The Anthropological Demography of Health 2020937519, 9780198862437

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The Anthropological Demography of Health

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The Anthropological Demography of Health Edited by

V É R O N IQU E P E T I T, KAV E R I QU R E SH I , Y V E S C HA R B I T, and

P H I L I P K R E AG E R

1

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1 Great Clarendon Street, Oxford, OX2 6DP, United Kingdom Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries © Oxford University Press 2020 The moral rights of the authors have been asserted First Edition published in 2020 Impression: 1 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by licence or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this work in any other form and you must impose this same condition on any acquirer Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America British Library Cataloguing in Publication Data Data available Library of Congress Control Number: 2020937519 ISBN 978–0–19–886243–7 Printed and bound by CPI Group (UK) Ltd, Croydon, CR0 4YY Links to third party websites are provided by Oxford in good faith and for information only. Oxford disclaims any responsibility for the materials contained in any third party website referenced in this work.

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Preface Programmatic efforts to improve public health were a motive force in the nineteenth- and early twentieth-century formation of disciplines we know today as demography and anthropology. From the beginning, the collaborative study of population and socio-cultural variation was recognized as an evident necessity. On one hand, quantifying vital events, human bodies and their characteristics, and distributions of diseases, showed that trends were closely bound up with social, cultural, and economic variation. On the other, it was clear that putting into action clinical and epidemiological criteria of good health would require many changes in everyday life, often impinging on strongly held moral values and practices. Social theorists, meanwhile, drew readily on analogies to medical concepts and evolutionary anthropology in formulating their vision of the new social sciences, and of the instrumental role which subjects like demography and anthropology could be expected to play in social improvement. There were ser­ ious false starts (eugenics, social Darwinism, nationalism), as the science of the time often came to be embedded in political agendas of vested cultural interests. Many of the racial assumptions in these agendas came to be projected globally as  part of colonial policies. In short, integrating quantitative and qualitative approaches to culture and population proved to be difficult and liable to controversy. No agreed programme for this purpose emerged over nearly a century. Major public health interventions again became a primary focus of science and policy in the post-war era, as controlling fertility and mortality was seen as a prerequisite to sustained economic modernization and political stability in the developing world. Early health programmes relying, for example, on vaccination and antibiotics, achieved major successes without giving major attention to social and cultural variation. By the 1970s, however, as agendas turned increasingly to fertility and to diseases bound up with poverty and inequalities, the demography of population and development was again confronted by the need to incorporate cultural diversity into explanation and programme implementation. In the same period, research was revealing the remarkable heterogeneity of demographic transitions, whether in the era of European industrialization or over the twentieth century. The difficulty of formulating an adequate general theory which could account for mechanisms underlying this diversity drew historical demographers and anthropologists together in recognizing that social and cultural processes at many levels of society underlie continued population heterogeneity. By the 1990s, a growing body of soi-disant ‘anthropological demography’ had emerged, initially with reference chiefly to fertility, family, and kin structures, and

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vi Preface in medical anthropologists’ attention to diverse aetiologies. Contributions by social and economic demographers now participated actively in this discussion, which recognized the need to formulate integrated qualitative and quantitative methodologies. Anthropological demography may be defined not merely as an academic sub-specialism of demography, but as an interdisciplinary demography grounded in ethnography and in critical examination of the social, political, and economic history that has shaped relations between peoples. The evolution of methods and concepts used to describe, analyse, and govern peoples has often become a central problem in those relations. This is especially the case where there is difficulty striking a fair balance between people’s local history and experience and the generalizing aims of science and policy. Anthropological dem­og­ raphy addressed to population and health directs this approach to population heterogeneity and socio-cultural diversity collaboratively with biomedical and other human sciences. Developments from the 1990s onwards have significantly opened anthropological demography to a significantly wider range of health issues, and increased the scope for collaborative projects. As the following pages show, the research brief now extends to a remarkable range of key human and policy issues, including, for example: genetic disorders; nutrition; mental health; infant, child, and maternal morbidity; malaria; HIV/AIDS; disability; and population ageing. Collaboration of anthropological demographers with social, medical, and demographic historians enables these issues to be situated in relation to the institutional structures and inequalities that commonly shape health and access to health care. The preoccupation of post-war population studies with fertility levels and trends has similarly widened, moving beyond parity, numbers of children, contraception, and rates of  childbearing to a wider purview on the many health risks and alternative health systems that shape the incidence and course of childbearing and rearing. Developments include, for example, renewed attention to endemic infertility and childlessness (linked variously to AIDS, pathological ster­il­ity, sex work, circumcision practices, and social and age-structural constraints), and to genetic and related medical developments (notably in vitro fertilization (IVF) and other assisted reproductive technologies). In these and other areas, collaboration between social, natural, and medical scientists is actively pursued. To synthesize and clarify recent and continuing methodological and conceptual developments, and to provide links between applications to substantively different health problems, a workshop was organized in March 2017, at the instigation of the Centre Population et Développement (CEPED, Paris), and the Institute of Human Sciences and Fertility and Reproduction Studies Group (Oxford). The chapters making up this book are revised papers from that meeting, which was supported by CEPED, the Centre Virchow Villermé (University Paris Descartes), the Institute of Social and Cultural Anthropology (Oxford), and by a start-up grant from the Lahore University of Management Sciences, to whom the editors

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Preface  vii express their warm thanks. We are also grateful to Mark Harrison and Simon Szreter, who participated in the meeting and whose research assisted the planning both of the meeting and this book. Oxford University Press have provided superb support in the final production of the volume, and our thanks go particularly to Henry Clarke, Fiona Barry, Sumintra Gaur, and Denise Bannerman. Finally, thanks too to Sara Randall, Elisabeth Schröder-Butterfill, Alison Shaw, and Soraya Tremayne, who provided acute comments on sections of the introduction.

April 2020

Véronique Petit Kaveri Qureshi Yves Charbit Philip Kreager

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Contents List of Figures List of Tables List of Contributors

xiii xv xvii

Introduction1 Philip Kreager, Véronique Petit, Kaveri Qureshi, and Yves Charbit I .   TA K I N G T H E L O N G E R V I EW: H E A LT H I N T E RV E N T IO N S I N H I ST O R IC A L C O N T E X T 1. Cultures of contagion and containment? The geography of smallpox in Britain in the pre-vaccination era Romola Davenport

61

2. Medical topography as an instrument of colonial management in French Algeria, 1830–71 Hugues Moussy

85

3. The prostitute as an urban savage, Paris 1830–1914: French nineteenth-century premises of the anthropological demography of health Yves Charbit 4. Peer learning and health-related interventions: family planning and nutrition in Kenya and Uganda, 1950–2019 Shane Doyle

103

127

I I .   H E A LT H A S A N O B J E C T O F C O N T E M P O R A RY D E M O G R A P H IC G OV E R NA N C E 5. An anthropological demography of mental health in Senegal Véronique Petit 6. ‘As list e karhayee ke bayad anjame midadam khat khord’: contemporary reproductive body politic in Iran Soraya Tremayne

153

183

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x Contents

7. Beyond the government document: migrant family experiences of birth registration in East Lombok, Indonesia Leslie Butt 8. Reporting statistics on undernutrition and obesity Stanley Ulijaszek

204 225

I I I .   I M P R OV I N G D E M O G R A P H IC T R A N SL AT IO N 9. Making measures: processes of demographic translation Jennifer A Johnson-Hanks

253

10. The tensions between comparability and locally meaningful data Sara Randall

276

11. Verbal Autopsy Interview Standardization Study: a report from the field Clarissa Surek-Clark

301

I V.   C OM P O SI T IO NA L D E M O G R A P H Y: L O C AT I N G H UM A N AG E N C Y I N P O P U L AT IO N A N D S O C IA L S T RU C T U R E S 12. Population ageing and conjunctural action Philip Kreager and Elisabeth Schröder-Butterfill

323

13. Incapacity and debility among Pakistani migrants and minorities in the United Kingdom Kaveri Qureshi

347

14. Family malaria management in Africa: at the crossroads of social epidemiology and medical anthropology Carine Baxerres and Jean-Yves Le Hesran

371

V.   R E C O N C E P T UA L I Z I N G R E P R O D U C T I V E R I SK 15. Reproductive genetics, risk, and context Alison Shaw

395

16. Sexuality and HIV among young urban Congolese Lucas Tchetgnia, Yves Charbit, and Benoît Libali

427

17. Body symbolics, obstetric practices, and the improvement of maternal health in Cambodia Clémence Schantz

450

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Contents  xi

18. Concealed pregnancies and protected postpartum periods: defining critical periods of maternal health in Nepal Jan Brunson

472

19. ‘They are more careful’: transnational care among Chinese migrant parents in Italy Elizabeth L Krause

493

20. Afterword Yves Charbit, Véronique Petit, Kaveri Qureshi, and Philip Kreager

516

Index

541

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List of Figures 1.1 Percentage of smallpox burials aged under fifteen years in England, 1700–9964 1.2 Poor law expenditure by parish, 1803: (a) per capita expenditure on the poor; (b) expenditure per pauper; (c) paupers as a percentage of the parish population

78

5.1 Mental health care provision in Senegal

157

6.1 Iran and selected international fertility trends

190

7.1 The Maternal and Child Health booklet cover

211

8.1 Biocultural ecology of child growth

228

8.2 All-cause mortality relative to body mass index for 894,576 adults in 57 prospective mortality studies in industrialized countries

231

8.3 Maternal body mass index and birth weight in India, value at body mass index 18.5–25.0 set to 100 per cent

234

8.4 Percentage difference in obesity rates between the least (first decile) and most (tenth decile) deprived index of multiple deprivation: local authority districts based on school postcode, England, between 2007–08 and 2013–14, children aged between four and five years, and between ten and eleven years

236

8.5 Obesity rates in adults, England 2012

238

8.6 Distribution of self-reported health scores (the higher, the healthier) according to obesity (according to body mass index) and chronic illness, United Kingdom

240

10.1 Age–sex pyramid of population recorded on the Mali 2012–13 DHS

283

10.2 Percentage of older men and women, by age, declaring themselves dependent on help from others: Ouagadougou DHSS Health Survey

295

11.1 Quality of cause-of-death statistics, 1980–2015

302

12.1 A framework for understanding vulnerability

332

12.2 The vulnerability framework viewed over the life course

333

12.3 Jasman and Mis’s vulnerabilities over the life course

339

13.1 Pakistani mill workers, West Ham Hospital, late 1960s

353

13.2 Long-term limiting illness in the United Kingdom (2010–13) by age and eth­ni­city, men

356

13.3 Long-term limiting illness in the United Kingdom (2010–13) by age and ethnicity, women

357

14.1 Packaging and naming of manufactured traditional medicine

385

14.2 Dosage and administration of artemisia tisane

386

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xiv  List of Figures 15.1 Mendelian inheritance: the possibilities for offspring where one parent has an allelic variant (Aa genotype)

399

15.2 Mendelian inheritance: the possibilities for offspring where both parents have a het­ero­zy­gous genotype (Aa)

400

15.3 Autosomal recessive inheritance

402

15.4 The likely ancestral origin of a mutation shared by first-cousin parents of a child with a recessive condition

404

15.5 The global prevalence of consanguineous marriages

405

17.1 Scratching in the wind

455

17.2 Traces of wind scraping

456

17.3 Traces of suckers

457

17.4 Woman with a hood covering her ears

460

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List of Tables 3.1 Two estimates of prostitution

106

6.1 Iran: population according to successive censuses

186

8.1 Per cent obesity, overweight, and undernutrition, India, adult women

235

11.1 HDSS verbal autopsy characteristics

306

12.1 Older people’s net availability of children by socio-economic strata in East Java (per cent)

341

14.1 Self-medication in cases of ‘palu’—Cotonou, Benin, 2016

381

17.1 Reasons for women’s use of perineorrhaphy

463

1 7.2 Sossay khchey and caesarean section

465

18.1 Trends in antenatal care in Nepal, 2006, 2011, 2016

478

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List of Contributors Carine Baxerres, Research Fellow, University Paris Descartes Jan Brunson,  Associate Professor, Department of Anthropology, University of Hawai’i Mānoa Leslie Butt,  Associate Professor, Department of Anthropology, University of Victoria, Victoria, Canada Yves Charbit, Emeritus Professor of Demography, Founding Director of Centre Population et Développement, University Paris Descartes Romola Davenport,  Senior Research Associate, Cambridge Group for the History of Population and Social Structure, Department of Geography, University of Cambridge Shane Doyle, Professor of African History, School of History, University of Leeds Jennifer A Johnson-Hanks,  Professor of Demography and Sociology, University of California, Berkeley Elizabeth L Krause, Professor, Department of Anthropology, University of Massachusetts Amherst Philip Kreager,  Senior Research Fellow in Human Sciences, Somerville College and Director, Fertility and Reproduction Studies Group, Institute of Social and Cultural Anthropology, University of Oxford Jean-Yves Le Hesran, Director of Research, French Institute for Development Research, University Paris Descartes Benoît Libali, Assistant Representative, United Nations Population Fund (UNFPA-Congo) Hugues Moussy,  Team Leader, Research and Development, International Institute for Education Planning (IIEP)/United Nations Educational, Scientific and Cultural Organization (UNESCO), Paris Véronique Petit,  Professor of Demography, Centre Population et Développement, University Paris Descartes Kaveri Qureshi, Lecturer in Global Health Equity, University of Edinburgh Sara Randall, Professor, Department of Anthropology, University College London Clémence Schantz,  Associate Research Fellow, Centre Population et Développement, University Paris Descartes Elisabeth Schröder-Butterfill,  Lecturer in Gerontology, Centre for Research on Ageing, University of Southampton

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xviii  List of Contributors Alison Shaw,  Professor of Anthropology, Institute of Human Sciences, University of Oxford Clarissa Surek-Clark, Senior Lecturer, Departments of English and Sociology, Ohio State University Lucas Tchetgnia,  Associate Researcher, Centre Georges Chevrier, Centre national de la recherche scientifique (CNRS), Paris Soraya Tremayne,  Founding Director, Fertility and Reproduction Studies Group, and Research Associate, Institute of Social and Cultural Anthropology, University of Oxford Stanley Ulijaszek,  Professor of Human Ecology, School of Anthropology and Museum Ethnography, University of Oxford

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Introduction Philip Kreager, Véronique Petit, Kaveri Qureshi, and Yves Charbit

Anthropological demography over the past four decades has expanded beyond the initial prioritization of fertility regulation, which it shared with demography up to the 1980s, taking on a wide range of health issues and often working in close collaboration with medical and historical research. The range of this development is impressive, both as it has addressed key policy issues (AIDS and other epidemic diseases, ageing, genetic disorders, infertility, malaria, mental health, new re­pro­ duct­ive technologies, nutrition, reproductive health), and has begun to locate them in the context of inequalities that have frequently given rise to major health differentials. These differences arise both from older, indigenous hierarchical arrangements of status and wealth and from the impacts of Western interventions— the two together often interacting, and compounding inequalities. Approaches to  population and health grounded in sustained ethnographic and historical research thus provide more than substantive knowledge of people’s values and health practices; they reveal wider and often entrenched structural constraints in society, and between its constituent subpopulations, that can pose formidable obstacles to health improvement. Clearly, being able to specify—quantitatively and qualitatively—the groups of which societies are composed is necessary, not only as standard administrative or census/survey units, but as the actual reference and resource-bearing groups that determine people’s health-seeking behaviour. This is a critical task in health improvement, which requires well-integrated anthropological and demographic methods. Structural constraints and differentials as they impact on different groups carry, in turn, implications for research methodology. Understanding people’s experience of vital events, together with the role of evolving local, national, and international institutions in shaping that experience, raises questions about the grounds of scientific knowledge and its uses. In particular, we need to ask how people’s experience comes to be translated into the demographic and health measures on which clinical and public health programmes rely. If we can compare, in a given setting, the cultural categories and social contexts of local ex­peri­ence to the terminology and units employed for scientific and administrative purposes, we are then in a position to consider the empirical adequacy of the latter—which are, in effect, translations between languages, institutions, and cultures. Research

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2  KREAGER, PETIT, QURESHI, AND CHARBIT and administration do not, of course, stand outside of society, since the conduct of ethnography, surveys, censuses, surveillance systems, and clinical trials influ­ ences cultures, thus altering local representations and attitudes to treatment, health, and well-being. If conventional demographic and epi­demio­logic­al pro­ ced­ures for specifying populations in society do not reflect the group relation­ ships and institutions that shape people’s decisions (eg the family, kin, and community patronage networks that determine whether an ill person seeks treat­ ment with a traditional medical practitioner or a clinic), can we consider the units employed in conventional social and health measurement adequate? What hap­ pens when such measures and the models based on them are used to lay down standardized evaluations of health statuses and programmes? What does this imply for governance? The tendency for scientific procedures to reify is a widely recognized and ever-present danger of ‘normal science’, and one which opens a door to biases. This danger is of fundamental and recurring concern in health interventions around the world today, given the tremendous variations of cul­ tures, wealth, and resources within which these programmes are carried out. The challenge which anthropological demography addresses lies in the design and implementation of collaborative research that integrates concepts and ­methods of quantitative and qualitative approaches, thus informing clinical and public health practice, and also demographic, social, and economic modelling. The remarkable breadth of health problems that are now being addressed, whilst encouraging, also tends to fragment our knowledge base. To take only one ex­ample, anthropological demographers and epidemiologists tracking malaria, like those working with clinicians implementing family planning, both have as a key concern maternal and child health. Ante- and post-natal care of pregnant women, together with infant care, are of concern to both because, on one hand, pregnant mothers and infants are very susceptible to malaria; but on the other hand, poverty and demands for women’s heavy agricultural labour make women and their infants in many places susceptible not only to malaria, but to insuffi­ cient nutrition and many physiological problems, not to mention mortality. Study of such adjacent health problems, however, is often carried out separately, med­ ic­al and social science specialists remaining unaware of the work each is doing. There can also be lack of communication when research, even on the same condi­ tions, is conducted in different countries, regions, or on particular ethnic and religious groups. And of course, findings may be published in journals aimed at specialist malariology, reproductive health, medical anthropology, demographic, or other audiences—and few specialists always manage to read across all of these fields. The task of assimilating diverse findings across multiple scientific, geo­ graphical, and other boundaries remains problematic, and what is called for is more than better bibliographic search engines. The issue, rather, is the need to develop ways of thinking adjacent problems cohesively, and constructing a com­ mon conceptual framework and methodology that can unite them.

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Introduction  3 A clear agenda based on important conceptual and methodological advances needs to be laid down, which may then serve as a central reference, or at least as a common framework for discussion. That is the broad purpose of this book. Our argument is that a substantial agenda has already begun to emerge in consequence of the many innovative research projects (many drawing on combined methods) that have taken place, or are currently under way. The book’s five principal parts chart the components of this agenda, which we hope will stimulate and guide further discussion and research design. The five parts are intended to outline in general terms the kinds of knowledge necessary for a critical understanding of how health problems are manifest, taking into account the multiple points of view that exist amongst constituent groups making up a society, and more particularly of medical pluralism.1 Although it is impossible to be comprehensive, chapters in each section provide a set of detailed case studies which give examples of particu­ lar substantive and recurring methodological issues. The five parts, as outlined in sections 0.2–0.6 in this Introduction, are: Part I ‘Taking the Longer View: Health Interventions in Historical Context’—that is, of the often ambivalent record of Western health programmes, case studies here  providing characteristic examples of varying approaches and outcomes in Europe and in the colonial world; Part II ‘Health as an Object of Contemporary Demographic Governance’—that is, how more recent institutional approaches to population and health, whilst enabling undoubted improvements, may continue to promote inequalities, ambiguities, and dilemmas reminiscent of the colonial era, and the problems this poses in different cultures; Part III ‘Improving Demographic Translation’—or, examination of the ways in which familiar research and admin­ istrative instruments alter, and indeed may misrender, actual health experience, pointing the way towards critical steps necessary to codifying a metalanguage that would enable these limitations to be documented and rectified; Part IV ‘Compositional Demography: Locating Human Agency in Population and Social Structures’—that is, the emergence of methodologies that enable us to identify the local sub-populations that shape the choices and conjunctures in which people’s health-seeking behaviour actually takes place, and to place these con­ junctures in the life course; and Part V ‘Reconceptualizing Reproductive Risk’ that has emerged with the expansion of the health issues that are now being addressed in anthropological demography. The interdisciplinary character of health research means that neither the researchers involved nor the audience for anthropological demography are confined to anthropologists and demographers. Contributors to the book thus include epidemiologists, nutritionists, linguists, gerontologists, educationalists, 1  As several types of healing, or systems of medical care, commonly co-exist in societies, the relation between such systems often becomes critical in the pursuit of care; while boundaries between them may become useful, they can also be perceived as potentially dangerous transgressions of professional, sacred, or other knowledge.

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4  KREAGER, PETIT, QURESHI, AND CHARBIT geneticists, sociologists, and social and medical historians. The phrase ‘anthropo­ logical demography’ remains a useful encompassing rubric, as it stresses a shared research focus that prioritizes bottom-up inquiry in which ethnography may be combined with historical research and contemporary demography, epi­demio­ logic­al field studies, or research which assists clinical, genetic, and other medical studies. Within this rubric, there is naturally much variation in the work that is done. Many studies remain within the longstanding tradition of ‘social morphol­ ogy’ which, as noted in section 0.1 ‘Anthropological demography: a short history’ below, addresses population issues and the collection of basic demographic and health statistics without more sophisticated quantitative analysis or modelling. These studies focus principally on the nature of the social construction of vital events in differing locales, and the issues of translating languages, institutions, and cultures that are needed to give us a realistic understanding of people’s ex­peri­ ence. Other studies are more closely attuned to the need to develop new concep­ tual frameworks and measures that permit realistic modelling of such experience, and hence of the underlying mechanisms of population health vari­ation and change. Examples of both approaches are included in this volume.

0.1  Anthropological demography: a short history To begin with, it will be helpful to give a brief narrative of how anthropological demography has developed, particularly over the latter half of the twentieth cen­ tury, thus setting the stage for understanding and addressing current issues. For convenience, this narrative may be divided into three phases: an early post-war era, in which there was little interest across disciplines in collaboration that would involve anthropologists and social historians on primary demographic topics, particularly those relating to policy; a ‘first phase’ of anthropological dem­og­raphy, articulating the role of a comparative, social constructionist approach, and raising attendant conceptual and methodological issues; and the current or ‘second phase’, in which a growing body of anthropological, historical, and demographic collab­ oration on health issues has been accompanied by new concepts and ­methods for studying population and health variation and their causes.

0.1.1  Initial denial The post-war era of the late 1940s and 1950s witnessed a remarkable amalgam of idealism and Cold War pragmatism, under the banner of modernization theory. Western experience of economic, scientific, and technological development, underpinned by state provision of education, public health, and the law, was taken to be a model of general social improvement which could be extended

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Introduction  5 directly to ‘backward’, ‘under-’ or ‘less-developed’ nations (to use the language of the time), and to poorer and disadvantaged populations wherever they are found. In contrast, ‘traditional’ societies existing in these places were recognized particu­ larly as legacies of the colonial era: populations in which traditional ties to kin and community took priority over individual choices, not only reinforcing static social and economic inequalities, but resulting in malnutrition, low life ex­pect­ ation, and inadequate medical provision. The radical transformation of such health conditions was seen to require no less radical transformation of old values and social institutions, notably those relating to individual agency, the family, and reproduction. Idealism was expressed, notably, in documents like the United Nations (UN) Charter for Human Rights, and in the formation of the many UN agencies charged with funding, training, and building new institutional structures in the ‘developing world’. The ‘millennial development goals’ and ‘sustainable development goals’ continue to articulate this idealism. Over the post-war decades, however, perceived severe threats of global in­stabil­ ity became a major force behind modernization thinking. The Second World War had left the major European economies dislocated, if not in ruins, and previously dominant European colonial powers faced the dismemberment of their empires. Meanwhile, new Soviet domination of much of Central and Eastern Europe, underscored by its military and new nuclear capacities, and coupled with the emergence of Maoist China, proclaimed the coming overthrow of Western cap­it­ al­ism. This ‘cold’ war translated into competition to control major areas of Africa, Asia, and Latin America, whether by economic influence or, where deemed ne­ces­sary, military intervention. The many consequent local conflicts and civil wars that followed, and which in many places remain either active or troubling legacies today, were anything but ‘cold’. The fate of ‘traditional’ societies, also rec­ ognized as key markets and sources of raw materials, manpower, and inter­nation­al influence, appeared to hang in the balance. Development programmes that could foster modernization, instigated by the UN and other international agencies, and by aid programmes from the several world powers, became vehicles for legitimiz­ ing and attempting to secure continuing Western or Soviet influence. The central framework of post-war population studies, ‘demographic transi­ tion’, was born of this post-war conjuncture. First presented by Notestein as a contribution to a meeting on post-war relief management, published as Food for the World (Schultz 1945), it was not intended as a major social scientific theory, but as a brief outline of main European population trends over the nineteenthand twentieth-century era of industrialization and nation building, together with explicit statement of their implications for modernization (Notestein 1945). The trends outlined, in an intentionally formulaic and simplified pattern, showed radical transitions from very high to very low mortality rates, followed by a fur­ ther radical downward transition in reproductive rates. Economic development, coupled with impacts of modernization such as rising education levels, were cast

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6  KREAGER, PETIT, QURESHI, AND CHARBIT in the role of prime motors of such changes. A key dynamic of population change arising from modernization theory was held to lie in the displacement of trad­ ition­al social obligations by individual agency: people would now voluntarily recognize and come to exercise their rights, rather than adhering to tribal, religious, and other customs.2 Given, moreover, that ‘traditional’ societies have young age structures which already showed a strong capacity for rapid population growth, time was short: the potential for Malthusian disasters in the near future appeared to follow directly. By the mid-1950s, not only political and economic stability, but family planning, came to be seen as imperative. In the immediate post-war context in which major food and other economic shortages were anticipated, Notestein’s sketch of ominous and imminent rapid population growth had the effect of compounding fears over the future governance of large areas of the ‘developing world’. The picture was unmistakeably sombre—while fitting seam­ lessly into the narrative of modernization as essential to peace and security. As the 1950s and 1960s proceeded, the implications for population research that followed from Notestein’s presentation were clear. Most ‘less-developed’ countries and colonies did not conduct censuses or have vital registration systems, nor specialized population research centres. Indeed, such centres in the West were initiated almost entirely after 1945, together with university departments, private population foundations, and non-governmental organizations (NGOs).3 The rapid expansion of demographic research capacity over the period 1950–80 remains remarkable. Reflecting the Weberian sources of modernization thinking, institutional models and training for population research from the 1950s empha­ sized the established role of official population statistics in economic and health planning, now aimed at assisting economic theories of national ‘take-off into growth’. Development programmes have relied overwhelmingly on standard sur­ vey formats to generate quantitative data, while the quality and comprehensive­ ness of censuses and cause of death registrations—such as were instrumental to the radical health improvements experienced, notably in nineteenth-century Britain—have often lagged behind. Reliance on surveys, however, has enabled uniform units of classification based on Western history and quantitative practice

2 The pervasive influence of Parsonian social theory in early post-war population thinking included the major role it assigned to voluntarism: the idea that modernization was best effected by interventions that created conditions in which people would ‘voluntarily’ shift their beliefs and prac­ tices. Here we have instead referred to ‘agency’, since individual and collective action is not only a response to external stimulae. On the period influence of Parsons on population thinking, see Szreter (1993: 683–6). 3  Greenhalgh (1996) provides an overview of institutional development in relation to political and disciplinary concerns in the United States. Although in some cases institution building began early in Europe (notably with the formation of the French Institut National d’Études Démographiques, in 1945), most, like the formation of the Centre Population et Développement (1988) or the Max Planck Insitute for Demographic Research (1996), came much later. Petit (2013) provides an in-depth ana­lysis of the institutional scene in France.

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Introduction  7 to be employed, sometimes with secondary modifications, across the vast diversity of social and health experience. A very considerable advantage of standard units, from a comparative and development agency point of view, is that analysis can use surveys to create standard modernization variables (education, urbanization, income, etc), then employing rigorous correlation and regression techniques to produce statistical associations, or ‘determinants’ of population trends, and programme evaluations based on them.4 While this methodology was well suited to depicting the relative progress of modernization at the national level, and by implication the modern trans­form­ ation in which individual choices displaced ‘traditional’ lifeways, the abstraction from everyday social processes that this entailed can scarcely be overstated. Four displacements are of particular note. First, conventional Western population units (eg households, family size, marriage, registration districts, provinces, states) came to stand in place of diverse family, kin, and other institutional networks, community structures, and cultural regions, each with their own histories and principles of population composition, patterns of life course vari­ation, and other characteristics that impact significantly on population size, growth, and distribu­ tion. This displacement of local norms and constituencies of social structure was coupled with a second displacement: in place of the great diversity of kin, class, caste, ethnic, communal, and other identities and groups, and of the networks of solidarity and power composing and relating them, ana­lysis came to emphasize just two levels of social phenomena, ‘micro’ and ‘macro’, usually assumed to move in tandem (perhaps with lag effects on some variables). While this redistribution of principal population units and relationships was characteristic of policy and research on social and economic development gener­ ally, a third and more specifically demographic displacement also occurred: the life courses of families and their members, and the distribution of vital events across them, came to be rendered using conventional period and cohort methods. Cohorts enable the experience of standard age groups to be tracked over time and, particularly in demographic surveillance systems, linked to epidemiological data, regional distributions of populations, variations in agricultural production, and other important variables (Delaunay 2018). Whilst cohorts thus remain fun­ damental for many purposes, they may not track network and related subpopu­la­ tion patterns that cut across cohorts, and provide many avenues of adaptation

4  Szreter (1993: 684–6), in giving a succinct account of this methodology, remarks that although statistical identification of ‘determinants’ may appear to establish causal forces, the results are in fact ‘conceptually indeterminant’. The problem is not only that ‘determinants’ are no more than statistical associations. Analysis is confined to data on outcomes (eg what people tell interviewers in a survey), not examination of actual processes. Indeterminancy further arises in part from ecological fallacy (the assumption that micro and macro phenomena move in sync, when this is not actually tested), and from the ambiguity that arguments could proceed both from the view that modernization induces population change, and that population change is a necessary condition of modern development.

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8  KREAGER, PETIT, QURESHI, AND CHARBIT and change.5 Cultural representations, moreover, commonly do not fit neatly into standard age groupings. The experience of belonging to a generation (cf Mannheim 1952), and to religious, social, and political movements that variously constrain or assist health-seeking behaviour (Pooley and Qureshi 2016: 15–20), commonly changes according to context, mixing and remixing members of different cohorts for different purposes. More generally in population research, as several chapters in Parts III, IV, and V show, major current health issues are bound up with evolv­ ing migration, multiple sexual relationships, and patterns of support in old age, in which intergenerational relations of support (or their absence) repeatedly change in ways that do not neatly fit cohort definitions. Finally, survey classifications of mortality and morbidity have likewise followed standard Western aetiology and terminology, even where no equivalent terms existed in local languages.6 With the benefit of hindsight, there can be little surprise that disciplines like social history and anthropology tended to remain uninvolved in modernization thinking. They follow a more inductive line of reasoning in order to understand local social formations and temporal processes that give rise to them. Having been assigned a ‘backward’ role, the histories, cultures, and institutions of ‘trad­ition­al’ societies seemed to exist only to be swept away. Indeed, Notestein firmly dis­ missed any positive influence on fertility of extant cultural values, laws, and fam­ ily systems: where the world faced a continuing ‘capacity for [population] growth of its backward populations’ the ‘strongest stimulus’ to modernization was the only option (1945: 39, 57). In retrospect, it is paradoxical that, in pursuit of the ideal of enhancing human rights, interventionist proposals gave a decidedly secondary status to understanding people’s own values, practices, and norms. No less striking is the assumption that it is possible to establish without bias the nature and causes of reproductive patterns or of endemic ill health in different cultures without giving close attention to people’s understanding of the body and its care.7 5  To take only one instance, childlessness and sub-fertility carry many negative implications for women and families across the life course, and societies in Africa, Southeast Asia, and Polynesia have long practiced ways of redistributing children to ameliorate the problem. In consequence, the kinds of macro-level cohort imbalances that are used by demographic models in ageing research may not reflect the young people to whom adults actually have access in many important subpopulations (Kreager and Schröder-Butterfill 2004; 2010). 6  By the 1970s, enhanced survey procedures like back-translation came to be recognized as im­port­ ant to ensuring that people responding to survey questions are clear about the questions being asked, and not responding to other issues. Whilst such procedures provide some check on individual terms and questions, statistical analysis still proceeds within the framework of the European classification of phenomena and premises of modernization theory. On issues that in consequence complicate backtranslation see eg Weinreb and Sana (2009). 7  Family planning programmes, of course, took into account a variety of local traditions as poten­ tial vehicles for promoting contraceptives and providing better access to them, such as embarking on training courses for indigenous midwives, utilizing local markets as commercial venues for distribu­ tion, and even puppet shows to explain family planning. These efforts, however, did not pri­ori­tize local health practices such as those studied by medical anthropologists of the time, nor did they attend to the structure and medical reliability of pharmaceutical distribution in local markets replete with patent medicines.

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Introduction  9 Many health programmes from the early 1950s, particularly those based on relatively straightforward technology transfers, nonetheless achieved remarkable successes. Vaccination and anti-malarial campaigns, for example, sharply reduced mortality levels (Davis  1956). Family planning programmes proceeded more gradually, in part reflecting the absence before the mid-1960s of contraceptive technology suitable to mass administration. A second, and arguably more im­port­ ant reason for the delay was gradual recognition that changes in reproduction entailed potentially profound changes that modernization did not address. As Notestein came to recognize, lower infant mortality was a readily recognizable good in all societies, but reducing the number of children—as many family plan­ ning programmes emphasized, to ‘two only’—ran counter to social norms in most of the world. Demographic thinking evolved over the post-war decades, recog­ nizing that, in Coale’s often repeated phrase, it would take time to generate a truly rational ‘calculus of conscious choice’ with regard to numbers of children (Coale 1973). Of course, this growing interest and concern about how rationalities in differing cultures might change their reproductive values opened a door to quali­ tative approaches necessary to understand such processes. There were, however, other reasons for the delay. In the early post-war era, ­formidable doubts remained as to the suitability of an anthropological contribution. An aversion amongst anthropologists to quantification was often remarked, but there were deeper reasons.8 From the nineteenth century, anthropology employed vital statistics as an elementary ethnographic task, and engaged more particularly in developing quantitative measures for physical anthropology and in studies of human evolution. Applied to contemporary populations, and particularly to aspects of fertility and health, the concerns of that era led—under the eugenic programme of Francis Galton and Karl Pearson—to important statistical in­nov­ ations, notably the first conceptualization and sophisticated development of cor­rel­ation and regression techniques. Doubts about eugenics were, however, expressed repeatedly, notably where statistics were used to support their argu­ ment that lower classes and non-European ‘races’ are innately and incorrigibly inferior.9 These doubts came to a head following the eugenic excesses of National Socialism during the Second World War, after which demographers found it even

8  The suggestion that quantitative methods did not figure in social anthropology prior to the postwar era is in any case demonstrably false, as both Petit (2013) and Kertzer and Fricke (1997) have noted. In the case of British social anthropology, for instance, the role of ‘social morphology’, as laid down by Durkheim (1899), and pursued by Mauss (1906) and Halbwachs (1938), made population composition and size integral to sociological methods; as later developed by the Manchester School, these approaches, following Mitchell (1969), led to pioneering work in network analysis. What is nonetheless true of earlier anthropologists’ approaches is that they rarely advanced to more sophisticated demographic analysis. 9  The role of demography in the development of evolutionary population thinking, and the influ­ ence of eugenics, is reviewed in Kreager (2019).

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10  KREAGER, PETIT, QURESHI, AND CHARBIT more necessary to distance any association of their research with eugenics and, by implication, anthropology. In this respect, it is noteworthy that the one demographic contribution to Food for the World other than Notestein’s was entitled ‘Population as a Problem in Quality’. Written by the distinguished demographer, Frank Lorimer (1945), this essay was not, as its title might now lead us to expect, a discussion of cultural and other qualitative dimensions of demographic change, or perhaps even of the role that disciplines like anthropology might play in understanding and integrating them into the study of demographic transition. Lorimer’s presentation was con­ fined to a categorical rejection of eugenics. In passing reference to the role of culture in understanding demographic change, he confined himself to repeating Notestein’s argument that traditional cultures stand as significant obstacles to modernization, adding that they are characterized by ‘frustration, defeatism, demoralisation’, reflecting master–slave relationships (1945: 60–61).10

0.1.2  Anthropological demography: phase one Notestein’s initial formulation of demographic transition as driven by modern socio-economic development soon gave rise to an immense literature, in which it was proven seriously incomplete and problematic. By 1970, historical dem­og­ raph­ers employing parish registers and local censuses to analyse European fertil­ ity and mortality in the era before modernization had demonstrated that nuclear and related small family systems characterized by later marriage and relatively lower reproductive rates—supposed by Notestein to be the products of nineteenthcentury industrialization and modern nation building—in fact preceded the nineteenth-century developments by at least two centuries (Hajnal 1965; Smith 1981). The historical emergence of sustained economic growth in European states that Notestein had believed to be exemplars—notably Britain—did not conform to the modernization paradigm (Wrigley 1972). Comprehensive analysis of nineteenth-century census and related data for the period of mortality and fertility transitions was unable to establish regular statis­ tical correlations between modernization variables and demographic trends at national levels; when pursued at the provincial level, an immense heterogeneity in the timing, pace, and scale of declines was observed, which in many cases pointed to the key role of particular cultural and linguistic subpopulations— whether modernizing or not—as distinctive loci of declines (Coale 1969). 10  Lorimer himself came subsequently to recognize that a role existed for social anthropology in the study of contemporary fertility transition, editing a major compilation of quantitative and qualita­ tive work on African fertility by British social anthropologists (Lorimer 1954). The aims of the book, however, were confined to demonstrating how ‘traditional’ social organizations tend inexorably to sustain high fertility.

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Introduction  11 Such a sweeping reversal of early post-war demographic orthodoxy not only created a space in which anthropological attention to the diversity and function­ ing of family and community systems became more welcome; but also anthro­ pologists became involved in the historical and contemporary ethnography of population change, either in collaboration with social and demographic his­tor­ ians, or by carrying out their own studies.11 By the 1990s, there was an evident need to draw together this growing body of inquiry, which was carried out in three seminal collections (Greenhalgh 1995; Kertzer and Fricke 1997; and Basu and Aaby 1998). As its title, Situating Fertility, indicates, the first of these collections retained the priority of fertility regulation that had emerged in post-war demography, but with a revised emphasis: understanding population changes in situ requires research to begin in close observation and analysis of reproduction as a social construction that is far from uniform across societies. Greenhalgh, in drawing together themes that emerged in the collection, points up three elements of this more holistic perspective. First is the need to historicize concepts and methods usually employed in demographic description of other cultures and social struc­ tures. As she says, the social construction of populations is a fundamental dimen­ sion of political economy. Indeed, the promise of health improvement has long been central to the legitimization of Western interventions, first into colonial dominions, and then in ‘developing’ countries, as chapters in this volume repeat­ edly show. Post-war modernization and family planning programmes are only a recent stage of an old story (Vaughan  1991). Second, understanding the social construction of fertility entails disentangling several levels of social organization, including local institutions with which people identify (eg marriage systems, sta­ tus differentiations, gender norms, marginal subpopulations) and how they vari­ ously constrain or open up childbearing potential. Demographers’ foregrounding of ‘fertility determinants’ (ie what decides the numbers of children people have) here begins to give way to a perspective in which reproduction, marriage, gender, and status are aspects of a single, inextricable process. Finally, looking forward, Greenhalgh remarks that then emerging technological developments, like genetic engineering, prenatal screening, and manipulation, have the potential to alter the realities of reproduction. These developments have, indeed, greatly moved for­ ward in the past twenty years, raising a host of health issues that have engaged anthropological demographers, as chapters in this volume show. Kertzer and Fricke’s synthesis, in continuing to develop the social construction perspective, reasserts the longstanding central focus of the anthropology of 11  Monographs included, eg, MacFarlane (1976); Howell (1979); Segalen (1991); Fricke (1994); and Kertzer and Hogan (1989). Demographers reflecting on anthropological approaches made major restatements of substantive and conceptual issues (eg Caldwell  1976; Lesthaeghe  1980; McNicoll 1980b), which were later followed by collaborative collections of independent studies (eg Caldwell et al 1988; Lesthaeghe 1989; Gillis et al 1992). Space precludes a more extensive listing.

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12  KREAGER, PETIT, QURESHI, AND CHARBIT kinship and marriage as the fundamental joint ground of anthropology and dem­ og­ raphy. Their collection thus further widens anthropological demography beyond questions of fertility control to include other dimensions of this ground, taking in ageing, parenting, the shifting composition and structure of constituent kin and other sub-populations and their many purposes, and language issues involved in the construction and maintenance of group identities and relation­ ships. In this period, more sharply critical analyses of Western-inspired family planning programmes also emerged, drawing on this wider purview. Feminist perspectives, in particular, showed how programmes aimed at providing incen­ tives to women to adopt contraception were ‘voluntarist’ only in the Parsonian sense noted in 0.1.1 ‘Initial denial’, ie they sought to implement much wider social control (Jaquette and Staudt 1988; Hartmann 1995; Jeffrey and Jeffrey 1997). By the third of these syntheses, as Basu and Aaby (1998) note, specifically methodological issues that arise in combined anthropological and demographic fieldwork had begun to come to the fore. Problems of integrating survey pro­ced­ ures with ethnography loom large. Standardized survey vocabulary, limited dur­ ations in which surveys must be completed, strict interviewer protocols, and formal population units prescribed by randomization and other statistical pro­ ced­ures, all appear to run counter to ethnographic conventions in which the duration, selection, and conduct of interviewing must fit into the flow of partici­ pation in community life and be balanced by extensive observation of variations between what people say and what they do. On one hand, the mismatch that eth­ nography often reveals between the formality of statistical norms and the flexibil­ ity and variation of local family, community, and other arrangements, raises questions about data quality, accuracy, and completeness. As noted in 0.1.1 ‘Initial denial’ above, a vast amount of necessary information becomes impossible to access where surveys presume the rationalistic premises of modernization theory, thus leaving out the possibility that other cultural mentalities are not only im­port­ ant, but effective, mechanisms of change. On the other hand, employing survey ­methods in light of the ethnography of local problem solving has the potential to open up key problems and further methodological developments. The rapid growth of the anthropological demography of health since the 1990s is an obvious case in point.

0.1.3  Anthropological demography in phase two Since the year 2000, the world’s population has added 1.5 billion people, reaching a current total of approximately 7.7 billion. Population growth remains a pressing concern for anthropological demography, with renewed attention to environmental limitations and disaggregated analysis of the ‘low levels of fertility . . . responsible for the vast bulk of [carbon] emissions’ (Murphy 2017: 138; Charbit 2018; Clarke

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Introduction  13 and Haraway 2018). Coupled with this, recognition of the enormity and growing urgency of contemporary health challenges is repeatedly headlined by the mas­ sive growth of new problems (like AIDS, population ageing, and the global bur­ den of chronic disease), by recalcitrant mass endemic ones (like malaria and malnutrition), by natural disasters, wars, and civil strife, and by the continuing resistance of entrenched gender and economic inequalities. In retrospect, we can see that the three 1990s syntheses, considered in 0.1.2 ‘Anthropological dem­og­ raphy: phase one’ above, although not addressed spe­cif­ic­al­ly to population health, served to place anthropological demography stra­tegic­al­ly in the current, and growing, demand for innovative health research. This is especially the case given its focus on the human experience of these problems, the need for better evidence and understanding of the social and biological mech­an­isms that perpetuate them, and its focus on the inadequacy of existing data and standards of evidence for those purposes. Moving forward in the new millennium from the three syntheses, three strands of anthropological demography are of particular note. The first takes up the theme of the critical role of historical perspectives. Research here consists of intensive comparative examination of categories employed in population research, how they have evolved and may give rise to mistranslations, and the influence of processes of institutionalization on them (Szreter et al 2004). Parallel to this work are historically based critiques of the paradigm of modernization and economic development, and of the consequences of imposing universalizing theories on  population heterogeneity (eg Riley and McCarthy  2003; Thornton  2005). Nineteenth-century Britain, regarded by Notestein and many others as the exem­ plar of rapid economic growth, fertility decline, and modern improvement, has been shown by historians as, rather, an era of profound social and health disrup­ tion, in which deprivation, disease, and early death proliferated, and social and health inequalities were entrenched (Szreter 1997). From the 1990s, a second strand was developed by a research group at the Centre Population et Développement (CEPED, University of Paris), based on field research mainly in Africa (Charbit and Ndiaye  1994; Petit  1998; HillcoatNalletamby 2002; Petit and des Robert 2004; Godard 2010). Aiming to link theory to fieldwork, the group built on the seminal paper by Davis (1963) on ‘the theory of demographic change and response’. It extended and enlarged his approach to ‘developing’ countries by addressing not only change, but also inertia as a core locus of underdevelopment (Charbit and Petit 2011; Petit 2017). On issues such as health, family planning, migration, and poverty, this work focused on identify­ ing not only demographic but also the economic and cultural responses integral to individual and household survival strategies. Drawing on Hammel (1990), Hammel and Friou (1997) and Mason (1992), among others, this led to seriously questioning mainstream modernization theory and its poor treatment of culture, and a call for a more comprehensive demography (Charbit  1999; Petit  2013;

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14  KREAGER, PETIT, QURESHI, AND CHARBIT Tchetgnia 2016). To that end, the CEPED group developed an interdisciplinary field methodology based on purposive samples of several local communities in order to provide a careful historical, sociological, ethnological, and economic—in a word, contextual—approach. This offered the major comparative advantage of approaching demographic behaviour at the infra-national level, where the main body of survey research in ‘developing’ countries (the Demographic and Health Surveys) is not representative. The third strand, which underlies our suggestion that anthropological dem­og­ raphy has moved into a new phase, is the emergence of new theoretical constructs that, drawing on the experience of empirical research into variation at local levels, propose new concepts and approaches for comparing processes of population change. One is the theory of conjunctural action (Johnson-Hanks,  2007; 2015; 2017; Johnson-Hanks et al. 2011), which provides a framework for understanding human agency and its contextual drivers at the level of social persons, rather than relying on the demographic idealization of individualistic rational decision makers. A second, and related, development is com­pos­ition­al demography. Building on the recognition, in phase one, that the social construction of vital events is shaped by relationships at several levels of social organization, anthropological dem­og­ raphy, together with historical demography and social history, has begun to address the need to identify, and where possible to measure, key subpopulations at meso-levels that define the human, cultural, and material resources which con­ dition different courses of demographic and health-seeking behaviour (eg Szreter and Garrett 2000; Kreager and Bochow 2017). Compositional demography is a direct response to the extensive displacement of everyday experience which, as remarked earlier in the section, is a widespread consequence of reliance on standard demographic units and modernization vari­ ables. In short, if the choices that people make in their health-seeking and demo­ graphic behaviour depend on resources and constraints of the actual groups and networks in which they participate, then these groups and networks are subpopu­ la­tions that crucially shape their values and actions. We cannot credibly claim to establish the determinants of health and demographic differentials without docu­ menting their identity, nature, and functioning. Returning to the paradox noted earlier in this section, the need to understand people in their own terms—which entails their reference groups as fundamental to who they are—is necessary to observing individual and collective human rights. No less fundamental is the responsibility of research to document differentials and their consequences using the best scientific criteria and methods. Comparison of the cultural categories and social contexts of local experience to the terminology and units employed for scientific and administrative purposes follows directly from these two fundamentals, as such comparison is necessary to ensure the empirical adequacy of the units and measures research employs. Comparison, moreover, can go further by assisting health research and personnel in two ways: by enabling communication in terms

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Introduction  15 with which patients can readily understand and identify (often assisting treatment); and by clarifying where pervasive behaviour and values tend to reduce or void the benefits of prescribed treatment (thus helping personnel to identify such conflicts and how they may be resolved). In anthropological demography, neither ethnography without surveys, nor surveys without prior ethnography, are likely to be sufficient in themselves to establishing the causes of health and demographic variation. That ethnography precedes and accompanies survey research—the ‘bottom-up’ orientation of the whole approach—reflects the fact that, without prior local knowledge there can be little or no check on whether standard demographic categories are appropriate, or what they may leave out.12 Three limitations that are basic to standard crosssectional demographic sources, like surveys and censuses, when used on their own, may be noted briefly here. Several chapters in this volume then give more extended attention to them. One is an empirical deficiency even in well-kept demographic databases, namely, that they rely on reported behaviour, values, and event outcomes. A single person’s report of ‘their own’ behaviour, values, or of a given event—as any ethnog­ rapher knows—needs to be weighed against those of others, and against observed behaviour. People occupying different positions in a network often see ‘the same’ events differently. Their differing accounts need to be considered not only in rela­ tion to each other, but to wider relations of power and influence between groups. This, of course, is rarely possible in representative demographic and health survey samples drawn from district, provincial, or national popu­la­tions, as they are unlikely to pick up more than one network member, and are not designed to document local power relations. Reported values and behaviour, in any case, are subject to the general tendency of people to avow a given norm, while many cir­ cumstances require them to act otherwise. As people are often inclined to push the margins of acceptable behaviour, norms change and allow them to give multiple interpretations according to circumstance. All of this points to a second serious limitation in one of the fundamental assumptions of survey design and analysis: that people’s statements and reported behaviour can be taken as coming from an autonomous individual—whereas responses are often qualified, situational, and contingent. It is here that the theory of conjunctural action comes into play. Its purpose is to place individuals in the configuration of group relations and constraints—the conjuncture that exists at a specific point in their life course—in which the implications for their life trajec­ tory of making one or another choice is revealed for what it says about their sub­ sequent lives, as well as the lives of those around them.13 12 Archival, oral history and other approaches play a similar bottom-up role in the case of ­his­­toric­al demography. See, eg Fisher (2008). 13  A analogous approach has been developed in family sociology in terms of ‘family configurations’, understood as ‘sets of directly or indirectly interdependent persons sharing feelings of family

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16  KREAGER, PETIT, QURESHI, AND CHARBIT The third limitation has to do with the nature of the populations that are the object of study. Classifications necessary to employing standard quantitative units and measures (like households, marriages, registration districts, provinces, etc) refer necessarily—for purposes of quantitative analysis—to discrete or closed popula­ tion units. They are human accounting procedures designed to track changes in the aggregate state of a population at fixed points in time where the characteristics of populations are defined exclusively and in advance by a survey or census ques­ tionnaire applied to administrative districts or to samples derived from them. As the total population under analysis, and each of the units as classified within it (age, sex, cohort, marital status, occupation, etc) are determined in advance, the only changes that can occur are individuals moving from one status to another (a single person marries; he or she gets older, changes from one designated occu­ pation to another, etc). While questions about attitudes or values may also be asked about such moves, an obvious limitation in using such data is the problem of unobserved variables. Statuses and behaviour that do not conform to this pre-determined universe, and are therefore left out of it, may be remarked in passing but not pursued sys­ tematically. This is particularly important in health and population research, where plural medical systems are influential, and an individual’s or household’s networks involve others in the community. Unobserved variables, in other words, are not only other potentially causal factors, but potentially key structural popu­ la­tion components in their own right. As noted above, the networks and other local groups in which people participate and which shape their actions are mul­ tiple, often overlap, and vary their membership according to need. They are not closed but open populations, the very nature of which is their flexibility and adaptive role in generating and responding to the changing needs of their several members. A household may, for example, draw on one network of kin and neighbours for agricultural or construction labour; on another for capital to support that labour; on another for financing a member’s medical care; another for identifying a suit­ able spouse for a member of the younger generation; and so forth. Some kin par­ ticipate in all of these groups, whilst others do not. Who is co-resident in a household may shift repeatedly in response to such varying needs, making house­ hold size and composition at a given survey point in time an unreliable index of support. The inherent flexibility of open populations gives rise to many feedbacks between subpopulations, including issues like reputation, identity, and social sta­ tus that then constrain or facilitate subsequent behaviour. The flexibility of open population memberships, such as networks, is thus fundamental to wider social adaptation: as members take different courses of action, and relations between belonging and connectedness’ (Widmer and Jallinoja 2008: 3). This draws more specifically on quanti­ tative social network analysis, rather than vital conjunctures grounded in life course analysis.

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Introduction  17 networks and groups evolve, variations within and between groups arise that impact, in turn, on the power of groups and their influence on wider opinion. Survey and census results, to the extent that they do not track group identities and processes, cannot address these many feedbacks directly; they tend, rather, to average out heterogeneity, giving a picture of central tendencies in population and health which disguise flexibility and variation.14 Familiar demographic survey questions, such as deciding to practice contraception, or who an older person can turn to for material support in a crisis, often require the respondent to make a complicated and tentative assessment of a range of network alternatives and the options they entail. What the respondent is implicitly required to do by the closed format of surveys and censuses is to exclude a great many, and perhaps all, of those key subpopulations and processes that are actually shaping their lives. When survey analysis addresses the aggregate results of these responses, that compilation is very unlikely to be based on identical choices, and what are taken to be similar answers in fact disguise different actual conditions. The five parts of the present volume build on these three strands—historical, comprehensive, and compositional—as they have together shaped the anthropo­ logical demography of health. Parts I and II provide a series of case studies of concerted attempts in European history to identify and resolve health problems, and their reflection in contemporary approaches to population health and their problems. Parts IV and V offer applications of conjunctural action and com­pos­ ition­al demography, and how they alter our understanding of demographic risk and its distribution in relation to chronic conditions, drug usage, ageing, and reproductive and sexual health. Part III, by addressing what is arguably the cutting edge of global health, translation between research methods and local cultures, provides a methodological bridge between the longer-term evolution of approaches to population health and new ways of thinking about them. We now introduce the five Parts, in turn.

0.2  Taking the longer view: health interventions in historical context Evans-Pritchard once remarked that anthropologists should consider knowledge of the history of social thought, particularly as it concerns relations between 14  The study of adaptive courses of behaviour is, of course, basic to understanding biological as well as longer-term social evolution. In population biology, for instance in ecology, genetics, and animal behaviour, local populations need first to be observed in conditions (whether in the field, or the la­bora­tory) that allow patterns of adaptation and variation to be identified before methods of closed popu­la­tion analysis can be employed exclusively. Open and closed population thinking thus address complementary aspects of population phenomena necessary to explanation. The long and distin­ guished history behind these approaches, embracing the biological and social sciences, and before them political theory and political economy, is outlined in Kreager (2015).

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18  KREAGER, PETIT, QURESHI, AND CHARBIT cultures, as obligatory to their field research: older theorizing, and its research and policy applications, remain ‘part of the content of the social thought of a changing present’ (1969: 56). His point is no less true of the demography of popu­ lation health (Woods 2007). The period of consolidation in anthropological dem­ og­raphy has also witnessed the remarkable rise of historical research addressing relations in the colonial and post-colonial era between Europe and the rest of the world. This body of research, which has arisen from concerns very similar to those motivating anthropological demography, is a tremendous resource, particularly as it has given major attention to the role of medicine.15 Contemporary popula­ tion and health interventions belong to a long history which began in Europe as scientific and elite groups sought to apply emerging medical know­ledge, together with policies of social control, to diverse populations of lower socio-economic classes and cultural minorities. Increasingly from the nineteenth and across the twentieth centuries, attempts to limit endemic and epidemic diseases, to embed health and related infrastructures, to provide education, and so forth, were extended to colonial and post-colonial states. Careful case studies are necessary to appreciate the lessons that may be learned from this past experience. Particular strategies recur, but the outcomes often vary from official and supposed programmatic intentions. Programme effects often come to have a life of their own, which can lead to further, and long-term, conse­ quences. Populations at which current efforts are now ‘targeted’ often perceive them in light of specific past programmes, and this inevitably colours their views of them. Population and health experts’ planning may be shaped by a legacy of medical and cultural assumptions underlying previous projects, of which they are unaware. Units and measures of population developed in past programmes, of which the role of census categories in the construction of Indian castes is a famous example (eg Cohn 1987; Kreager 2004), have a way of inserting biases into cur­ rent experience. Problems may be compounded over time, as incomplete under­ standing of the record of European interventions may be coupled with an absence of the voices of those (whether in Europe or elsewhere) to whom programmes were applied. The chapters in Part I take a broadly chronological approach, beginning in an earlier era than might be expected. As Romola Davenport shows in Chapter  1, major health improvements addressed to the incidence of smallpox had emerged in Britain by the early eighteenth century, that is, a century-and-a-half ahead of co-ordinated, large-scale state intervention, and before techniques of inoculation or vaccination made widespread treatment possible. Local government at the parish level faced the daunting threat of endemic smallpox, with the potential for recurring epidemic outbreaks. This threat was much greater in the south of

15  Examples would include Vaughn (1991), Harrison (1994), and Jackson (2018), amongst many others.

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Introduction  19 the country, given its much denser population, which is normally a major factor facilitating rapid spread of the disease. The national government was completely passive in the face of the threat, but in the south, local authorities at the parish level began to implement isolation by removing sufferers to pest-houses, and by the early nineteenth century, enforcing inoculation. Their efforts relied, of course, on their close knowledge of the populations in which they lived, of their social values, and on local awareness of disease. The north of the country, not engaging in these steps, suffered much higher levels of smallpox mortality, despite having lower population densities. Davenport’s case study thus provides a salutary ex­ample of the potential of local values of health management, and of administra­ tive arrangements, to play a major role in reducing the impact of health crises, even without the implementation of modern medical technology and practices. Chapter 2 by Hugues Moussy moves into the modern era by providing a case study of the role of medical topography in the French conquest and administra­ tive consolidation of Algeria as a colonial territory, from 1830. As Hugues Moussy details, nineteenth-century physicians, military personnel, and administrators employed extensive quantitative mapping and classificatory techniques to iden­ tify health and economic conditions, and as a body of information on population and environmental characteristics useful for political control. The French were not alone in this practice, as it was widely adopted by the British in India, and elsewhere (eg Harrison  2000). Mapping the demography and environment of healthy and unhealthy spaces introduced a scientific rationality that legitimized colonization as a civilizing project; improving the condition of populations went along with identifying economic resources readily susceptible to development, the siting of strategic military positions, and the relocation of native populations. Moussy charts the progress of medical topography and its methods across Algerian space as the French established control. Yet, as he also remarks, the pro­ fessed ideology of improving health, social, and economic order, while serving to legitimize colonial domination, was belied in practice: provision of medical ser­ vices was directed chiefly to the health of the colonizers. Chapter 3 by Yves Charbit addresses parallel developments in the same period, showing how early scientific measures of population and health could be applied no less systematically to the metropole as in colonies. Over the course of the nine­ teenth century, when disciplines like demography and anthropology were in the process of formation, prostitutes became the recurring focus of social and health observation, quantification, and commentary. Prostitutes were perceived both as proximate and exotic: they were seen as ‘other’ in essentially the same ways used to describe distant inhabitants of colonial empires, yet such ‘urban savages’ were an ever-present danger at the heart of the modernizing nation-state. Taking nineteenth-century Paris as his case study, Charbit describes how professionals belonging to dominant social groups ascribed specific physical, demographic, and moral characteristics to prostitutes. Although prostitutes’ social and economic

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20  KREAGER, PETIT, QURESHI, AND CHARBIT conditions were recognized to mark them off from mainstream society, poverty was considered only a partial and inadequate explanation of their behaviour. The principal matter was, rather, their natural attributes as ‘born prostitutes’ pos­ sessed of negative racial, mental, and pathological characteristics. At the begin­ ning of the period, physical anthropologists blamed prostitutes for propagating syphilis. Later on, when the ‘venereal peril’ reached alarming proportions all over France, public health specialists adopted a different stance, arguing that male members of dominant groups were mainly responsible for contamination, conse­ quent on widespread recourse to sex out of wedlock. From the 1860s, a new factor emerged, as the sexual behaviour of women of higher-status groups was seen to evolve towards more open promiscuity: the boundary between higher and lower status groups was porous. A fundamental contradiction thus could never be resolved: the physical body of the prostitute remained the site of satisfaction for male sexual needs and fantasies, even as dominant moral codes governing gender and class domination ostensibly forbade this. The social and medical history of this episode provides a classic case study of how ostensibly scientific measures and concepts may be shaped by racial, eugenic, class, and gender biases of dominant social groups. In the final chapter of Part I, Chapter 4, Shane Doyle gives a comparative over­ view of differing outcomes of health education programmes in three major East African ethnic populations, the Luo, the Ganda, and the Kikuyu. Doyle brings the historical focus of Part I up to the present by placing contemporary oral historical data in contexts going back to the colonial era, including the differing structure of kin groups, their relations to colonial administration, and the story of past health interventions. This longer perspective is informative not only as it enables research to clarify why recent programmes have had differing outcomes, but also how, by the 1960s, local medical personnel, and religious and civil society organiza­ tions were drawing on awareness of past health programme successes and failures to shape new strategies of communication. By focusing on learning rather than teaching, the chapter places emphasis on what Doyle refers to as a process of vernacularization. Local medical practices and people’s health-seeking behaviour gradually adapted as medical concepts, practices, and logics could be presented in ways that resonated with individuals’ worldviews and felt needs—even while not directly replicating them. Particular significance is placed on the role of peer associations as venues for the transmission of usable knowledge. Thus, improving infant and child mortality levels occurred where local civil society groups, par­ ticularly women’s associations, played an active role. The importance of know­ ledge of local structures and experience, as with Romola Davenport’s case study of a much earlier era, stand in marked contrast to the direct imposition of sup­ posed­ly general scientific criteria that occurred in the nineteenth-century case studies of Algeria and Paris, described by Charbit and Moussy.

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Introduction  21

0.3  Health as an object of contemporary demographic governance As we have seen in 0.1 ‘Anthropological demography: a short history’, the role of population research as a means of establishing and improving population and health governance was a fundamental premise of Notestein’s demographic transi­ tion idea, put forward at the very start of the post-war era. The chapters in Part I provide a salutary reminder that a long, and often troubled, history lies behind the mixture of political pragmatism and idealism of this whole approach. In recent years, this history has become an object of increasing critical attention, of which two approaches deserve note. One is the far-reaching analysis of coercive tenden­ cies implicit in state strategies of population control, which began to be developed in lectures at the Collège de France in 1977–78, by Michel Foucault (2004). A large literature has applied his concepts of ‘bio-power’ and ‘governmentality’ to many aspects of modern public policy, civil society, and health, including colonial and post-colonial settings (eg Inda 2005). Historical demographers and anthro­ pologists working more particularly in the area of health and health interven­ tions, however, have remarked a tendency in Foucauldian critiques to portray interventions as obtrusive and sinister—indeed, hegemonic—programmes of state control over individual bodies and intimate lives. Detailed ethnography and archival study, in contrast, show a characteristic unevenness of programme implementation: major gaps appear between programme goals and actual deliv­ ery, and this is compounded by the diversity of local populations that make for differing programme reception. As Unnithan remarks in her case study of health inequalities in Rajasthan, there remains ‘a strong need to historically particularise and culturally situate Foucault’s ideas’ (2019: 11).16 A second approach arises directly from the demographic literature on con­tem­ por­ary health interventions. As the immense international effort to promote family planning, maternal and child health, gender, and related programmes developed from the 1950s to the 1990s, the need to clarify assumptions and promote empirical research on governance became the focus of a series of seminal articles by  Geoffrey McNicoll (1978; 1980a, b; 2011). McNicoll drew on the ex­peri­ence of  widely discussed national family planning programmes, chiefly in Asia (Indonesia, Thailand, China, India, Bangladesh) but also Africa (Nigeria) as the basis for a comparative analysis in which he isolated several key concepts and 16  Alice Reid’s (2017: 118) historical demographic study of the maternal and child welfare move­ ment in early twentieth-century Derbyshire is exemplary of reservations on this ground. Whilst the pioneering Derbyshire health-visiting scheme may rightly be critiqued for systematic imposition of a norm (a middle-class norm of infant care), Reid asks us to analyse empirically, ‘what health workers actually did and what effect they had on mothers’. The scheme appears to have delivered ‘clear benefits for infant survival’ and thus ‘bio-power is not necessarily sinister’.

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22  KREAGER, PETIT, QURESHI, AND CHARBIT themes. Much of his analysis anticipates the agenda outlined here. A central theme was the critical need for histories of national institutional development, together with examination of how they relate to local experience; as he remarked, conventional social, economic, and demographic indices by themselves do not tell us about the realpolitik of this relationship (1980a: 459). A second theme is the need for an empirical methodology to examine the realpolitik, entailing ‘a chief research instrument . . . ideally something midway between a sample survey and anthropological study’ (1980a: 457). A third need is to situate the agency that people exercise in making reproductive choices in the context of their ‘institu­ tional inheritance’ (2011: 192). His characterization of the institutional matrix in which reproductive decisions are made underlines the importance of reference and resource groups that shape people’s awareness of courses of action they may take. The ‘particular institutional settings’ McNicoll regards as essential anticipate the subpopulations emphasized here as the elements of compositional dem­og­raphy, notably: family and kin group structures, community patronage arrangements, labour force sectors, and national and local government networks (1980a: 451–3). Finally, the need to place this agency in individual and family life courses he likens to ‘long-haul risk management’ (1980a: 452–3), to which we will return in 0.5 ‘Compositional demography: locating human agency in population and social structures’ below. Given that by the 1980s family planning programmes were observed to have a mixed influence on reproductive choice, McNicoll sought to conceptualize what makes for effective governance, and hence for the success of programmes in their own terms. His answer to this question focused on two dimensions of state policy (1980b). One he calls ‘regularity’; that is, whether national and local government is able to establish a degree of predictability in people’s economic and social lives that enables them to plan their futures securely—the objective of national popu­la­ tion policies being choices to limit childbearing at or near replacement level fer­ tility. State policy in its local administrative implementation should aim to create conditions of stability that encourage people to accept governmental authority, not only in family matters, but as establishing conditions of reliable economic, educational, and social opportunity. There should, in effect, be a kind of goodness of fit in which family, kin, and community institutions come to see small family size as consistent with other goals. The second dimension McNicoll terms ‘duress’, or ‘the use of political or administrative pressure, or at the extreme, physical force to attain fertility objectives’ (1980a: 17). Indonesia in the period of Suharto’s ‘new order’ government (1969–98) pro­ vided McNicoll with a case in point of state intervention in which regularity and duress were powerfully integrated. Three extant institutional arrangements were conducive to family planning, particularly in the dominant (Javanese) popu­la­tion: first, a long-established norm of deference to local government, whether indigenous or colonial; and second, prevailing nuclear family organization and gender norms

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Introduction  23 that gave women more say in matters of marriage and property. Additionally, as Hull (2003) notes, discussion of family limitation was hardly new, having been a subject of considerable discussion in the colonial and early national eras. Third, the first national government, from 1949, had already embarked on a popular expan­ sion of education and health care. Economic reforms initiated in the Suharto period then built on these institutions by attracting major external funding that stimulated economic growth, jobs, and market expansion. As part of ‘new order’ modernization, a massive family planning programme followed directly, under the slogan ‘two is enough’ (Niehof and Lubis 2003). As an ostensible poster-child of modernization and family planning theory, however, these developments were strongly facilitated by a further and extensive institutional matrix which McNicoll terms ‘the militarisation of provincial and local government’ (2011: 208)—a structure of duress that contains more than a mild echo of the system of control described in Moussy’s chapter on colonial Algeria, in Part I. The political transition of 1965–66 that led to the Suharto ‘new order’ government has come to be known as the Indonesian Killings, a purge of leftist and other groups in which an estimated half a million people died; military and international support for the purge have subsequently been documented (Robinson  2018). Under Suharto, the longstanding top-down pattern of local government became ‘sternly authoritarian, with ex-military personnel appointed to many regional and local leadership positions . . . additionally maintained by a regionally deployed military hierarchy that paralleled the civilian one at each administrative level (2011: 203). As the family planning programme proceeded, ‘officials were enlisted in promoting the program’s ambitious goals—set in terms of target numbers of “acceptors” ’, chiefly of oral contraceptives (2011: 199). Indonesia is, of course, not the usual example of such duress as a potential issue in modernization and family planning interventions. China’s one-child policy, and India during the ‘emergency’, are commonly cited instances, often regarded as excessive (Tarlo 2000; Greenhalgh 2003). What the Indonesian case makes clear, however, is that pressures in governance cannot be relegated only to a few extreme cases. As early as 1980, McNicoll candidly saw state pressure as a normative dimension of modernization and development goals, calling attention to the need for the history and ethnography of programme implementation.17 As the several case studies in his essays show, governance evolves differently as insti­ tutional matrices, their history, and culture vary between states and amongst the

17 Chapter  2 by Hugues Moussy and Chapter  3 by Yves Charbit in Part I are consistent with McNicoll’s pioneering work, showing just how extreme the claims made for health interventions can be: in Algeria, ostensible health benefits were used to justify wider military intervention; in midnineteenth-century Paris, vital statistics appeared to justify racial, class, and gender biases. Yet in both cases, actual health benefits to targeted populations remained at best incomplete and uneven. Even allowing for the fact that such cases of duress are excessive, the extent to which benefits actually are delivered in health interventions remains a fundamental issue.

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24  KREAGER, PETIT, QURESHI, AND CHARBIT several subpopulations that compose them. The need remains to document and compare, qualitatively and quantitatively, how, and how well, international family planning efforts engaged with national and local institutional matrices. How effectively did the resulting programmes balance ‘regularity’ and ‘duress’? Explaining the heterogeneity of fertility declines across the global South is doubt­ less bound up with this question, and the uncertain extent to which family planning programmes actually contributed to declines is likely to contain important l­essons for other health interventions. As the field of population health has expanded beyond the obsessive focus on child numbers that prevailed over the third quarter of the twentieth century, the question of what constitutes good governance, and what can make health inter­ ventions effective, has necessarily broadened. While McNicoll’s insight—that people should be able to expect reasonable stability and trustworthiness—remains a central consideration, it is not possible to view such ‘regularity’ simply as a cor­ relate of modernization and economic growth. If improved health governance depends on the relative ‘fit’ between institutions of local culture and improved public health facilities, then two further issues become unavoidable. First, and most obvious, are the diverse aetiologies of illnesses and the nature of treatments, inclusive of the pluralism of medical systems as they shape locally perceived health problems and care. What counts as good governance depends in part on what good care is understood to be, and what local institutional matrices can facilitate. Endogenous medical systems and health understanding interact with exogenous governmental and international health interventions; the inter­ face between them shapes what people understand as their health risks, and how they seek to deal with them. Both sides of this interface need to be treated on par. Second, to achieve this the primarily bottom-up approach of anthropological demography situates people’s health-seeking behaviour and access to care within a compositional demography in which, for example, the risks that an individual or group associates with a given illness or condition depend on the perceived impact of that condition on personal, kin, and community network ties, together with what those ties may enable towards its treatment. As the case studies in Part II show, good and bad health often have profoundly moral connotations, and these require close attention if human rights are to be observed. Or, put another way, if governance in matters of health is grounded in collective representations of illness, coping with risks, and well-being, then the anthropological dem­og­ raphy of health is always, at least in part, the study of mental health. Many of the disruptive concomitants of modern economic growth that his­tor­ ians have documented in nineteenth-century European countries, like Britain, are now readily observable in the global South. Their effects on mental health are profound, as Véronique Petit’s ongoing research in Senegal shows. In Chapter 5, we see how conditions of economic development induced by globalization can lead to a veritable maelstrom of human vulnerabilities, both for individuals and

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Introduction  25 the groups to which they belong. Educational improvements, aspirations to escape rural poverty, and movement to urban spaces—both within countries and to distant European destinations—have become a general phenomenon. National governance, however, has not kept up in providing the kind of regularity and secure living conditions that people hope to achieve. Individuals cannot count on affordable health care, efficient labour markets, social welfare, or unemployment benefits. Their families, kin, and community networks must try to make up the difference by pooling resources to finance health care, employment difficulties, and other costs, particularly of younger members. Governance as a norm exercised within these local networks, however, functions in conflicting ways. To begin with, support to younger members is commonly given in the hope of fulfilling their and other members’ aspirations. However, to take the example of migration, where young people do not succeed in securing employment, and remittances and enhanced modern status do not accrue for the support group, then the stress already experienced by that young person is compounded by further pressures from the group, redoubled by shame and recrimination. Duress is likely to build as mental health deteriorates and alternative sources of health care are tried—but all the while, group expectations and shame continue. Senegal provides a remarkable setting in which to document this process, and to assess where both national and local governance let people down, and the con­ sequences. Traditional medical practices, often involving supernatural ex­plan­ ations, have continued to be a major, and usually first, source of treatment. Since the early twentieth century, however, families have had recourse to the unique clinical programme of psychiatric care implemented continuously from the colo­ nial era. Petit’s research combines examination of extensive clinical records (cur­ rently being compiled as a quantitative resource on treatment distribution and change) with interviews of clinic staff, patients, and their families. To understand how poor mental health as a chronic condition is managed, it is necessary to track whether clinical treatments are adhered to, what relationship exists between them and other treatments over time, and how the trajectory of health care varies for different causes and between subpopulations with differing characteristics. The history of clinical psychiatry in Senegal, and particularly of its assumptions about traditional African society, provides Petit with an essential context for examining how understanding of mental health has evolved in local cultures and shaped treatments. A different dynamic of regularity and duress characterizes the history and cur­ rent status of fertility policy in Iran, the subject of Chapter 6 by Soraya Tremayne. As early as the Qajar dynasty, in the nineteenth century, governments have assigned the central responsibility for reproducing the nation to women, and all successive governments have reiterated care for women’s health and hygiene as a central objective. Yet the instructions are never the same. The Qajars enjoined high fertility, a policy reversed under the Pahlavi dynasty with its mass family

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26  KREAGER, PETIT, QURESHI, AND CHARBIT planning programme. After the Islamic Republic was established in 1979, birth control programmes were soon closed, abortion and sterilization outlawed, and maternity promoted in the media and the law. Ayatollah Khomeini reversed the policy in 1986, Islamic jurists arguing that having fewer children was better for maternal and family health. As fertility nonetheless continued to fall to below replacement level, in 2011 Ayatollah Khamenei again returned to an emphatic pronatalist policy, including strong support for in vitro fertilization (IVF). As Tremayne shows, the irony that women’s health is regularly emphasized, yet support for childbearing is repeatedly destabilized, has not been lost on young Iranian women. Sub-replacement-level fertility has spread across all regions of the country, urban and rural. While the continuing economic crisis is undoubtedly significant, it hardly accounts for the shifts in compositional demography that Tremayne’s case studies indicate. Behind lower rates of reproduction are changing attitudes to marriage and the family, in which duress arising from the lack of fit between state and local family governance has become a major factor. Rates of marriage have fallen, such that nearly half of women aged between fifteen and twenty-nine remain unmarried. While many young women nonetheless continue to desire a stable marital relationship, the loss of reproductive rights under pronatalist policies, together with the inequalities between spouses that still com­ monly prevail, have led to a rise in women questioning marriage as a normative lifeway. Cohabitation or ‘white marriage’, although forbidden by the Islamic hier­ archy, is now acknowledged as a general pattern. The risks that young women undertake in such forbidden relationships can scarcely be understated. One obvious risk is pregnancy. Contraception must be obtained illegally. Abortion, although illegal, is common, but as it is unregulated, health complications may ensue. Births resulting from cohabitation must somehow go unrecorded, as they inevitably reveal sexual transgression punishable under Islamic law. Even when a woman subsequently decides to marry, or agrees to an arranged marriage, med­ ic­al complications arising from past relationships may not be solvable via IVF. It is hardly surprising that Iranian fertility is so low. In Chapters 7 and 8 of Part II, discussion of governance moves towards the key cutting-edge problem in anthropological demography—the need for combined qualitative and quantitative methodologies that provide health measures and models that accurately reflect the motivations, constraints, and alternatives that people face in their health-seeking behaviour. The two chapters give case studies at opposite ends of a spectrum. In the first, at what is supposed to be the simplest, ground-level of essential health measurement—vital registration—we see how and why the ‘regular’ data produced for governance purposes may scarcely count as data at all—and how unaddressed problems of regularity and duress lie behind people’s seeming obstruction of measurement. In the second, we move to obs­ tacles that exist at the international policy-making level, and how the historical

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Introduction  27 development of conventional measures may block development and confirmation of potentially more realistic indices. Chapter 7 by Leslie Butt on birth registration in rural east Lombok, Indonesia, provides a test case in which policy is considered in relation to implementation, and the uneven effects of failing to carry agreed national and international standards through to the local level are documented. She assesses the realism of a core objective of the sustainable development goals as grounded in the UN Convention on the Rights of the Child (United Nations 1989): that national vital registration enfranchises citizens, their rights, and access to health care, thus becoming a major force for improving children’s well-being and life chances. In the 1970s, Indonesia embarked on a programme in which each birth would be registered by the attending midwife. By 2017, however, only a minority was actu­ ally registered in the Lombok communities studied, a pattern observed in much of the country. Even allowing for incomplete registration, however, levels of neo­ natal mortality and deaths to children under age five remain high. Bureaucratic procedures and cumbersome registration forms serve to reinforce alienation, for example, by taking no account of local values and practices to ensure the health of mothers and children in birthing. The system is limited to registering physical birth events, not persons.18 In consequence, people continued to prefer midwives who were not participating in government programmes, and women often returned to their natal village for childbirth, usually ensuring incomplete registration. Unsurprisingly, few people saw registration at birth as in any way connected with a better life. Rather, registration enters as an issue in a different context of local vulnerability: in poor island communities with few remunerative jobs, men and women coming of age are in need of legal documents for labour migration pur­ poses, often purchasing birth registration at considerable cost through fraudu­lent brokers. Most large-scale migration, notably to work on palm oil plantations in  Malaysia, is achieved without documents, at the risk of considerable further exploitation. Once again, national goals not regularly implemented feed duress in the lives and livelihoods of women, children, and men, removing their healthcare opportunities and increasing their risks—with the additional serious liability that reliable health statistics remain unrealized. Of course, the assumption that vital measurement should be addressed strictly to peoples’ physical events and attributes goes much further than birth registration. Clinical practice depends on a vast body of biomedical research on human physiology and genetics, in which anthropometry is the longest-used metric. As Yves Charbit observed in Chapter 3, anthropometry has a long history as a guide to 18  Given that improved life chances and rights do not follow automatically from the mere fact of registration, sustainable development goals clearly imply that birth records should be part of a more general functioning health system, attentive to the rights and life chances that people value.

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28  KREAGER, PETIT, QURESHI, AND CHARBIT health policy, beginning from the nineteenth century. Population differentials revealed by standardized measures of height and other physical attributes have been used not only to identify health problems, but also to stigmatize particular groups, such as the prostitutes with which his chapter is concerned. In the conclud­ ing chapter of Part II, Chapter 8, Stanley Ulijaszek reviews developments based in anthropometry since the nineteenth century, particularly in the study of nutrition. As he shows, the use of anthropometry in constructing the body mass index (BMI) lies at the centre of international attempts to devise standard measures of undernutrition and obesity that can be applied to all populations, and which have the important comparative advantage, noted earlier in health statistics, of en­ab­ling rigorous correlation to other economic modernization indices. BMI, for example, enables body size variation to be linked to mortality rates and the incidence of  chronic diseases, which can then be translated into economic measures of reduced productivity and higher health-care costs. From the standpoint of state governance, if good nutrition is a prerequisite of economic development, BMI becomes a guide to constructing healthful citizenship. Indeed, interventions in some countries have led to obesity being classified as a disease, again raising the issue of stigmatization. As Ulijaszek shows, however, there remains con­sid­er­able disagreement over BMI as a universal index, notably because anthropometric standards are based on the measurement of Western populations. Do applications of such standards actually measure something that is real in other conditions, given that human variation over the course of evolution reveals many local adaptations? In some parts of the global South, smaller body size is argued to be adaptive; the experience of living with a fat body or a smaller one, if this is not associated with ill health, is not part of any metric. As Ulijaszek also notes, measures of waist circumference and waist hip ratio show as good, if not better, associations with disease and death, but have not been adopted for international comparison, both because data have not been collected as systematically as has BMI, and because their adoption would risk delegitimizing existing policies based on BMI popula­ tion monitoring as the standard of programme success or failure.

0.4  Improving demographic translation The vast body of demographic and health statistics lies between the two ends of the spectrum —from local vital registration, discussed in 0.2 ‘Taking the longer view: health interventions in historical context’ to synthetic global health indices, discussed in 0.3 ‘Health as an object of contemporary demographic governance’. Surveys, censuses, clinical trials, and surveillance systems are the mainstay of data collection on which most population health research and policy depend. Parts III–V of this book move forward from the preceding discussion of the history of health measurement, and the problems of governance in which it is bound up,

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Introduction  29 to consider specific steps that can be taken to improve the empirical and concep­ tual knowledge base on which interventions depend. As is generally recognized, improving research means asking elementary questions. To what extent do the concepts, measures, observational practices, and other elements of inquiry result in a methodology that actually presents phenomena under study accurately? Here it is important to note that a growing body of recent anthropological research (eg Adams 2016; Biruk 2018; Brunson and Suh 2019) has questioned the integrity and accuracy of standard indices used in contemporary global health assessment, particularly techniques used to justify the scaling up of interventions. Accuracy is not only a matter of precise accounting. As remarked at the begin­ ning of the chapter, measures and models employed for scientific and adminis­ trative purposes in population research are translations between languages, institutions, and cultures. Good translation must answer the question: ‘Meaning for whom?’ Assumptions that have become normative in the history of governance and the traditions of research that have grown up with that history, are encoded in the language and procedures that research employs. Many aspects of survey conduct and analysis, such as the choice of sampling frame, data smoothing, or whether reasons for non-response are considered important, may all conform to statistical convention. Yet the purpose of conventional procedures is not to address prevailing assumptions about the nature of human behaviour or culture, which usually remain implicit in the culture of research and policy. The outcomes of research nonetheless provide grounds for policy. What are the ramifications of this approach for life in the societies and environments in which procedures and their assumptions are deployed? On one hand, as the data mainstays have developed, an impressive body of technical procedures has grown up to produce rigorously comparable data, upon which standard indices, models, and institutional strategies may be based. The objective is to produce methods that are, or are at least supposed to be, context independent, or to allow minimal secondary adjustments which enable them to be applied in the vast majority of settings. Great simplification and stylization of social experience and expression is recognized as necessary for this. For example, life course processes are reduced to what can be observed at the single time point of a survey. The fluidity of household networks and changing marriage norms is reduced to a small number of discrete household and marriage types. Only some causes of death, ranked according to a given priority, may be recognized, and the patterns of morbidity that usually combine to end lives are put aside. As the every­day language of community life does not employ the precise classifications and time intervals of formal research protocols, survey and clinical manuals pro­ vide interviewers with recipes to codify ambiguous answers so that they fit the ‘right’ protocol. And so forth. On the other hand, it is not necessary to question the objectives and ideals of  conventional health demographics to recognize that they are scientifically

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30  KREAGER, PETIT, QURESHI, AND CHARBIT in­ad­equate so long as they do not include empirical procedures for observing the impact of such conventions, and the social processes of data collection, com­pil­ ation, and analysis as they shape the evidence collected and how it is interpreted. It is necessary to identify and understand what is being excluded and the system­ atic biases that may result. Demographic translation addresses social processes of data production and analysis. Central to demographic translation is comparison of the cultural ­cat­egor­ies and social contexts of local experience to the products of research meth­od­olo­gies that aim to represent them. Is the accounting correct? Are the ramifications understood and articulated? Or do the simplifications and styliza­ tions employed exclude variables or devalue relationships fundamental to social experience, thus misrepresenting it in key ways? Such comparison carries impli­ cations, in turn, for the theories that methods are intended to explore and docu­ ment. Demographic translation, in short, addresses how well quantitative and qualitative knowledge and techniques are or are not combined, and whether ad­equate account is taken of variation in the phenomena under study. The starting point for understanding processes of demographic translation is recognition that the customary distinction between quantitative and qualitative methods is a convention that refers more to the end products of research than to its actual conduct. Population description and analysis begin and end in language. They return to it again and again in the course of inquiry. Demographic practice shapes language, just as it is shaped by it. Thus, at the very start of survey or cen­ sus taking, a comprehensive classification of population characteristics is essen­ tial. By the time that national censuses and surveys became customary in the nineteenth century, two hundred years of population arithmetic had given or­din­ ary language words like sex, marriage, household, and population a familiar sta­ tus as quantifiable and proportionable things. With time, demographic reference in ordinary language has extended further to make more complex popu­la­tion characteristics recurring tropes in everyday speech (cohorts, life expectation, agespecific fertility, etc), which population and global health research and policy may employ with scarcely any knowledge of underlying methodologies. Even os­ten­ sibly formal demographic relationships, say, between rates of population growth and changing cohort sizes, can never be purely mathematical in the sense of algebra or set theory (which, by definition, do not have physical or social correlates). Demography and related population sciences, to use a classical phrase, are ‘mixed mathematics’. As the doyen of formal demography, Alfred Lotka, put it, ‘Probability is essentially a matter of classification. An improbable event is one that is a member of a small class, and whether it is so or not depends, clearly, on our system of classification’ (1925: 35). Unpacking mixed mathematics, as Jennifer Johnson-Hanks shows in Chapter 9, is a stimulating and fruitful exercise. As she notes, the phrase ‘demographic trans­ lation’ owes to Norman Ryder (1964), who was concerned with a core technical

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Introduction  31 problem in formal demography: mathematical formulae that would enable period (ie cross-sectional) data to be expressed in cohort (ie longitudinal) series. This kind of problem arises, as she shows, only at the end of a long series of other translations necessary to reduce people’s experience of vital events, and ordinary language expressions of them, into the categories, measures, and concepts of demography. To clarify this whole process, Johnson-Hanks divides demographic translation into two basic types or orders. First-order translation is concerned with the production of data. It begins, typically, when a person answers a survey or clinical questionnaire. Where a questionnaire follows ordinary language practice directly (eg as in cultures in which it is customary to state one’s age since date of birth), translation issues scarcely arise. In the great majority of questions, however, a great variety of every­ day arrangements (eg household membership, different forms of conjugality, rep­ resentations of illnesses) have to be reduced to a set of discrete demographic and epidemiological types. Other questions may ask about entities without customary local meanings (‘What is your ideal family size?’), requiring the respondent to weigh up various priorities that she and other family members may have. Or the interviewer may simply tick a box that a given response might appear to resem­ ble. The ‘meaning for whom’ question looms very large, whether translation is between languages or ‘intra-linguistic’ (ie where the respondent is asked to trans­ late complex family and social relationships into a single numerical answer). As the purpose of survey research is normally bound up with health policy ob­ject­ives, the ‘meaning for whom’ is likely to prioritize governance objectives. The vast majority of population data depend on first-order translations of these many kinds. Yet there exists no metalanguage in demography (or other social sciences) which would enable the influence of such translations on data quality to be tracked, evaluated, and—where necessary—corrected. Second-order translation, such as the model construction in which Ryder was engaged, relies on first-order translations whenever technical analysis is applied to data. Ryder described his mathematics as ‘working in the imaginary realm of formal methodology’ (1964: 82), his ‘imaginary’ referring to its algebraic character. However, apparently well-established but unmonitored first-order translations may give rise to seemingly regular relationships, on which demographers then build models, when the relationships are mere artefacts of the translation process. Without checks on translation, many imagined demographic constructs— ‘contraceptive prevalence’, ‘ideal family size’, ‘marriage markets’, etc—commonly remain of uncertain reliability, and hence controversial. As Johnson-Hanks shows, most demographic description and analysis consists of second-order translations: a process of description and analysis by which questionnaire responses are translated into specific linear representations—series, age, and sex structures, probabilistic measures of many kinds. While, as noted above, many of these abstract entities have come to have ordinary language translations, there is no

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32  KREAGER, PETIT, QURESHI, AND CHARBIT guarantee that second-order translation adequately renders the complex ­compositional demography of reference and resource groups to which p ­ eople belong, and which shape the range of choices available to them, not to mention the choices they do make. Johnson-Hanks here introduces an important caveat. Second-order translation may systematically misrepresent local experience (without a metalanguage we often cannot tell), but its aims are in important respects to construct a different, population-level, account of that experience, which otherwise is not available. Thus, if the person with a potentially fatal illness belongs to Lotka’s class of small probabilities, he is in a very different position to a person in the large group, who faces significantly heightened odds of death. Without the models and measures at the population level that second-order translation enables, such knowledge is impossible. It is certainly possible to apply models to carefully constructed data­ sets and get realistic results: by the early nineteenth century, demographic models like the life table had become a reliable foundation of life insurance, pensions, and some areas of public health policy that were instrumental to mortality transition. Clearly, as Johnson-Hanks says, there is an important gain. Sara Randall’s Chapter 10 takes discussion of demographic translation to the ground level of survey practices, examining issues of first- and second-order translation in large-scale demographic data collection exercises, including cen­ suses, and the most widely used data source in the global South, the Demographic and Health Surveys (DHS). Drawing on many years’ experience of data collection in rural and urban Africa, Randall considers how the DHS achieves its objective of strict data comparability, and then asks to what extent the conduct of surveys produces results that adequately represent local institutions and relationships, and whether those representations are meaningful. What is the nature of the comparability that DHS procedures produce? To answer this, she identifies three different issues: standardized core demographic units and concepts; the comparability of comprehension and answerability of questions; and stand­ ardization of interviewing procedures. Randall takes as her first case in point the standard definition of a household, understood as a unit of population sharing production and consumption func­ tions, whose members are normally co-resident. In three different small-scale surveys of three ethnic groups in Mali (the Bambara, Tuareg, and Bwa), working with anthropologists who knew these populations enabled each survey to identify and use the locally named domestic unit in each specific language to collect basic ‘household’ data, and all responses to survey questions were understood with ref­ erence to members of that unit. However, as Randall notes, production, consump­ tion, and residence are not in practice confined to any single unit, and may be shared with kin in ways that vary significantly between the three groups. In the three populations, co-residence did not align with production or consumption in the same ways, but in local population-level age–sex structures generated by this

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Introduction  33 approach, using locally defined domestic units, few types of people appeared to have been systematically omitted. In contrast, the age–sex pyramid for the whole country generated from DHS data, collected using a standardized definition of a household, reveals substantial deficits of certain types of people, namely younger men and older women, who are excluded by that definition and not picked up elsewhere. In succeeding sections of her chapter, Randall continues this scrutiny with reference to definitions and findings on marriage, reproductive preferences, behavioural methods of contraception, and the logistics of survey interviews. Randall’s detailed analysis shows that the ‘Meaning for whom?’ question, at least where survey and related mainstays of population research are concerned, becomes a question of comparability for whom. While emphatic that the objective of producing comparable findings remains important, if highly challenging, she remarks that there is a fundamental inequality between standardized and local meanings, and between what researchers think they are asking and what respond­ ents hear and try to interpret. In other words, knowledge crucial to understand­ ing reproduction, production, and consumption, as well as providing accurate denominators, depends on a more accurate understanding of the ways in which the respondents see and interpret their own world. Whether for scientific or policy purposes, such large-scale survey results are often a misrepresentation. A particu­ lar worry, as she remarks, is that in a world in which digitized, harmonized data sets like the DHS are widely available, analysts can readily produce comparative analyses, with no awareness whatsoever of the localities to which they refer, or of translation issues that have shaped survey conduct and data compilation. The pages of peer-reviewed journals are now full of such analyses, underpinned by institutional funding of doctoral theses. The priorities of governance continue to take precedence over the life conditions and experience of the governed. With Chapter 11, by Clarissa Surek-Clark, we remain at the level of first-order translation, attention now turning to the linguistic accuracy of reported medical conditions. Since the nineteenth century, cause-of-death data have been the epicentre of health assessment, since tracking the changing incidence of specific causes to which health interventions have been directed provides powerful evi­ dence of their relative effectiveness. As she notes, the majority of deaths worldwide remain unrecorded in vital registration, and within this huge lacuna, cause-ofdeath information remains severely deficient. To help remedy this situ­ation, systems of health surveillance to carry out verbal autopsy interviews have been established by the World Health Organization (WHO) and other medical organizations, with the intention of providing comprehensive demographic and health data on selected localities within countries, which can then be used to study particular health aspects of HIV, fertility, sexual behaviour, and other issues. As part of the Verbal Autopsy Interview Standardization Study (VAISS), Surek-Clark observed linguistic, cultural, and survey administration practices during ongoing verbal autopsy interviews in surveillance sites in five of the sub-Saharan African

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34  KREAGER, PETIT, QURESHI, AND CHARBIT countries participating in the London School of Hygiene’s ALPHA Network. In these sites, local populations are usually made up of a number of language groups, with additional dialect variations, and distinctive idioms for sensitive subjects. Verbal autopsy interviews are usually conducted with care­givers of the deceased (often family members). Interviewers may be medically qualified, but in most cases, they are selected on the basis of good performance in censuses or inquiries for other purposes. Although traditional periods of mourning are observed before interviews take place, issues of grief, of economic and other practical problems families face con­ sequent on a member’s death, of difficulties encountered in adhering to expected and sometimes costly burial arrangements, and other issues, often make inter­ views stressful—for respondents and interviewers alike. Interviews are designed to contain both structured questions to which quantitative responses are expected, and a narrative of the death from respondents’ perspectives, both of which pose challenges. The interview record, when written up, is then read and codified by experienced physicians to conform to mortality classifications. As Surek-Clark notes, linguistic variations, and interview contexts and pro­ced­ ures, create many possible points of variability in what is actually recorded. Yet the key role of interviewers, both as interpreters and cultural mediators between local groups and surveillance systems, has remained largely unexamined. In the vast majority of surveillance sites, the survey instrument on which interviews are based is in English, while the interview is conducted in local languages, or in a lingua franca like Swahili. Where there is great variety in local languages, and respondents are not very familiar with a lingua franca, each interviewer negotiates his own on-site translations as the interview proceeds. Where medical criteria specify nuanced differences, say in symptoms, dermatological conditions, breath­ ing, and so forth, interviewers may need to try to explain further via gestures and mimicry. As noted in preceding chapters, on the respondents’ side, intra-linguistic translations are bound to occur where some judgement has to be made as to which circumstances, symptoms, and predisposing factors can be mentioned. The problems, noted in Chapters 10 and 11, of fitting responses into the types of answers expected for structured and numerical questions, is often left to the interviewer’s assessment of which category a given response most seems to imply. In a sense, verbal autopsy interviewers are unsung heroes of surveillance systems. Yet that does not mean that their efforts do not influence which causes of death do, or do not, become the medical record.

0.5  Compositional demography: locating human agency in population and social structures Two developments in anthropological demography are closely bound up with demographic translation. One is compositional demography; that is, the selection

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Introduction  35 of parameters that delimit units and categories of population for the purposes of  description and analysis. The other is the reconceptualization of individual agency as conjunctural action. Conjunctures are ‘historically specific situations in which structure is mobilised and social action takes place’; in this demography, vital events are considered as ‘products of life circumstances, rather than the traits of individuals’ (Johnson-Hanks 2007: 13). Compositional demography and con­ junctural action together provide a dynamic picture of health-seeking behaviour and the impacts of interventions, since the contextualized choices that people make respond not only to externally induced health programmes, but are part of the normal processes by which people’s reference and resource group memberships, and behaviour appropriate to them, are organized. A person’s several sub-population memberships define the human, social, and material capital on which they are able to draw in seeking to resolve health and other problems. Health-seeking behaviour is thus commonly constrained, but may also be greatly assisted, by the configuration of a person’s memberships. A person’s actions are not intelligible as purely individual, as they carry implications not only for themselves, but also for their fellow members, and these implications may be compounded across their life courses: the conjunctural choices people make are the micro-components that constitute population and social structures. Compositional demography and conjunctural action thus break new ground in two ways. They provide an account founded in local experience and its vari­ ations, which demographic translation can use to assess the accuracy and possible wider ramifications of formal survey and other conventional methodologies, and to help improve their design and assist health interventions. Further, they provide an endogenous foundation for understanding population change. Prevailing social and medical science approaches, as is well known, have commonly treated health, mortality, fertility, and other changes as ‘dependent’ variables, tracking their trend lines on the assumption that they are ‘determined’ to a greater or lesser degree by ‘independent’ variables (formal education, changes in income, urban vs rural residence, etc) introduced or promoted as part of the modernization process. Change thus tends to be seen for the most part as externally induced. This way of thinking has seemed particularly compelling in health research: the very phrase ‘health intervention’ often presupposes that clinical, pharmaceutical, and other instruments have not been generally available in a population, or perhaps even present for an elite. However, as Parts I–III have shown, the assumption that health interventions consist only of immediate clinical and public health func­ tions may fail to take account of endogenous and historical factors that seriously undermine current efforts. As we have seen, these factors are institutional, methodological, and ethical. The first is the history of governance, which has conditioned the relative security and regularity people experience in their lives, and hence the meanings given to any given intervention from their points of view. Second is the continuing reli­ ance on data systems that displace the conjuncture of resource and reference

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36  KREAGER, PETIT, QURESHI, AND CHARBIT groups basic to health-seeking behaviour, in favour of systems of classification driven by Western research traditions and governance objectives. Third is the tell­ ing question of whether people’s human rights are being considered sufficiently if research and interventions proceed without first observing and reflecting ser­ious­ly in a sustained way on the structure of local values and behaviour. Taken together, these exogenous assumptions continue the early post-war premise that cultures and social structures are likely to be obstacles rather than actual or potentially helpful agents of population change, while providing no core method­ ology for understanding the feedbacks—what McNicoll (1980a: 457) called the realpolitik—of interactions between interventions and society. The core methodology of compositional demography is one in which sustained ethnography precedes the design of local surveys and quantitative modelling, so that the structure of social relationships can first be observed and the several sub­ populations of which they consist can begin to be established empirically. As dis­ cussed in Part III, ethnography is an essential step for accurate translations into quantitative units for survey purposes. Documenting people’s multiple subpopu­ la­tion memberships (eg families and households; kin and community networks; religious, labour market, and other institutional groups; class and other local hierarchies; healers and public medical services; local government) brings both practical and theoretical gains. By situating individual agency, it helps us to identify and understand issues that may be contested in health and other choices a person and community faces. Chapters in both Part IV and Part V provide specific examples. Conceptually, we begin to see that a specific problem or risk on which a given health intervention is focused—malaria treatment, take-up of contraception, mental health, etc—does not come singly. Each is bound up with other risks and problems which are properties of the reference and resource groups in which a person participates. As Johnson-Hanks says, ‘if populations are structures of interrelated subgroups, then processes of subgroup recruitment and loss are at the heart of population dynamics’; the vital conjunctures in which people con­ front and make choices about health-seeking or other population problems define what counts as ‘demographically relevant action’ (2015: 336, 337). A key issue, then, is how to disentangle the multiple resource networks and reference groups as they intersect and shape health-seeking and other population behaviour. Following on Greenhalgh’s emphasis on social construction, a number of approaches have begun to consider how the coming together of several local and meso-level population formations can be represented in a given instance. Complementary to Johnson-Hanks’s theory of conjunctural action, there are now several major statements, including social learning as a function of network com­ position and structure (Kohler 2015), the historical influence of diverse commu­ nication communities in differentiating courses of fertility decline (Szreter 2015), and the common ground between these approaches and the close attention in

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Introduction  37 population ecology and evolutionary theory to the relationships between demes and species (Kreager 2015). Geoffrey McNicoll’s account of ‘institutional inherit­ ance’, outlined in 0.3 ‘Health as an object of contemporary demographic govern­ ance’, anticipated these developments in the context of governance. A further helpful conceptualization is ‘intersectionality’, in which the multiple social iden­ tities that people hold simultaneously are seen to be related not only to the groups in society in which they participate, but to power differentials between those groups as they lead to health inequalities. These have been used by scholars of  health and social inequalities to examine differential patterns and ‘consider the  heterogeneous experiences of groups defined by any one social category’ (Hill 2015: 104). Compositional demography builds on these approaches by recognizing the critical importance of formulating the several local and meso-level groups as constituent subpopulations. Only when we can express the experience of communities, networks, and other groups as aggregate structures will we have a basis on which to compare them explictly to the classifications, units, and measures employed in conventional survey and other quantitative compilations. Compositional dem­og­ raphy is thus integral to demographic translation. Further, the attention which compositional demography brings to several levels of popu­la­tion phenomena enables us to assess whether widely used standardized units and measures take sufficient account of population variation. In short, taking the endogeneity of local and meso-level population structures seriously by observing processes of demographic composition and recomposition in them enables research to strike a level of explanation that inferences from statistical cor­rel­ations do not reach. The core role of ethnography thus does not stand alone, but exists in ­com­bin­ation—or for purposes of integration—with rigorous local surveys and other formal demographics. Once ethnography enables contextualized translation of events, actions, and networks or other local subpopulations, formal demographic and epidemiological methods employing these translations then provide a real opportunity both to test the ethnography and to construct quantitative units of social structure which can be used for wider comparative purposes. This is par­ ticularly important, as Johnson-Hanks emphasises in Chapter 9, for the significant gain in knowledge that can occur when the subpopulation differentials identified are matters not understood quantitatively in local discourses. Examples discussed in this section and 0.6 ‘Reconceptualizing reproductive risk’ include access to child support, incidence of diseases, and health variations between local groups. Ethnography is also very important for identifying variations in health pro­ gramme implementation. Both sources of variation (amongst subpopulations and programme impacts), and their relation to each other, are essential to evaluating programme efforts. Improving the range, content, and quality of data on social variation is in many respects prior to addressing variation in health programme implementation. After all, how can we begin to evaluate programmes if we lack

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38  KREAGER, PETIT, QURESHI, AND CHARBIT adequate data on the several subpopulations that fall within the remit of a given intervention, and may be responding differently to it? In sum, systematic attention to demographic translation, to compositional demography, and to the dynamics of conjunctural action, together comprise a methodology for aligning social processes of data collection and analysis closely to the social units and processes that are actually differentiating people’s health and well-being. The chapters in Part IV provide a sequence of case studies addressed to subpopulation relationships as they shape health-seeking behaviour. Successive chapters introduce increasingly complex subpopulation con­fig­ur­ations, and provide a starting point for consideration of the potential gains to knowledge from com­ positional demography.19 As the chapters make clear, there are different ways in which the methodological core can be developed, and as is usual in ethnography, the combination of quantitative and qualitative methods of observation needs to be adjusted to the nature of health and demographic phenomena at issue. The concept of vital conjunctures, although developed initially in the study of fertility, is applicable to events and relationships that commonly arise at succes­ sive stages of the life course. It enables us to formulate methodologically practices of ‘long-haul risk management’, raised by McNicoll (see 0.3 ‘Health as an object of contemporary demographic governance’). As Kreager and Schröder-Butterfill note in Chapter  12, life-course interviews which are fundamental to ageing research, facilitate understanding compositional demography in two ways. First is that an interview with an older person inevitably becomes a discussion of his or her rela­ tions with others, the networks and groups in which they have lived their lives, and of how these contacts and relationships have been built, disappear, or other­ wise shift over the life course. Life-course interviews thus track a series of vital conjunctures, placing them in the compositional demography of a person’s mem­ berships: the opportunities and constraints on members’ actions that are their resources at successive life stages. The dynamic nature of networks as open populations—expanding or contracting according to several members’ changing needs—is unmistakeable. Second, we see how problems that arise late in life are accumulative: they are consequences of past actions at previous life-course stages, inclusive of the actions and values of other network members. Vital conjunctures, and the problems and risks at issue in them, thus involve more than one person: they are more realistically viewed as properties of subpopulations than matters solely of individual choice. For this reason, interviews also need to be carried out with other network members—especially as the differing position of people in a given network structure is likely to lead members to take different views of ‘the same’ events, risks, and relationships. 19  On historical demographic approaches to compositional demography, which have arguably led the way to the whole approach, see Szreter and Garrett (2000) and Cambridge Group for the History of Population and Social Structure (2019).

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Introduction  39 The focus of Kreager and Schröder-Butterfill in Chapter  12 is on late-life vulnerability experienced in poorer groups in three rural Indonesian communities, and particularly on vital conjunctures in which older people face growing frailty compounded by uncertainty as to whether support for them will actually be avail­ able. In these communities, the principal subpopulations on which people rely for support and advancement in their lives are kindreds, and the chapter shows how kindreds are composed of subgroups whose memberships change across a per­ son’s life course. As poorer groups generally do not have advantaged access to wider political patronage, conjunctural action with kin during a person’s succes­ sive life-course stages is critical to their accumulating social capital. If they have not been able to build a secure moral and practical reputation, one consequence is likely to be that they have very limited resources to address health problems as they near the end of their lives, which can lead to extreme vulnerability. A series of ethnographic case studies is used to show how kindred member­ ships evolve at successive life-course conjunctures as persons succeed (or not) in building reputations and more or less reliable networks. The picture we gain in this compositional demography is thus not static, but longitudinal, and gives rise to a general model of vulnerability and its distribution. Life course and other observational data gained in ethnography then become very useful in informing stratified sampling: first, by directing survey design to recurring problems, like vulnerability, as experienced within and between households; and second, by ensuring an up-to-date comprehensive mapping of these groups for purposes of random sampling. Combining this ethnography of open network dynamics with survey data on economic and health characteristics produces a simple demographic model of four socio-economic strata in which the distribution of vulnerable latelife vital conjunctures in society can be tracked. In addition to improved data quality, the approach thus addresses directly two major shortcomings in population research: the need to explain mechanisms underlying the evolution of population heterogeneity, and the dynamics that entrench inequalities. Ethnography and the survey of networks amongst lower strata of Indonesian society provides a relatively simple introduction to compositional demography and conjunctural thinking. Chapter 13 by Kaveri Qureshi, in addressing the evo­ lution of migrant South Asian communities in Britain, enlarges this picture, as she shows that the experience of vital conjunctures changes not only over the life course but also through historical time. She places life-course conjunctures of chronic illness and disability within wider, changing economic contexts, which are of general importance for understanding how family and kin groups negotiate ill health and its consequences. In her fieldwork with Pakistani families in East London, Qureshi examines the long-term health consequences of work in car factories, the docklands, chemical, and other industries for the generation of primary migrant men who came to Britain from the late 1950s to the 1970s. A substantial body of UK census and

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40  KREAGER, PETIT, QURESHI, AND CHARBIT survey data confirms that the labour market these men entered was segmented by regional, class, educational, and gender boundaries, to which was added their racial or ethnic identity. Their wives and older children in most cases joined them later, facing similar constraints. With time, a further characteristic came to iden­ tify them: long-term health incapacity. Case studies from fieldwork carried out over two extended periods (2004–07, and 2012–14) reveal that family members suffered a compound of chronic illnesses, in various combinations, including metabolic and respiratory disorders, cardiovascular and kidney disease, cancer, diabetes, and mental illness. To this duress further insecurity was added, as the industries in which they worked were in decline: many men were let off, and their ill health, coupled with a lack of skills necessary to employment in other sectors, meant that re-entry into the workforce was often impossible. Qureshi’s case studies confirm not only the findings of wider UK surveys that South Asian groups experienced unusually high levels of work-related ill health. As she also shows, the onset of serious illness is a vital conjuncture that leads to a series of problems and attempted family responses that meet with varying suc­ cess. Tracking what this conjuncture has entailed for the group reveals not only a sequence of mental and physical health-seeking behaviour, but how marginaliza­ tion has restricted the coping strategies available to men and their fam­ilies as they found themselves unable to continue working life much beyond their mid-forties. While networks of trust that some men were able to build with co-workers might provide personal avenues to subsequent meaningful work, phys­ic­al disability left most permanently vulnerable to wider market forces. As with the lack of adequate industrial health regulation, public policies designed to re-establish a regular working life which could reduce duress were not established. Further case studies describe how the increasing prevalence of insecure and low-paid servicesector employment has, for younger generations, created a different unregulated environment, which is now generating further series of mental and physical health disabilities. In Chapter  14 on malaria health-seeking behaviour in West Africa, Carine Baxerres and Jean-Yves Le Hesran address a further, critical set of market struc­ tures that have had long-term impacts on people’s susceptibility to illness and the availability of prompt and effective treatment. Concerted anti-malarial programmes were launched by governments in the region from 2001, emphasizing prompt clinical diagnosis, mass distribution of proven preventive methods (impregnated bed nets), and special programmes for particularly vulnerable groups (pregnant women and young children). While initial impacts were promising, from 2010 improvement stalled and coverage of the population remained very incomplete. In the chapter, the authors draw first on their long-term research on malaria, which began in Cameroon and Senegal before the 2001 governmental initiatives, adding Benin during the early 2000s. A combined epidemiological and anthropo­ logical approach moved the focus of attention from clinics to family homes in

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Introduction  41 order to examine local health concepts and practices. In-depth interviews showed very clearly that people often treat illnesses themselves in the first instance, using a combination of traditional practices and medicines purchased in informal markets. This delays seeking clinical treatment, often fatally. Two further features of delay greatly complicate the situation. First, interviews show that fevers are common and repetitive, and malaria is often not distin­ guished from other causes. Direct translation between local aetiologies and clin­ic­al diagnosis is a subtle business, and can often be misleading. Competing interpretations and repeat consultations, both with local healers or health centres, steadily increase families’ uncertainties and costs. More than one health centre may be consulted, and liaison between centres and hospitals—if a decision is finally taken to seek full clinical care—is often lacking. As drugs available in the marketplace are generally simpler and cheaper, there are strong incentives to stick to self-treatment. The second complication that comes with delay has to do with the ‘industrialisation of traditional medicine’. A substantial and incompletely regulated market for pharmaceuticals exists between West African countries, non-proprietary drugs manufactured in Asia are now widely available, and many herbal treatments can be packaged commercially to reflect modern drugs. One consequence is that mainstream medical data, which are confined to provision from official hospital and clinic sources, give a seriously incomplete record of the actual range and content of current treatments. Drawing on trust established in the course of ethnography, contacts with market sellers were used to compile quantitative data on sales in local areas, both urban and rural, in effect creating a selective survey of informal markets in a ­context in which formal survey protocols would meet with great resistance. These data on usage could then be compared in interviews to families’ practices and perceptions of products. This combined qualitative and quantitative database has, since 2014, led to a further stage of research in which ethnographically informed questions are introduced into the design of a wider epidemiological survey addressed to the circulation and consumption of anti-malarial drugs in the gen­ eral population. As Baxerres and Le Hesran show, the survey reveals a remarkable heterogeneity in which different combinations of treatments, often contrary to best medical practice, prevail. One central consequence is the high mortality rate of children hospitalized for severe malaria (over 30 per cent). As they remark, despite initial success, anti-malarial programmes have not succeeded in creating regular and reliable links between local populations and public health systems, and are unlikely to do so if official control strategies and the information on which they are based are not adapted to populations’ life conditions and experience. To summarize, the chapters that make up Part IV all address entrenched health problems that continue to prevail, and even be renewed, despite the enhanced medical capacities of contemporary societies. Merely tracking the incidence and distribution of these problems accurately for health intervention purposes appears

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42  KREAGER, PETIT, QURESHI, AND CHARBIT to lie beyond the capacities of conventional data systems in their current forms. Understanding is particularly deficient where critical factors include the diversity of people’s health-seeking behaviour, its uneven distribution in time, the changing influence of several subpopulation memberships as they combine to structure health behaviour as part of expected social identities, and the role of local healing practices. These several factors not only combine variously to influence health conditions and outcomes, but they also have an accumulative and conjunctural character that shapes the language and experience of illness, health, and care, and hence people’s participation in wider markets and governmental institutions. Chapters 12–14 provide examples of different ways in which ethnography and formal population accounting are being combined to clarify these issues.

0.6  Reconceptualizing reproductive risk At the start of this Introduction, we noted how the longstanding tendency of demographic research to prioritize fertility and its control has in recent decades given way to a wider agenda on population health. Fertility limitation, after all, is only one aspect of human reproduction, and successful or unsuccessful child­ bearing is but one part of patterns of morbidity, mortality, and social well-being. Understanding these patterns requires, in turn, attention to nutrition, work, care, genetic endowments, and other factors that condition human physiology, acting to form, perpetuate, wear out, or break down people’s bodies—whether in child­ bearing or any other stages of the life course. Differential physical and mental health then lead us, inevitably, to consider the influence of constituent groups and networks in society as they act on people’s bodies and distribute health impair­ ments, often reflecting inequalities in social structures and institutional arrange­ ments. Population health is thus a system of feedbacks in which the compositions and structures of groups in society shape people’s health, which in turn shapes those compositions and structures. Health interventions may originate in tech­ nology and institutions exogenous to this local and meso-level process in a given context, but on entering it they introduce but a further set of options subject to people’s perceptions and interpretations in such contexts. The chapters in Part V return to the subject of fertility control and re­pro­duct­ ive choice, now in this expanded perspective. They thus carry forward the social construction approach put forward in the first phase of anthropological dem­og­ raphy. As noted in 0.2 ‘Taking the longer view: health interventions in historical context’ above, Greenhalgh and others in the 1980s and 1990s confronted the ‘calculus of conscious choice’ famously dictated by Coale (1973), namely the idea that fertility is determined by individual rational actors making an explicit choice to use contraception in order to practice parity-specific birth control. Their ­painstaking critiques showed that the matter was not simply up to individuals or

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Introduction  43 ­couples; that many other family and kin group members might be involved; that constraints of community values and modes of production could be a powerful influence; and that the ‘choice’ that often mattered was not a discrete ‘baby/no baby’ question, but a consequence of many choices made in resolving other prob­ lems shared in their networks. Post-war demography was doubtless led to prefer rational-choice formulations by its close reliance on economics, with which it shared a methodology in which macro-level trends are the direct outcome or accumulation of micro-level deci­ sions made by autonomous individuals. According to this logic, each woman of reproductive age may be at some risk of becoming pregnant, and a changing rate or trend of fertility provides an index of how this risk is changing in a given period or cohort in a population as a whole. Working within modernization and economic development approaches, however, demographers needed to do more than just track such changes: the contemporary governance imperative that pro­ grammatic efforts are necessary to reduce fertility meant that it was crucial to understand what economic and social variables influenced the onset of declines, and might speed them. The very reduced concept of reproduction focused pri­ marily on a single alternative of ‘baby/no baby’ thus fitted seamlessly with a wider concept of risk in which societies were supposed to face a binary choice between remaining ‘traditional’ or ‘backward’ with higher fertility, or embarking on mod­ ernization and reduced childbearing (cf 0.1 ‘Anthropological demography: a short history’). The empirical and conceptual loss consequent on this governancedriven research strategy, as chapters in Parts I–IV of this book document, is that reliance on only two levels (macro and micro), and assuming that alternative courses of action come down to explicit, discrete, and individualistic decisions, displaces the many local and meso-level reference and resource groups in terms of which people’s agency is exercised, the influential relations that exist between them, and how these memberships and their implications for childbearing and other vital processes vary over time. An exogenous approach to explaining popu­ la­tion change thus displaced the primary scientific activity of directly observing endogenous processes and entities. If, in contrast, we locate human agency within the subpopulation and network structures in which people face life choices, then we can begin to examine or­din­ ary experience in which risks commonly do not come singly, or as simple binary choices. The great importance of formal demographic measures and models remains undiminished by this approach; indeed, their importance would doubtless be enhanced as the empirical reference of population units and variables comes to be better grounded in local and meso-level processes and people’s ex­peri­ence of them. A major consequence of the growing significance of population health is thus that common phrases, like ‘fertility limitation’, need to be rethought in the light of the many feedbacks that shape reproduction. Observing and explaining changes

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44  KREAGER, PETIT, QURESHI, AND CHARBIT in fertility entail much more than determinants of numbers of babies. ‘Fertility limitation’ refers, rather, to processes that shape more or less healthy childbearing and rearing as an aspect of the reproduction of groups and societies. The chapters in Part V address further dimensions of reproductive risk that are major concerns in this expanded perspective of population health. First, popu­la­tionlevel implications of reproduction are now recognized to have a major genetic component, reflecting developments in population biology that enable diagnosis and possible treatment of inheritable disorders. A case in point is the genetic implication of widespread consanguineous marriage practices, the subject of Chapter 15 by Alison Shaw. Some 20–55 per cent of unions across many groups in the Middle East, South Asia, and North Africa practice ‘cousin marriage’, and the pattern may be intensified in migrant populations from these areas in Europe. Scientific genetic knowledge here enters into a complex set of moral and practical alternatives in marital decision making, reflecting a ‘calculus’ of the religious, eco­ nomic, sexual, and other criteria that shape family and community behaviour and norms. Family, peer, and kin networks such as described in earlier chapters (eg Chapters 4, 5, 10, and 11), and links between these networks and labour sectors (Chapter 13), local markets (Chapter 14), and other community institutions, are usually involved in shaping marital choice and reproductive decisions. Applying Western genetic knowledge in such contexts may at first seem a bit like family planning, since numerical considerations may be important in both. In genetic applications, however, the reproductive options are not binary, but come down to the classic Mendelian arithmetic in which the risks of a child inherit­ ing deleterious recessive genetic characteristics are one in four. In the case of con­ sanguineous marriage, genetic disorders occur, in most cases, where both the husband and wife are carriers of a recessive gene, such as beta thalassaemia. Shaw (Chapter 15), in considering an impressive body of anthropological and epi­demio­ logic­al research on this subject (her examples include subpopulations in Turkey, Pakistan, Qatar, Oman, and Bangladesh, amongst others), describes the different ways in which people construe genetic risks that they are, or might be, taking in having a child, together with the extent to which governmental and other health programmes are making adequately available the critical information necessary to understand such risk. She thus introduces a key theme that runs through all the chapters in Part V: that new, exogenous biomedical knowledge about reproductive risk is taken up in markedly different ways in different cultures, and with varying consequences. One response is to take up new knowledge and techniques actively as a way of preserving cousin marriage preferences. Younger members of Alawi groups in southern Turkey, for example, readily undergo premarital screening for known disorders; in Qatar, such screening is now mandatory for all couples; in Oman, certain tribal communities are singled out for tests, as they are regarded as the most likely to be affected. In these, and other countries like Pakistan, having a

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Introduction  45 blood test is believed to ensure genetic security in consanguineous marriages. Unfortunately, this is far from necessarily the case. Tests that identify frequent disorders may not capture more rare recessive genetic diseases. Where many gen­ erations of cousin marriage have spread recessive traits widely within a popu­la­tion or subgroup, and where out-marriage is restricted, as in Oman, security from genetic disease is far from guaranteed. What characterizes these and other apparently straightforward medical tech­ niques is that local interpretations are likely to contain much more than the med­ic­al community expected. The decision to take a test is no more a discrete, one-off event than is the choice of a given contraceptive: they are part of wider discourses about relations within and between communities. The interaction of local and biomedical practices adds many further avenues of interpretation. In Oman, insisting on genetic tests for tribal groups is part of a discourse that stig­ matizes these populations as ‘backward’; meanwhile, Alawi couples assert their modernity by seeking blood tests, thus defending themselves against pejorative Turkish stereo­typ­ing of them as traditionalist. More generally, scientific blood tests are assimilated readily in all of the cultures Shaw describes to longstanding kin logics, in which a person’s moral and physical characteristics are more safely passed through ‘shared blood’, as opposed to marrying outsiders. On one hand, cousin marriage ensures traits from known kin networks. Yet, on the other, a test showing that a family member carries a recessive mutation suddenly makes the marriage system look vulnerable: will anyone now dare marry them? Further in­ter­pret­ations then proliferate. One strategy is to hide the results, even from close kin, who may also carry the recessives (Shaw  2009). Alternatively, closer reasoning can seem to resolve the issue in one way or another—when it doesn’t. For instance, following a common view that ‘stronger’ blood flows in the male line, people reason that greater protection can be achieved by marrying cousins amongst the wife’s kin, rather those amongst of the husband’s. As Shaw details, many further seemingly logical, but mistaken, strategies become possible. As she further notes, following Douglas (1992), anthropologists have long remarked how risks, and strategies to cope with them, function to maintain boundaries between groups. Risks cluster around perceived dangers of contact. British Pakistani couples, when advised to have a blood test, may well contemplate whether the medical recommendation is not part of wider antagonism to Islam. Stigmatization, whether of Omani minorities, or the Alawites in Turkey—or of prostitutes by the public health movement in nineteenth-century Paris, as discussed by Charbit in Chapter 3—is an activity in which scientific measures may readily be employed. More generally, to the extent that scientific practices often admit multiple interpretations, they open a door to multiple criteria of validity which can then be combined in several ways, and played off against each other (Beck 1992: 157). The complex nature of risk perception thus returns us to the issues of vernacu­ larization, translation, and compositional demography raised in Parts I–IV, now

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46  KREAGER, PETIT, QURESHI, AND CHARBIT in the context of clinical practice and genetic counselling. First, the Mendelian logic that identifies people who carry recessive genes does not translate directly into the language of kin relationships, despite the seeming similarity of talk about ‘blood’ and ‘blood tests’ that both clinicians and their patients employ. And sec­ ond, as the interpretations of the latter vary as shaped by the groups with which they identify, any attempt to improve translation and medical practice will require these subpopulations and their relations in society to be specified. The epidemic spread of AIDS in tropical Africa provides a second setting in which new biomedical knowledge and practices interact with local cultures and history to generate multiple, competing interpretations of health risks and how to deal with them. As Tchetgnia, Charbit, and Libali remark in Chapter 16 on sexuality and AIDS in the Congo, despite the fact that repeated prevention campaigns have made young people aware, sexual risk-taking behaviour remains prevalent. A 2009 national survey indicated that 65 per cent of men and 51 per cent of women aged between fifteen and twenty-four engaged in unprotected sex. Findings of the 2012 DHS survey underline this picture: some 90 per cent of women experience sex by the age of twenty, and multiple partnerships are common. As older mar­ ried men may have sexual relations outside of marriage, often with members of these young cohorts, a much wider population is exposed. That so many people are prepared to risk AIDS infection, with strongly increased risks of subsequent reproductive complications and early death, appears astonishing. The task the authors set themselves is to explain how local norms and behaviour are addressed to immediate, practical problems seen as more pressing, particularly in a context in which governmental health provision is not trusted. The vital conjunctures that determine the incidence of AIDS in a population are in some ways even more complex than the genetics of marriage decisions dis­ cussed by Shaw in Chapter 15. The probability of infection cannot be expressed in terms of a simple binary or proportion, and people often do not know they are infected (or may disguise that possibility). Sexual conjunctures involve the gamut of relationships. Many sexual relations are transactional; that is, poor young women agree to relations with men who will support them. If they have more than one potential sponsor, competition between them and appropriate sexual responses may ensue. Some sex is straight prostitution. In others, sexual relationships may be entered into in the hope of establishing a more enduring partnership. Casual sex may be valued, as it is spontaneous and improvised. Whether a condom is used in any of these circumstances depends on a great many factors. People use condoms with some partners and not others. Expecting a partner to use a condom often becomes an implicit statement that they cannot be trusted, or is seen as an admission of infidelity. While people commonly have incomplete knowledge of each other’s pasts, that need not lead to condom use. Such a range of contexts characterized by uncertainty, poverty, and vulnerability poses considerable difficulties for research. Shifting relationships are notoriously difficult to track in standardized surveys, and the continuing observation required

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Introduction  47 in ethnography is usually impossible to sustain across many such relationships. The authors, following a procedure similar to Baxerres and Le Hesran (Chapter 14), combined ethnography with a selective local survey based on known contacts: individuals, who the authors considered to have reliable and trusted access to peers in the community, were encouraged to contact and talk with people they knew to be taking risks. Research was carried out in a variety of everyday social contexts so that interviews more closely resembled ordinary conversations. Particular attention was given to people’s own wording of the nature and conduct of risk relationships, and of the multiple forms of risk that enter into any one relationship. The findings showed, again and again, the extent to which vulnerability, pov­ erty, and uncertainty worked in combination to reinforce risk taking. First, deep suspicion of government and health authorities undermined the credibility of official warnings. Here Douglas’s point—that people’s perception of risk, and their strategies to cope with it, maintain boundaries between groups—takes a specific causal form where AIDS is concerned: if official authorities are dubious sources of ­ eople, truth, then the sensible thing to do is ignore them, as they wilfully mislead p and do not share their interests. They are ‘others’. Second, but in combination with the first, many values readily out-weighed AIDS risk in the immediate con­ junctures in which sexual contacts occurred: needed money for self or family; physical pleasure; observing gender norms; avoiding accusations of infidelity; the power of sorcery; peer pressure. These values make evident the profoundly moral nature of these conjunctures. Religious rationales could then be added as support: man’s sinful nature, it was argued, is a norm.20 Chapter 17 by Clémence Schantz on childbirth practices and the improvement of maternal health in Cambodia provides a sharp contrast to the dilemmas of reproductive and sexual risk in Chapters 15 and 16. Rather than distrust of med­ ic­al authorities, over 90 per cent of births in Phnom Penh take place in modern hospitals, and specialized surgical practices are widely requested and administered. Episiotomy, caesarean section, and vaginal surgery (perineorrhaphy) are generally recognized amongst patients and their families as the most effective means of protecting women from the dangers of postpartum illness and death that are considered most serious in traditional Khmer medicine. This medicalization of childbirth, in which Western practices have been assimilated closely to Khmer concepts of bodily protection, humoral balance, and dangers of pollution, has reached levels of surgical intervention that greatly exceed WHO re­com­menda­tions, and are regarded outside of Cambodia as dangerous. Schantz’s study, as with several preceding chapters, employs a combined methodology linking ethnography, extensive in-depth interviewing, data drawn from medical recordkeeping, and local survey. Her chapter focuses particularly 20  Trinitapoli and Weinreb (2012) provide extensive documentation and discussion of the centrality of the moral and religious dimension of AIDS in Africa.

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48  KREAGER, PETIT, QURESHI, AND CHARBIT on the ‘fit’ that has enabled clinical and surgical practices to be assimilated to Khmer medical knowledge. The risks that women take in connection with child­ birth are understood to occur when polluting substances are allowed to enter the body, and when there is a weakening or loss of vital force consequent on the effort of giving birth. She reviews a range of Khmer healing and dietary practices that ensure proper circulation of the blood, maintain humoral balance by pro­ tecting against excessive heat or cold, and protect against supernatural influences. Protecting orifices of the body—ears, the vagina, etc—is particularly important, as they provide conduits for ‘wind’, a local expression for endemic sources of illness. This potential vulnerability is especially important in periods of weakness, such as childbirth and the postpartum period. In this context, the value of perine­ orrhaphy (which tightens the vaginal opening), episiotomy (which protects against vaginal tears) and caesarean section (which provides immediate surgical closure) appears to be common sense, as each practice seeks to avoid excessive vaginal damage and to return the opening quickly and as much as possible to its normal state. In contrast to the proliferation of local interpretations of biomedical knowledge which reveal serious misunderstanding (as Shaw noted for radically different meanings of ‘blood’ and ‘blood tests’ in the context of consanguineal marriage), Khmer interpretations neatly align surgical practice with humoral body symbolism. Duress, both of the body and as fear of longer-term health problems consequent on loss of vital force, are replaced by the regularity of surgical procedures under clinical control. As Schantz further notes, the majority of female obstetrician gynaecologists she interviewed also had caesarean sections themselves. Chapter 18 by Jan Brunson on maternal health in a Nepalese community con­ tinues this discussion of women’s vulnerability in relation to childbirth, broaden­ ing it by a comparison of local practices in ante- and postpartum periods that seek to control risks of ill health, and considering how government health inter­ ventions may better address women’s experience and perception of these risks. Inadequate nutrition is a serious issue, often coupled with heavy physical demands of agricultural and domestic labour in many women’s lives. The question of what steps may be taken to improve their situation, and whether they are effective, is, as in previous chapters, bound up with issues of measurement. As Brunson notes, the conventional metric employed in national and international evaluations is the maternal mortality ratio (MMR); yet the fact that fewer ­mothers may be dying can only be a crude measure of improved health status, since issues such as Nepali women face, and the incremental impacts on their bodies, are ongoing condi­ tions, with multiple consequences. A measure of mortality does not capture lived ill health.21 21  There is a parallel here to the earlier Chapter 8 on governance, by Stanley Ulijaszek, which also addresses measures relating to nutrition as indices of health liabilities and improvements. As he shows, the body mass index (BMI) is valued as a standard measure for evaluation purposes, since it enables height and weight to be linked to mortality; this statistical association, however, may disguise variation, including people’s health experience.

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Introduction  49 To explore and compare Nepali ante- and postpartum health strategies, Brunson, like Schantz, employed a combined methodology involving ethnography, in-depth interviews, medical records, and local survey. In addition, analysing DHS data helped to identify basic compositional, or intersectional, differences in Nepal (such as caste, material wealth, household organization, and education) so that the influence of membership in different groups and their cultural identities could be explored in detail in interviews and the local survey. A marked contrast between ante- and postpartum care emerged from this approach. In the latter, elaborate norms of seclusion, diet, and bodily care estab­ lished a closely regulated set of steps designed to protect and ensure mothers’ health. In the former, however, women were expected to conceal their pregnan­ cies as long as possible, eat a usual diet (deficient in many nutrients needed in pregnancy), and continue their workload unabated. The postpartum regime was based, as in Schantz’s case study, on practices to ensure humoral balance, and to protect against dangerous ingress of ‘air’ (similar to Cambodian ‘wind’). The ante­ natal period, in contrast, was not considered a particularly vulnerable time, either for the mother or the foetus. Wide acceptance of gender norms ensured that women should conceal pregnancy as an outwardly visible sign of sexual activity, and hence of shame; often in poorer households there was no one else to do a woman’s daily chores; poverty frequently limited access to more than basic foods, and expressing a need for special foods, even when experiencing nausea, was consistently avoided. As Brunson notes, the compositional demography under­ lying these practices varied their enforcement. Women in poorer castes ex­peri­ enced shorter periods of postpartum care, and often had to return to normal labour more quickly. Women in higher castes and wealthier, extended families, in contrast, had additional support which delayed their need to work, might stay for an extended period with their natal kin after giving birth (where they were kept from household and other tasks), and enjoyed special diets. Governmental health interventions have taken some important steps, such as promoting vitamin sup­ plements and deworming medication, but reliance on statistics that homogenize the population by not distinguishing subpopulations with differing needs has left most poorer young women’s ante-natal and postnatal needs unaddressed. In Chapter 19, Elizabeth L Krause takes up a theme which has become basic to research in social demographic history (eg Pooley 2013): issues of parenting and child care as critical factors in reproductive decision making. She begins from the surprising fact that, in the Italian city of Prato, where her research is placed, the majority of births in recent years have been to foreigners, of which Chinese work­ ers in the garment industry are a principal group. No less striking is that the great majority of their infants are sent to China within a few months of birth. As she notes, hospital and clinic staff in Prato are very concerned about the health impli­ cations of this separation of infants and parents, and have worked conscientiously to encourage parents to keep their children with them. While aware that factory conditions are far from optimum (families live in dormitories, pay is low, and

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50  KREAGER, PETIT, QURESHI, AND CHARBIT independent child care is not provided), they remark the higher incidence of child health problems among Chinese infants (such as hearing deficiencies), and that mothers are less likely to follow clinic childcare recommendations closely. If the infants are sent within months to China, there is no way that standard Italian clinical provision can be sustained. Krause’s ethnography, in addition to in-depth interviewing with patients and clinic staff, focuses on observation of the central event in their relationship: the clinical examination of infants that takes place when they are brought into the hospital for routine check-ups. She considers particularly the language and pro­ced­ ures followed in these meetings, their significance for the migrant couples, and the wider perception of migrant factory workers and their fertility in the context of Italian reproductive values and levels. The latter have been substantially below replacement-level fertility for more than two decades, and poor Italian factory workers face many of the disadvantages of migrants. Although clinic staff seek to avoid negative stereotypes of foreign workers such as frequently appear in the local press, the advice and support they provide to couples reflect what Krause calls ‘sedentarist bias’; that is, the assumption that infant care normally takes place in a fixed, independent, nuclear family setting. Chinese couples, however, insist that they seek the highest-quality care for their infants and children, and have a very different understanding of what this entails. The risks to their offspring are simply too great in the conditions of their Prato factory and dormitory workplaces. Not only do factory schedules leave little time and place for parenting, in Chinese cultures kin normally play a major role in child care, particularly grandparents, who are often considered more ex­peri­enced and better carers. Not only is a normative home and family context much more possible with kin in China, children can go to school and be socialized there in a way that is impossible in Prato. Cultural boundary risks are thus also an elem­ent in their considerations: kin are felt to be safer carers than employing other people to look after children. Once again, it is necessary for research and policy to base understanding on the reference and resource groups that are actually relevant to reproduction and health choices. Indeed, the boundary risk issues this Chinese community faces in their reproductive and care choices are not, as Krause remarks, adequately considered as a matter of Chinese–Italian cultural differences: they are an instance of wider conditions of migrant labour in the global economy.

0.7  Concluding note By way of conclusion, we may note how the chapters in Part V exemplify the widen­ing and deepening of population research that has taken place in recent decades in order to address the great diversity of contemporary health problems. Close consideration of the interaction of endogenous health knowledge and

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Introduction  51 practices with exogenous state and other health interventions is a key locus for understanding whether and how people’s health needs are being met. By moving on from the earlier era of demographic pre-occupation with macro fertility rates and limitation, it has become possible to place childbearing and other health issues more fully in the interaction of meso-level social structures and the several sub-populations that compose them, and hence in the life-course conjunctures in which reproduction and other health risks are weighed differently by members of different groups. As we have seen, reproductive risk is not experienced and acted upon simply as a binary choice: risks come in sets, and these sets are made up not only of an immediate threat of illness or pregnancy or other health concern, but also in terms of risks important in the reference and resource groups in which a person participates. Successive chapters in Part V show this is true for fertility and reproduction, considering, in turn: genetic disorders with consequent child deaths and infertility; networks of sexually transmitted diseases that have reached epidemic levels; how cultures accommodate surgical and clinical childbirth pro­ ced­ures into traditional and supernatural medical knowledge; the distribution of health risks and health-seeking behaviour before and after parturition; and differ­ ent parenting and childcare strategies as integral to good reproductive health. The preceding chapters in Parts I–IV provide a series of case studies ­demonstrating the kinds of conceptual and methodological groundwork needed to support close consideration of people’s health experiences, coping with risks, and how they may be improved. These chapters address not only reproductive health, but also chronic disabilities, epidemic diseases, malnutrition, mental health, vulnerability in old age, and other widely experienced problems. Each of Parts I–IV focuses in particular on one dimension of the contexts that determine con­tem­por­ary health risks: local and national histories of health governance; the legacy of these histories as they continue to shape health seeking and provision; the com­ pos­ ition­ al demography of subpopulation memberships and how it shapes the way life-course processes and conjunctures resolve or accumulate peo­ ple’s vul­ner­abil­ities; and the immediate confronting of risk in such vital conjunc­ tures. Combined methodologies, such as those now employed in anthropological dem­og­raphy, address these issues from the bottom up, bringing together insights from ethnography and historical research, and local surveys and other quantita­ tive techniques. Historical, compositional, governance, and life-course factors are no less crit­ ic­al to improving the data systems on which health research and programme interventions rely. As emphasized in Part III, data systems are social and linguis­ tic, as well as mensurational phenomena, which have shaped not only people’s health experience, but also the institutions, categories, measures, and models with which we seek to understand them. No less than the conduct of health inter­ ventions, their improvement requires close consideration of the way endogenous and exogenous knowledge and practices interact. We hope that the five parts of

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52  KREAGER, PETIT, QURESHI, AND CHARBIT this book, by outlining principal dimensions necessary to contemporary health understanding, provide a constructive agenda for health improvement.

References Adams, V (2016). Metrics: What Counts in Global Health. Durham, NC: Duke University Press. Basu, A and P Aaby (eds) (1998). Methods and Uses of Anthropological Demography. Oxford: Clarendon Press. Beck, U (1992). Risk Society. London: Sage. Biruk, C (2018). Cooking Data: Culture and Politics in an African Research World. Durham, NC: Duke University Press. Brunson, J and S Suh (2019). ‘Behind the Measures of Maternal and Reproductive Health: Ethnographic Accounts of Inventory and Intervention’, Social Science and Medicine. Pre-proof available at https://doi.org/10.1016/j.socscimed.2019.112730. Caldwell, J C (1976) ‘Toward a Restatement of Demographic Transition Theory’, Population and Development Review 2(3–4): 321–66. Caldwell, J C, A G Hill, and V J Hull (eds) (1988) Micro-Approaches to Demographic Research. London: Kegan Paul International. Cambridge Group for the History of Population and Social Structure (2019). An Atlas of Fertility Decline in England and Wales. http//campop.geog.cam.ac.uk/research/ projects/Victorian fertility decline/. Charbit, Y (1999). ‘Famille et fécondité: pour une démographie compréhensive’, Sociologie et sociétés XXXI(1): 23–34. Charbit, Y (2018). ‘Women as Actors in Addressing Climate Change’ in N. Riley and J Brunson (eds), International Handbook on Gender and Demographic Processes. Dordrecht: Springer, pp 317–29. Charbit, Y and S Ndiaye (eds) (1994). La population du Sénégal. Paris: DPS/ CERPAA. Charbit, Y and V Petit (2011). ‘Toward a Comprehensive Demography: Rethinking the Research Agenda on Change and Response’, Population and Development Review 37(2): 219–39. Clarke, A and D Haraway (eds) (2018). Making Kin not Population. Chicago, IL: Prickly Paradigm Press. Coale, A J (1969). ‘The Decline of Fertility in Europe from the French Revolution to World War II’ in S J Behrmann, L Corsa, and R Freedman (eds), Fertility and Family Planning, Ann Arbor, MI: Michigan State University Press, pp 3–24. Coale, A J (1973). ‘The Demographic Transition Reconsidered’ in International Union for the Scientific Study of Population, International Population Conference 1973. Liege: Ordina, pp 53–72.

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Introduction  53 Cohn, B (1987). ‘The Census, Social Structure and Objectification in South Asia’ in B Cohn, An Anthropologist amongst the Historians and Other Essays. Delhi: Oxford University Press, pp 224–54. Davis, K (1956). ‘The Amazing Decline of Mortality in Underdeveloped Areas’, American Economic Review 46(2): 305–18. Davis, K (1963). ‘The Theory of Change and Response in Modern Demographic History’, Population Index 29(4): 345–66. Delaunay, V (2018). ‘Du suivi longitudinal à l’observatoire multidisciplinaire. La method au Coeur du dispositive (1960–2000)’ in V Delaunay, A Desclaux, and C  Sokhna (eds), Niakhar, mémoires et perspectives. Recherches pluridisciplinaires en Afrique. Paris: IRD editions and L’Harmattan Sénégal, pp 131–42. Douglas, M (1992). Risk and Blame: Essays in Cultural Theory. London: Routledge. Durkheim, E (1899). ‘Morphologie Sociale’, L’Anne sociologique 11(3): 520–1. Evans-Pritchard, E E (1969). Essays in Social Anthropology. London: Faber and Faber. Fisher, K (2008). Birth Control, Sex and Marriage in Britain 1918–60. Oxford: Oxford University Press. Foucault, M (2004). Security, Territory, Population, ed M Senellart, trans G Burchell. New York: Palgrave MacMillan. Fricke, T E (1994). Himalayan Households: Tamang Demography and Domestic Processes. New York: Columbia University Press. Gillis, J R, L A Tilly, and D Levine (eds) (1992). The European Experience of Declining Fertility, 1850–1970. Oxford: Blackwell. Godard, A (2010). Economie domestique et société. Le travail des femmes en Guinée Maritime. Paris: L’Harmatan. Greenhalgh, S (ed) (1995). Situating Fertility: Anthropology and Demographic Inquiry. Cambridge: Cambridge University Press. Greenhalgh, S (1996). ‘The Social Construction of Population Science: An Intellectual, Institutional, and Political History of Twentieth-century Demography’, Comparative Studies in Society and History 38(1): 26–66. Greenhalgh, S (2003). ‘Science, Modernity, and the Making of China’s One-child Policy’, Population and Development Review 29(2): 163–96. Hajnal, J (1965). ‘European Marriage Patterns in Perspective’ in D V Glass and D E C Eversley (eds), Population in History. London: Edward Arnold, pp 101–43. Halbwachs, M (1938). Morphologie Sociale. Paris: Librarie Armand Colin. Hammel, E A (1990). ‘A Theory of Culture for Demography’, Population and Development Review 16(3): 455–85. Hammel, E A and D S Friou (1997). ‘Anthropology and Demography: Marriage, Liaison, or Encounter?’ in D I Kertzer and T Fricke (eds), Anthropological Demography: Toward a New Synthesis. Chicago, IL and London: University of Chicago Press. pp 175–200.

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54  KREAGER, PETIT, QURESHI, AND CHARBIT Harrison, M (1994). Public Health in British India: Anglo-Indian Preventive Medicine 1859–1914. Cambridge: Cambridge University Press. Harrison, M (2000). ‘Differences of Degree: Representations of India in British Medical Topography, 1820–c 1870’, Medical History (Suppl) 20: 51–69. Hartmann, B (1995). Reproductive Rights and Wrongs: The Global Politics of Population Control. Boston, MA: South End Press. Hill, S E (2015). ‘Axes of Health Inequalities and Intersectionality’ in K E Smith, C Bambra, and S E Hill (eds), Health Inequalities: Critical Perspectives. Oxford: Oxford University Press, pp 96–108. Hillcoat-Nalletamby, S (2002). La pratique de la contraception à l’Ile Maurice. Paris: L’Harmatan. Howell, N (1979). Demography of the Dobe Kung. New York: Academic Press. Hull, T (2003). ‘The Political Framework for Family Planning in Indonesia: Three Decades of Development’ in A Niehof and F Lubis (eds), Two is Enough: Family Planning in Indonesia under the New Order 1968–1998. Leiden: KITLV Press, pp 57–81. Inda, J X (2005). Anthropologies of Modernity. Oxford: Wiley-Blackwell. Jackson, M (ed). (2018). A Global History of Medicine. Oxford: Oxford University Press. Jaquette, J S and K A Staudt (1988). ‘Politics, Population and Gender: A Feminist Analysis of US Population Policy in the Third World’ in K B Jones and A G Jonasdottir (eds), The Political Interests of Gender: Developing Theory and Research with a Feminist Face. London: Sage, pp 214–33. Jeffery, R and P Jeffery (1997). Population, Gender and Politics: Demographic Change in Rural North India. Cambridge: Cambridge University Press. Johnson-Hanks, J A (2007). ‘What Kind of Theory for Demographic Anthropology?’, Demographic Research 16(1): 1–26. Johnson-Hanks, J A (2015). ‘Populations are Composed One Event at a Time’ in P  Kreager, B Winney, S Ulijaszek, and C Capelli (eds), Population in the Human Sciences: Concepts, Models, Evidence. Oxford: Oxford University Press, pp 238–56. Johnson-Hanks, J A (2017). ‘Vital Conjunctures Revisited’ in P Kreager and A Bochow (eds), Fertility, Conjuncture, Difference: Anthropological Approaches to the Heterogeneity of Modern Fertility Declines. Oxford: Berghahn, pp 326–40. Johnson-Hanks, J A, C A Bachrach, S P Morgan, and H-P Kohler (eds) (2011). Understanding Family Change and Variation. Dordecht: Springer. Kertzer, D and T Fricke (eds) (1997). Anthropological Demography: Towards a New Synthesis. Chicago, IL: University of Chicago Press. Kertzer, D and D Hogan (1989). Family, Political Economy, and Demographic Change: The Transformation of Life in Casalecchio, Italy, 1861–1921. Madison, WI: University of Wisconsin Press. Kohler, H-P, S Helleringer, J R Behrman, and S C Watkins (2015). ‘The Social and the Sexual: Networks in Contemporary Demographic Research’ in P Kreager, B

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Introduction  55 Winney, S Ulijaszek, and C Capelli (eds), Population in the Human Sciences: Concepts, Models, Evidence. Oxford: Oxford University Press, pp 196–237. Kreager, P (2004). ‘Objectifying Demographic Identities’ in S Szreter, H Shokalmy, and A Dharmalingam (eds), Categories and Contexts in Demographic Research. Oxford: Clarendon Press, pp 1–19. Kreager, P (2015). ‘Population and the Making of the Human Sciences: A Historical Outline’ in P Kreager, B Winney, S Ulijaszek, and C Capelli (eds), Population in the Human Sciences: Concepts, Models, Evidence. Oxford: Oxford University Press, pp 55–85. Kreager, P (2019). ‘Evolution in the History of Population Thought’ in O Burger, R Lee, and R Sears (eds), Human Evolutionary Demography. Open Book Publishers. https://osf.io/p59eu/. Kreager, P and A Bochow (2017). ‘Introduction’ in P Kreager and A Bochow (eds), Fertility, Conjuncture, Difference: Anthropological Approaches to the Heterogeneity of Modern Fertility Declines. Oxford: Berghahn, pp 1–42. Kreager, P and E Schröder-Butterfill (eds) (2004). Ageing without Children: European and Asian Perspectives. Oxford: Berghahn. Kreager, P and E Schröder-Butterfill (2010). ‘Age-Structural Transition in Indonesia: A Comparison of Micro- and Macro-Level Evidence’, Asian Population Studies 6(1): 25–45. Lesthaeghe, R (1980). ‘On the Social Control of Human Reproduction’, Population and Development Review 6(4): 527–48. Lesthaeghe, R (ed) (1989). Reproduction and Social Organization in Sub-Saharan Africa. Berkeley, CA: University of California Press. Lorimer, F (1945). ‘Population as a Problem in Quality’ in T W Schulz (ed), Food for the World. Chicago, IL: University of Chicago Press, pp 58–65. Lorimer, F (ed) (1954). Culture and Human Fertility. Paris: United Nations Educational, Scientific and Cultural Organization (UNESCO). Lotka, A J (1925). Elements of Physical Biology. Baltimore, MA: Williams and Wilkins. MacFarlane, A (1976). Resources and Population: A Study of the Gurungs of Nepal. Cambridge: Cambridge University Press. McNicoll, G (1978). ‘Population and Development: Outlines for a Structuralist Approach’, Journal of Development Studies 14(4): 79–99. McNicoll, G (1980a).‘Institutional Determinants of Fertility Change’, Population and Development Review 6(3): 441–62. McNicoll, G (1980b). ‘Governance of Fertility Transition: Regularity and Duress’. Working Paper 85, New York: The Population Council. McNicoll, G (2011). ‘Achievers and Laggards in Demographic Transition: A Comparison of Indonesia and Nigeria’, Population and Development Review 37(Suppl 1): 191–214.

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56  KREAGER, PETIT, QURESHI, AND CHARBIT Mannheim, K (1952). ‘The Problem of Generations’ in P Kecskemeti (ed), Essays on the Sociology of Knowledge. New York: Routledge, pp 276–322. Mason, K Oppenheim (1992). ‘Culture and the Fertility Transition: Thoughts on Theories of Fertility Decline’, Genus 48(3–4): 1–13. Mauss, M (1906). ‘Essai sur les variations saisonières des sociétés eskimos. Etudes de morphologie sociale’, L’Année sociologique IX 39–132. Mitchell, J C (1969). Networks in Urban Situations. Manchester: University of Manchester Press. Murphy, M (2017). The Economization of Life. Durham, NC: Duke University Press. Niehoff, A and F Lubis (eds) (2003). Two is Enough: Family Planning in Indonesia under the New Order, 1968–1998. Leiden: KITLV Press. Notestein, F (1945). ‘Population—the Long View’ in T W Schulz (ed), Food for the World. Chicago, IL: Chicago University Press, pp 36–57. Petit, V (1998). Migrations et société dogon. Paris: L’Harmatan. Petit, V (2013). Counting Populations. Understanding Societies. Dordrecht: Springer. Petit, V (2017). Change and Response. From Theory to Fieldwork. Dordrecht: Springer. Petit, V and M-L des Robert (eds) (2004). Entre résistance et changements: la planification familiale en milieu rural sénégalais. Paris: L’Harmatan. Pooley, S (2013). ‘Parenthood, Child-rearing and Fertility in England, 1850–1914’, The History of the Family 18(1): 83–106. Pooley, S and K Qureshi (2016). ‘Introduction’ in S Pooley and K Qureshi (eds), Parenthood between Generations: Transforming Reproductive Cultures. Oxford: Berghahn, pp 1–42. Reid, A (2017). ‘Infant Feeding and Child Health and Survival in Derbyshire in the Early Twentieth Century’, Women’s Studies International Forum 60: 111–19. Riley, N E and. McCarthy (2003). Demography in the Age of the Postmodern. Cambridge: Cambridge University Press. Robinson, G B (2018). The Killing Season: A History of the Indonesian Massacres, 1965–66. Princeton, NJ: Princeton University Press. Ryder, N B (1964). ‘The Process of Demographic Translation’, Demography 1: 74–82. Schulz, T W (ed) (1945). Food for the World. Chicago, IL: Chicago University Press. Segalen, M (1991). Fifteen Generations of Bretons: Kinship and Society in Lower Brittany, 1720–1980. Cambridge: Cambridge University Press. Shaw, A (2009). Negotiating Risk: British Pakistani Experiences of Genetics. Oxford: Berghahn. Smith, R M (1981). ‘Fertility, Economy, and Household Formation in England over three Centuries’, Population and Development Review 7(4): 595–622. Szreter, S (1993). ‘The Idea of Demographic Transition and the Study of Fertility Change’, Population and Development Review 19(4): 659–702.

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Introduction  57 Szreter, S (1997). ‘Economic Growth, Disruption, Disease, and Death: On the Importance of the Politics of Public Health for Development’, Population and Development Review 23(4): 693–728. Szreter, S (2015). ‘Populations for Studying the Causes of Britain’s Fertility Decline: Communication Communities’ in P Kreager, B Winney, S Ulijaszek, and C Capelli (eds), Population in the Human Sciences: Concepts, Models, Evidence. Oxford: Oxford University Press, pp 172–95. Szreter, S and E Garrett (2000). ‘Reproduction, Compositional Demography, and Economic Growth: Family Planning in England Long before the Fertility Decline’, Population and Development Review 26(1): 45–80. Szreter, S, H Sholkamy, and A Dharmalingam (eds) (2004). Categories and Contexts: Anthropological and Historical Studies in Critical Demography. Oxford: Oxford University Press. Tarlo, E (2000). ‘Body and Space in a Time of Crisis’ in V Das, A Kleinman, M Ramphele, and P Reynolds (eds), Violence and Subjectivity. Berkeley, CA: University of California Press, pp 242–70. Tchetgnia, L (2016). Face au Sida, quel comportement en Afrique. Le cas du Cameroun. Paris: L’Harmatan. Thornton, A (2005). Reading History Sideways: The Fallacy and Enduring Impact of the Developmental Paradigm on Family Life. Chicago, IL: University of Chicago Press. Trinitapoli, J and A Weinreb (2012). Religion and AIDS in Africa. Oxford: Oxford University Press. United Nations (1989). ‘Convention on the Rights of the Child’. www.ohchr.org/EN/ ProfessionalInterest/Pages/CRC.aspx. Unnithan, M (2019). Fertility, Health and Reproductive Politics. London: Routledge. Vaughan, M (1991). Curing their Ills: Colonial Power and African Illness. Cambridge: Polity Press. Weinreb, A and M Sana (2009). ‘The Effects of Questionnaire Translation on Demographic Data and Analysis’, Population Research and Policy Review 28(4): 429–54. Widmer, E D and R Jallinoja (eds) (2008). Beyond the Nuclear Family: Families in a Configurational Perspective. Bern: Peter Lang. Woods, R (2007). ‘Medical and Demographic History: Inseparable?’, Social History of Medicine 20(3): 483–503. Wrigley, E A (1972). ‘The Process of Modernisation and the Industrial Revolution in England’, Journal of Interdisciplinary History 3: 225–59.

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PART I

TA KING T HE LONG E R V I EW Health Interventions in Historical Context

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1

Cultures of contagion and containment? The geography of smallpox in Britain in the pre-vaccination era Romola Davenport*

1.1 Introduction In 1794, four years before Jenner self-published his first paper on vaccination by cowpox, the eighteen-year old cooper William Hart caught smallpox during a visit to his uncle to London. His autobiography recounts that upon his return to the small town of St Albans, twenty miles north of London, in a few days I sickened with the Smallpox, which I had caught in London. In this dilemma I knew not what to do, as this disease was so terrific in the Country at that time for the Cowpox [Jennerian vaccination] was then unknown. No one in the town could be found who would take me in. My master used every effort. The people where I lodged would not let me remain with them on any account. It was an old maiden woman who kept a shop and was afraid of losing her customers . . . I was 20 miles from my grandfather’s home, but . . . I dare not go there, for he had not had the disease and was terrified at the thought of the smallpox. (Hudson and Hunter 1981: 152)

William then recalled that the town of Luton, where he had served his apprenticeship as a cooper, had been infected some time before, and he thought he knew one family where all the members had had smallpox, who might be persuaded to take him in. His employer arranged for him to travel to Luton in a one-horse * This work was funded by Leverhulme Trust award RPG-2012–803 (to R J Davenport) and Wellcome Trust award 103,322 (to Professor Richard Smith, University of Cambridge). The author gratefully acknowledges these funders. She also thanks the following organizations and individuals for generous donations of data and advice: Lyn Boothman, Alan Clarke (www.familyhistory.northants. co.uk), Stephen Coleman, Jonathan Healey, Gill Newton, Ellen Potter, Richard Smith, Buckinghamshire Family History Society (FHS), Cambridgeshire FHS, Cumbria FHS, Derbyshire FHS, Devon FHS, Durham Records Online, Kent FHS, Lancashire Online Parish Clerks, Manchester and Lancashire FHS, Norfolk FHS, Nottinghamshire FHS, Shropshire FHS, Suffolk FHS, and Wiltshire FHS. Romola Davenport, Cultures of contagion and containment: The geography of smallpox in Britain in the pre-vaccination era? In: The Anthropological Demography of Health. Edited by: Véronique Petit, Kaveri Qureshi, Yves Charbit, and Philip Kreager, Oxford University Press (2020). © Oxford University Press. DOI: 10.1093/oso/9780198862437.003.0001

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62  Romola Davenport chaise (ie alone except for the driver, to avoid infecting fellow travellers). However, on his arrival his friends in Luton immediately notified the Parish Officer, who would not let me remain in the town for fear of communicating the infection. As I was a Parishioner by my servitude [William had gained a legal right to welfare in Luton through his apprenticeship there] they must provide for me. They therefore sent me to the Pest house, a place provided in those days for persons who had this disease. It was but a short distance from the town . . . Here they provided me with two nurses (poor parish paupers) and every necessary for my recovery, and the Parish Doctor attended me . . . [for three weeks I] was provided with medical aid and nurses free of expense. (Hudson and Hunter 1981: 153)

William thanked God for his luck. I a poor lad only 18 years and a few months old in a strange place where I knew no one, no relations, no friends, no acquaintances near me. Seized with a dreadful and oft times a fatal disease and no home to go to . . . obliged to be removed 10 miles when the disorder was upon me, which might have proved fatal . . . I got no harm. I was taken to the Pest House and provided with medical aid and nurses free of expense.  (Hudson and Hunter 1981: 153)

William Hart’s account encapsulates in vivid detail a common set of responses to smallpox in southern England on the eve of the debut of Jennerian vaccination. The fear with which the disease was regarded, and the clear perception of its contagious nature, are palpable in his writing. It is also evident that although William had grown up within about twenty miles of London, where smallpox was everpresent, he had never contracted the disease before he visited London. Many other adults in the area, including his grandfather, were similarly vulnerable. Finally, his treatment presents a curious mixture of aversion and careful nursing at communal expense. Hart’s experience stands in stark contrast to Monro’s account of smallpox in mid-eighteenth-century Scotland. In response to a list of questions circulated by the Parisian Faculty of Medicine, Monro responded: The inhabitants of Scotland generally have the small pox in their infancy or childhood; very few adults being seen here in this disease. Whether this is owing to any particular constitution of the air, or of the people, or to the disease not being so much dreaded as to cause any to fly from the place where it is, or to the great intercourse which must be among the inhabitants in the towns, of which several, nay many, families enter to their houses by one common stair, while in the villages the peasants are generally assistant to their neighbours of whose family any is sick, is not necessary to inquire.

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Cultures of contagion and containment?  63 When small pox appear favourable in one child of a family, the parents generally allow commerce of their other children with the one in the disease; nay, I am assured, that in some of the remote highland parts of this country, it has been an old practice of parents whose children have not had the small pox, to watch for an opportunity of any child of their neighbours being in good mild smallpox, that they may communicate the disease to their own children by making them bedfellows to those in it, and by tying worsted threads wet with the pocky matter round their wrists.  (Monro 1765: 3–4)

Thus, in mainland Scotland Monro claimed that smallpox was an endemic childhood disease, and that people did not fear and avoid it, but in fact often chose to expose their children to infection. Monro did note, however, that smallpox was a rare and epidemic disease of all ages in the more remote islands of Scotland, where it was occasionally introduced by sea (Monro 1765: 8). In a companion paper (Davenport et al 2018), we presented evidence that these contrasting attitudes to smallpox described by Hart and Monro were mirrored in patterns of smallpox mortality in northern and southern Britain (Figure  1.1). Smallpox was the single most lethal disease of eighteenth-century Britain, and appears to have grown in importance over the period 1650–1750.1 It was endemic (ever-present) in the larger towns and cities and accounted for 10–20 per cent of all burials in towns and cities in northern Britain (Mercer  1990, chapter  3; Davenport et al 2016). It was also a common and childhood disease in rural areas of northern England (and probably mainland Scotland: Brunton  1990;  1992). However, in southern England, outside the major cities, smallpox remained a relatively rare and epidemic disease. This claim is based on a large-scale scoping of pre-nineteenth-century English burial registers that contained information on age and smallpox burials. Burials attributed to smallpox provide a reasonable guide to the incidence of smallpox infection, because smallpox (variola major) caused death in 10–30 per cent of those infected, and was readily identified by contemporaries (Buchan 1774: 161; Creighton 1894: 530). It was virulent enough to kill adults as well as children, and therefore age at burial broadly reflected the age profile of those infected. Smallpox infection conferred lifelong immunity on survivors, and therefore where it was a persistent, endemic disease, then it was also largely a disease of children, because most adults had already acquired immunity in childhood. This was the case in northern England: in our sample of northern parishes and chapelries, adults (aged fifteen plus) comprised less than 10 per cent of smallpox burials 1  Both historical and molecular-phylogenetic evidence suggest that there was a major change in the smallpox subtype in Europe in the mid- or late seventeenth century. This may have been due to mutations within the existing subtype or to a new type, and this novel variant then displaced previously circulating subtypes, and underwent subsequent diversification to produce the variety of subtypes that circulated in the mid-twentieth century (Carmichael and Silverstein 1987: Li et al 2007; Duggan et al 2016).

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Smallpox burials aged