and somatic being. Hedevelops Foucault’s later arguments that political power is not monolithic but diffuseand diffused through heterogeneous and global “assemblages” (Ong and Collier2005), including both state and nonstate institutions, forms of knowledge, expertise,and technologies. He shows how biotechnology and the interventions it makespossible are opening up our somatic individuality to choice and experimentation.He pays attention to values and meanings attached to notions of health and well-being, and to how “people actually understand, experience or ethically evaluatethese issues, choices and dilemmas.” Using the example of interventions in themolecular basis of psychiatry, he is attune to how this new politics of life mayconfuse vital norms with social norms, and take key elements of the vita (such assadness) as errors open to correction in the name of a social norm of health (Rose2007:76).

However, the realm of biomedicine analyzed by Rose and Rabinow (e.g., geneticand new reproductive technologies) is limited to the frontiers of biomedical tech-nology and innovation. Such forms of intervention are expensive, and are availableto only a small proportion of the world’s population. Although the argument thatthese innovations are “transforming human capabilities” are well taken, it does begthe question of whose capabilities in particular: Who does this technology reach?

Our ideas for this special focus section arose from our own sense of a certain dis-connect and disjuncture between this “emerging politics of life” and the experienceof biomedicine in the East African sites in which we work, where harsh inequalityand the struggle for survival seem much more about the here-and-now of medicinethan about its future possibilities. We, like Fassin (2009:49) were intrigued by whathe has described as a “curious” absence of attention to inequality in Foucault’sthinking, and we wanted to think more carefully about the values implicit in theexercise of biopower, in particular how it distinguishes between those who live andthose who are left to die.

This led us to ask if this literature on the “politics of life,” takes as too encom-passing the reach of interventions into “life itself”? And does it buy too much intothe language of choice, of possibilities, the opening of futures that biotechnologypromises—even though, as Rose cautions, “we cannot take this promissory biomedi-cal culture at face value” (2007:79)? The promises of biotechnology are always justout of reach. Despite Rose’s own disclaimers to the contrary (e.g., 2007:64), hetends to argue for a rupture—between a “politics of health” in the 19th century and“politics of population” in the 20th century to a “politics of life” in the 21st century(2007:3). He implies a chronology, in which the politics of health and populationsare placed firmly in the past. This collection of articles shows that Rose’s “politicsof life itself” exists side-by-side with these older but still existing politics while at thesame time marginalized, impoverished individuals are excluded from these circuitsof vitality.

Moreover, Rabinow and Rose largely leave aside questions of differentiation,and do not question the experience of those on the margins or out of the reach ofthis biopolitical life. Thus, although Rose refers to the “huge discrepancy” betweenlife expectancy statistics of Malawi and those of developed countries, and notesthat “this is ‘letting them die’ on a massive scale” (2007:64), he rarely follows this


through. To be fair, this is not his interest: like Foucault, he is more concernedwith the transformations in power and its effects on the subject than with theinequalities and judgments about life’s value that accompany decisions about healthand other interventions. However, his interest in the possibilities and choices thatbiotechnology gives to “us” leads him to mostly bracket out questions of who “we”are and of the exclusions and judgments of value involved in the pouring of financesinto new biotechnologies.

Our view is that there is more to 21st-century (bio)politics than the subjectivitiesand ethics forming around new biomedical technologies and rationalities. This isnot to say that biotechnology is irrelevant to marginalized and impoverished popu-lations, or that it does not open up trajectories of life and living that were previouslynot possible. Science, biomedicine, and technology and capital are moving aroundthe globe and becoming available to expanding populations. But here, again, weshould pay attention to questions of inequality: Who can access this technology andat what price? Through which values is this technology made available and does itcome at the price of other interventions into health and life?

Such questions about value became obvious in the long time gap that existedbetween the development of antiretroviral drugs that could suppress the humanimmunodeficiency virus (HIV), thus extending lives, and their availability to pop-ulations at an affordable price. The value pharmaceutical companies could reapfrom their investments into developing a new treatment—protected by intellectualproperty rights—held precedence over the value of the lives of millions of peopleliving with HIV in countries whose governments could not afford these treatments.This hierarchy of value was only overturned through the activism of patient groupsworking with Medecines Sans Frontiers and the South African government (Robins2004), and with the state in Brazil (Biehl 2004), which, appealing to the greatervalue of humanitarianism as a response to suffering, managed to shame the phar-maceutical corporations into making an “exception.”

Biomedical advances—for example, better treatments for such painful and life-threatening diseases such as cancer or for conditions such as HIV—are desperatelyneeded. Yet, as Rose reminds us, the major advances in life expectancy and health inthe West “do not owe much to highly medicalized medical intervention” (2007:78)but, rather, to more basic conditions for living: clean water, sufficient food, a livingwage. Joao Biehl argues that the tendency to focus on technical solutions to diseasehas led to a “pharmaceuticalization of public health” (2007:97); a shift from amodel of “public health understood as prevention and clinical care” to “access topharmaceuticals” (2007:100). In Brazil, he argues, the idea of public health hasmorphed from “health for all” citizens toward vertical disease programs targetingparticular diseases, while the rise of health activism around particular diseasesindexes a shift from political to biological-based rights. Although efficacious intreating particular diseases, this also creates new inequalities.

Technologies and the “ethopolitics” associated with them (the focus on patient“choice” and the “care of the self”) may be being pressed into the service of healthand well-being of targeted populations around the world, but in sites that do nothave the resources to support them. These ethics are emerging as forms of gover-nance but people might not be in the position to “comply,” leading to their “failure”to make use of available resources. Such “failure” may be interpreted as owing to


the lack of resources, or it may take the form of a moral judgment according tothe dominant ethic of health. Those whose health fails are seen as having chosennot to take care of themselves. We can see this in the dominant discourse in India,which casts the disabled as “careless” (Staples). Others are assumed by health pro-fessionals as not even capable of understanding biomedical techniques of self-care,for example Turkish migrants with diabetes living in Berlin (Guell).

This is the argument that Annemarie Mol makes in The Logic of Care (2008). Shedraws up differences between a logic of choice, in which patients become customersand the market offers them choices of which health products to buy, and the logicof care, which cannot be marketed—it does not lend itself to attractive lifestyleadvertisements, and it is always subservient to the unpredictability of life’s twistsand turns. The market, in contrast, can only offer a fixed product, which must bethrown away if life, as it always does, intervenes. Zygmunt Bauman likewise arguesthat in modern life, orientated to the prevention of disease and the promotion ofhealth, the fact that your survival is construed as your own choice, “polarizes ratherthan unites” (1992:31). The focus on choice produces inequalities, because accessto choice depends to a large extent on the means people have at their disposal andthe environments in which they live. Not everyone can choose to live by devotingtheir lives to preventing disease and taking care of their own health.

Thus, there are significant gaps among technology, “ethopolitics,” and life. Thesegaps have been largely overlooked, or glossed over, by work on biopolitics, partlybecause it is interested in a different set of questions. However they have been thesubject of some recent ethnographies of medical interventions. In the section thatfollows, we will explore the work of scholars who ask a different set of questionsto Foucault, analyzing not only technologies and rationalities of biomedical powerand not only how power transforms but also how it differentiates. They bring us toquestions of life’s worth.

The Value of Life

In 2009, Didier Fassin argued that we need to take biopolitics in a different directionfrom that proposed by Foucault, that is, as a question about and investigation intothe values and meanings of both “life itself” and of particular lives. Biopolitics is notonly about technologies of power, where they reside, and how they define truthsand produce subjects but also the effects of power: how it differentiates life andlives, shaping “the concrete ways in which individuals are treated and valued, underwhich principles and in the name of which morals” (Fassin 2009:57). Meaningsand values are important here, as they link “the biographies of lives as well as theirbiology” and “the meanings we attach to life as such as well as to lives concretely”(Fassin 2009:49). In contemporary societies, the legitimacy of life and its sacrednessare dominant values; however this also entails decisions about what sort of lifepeople may or may not live.

We argue that there are two ways of looking at the value of life. The firstcan be measured as economic value—the amount we will pay to keep somebodyalive (the cost of a National Health Service, of a pharmaceutical regime, healthinsurance, the implementation—or otherwise—of health and safety regulations), agovernment’s investment in improving living standards, DALYS, welfare provision,


donations to charities and humanitarian work, the impact of a population’s healthon a country’s GDP. The second is linked to morality and ethics—the kind oflife that is worth living, “the good life,” “quality of life,” “well-being,” and ouropinions about who deserves to live and those who can be “rejected into death”(Fassin 2009:54). These two “values,” of course, are intimately tied together—ourmoral values affect economic decisions; our financial situation may mean that wemust look after ourselves first, or conversely become benefactors or endanger ourhealth through greedy overconsumption. Political ideology, which is deeply moral,is tied up with decisions to implement vertical or primary health care programs,public–private partnerships, cost sharing, and state welfare.

Then we have another kind of value altogether, introduced by Canguilhem—a“vital value” (Mol 1998:275). In relation to health, we can conceive that economicand moral value converge as a “vital value” as a product of the interaction betweenan organism and its environment. This is linked to Canguilhem’s idea that a healthybody is one that can respond to the demands of its environment, even to radicalchanges in its environment. The organism can be seen as problem solving, and astesting, and being tested by its environment. This in turn reveals the values—or the“vital norms”—of the society in which we live.

Medical anthropologists have for long pointed to the intricate relations betweenpolitical economy and the socioeconomic and global distribution of disease—the“structural violence” of inequality (Baer and Singer 1995; Farmer 1992, 1999,2003; Fassin 2007; Packard 1989; Scheper-Hughes 1992). Although earlier medicalanthropology tended to take the political economy at face value as the backgroundor context producing disease patterns and health inequalities, anthropologists arenow turning to the production of these economics and politics of health as a researchsite, and are asking questions about how value is created—around health or life—and with which consequences.

For example, Sunder Rajan (2007) analyzes the political economies taking shapearound biotechnology companies, showing how these are driven by hybridizationsof markets with moral values. Drawing on fieldwork among U.S. venture capitalistsand Indian biotech “research parks,” he highlights the inequalities underwritingbiotech developments: those between nations along which capital, technology, andscientific research flow, and those within nations along lines of class—as the subjectsof experimental research are unemployed former millworkers, who have lost theirjobs as a result of neoliberal reforms (see also Cooper 2008). In his analysis of phar-maceutical markets in India, Stefan Ecks (2005) shows that feelings of marginalityare invoked, and then exploited by corporations, under the logic of what Rajancalls “surplus health”—the “function of potential therapeutic consumption that isalways already greater than that required to maintain healthiness” (Sunder Rajan2007:7). Pharmaceutical markets are tied to clinical trials, raising questions aboutthe political economy of health, life, and labor as well as capital that enter medicalresearch trials (Kelly and Geissler 2011; Petryna 2009).

The “vital norms” established by our society are increasingly those of a neoliberalmarket model of health. Health is being commoditized, and health care transferredfrom the realm of the care and protection of citizens to the realm of economicvalue and consumer choice. This market rationality focuses on the behavior ofindividuals, rather than the institutional, political, and economic contexts which


set limits on their ability to conduct themselves according to market rationalities.Market ideologies create the illusion that good or bad health is a matter of choice.The result is that poor health practices—such as eating raw shellfish in a choleraepidemic, because there is not enough money to buy fuel to cook (Briggs andBriggs 2003:291)—become reframed in terms of choice and responsibility. In ourcollection, Ruth Prince shows how difficult it is for people living with HIV inKisumu, Kenya to “live positively.” Such an admonition makes assumptions aboutchoice and autonomy, and is at odds with the environment in which people live.These dominant discourses of health and choice, frame disability and ill health asa moral shortcoming which, as James Staples makes clear, can silence alternativevoices that recognize the role of poverty and inequality.

For example, in writing about AIDS patients in Brazil, Biehl makes it clear that,although new antiretroviral drug regimes were saving lives, the ethopolitics aroundthe “care of the self” that “positive living” demands also created new exclusions.In “zones of abandonment” the hopeless (Biehl 2001:141–142) are left to die. Theyare responsible for their deaths because they are incapable of “living up to the newrequirements of market competitiveness and profitability” (Biehl 2001:139). Theironly purpose is that they serve a lesson for the living. A similar form of biopoliticaltriage operates around access to AIDS treatment in Cote d’Ivoire: those who areadept at therapeutic techniques of the self gain access to treatment for HIV (Nguyen2010).

While these authors point to the gaps among technologies, ethics, and life insituations of economic deprivation and political marginalization, Petryna’s (2002)work on Chernobyl survivors points to how biomedical technologies and ratio-nalities may be used by people who have few other options in which to survive.Radiation survivors can access social benefits, giving rise to a medical economyof radiation experts and sufferers, and biological life becomes an unexpected re-source. Similarly, Koch reveals how the biomedical standardization of tuberculosistreatment programs has opened up a shadowy traffic in sputum among Georgianprisoners. A positive sputum sample will ensure a transfer to a prison with betterconditions. Sputum gains economic value and “disease becomes a survival strategy”(Koch 2006:50). Other bodily products—blood, organs—have become commodi-fied and enter into circulations of value. It is often the economically marginalizedwho depend on the sale of body products or parts, ensuring that these “prod-ucts” are always available to the better off (Scheper-Hughes 1996, 2000; Shao2006).

Biomedical interventions thus structure conditions of survival, but they alsoopen up opportunities to survive, for example through the flow of funds and goodsdistributed by NGOs to HIV-positive people in Kisumu (Prince). At the same time,biomedical definitions limits what “counts” as survival, as Frederic Le Marcis revealswhen he writes of HIV-positive people in South Africa that “a recognition of theirbasic needs goes along with a denial of their singularity.” These subtle ethnographiesof both political economies and the lives they structure follow the processes set inmotion when the logic of choice is “moved” to a site where people cannot makea choice and where they are judged for it, or analyze the novel ways of extractingeconomic value out of bodies or out of life. They place lives and their value squarelywithin the logic of biopolitics and capitalist economies.


However, a focus on life’s value and on inequalities does not do justice to twoimportant arenas. First, it does not give adequate weight to the more mundane yetstill liberating effects of many medical interventions: they enable life in the faceof death, they allow people to create new networks and different forms of value(antiretroviral treatments for HIV/AIDS being a case in point). In this collection,both Ruth Prince and Rebecca Marsland write of new livelihoods made possible byNGOs working for people living with HIV. Second, it does not tell us much aboutthe spaces of biopolitics, the edges, the margins, the interstices. What kind of lifespills out beyond biopower and biopolitics, biomedical rationality, and biomedicaltechnologies?

Notions of the “good life” help us think about these tensions. As Corsin-Jimenezpoints out, ideas about a “good life” produce systems of values and ethical imagi-naries linking ideas about social equality and inequality to concepts of personhoodand to modes of living. Ethnography can provide insight into particular historicallyshaped, cultural and social values that inflect ideas of what a good life is or couldbe. As Annemarie Mol reminds us (2008), social interactions in the clinic take shapearound values such as solidarity, justice, and care as well as principles of individualchoice and autonomy. In this collection Christopher Davis points us toward therole of empathy in response to witnessing “lethality”: when we encounter deathand pathology we form moral communities to find answers to the questions thatthey pose.

This leads us in two directions. First, away from the “institutionally sanctioneddistribution of values” (of life) and toward what Susan Whyte calls the “situatedconcerns” of subjects (2002:172), whose lives are intertwined with those of others.Second, toward an understanding that the value we place in biological life is itselfan artifact of historical processes, and that, therefore, the value of life can be castin broader terms.

Life and Living

Recent scholarship, with the notable exception of Fassin (2009), has taken the “life”in Foucault’s famous definition of biopolitics to refer only to the biological. Thismuch is implied in concepts such as zoe, “bare life,” or vita activa (Agamben 1998;Arendt 1958), and “life itself” (Franklin 2000; Rose 2007). Agamben limits hisinterest in “life” to the simple fact of being alive and the centrality of this to mod-ern politics. Franklin and Rose focus their enquiry on the emergence of new formsof life (and the sociological questions that it produces) as our knowledge aboutgenetics and molecular biology has progressed. But as Foucault himself argued inThe Order of Things, there was no biology in the 18th century, there was no “lifeitself”—only living beings (Franklin 2000:193). It was of course this formulation ofa self-conscious biology, our awareness and increasing knowledge of ourselves asliving beings, that brought biopolitics into being, introducing “a quieter and moreinsidious form of power relations that aimed at producing, nourishing, and admin-istering forces that exerted a positive influence on life” (Rabinow 1998:194). It wasthis then that separated our biology from us, as it became the object of politics. Andyet, as Canguilhem argues in The Knowledge of Life, biology is not disconnected


from life, it is something that living humans “do.” Biology is a philosophy of life,and we cannot do it without being aware of ourselves as living creatures.

What does this historical emergence of a self-conscious biology imply? It sug-gests that the biology in our concept of life is not a given—instead it is a productof human activity. For example, in this special focus section we learn from AstridChristoffersen-Deb that in North American obstetrics and gynecology wards, physi-cians must calculate at what stage of gestation a fetus can be considered “viable,”and can meet the conditions required to survive. This stage is continually shiftingwith the technology and human resources that are available. And what then ofcontemporary contexts where the biological is not privileged, where there are notso many humans doing biology? In places where the definitions of the “beginningsand ends of life” differ from “ours” (Kaufman and Morgan 2005; Lock 2002; Parry1989), where spiritual or communal concepts of life might predominate, or whereeven if the biological is taken to be the central component of “life,” individuals donot have the resources to access “molecularized” medicine or techniques of opti-mization? (But see Ecks 2004 for a description of techniques of self-care in Kolkata.)And it is not just the biology that does or does not travel evenly across the differentsites in which we work. So must the new “ethopolitics” that bioethicists must workout if the rest of us are to live comfortably with these new technological possibilities.With this comes the possibility that the ethos might travel more easily (at least morecheaply) than the technologies, with the result that a new ethics of optimization,of “responsibilized” patients is being implemented in places where the technologiesthat produced them are not always available.

When we separate zoe from bios are we not artificially separating the politi-cal from the biological? Is this not akin to Latour’s (1993:11) characterization ofmodern thought that “purifies” out the nonhumans (the purely natural) from thehumans (purely cultural). Put this way, we can recognize that seeing life in one wayor another, reflects our own political philosophy. Biology is not neutral. The con-cept “life itself” might be yet another way of depoliticizing our own bodies, at thesame time as it is mobilized so powerfully in the name of biopolitics. This sets outan agenda for anthropology in which we cannot take the concept of “life itself” forgranted. It is a cultural and historical product, and one which may well look differ-ent in the varied locations in which we work. As the concept of “life itself” travels,it must meet and resolve contradictions and limitations, or discover new resonancesand embed itself into new practices and ideologies. Neither does “life itself” travelon its own. We need to be alert to who and what travels with it—the “collective”of carers, biotechnologists, pharmaceuticals, ideas about “responsiblized patients,”public health care budgets—the list goes on. Likewise, we ask what happens to theidea that “life itself” is molecular and optimizable as it moves about our differentfield sites.

We also take issue with the limitations posed by the concept of “bare life” or“life itself.” For us, and for the people we work with in our field sites, it is notenough that zoe is the focus of our politics (Arendt 1958). Again, this is whereCanguilhem comes to our rescue. Although his work has always focused on thebiological sciences, one gets the sense that for him, “life itself” was never sufficient.If we visit his conception of “health,” we see that he turned around conventionalnotions of illness as a deviation from a healthy norm. Instead he argued that it


is illness that produces fixed norms—in this special focus section we can see howblood sugar levels (Guell), CD4 counts (Marsland), and the “viability calculator”of the National Institutes for Child Development (Christoffersen-Deb) are all normsproduced by illness. Canguilhem distinguishes “static norms” from “normality,”which he saw as the ability of an organism to keeping adapting itself to a changingenvironment. Thus, health depends on error, leading us to actively rise to challengesfrom the world around us, and “try out” solutions to the questions that illnessposes (Whyte 2002:172). It is this that allows us to “flourish” as Rabinow puts it(1998:197).

It is this vitalism with which medical interventions engage in dialogue as Christo-pher Davis puts it. Medicine and its techniques ask questions of life. And so, wecan see in Rebecca Marsland’s contribution that CD4 counts are used as an indexof hunger and social connectedness in Tanzania, and in Ruth Prince’s article thatHIV clinics provoke conversations about hunger. Turkish Berliners with diabetes,according to Cornelia Guell, use glucose meters to interrogate their bodies so thatthey can meet the social expectations of commensality.

The idea of perfecting bodies alone—as if they exist in some social, cultural,political, and economic vacuum—does not make sense. Canguilhem argues that oneof the characteristics of life is its “fecundity” (2008:125); life continually generatesanomalies. The idea of the “normal” is in itself a value judgment based on themorality of the society in which any of us live (Canguilhem 2008:132)—it is, as Molputs it, a “vital value” (1998:275). Thus, any anomaly only becomes pathological inrelation to the “milieu” in which it lives. If we take into account that humans createtheir own “milieu” then we can see that “pathology” does not always emerge untilit becomes difficult to live in any (human-made) environment. Health is ultimatelythe product of a relation—between the “biological,” if you will, and the milieuwhich we create for ourselves. This milieu includes a moral community, and we canfind hope here, in Christopher Davis’s observation that it is the empathy that wefeel on witnessing forms of human-made lethality that can lead to movements forsocial change.

So, any optimization cannot be oriented simply to “life itself,” because thatwould put life outside of ourselves. Instead it must take into account the other“collectives” in which life takes place. Mol gives us a clear indication of where thesecollectives might be found—they are the “hidden company” in a consulting roomthat ostensibly only contains a patient and a doctor (2008:59–61). These mightbe blood relatives who predispose an individual to a disease, or family, friends,colleagues, and community with whom a patient must share their daily lives—making some elements of self-care difficult (eating unhealthy food so as not to offendothers, not having time to exercise because of familial or work responsibilities)—and others easier (the wife who incorporates dietary changes into family meals,attending exercise classes organized by an employer). Such “hidden others” havenot been concealed from anthropologists however—from John Janzen’s therapymanagement group in Central Africa (1978; see also Feierman 1985; Whyte 1997)to the “structural inequalities” created by global politicoeconomic processes wealready know that life—or living—is not a matter of biology alone. In this specialfocus section, these “others” around whom living revolves do not always share abiological identity. They include the relatives whom a young woman who is HIV


positive must care for (Marsland), the family members who must be rememberedwhen food is distributed in the HIV clinic (Prince), and the need for domestic spacesof love and recognition outside of HIV support groups in South Africa (Le Marcis).

We must also pay attention to personhood. The “self” to whom optimization,or technologies of the “self” is imagined to be directed, does not necessarily exist inthe uncomplicated way that these concepts imply. The self does not exist alone. Wemust pay attention to contexts in which “others” can enter the self, for example themoral etiologies of disease that are familiar to anthropologists. Not only that, but weare rarely solely responsible for “ourselves.” We may not even “own” our storiesof sickness (Sansom 1982), or illness may be a manifestation of neglect towardsothers, and a commentary on morality (Livingston 2005; Geissler and Prince 2010).For the Turkish Berliners with diabetes, the “self” was less important in therapeuticterms than the diabetic body, and the gadgets that made it visible (Guell), whereasfor people living with HIV in South Africa, it was others who were essential for“remaking a world” and “rediscovering what it is to be taken care of and whatit is to care for” (Le Marcis). We cannot take for granted the relative significanceof the individual, the body, or the collective when we examine the ways in which“techniques of the self” might travel.

Taking another angle on the question of personhood, it is not even clear whenour own lives begin or end, and our answers to these questions reveal further “vitalvalues,” as is only too clear in debates about ending life, be it through abortion (Mor-gans and Michaels 1999), neglect (Biehl 2001; Scheper-Hughes 1992), or throughthe troubled debates about “brain death” (Lock 2002). Astrid Christoffersen-Deb’sarticle interrogates the very beginning of life, the values of risk and medical liabilitythat determine fetal “viability,” and the subsequent “conditional persons” that theenvironment of the obstetrics and gynecology wards produce.

Rabinow tells us that Canguilhem thought about life in two ways. First of allthere is life as “form,” and it is this that he addresses directly in his writings onthe history of the biological sciences. The second is life as experience—and this isalways present in the background of his work, its “affective or affected presence . . . isfrequently felt” (Rabinow 1998:197). It is this “life itself” as experience that wewish to address in this collection.

So, perhaps what we can learn from these ethnographies and reflections onbiomedical practice and the social environment in which people seek to treat illnessand gain health is that a view of the “politics of life” depends very much on whereyou start from. If you start from the “negative minimalisms” (Thin 2008:149) ofsheer survival and bare life, of violence, suffering, deprivation, and destitution, thenyou provide a very different description of lives than if you begin from people’s situ-ated concerns: “An anthropology of hope opens up a very different political space toone based on anxiety or violence” (Corsin-Jimenez 2008:26). As Christopher Davisputs it, our tendency to focus on the dystopic has been at the price of forgettingto think about “other ways of thinking”—supposedly this is what anthropologistsdo best. This is not to underplay the force of structural violence and the structuralconstraints shaping people’s abilities to seek solutions (and enlist others in doingso). But, as Hannah Arendt (1958) reminds us, the fundamental condition of politicsis that is plural. It goes on among plural human beings, each of whom can act andstart something new.


This collection addresses these tensions between the value and meaning of life—its “worth” measured and distributed by institutional interventions, by statistics anddifferential life expectancies, and the meaning and values of lives lived—the qualityof life as it is lived, in all its complexity, which exceeds the logic of bureaucracy or ofmedical regimes. Medical technologies and disease interventions produce inequali-ties, creating conditions in which some values have more value than others. Yet theyalso offer hope and new opportunities to create a socially meaningful life. In doingso they intersect with other moral economies—of care, recognition, love—as wellas with political economy. The essays here offer a handle on this level of complexityas they move, not beyond the politics of life, but between it and the complexities oflived lives.

Themes and the Articles

The articles address a range of topics from antiretroviral regimes of care, disability,diabetes, and the viability of newborns. They travel from East and Southern Africato Berlin to India to North America. In this final section of our introduction weoffer ways of reading them by suggesting the different perspectives that they offeron “life.”

The Value of Life

Predicated on the rational, maximizing individual, biomedical subjectivities in manycontexts frequently presuppose independent financial means and assets, or they de-pend on an outsourcing of the costs of care to relatives, friends, and neighbors. Theseare the inequalities in which regimes of self-care are embedded, and they set up theconditions in which drug adherence and biological self-governance are predisposedto failure, leading to the characterization of the disabled as “careless” in India (Sta-ples). The devaluation of the poor, as culpable for their own misfortune is madepossible by the hegemonic model of medicine, and so the conditions are set in whichthe structural constraints that are responsible for disability are rendered invisible,and humanitarian interventions, such as the provision of free antiretroviral drugs,act to depoliticize shortages of food (Prince). Yet biomedical technologies also openup new opportunities, creating new social networks and different forms of value.Biomedical regimes of care themselves produce alternative economies and modesof making a living. This is particularly evident in the world of the HIV positive: inKenya, support groups are paid to “witness” their status, and the economy of HIV-based NGOs “offer some of the few economic opportunities available” (Prince).In Johannesburg, such opportunities to turn one’s misfortune into a living, exposeindividuals to the contempt of others whilst working as a volunteer for home-basedcare organizations (Le Marcis) and in Tanzania, a price is put on the identities ofthe HIV positive, when they are faked or stolen in exchange for the material goodsdistributed by NGOs (Marsland).

Interrogating Life

Biomedical definitions of life, increasingly at the molecular level, are central to theways that populations are managed. However, as Julie Livingston commented on


this collection of articles “we are so much more than our biology, even though it hasthe force to make us wholly vulnerable.” In a Boston newborn intensive care unit,the question “where does life begin?” is rendered unanswerable by technologicaland political interventions in fetal “viability” (Christoffersen-Deb). This brings usto the role that fatality plays in insisting that something be done about life, the sheerwaste of life demanding recognition that there is something seriously amiss with themoral community, reopening debate about what life should be like (Davis).

Sharing Life

What kind of life is made possible by biomedical regimes of care? What kind ofperson is required by biomedicine? Although antiretroviral (ARV) therapy keeps theHIV positive person alive, a pharmaceutical preservation of life does not guaranteeanything more. Nevertheless, people must eat, make a living, and support theirfamilies. A pharmaceutical life presupposes bounded individual bodies, whereaslife-as-lived demands intersubjectivity; donations of food to the barely alive mustbe shared with other family members (Prince), just as the generosity of familymembers, and the recognition of others is essential if life on ARVs is to be livedat all (Le Marcis, Marsland). Likewise, commensality intervenes in the self-careof diabetic Turkish immigrants in Berlin, who must develop tactics to make theircondition “habitable” (Guell). Further, worlds must be remade and reinhabited afterthe discovery of disease and infection. Essential to this is recognition, not just by thestate through disability grants and other rights-based claims, but a more intimatekind of recognition that enables mutuality, intersubjectivity, and love to return(Le Marcis). Biomedical technology, may also enable claims about responsibilityand enactments of care (Christoffersen-Deb), and draw attention to questions ofintersubjectivity forcing people to renegotiate their relations and their selves.

Notes

Acknowledgments. We would like to thank everyone who joined us on the panel thatinspired this special focus section at the Society for Medical Anthropology meeting inYale, September 2009. Nadine Beckman, Arielle Rittersmith, and Wilson Will were un-able to include their articles for various reasons, but made valuable contributions. Ourdiscussants, Julie Livingston and Vinh-Kim Ngyuyen gave generous and thoughtful com-mentaries, which have helped us formulate our ideas for this introduction. Daisy Fungworked on the manuscript as an editorial assistant, but her intellectual input exceeded thisremit. Finally, sincere thanks to Mark Luborsky for his generous and enthusiastic supportand to the anonymous reviewers of MAQ.

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what is life worth? exploring biomedical interventions, survival, and the politics of life

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