Technologized Images, Technologized Bodies 9781845458300

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Technologized Images, Technologized Bodies

Technologized Images, Technologized Bodies Edited by Jeanette Edwards, Penny Harvey and Peter Wade

Berghahn Books New York • Oxford

First published in 2010 by Berghahn Books www.berghahnbooks.com

©2010 Jeanette Edwards, Penny Harvey and Peter Wade All rights reserved. Except for the quotation of short passages for the purposes of criticism and review, no part of this book may be reproduced in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system now known or to be invented, without written permission of the publisher. Library of Congress Cataloging-in-Publication Data

British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Printed in the United States on acid-free paper ISBN: 978-1-84545-664-1(hardback)

Contents

List of Figures and Tables Preface and Acknowledgements

vi viii

1.

Technologized Images, Technologized Bodies Jeanette Edwards, Penny Harvey and Peter Wade

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2.

Pharmaceutical Witnessing: Drugs for Life in an Era of Direct-to-consumer Advertising Joseph Dumit

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3.

Picturing the Brain Inside, Revealing the Illness Outside: A Comparison of the Different Meanings Attributed to Brain Scans by Scientists and Patients Simon Cohn

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4.

Embodied Brains: Why Science Studies Needs the Anthropology of Museums Anne Lorimer

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5.

Spectacles of Reason: An Ethnography of Indian Gastroenterologists Stefan Ecks

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6.

Technokids? Insulin Pumps Incorporated in Young People’s Bodies and Lives Griet Scheldeman

137

7.

Wearable Augmentations: Imaginaries of the Informed Body Ana Viseu and Lucy Suchman

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8.

‘Embryos Are Our Baby’: Abridging Hope, Body and Nation in Transnational Ova Donation Michal Nahman

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9.

Living Differently in Time: Plasticity, Temporality and Cellular Biotechnologies Hannah Landecker

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Notes on Contributors

237

Index

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List of Figures and Tables

Figures 2.1.

Zoloft Liminality (screen shot from TV)

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4.1.

This is the entrance to the exhibit

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4.2. These starkly monochrome photographed figures and statues run around the exhibit’s back wall 6.1.

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A well-stocked table (photograph by author)

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6.2. Inserting the canula (photograph by author)

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6.3. The pump is attached, ready for use (photograph by author)

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6.4. The pump in its bright red ‘scuba-diving wetsuit’ (photograph by author)

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6.5. William’s drawing (from memory)

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6.6. Callum’s drawing (from memory)

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6.7 and 6.8. In comparison, drawings by two young people for whom the pump ‘did not work’

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7.1.

Bell service technician, 2002 (Photo by Ana Viseu)

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7.2.

Sonica’s wearable computer (Photo by Ana Viseu)

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7.3.

InfoBody’s armband (By permission of Infobody)

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7.4a and 7.4b. General Electric’s Hardiman produced in 1963 (by permission of General Electric); and a full-scale mock-up of an Exoskeleton system being developed by Sarcos Research Corporation (by permission of Sarcos Research Corporation)

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8.1.

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‘Embryos are our baby’ (photo by Michal Nahman)

8.2. UFC Company Logo (by permission)

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8.3. Preferred External Features Form (author’s translation from Hebrew)

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Tables 2.1.

Text of TV Advert for Lilly’s Depression Kit

2.2. Zoloft TV Commercial

39 51

Preface and Acknowledgements

This volume grew out of the Fifth Decennial Conference of the Association of Social Anthropologists of the U.K. and Commonwealth (ASA), which we organized in Manchester in July 2003 on the theme of Anthropology and Science. Our original intention was to publish two, linked volumes with the same publisher or, later, a single large volume. The constraints of today’s publishing climate eventually meant that we published a first volume as part of the Association of Social Anthropologists Monographs series: Anthropology and Science: Epistemologies in Practice (Berg 2007) and now are very pleased to publish this companion volume on technologies, images and bodies. We would like thank all the convenors of the panels at the 2003 Decennial Conference of the Association of Social Anthropologists of the U.K. and Commonwealth (ASA) who, in addition to their notable efforts in arranging an impressive range of panels, and contributing to an exciting and intellectually stimulating event, assisted us with the initial selection of papers for this volume. We are grateful for the financial support for the Conference given by the Wenner-Gren Foundation, the University of Manchester, the British Academy and the ASA. We would like to thank Marion Berghahn and staff at the press for their unstinting enthusiasm for this project; and the anonymous readers of the book proposal and two readers of the manuscript, Rachel Prentice and Natasha Myers, for their helpful and insightful comments. Jeanette Edwards Penny Harvey Peter Wade January 2009

CHAPTER 1 Technologized Images, Technologized Bodies Jeanette Edwards, Penny Harvey and Peter Wade

Introduction As we write the introduction to this volume, the media reports on a dispute between athlete Oscar Pistorius and the International Association of Athletics Federation. Pistorius, whose legs are amputated at the knee, is running on carbon-composite prostheses developed at the Massachusetts Institute of Technology (MIT). In the 2007 South African Senior Track and Field Championships, Pistorius came second in the 400 metres. The Federation is deliberating whether his prostheses gave him an unfair advantage over the able-bodied runners against whom he was competing. The director of the Biomechatronics Group at MIT, Professor Hugh Herr, himself a double amputee, observes that ‘in the next decade we will have artificial legs that are better than human legs for running’. He for one, it is reported, would not swap his prosthetic legs for ‘natural’ ones.1 This is a remarkable example of the contemporary technological capacity not only to enable disenabled bodies but also to enhance them in ways that reconstrue the ‘natural’ body and its limitations. Furthermore, the example comes to light as an ethical dilemma partly because of the ways in which the global media produce sport as spectacle. What kinds of human capacity are we called on to witness? Whose skills and tenacity are on display? What kinds of bodies are we encouraged to admire? Our interest in this volume is to look more closely at the interconnections between technologized bodies and technologized images to ask what light ethnographic work can throw on these contemporary processes of mediation.

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This book explores the relationship between cultural apprehensions of the body, and the ways in which the body is mediated, imaged and imagined, at a time when visualization and communications technologies have combined to provoke new awareness of the body and of the self, new regimes of power and knowledge, new possibilities for the enhancement of human life, and new fears for its degradation and destruction. Our ethnographic explorations of what might be at stake in the current relationships between technologized images and technologized bodies are firmly based in anthropological understandings of social change – attentive to the narratives that have always surrounded the very notion of modernity, and to the complex ways in which such narratives are negotiated, circumvented or reproduced in practice. The shift to digital imaging technologies is a key issue in this lively and densely populated field of debate. Digitalization has rendered images more easily manipulable, less stable and more ubiquitous for they are now far cheaper to reproduce and far easier to doctor. Digitalization also enables diverse data forms to be brought into contact with each other, with the potential for new synergies and points of engagement to emerge between numerical, statistical, photographic, narrative and diagrammatic forms. Contemporary social and physical mapping devices explicitly build on these potentialities (Kain and Baigent 1992; Wood and Fels 1992; Escolar 1997; Pickles 2004; Craib 2004). Beyond our interests, then, in the imaged and the enhanced body, we are also compelled to consider the virtual and the informational body. Computerized digital data produces the informational body through the increasingly routine collection and storage of data such as digital fingerprints, dental records, iris markings and DNA sequences. Networked information systems render the bodies of others accessible at a distance and people increasingly launch versions of themselves into the virtual world of avatars, gaming, dating and socializing via their identities of choice. Smart clothing, electronic tags or biometric data monitor the state of the body, regulating its movements and its health. As might be expected there are social tensions around the transformations that these technologies appear to be propelling. In some accounts the good life is there for the making/taking, producing a flattened world of ‘equal opportunity’. Choice and agency are the core values. Where you have been and where you come from are less important than where you are going, and who you are matters less than who you could be. Any such naïve/cynical optimism is matched by the darker narratives of inequality and exclusion, the experientially immovable forces, institutions and social structures that may not be visible but which certainly render some more equal (and capable of action and choice) than others. Indeed our contemporary investments in and relationships to modern visualization technologies replay the classic hopes and fears that have characterized the dreams and spectres of modernity. But the potential contained in novel assemblages of knowledge, materials and desire give a new twist to the story.

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This collection is a companion volume to Anthropology and Science: Epistemologies in Practice (Edwards, Harvey and Wade 2007), and both stem from the Fifth Decennial Conference of the Association of Social Anthropologists of the U.K. and the Commonwealth (ASA), held at Manchester in 2003. Anthropology and Science also pivots on ways of knowing, but there we place ‘science’ (broadly speaking) in relation to, and in dialogue with, contrasting and overlapping epistemologies and, with fine-grained analysis, contributors to that volume illustrate ways in which competing epistemologies co-exist. This volume continues the theme by looking more specifically at how visualization and communication technologies are implicated in what it is possible to know and in how the body mediates such knowledge. It builds on the premise that seeing and knowing are not separate or separable activities and that one does not precede or pre-empt the other (Grasseni 2007; Hallam and Ingold 2007). Uniting the chapters in this volume is a focus on the body – the body that is enhanced, augmented, diminished or otherwise modified by various technologies, including those that produce images of it which subsequently shape ways in which bodies, body parts and bodily processes are imagined. This at a time when a number of significant social theorists have identified what amounts to an epochal change in the ways in which ‘western’ subjectivity, personhood and being-in-the-world are understood. The change is partly related to major developments in the biological and informational sciences, and has been dated more or less to the middle of the twentieth century. Without implying links of causality, the following are just some of the developments identified as impacting on the way in which human life and being are conceptualized: developments in ‘new genetics’ (Rabinow 1996), the increasing ability of biomedical science to intervene at the molecular level (Rose 2007) and the emergence of a synthetic biology, which draws together biological disciplines previously distinct and entails a re-organization of the biological sciences in the universities forging new research collaborations and interdisciplinarities (Pickstone 2000; Wilson and Pickstone 2007). Paul Rabinow, for example, predicted that the new genetics would ‘prove to be an infinitely greater force for reshaping society and life than … the revolution in physics’ (Rabinow 1992: 241). Nikolas Rose has demonstrated a shift of attention from the molar to the molecular level: ‘It is now at the molecular level that human life is understood, at the molecular level that its processes can be anatomized, and at the molecular level that life can now be engineered’ (Rose 2007: 4). Manipulation at the molecular level allows new bodily configurations or ‘emergent forms of life’ to appear and circulate and, for Rose, entails new understandings of ‘life itself’. Similarly, Nigel Thrift sees radical change in the ‘background of being’ as technology enters the interstices of everyday life and augments – in his term ‘boosts’ – ‘bare life’ (Thrift 2005; see also Agamben 1998).2 Social theorists, then, from

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a range of disciplinary perspectives, argue that attention and intervention at the micro-level of ‘life’ marks the current era, and that the synthetic possibilities afforded by the entanglement of the various biological sciences and informatics produces a powerful sense of flux, with configurations and assemblages that are unsettled and, from many perspectives, unsettling. Alongside attention and intervention at the micro-biological level, there is also increasing intervention at the micro-public level. A range of technologies are deployed to make public life more visible and thus more amenable to audit and accountability (see, for example, contributors to Strathern 2000). If we focus specifically for a moment on the U.K., transparency is still in vogue: public institutions such as the national health service (NHS), education at all levels, local and national governmental organizations, as well as non-governmental organizations (NGOs), are all privy to regimes of accountability which demand transparency and openness via the input of their publics through consultation. Public institutions are compelled to manage knowledge about their publics (Harvey and Knox 2007) and interdisciplinarity is promoted as a way to make knowledge more ‘social’ and curb the excesses of either the individual researcher (Corsín-Jiménez 2007) or the out-of-touch public servant (Born 2007). Of interest here is the way in which the micro-management of knowledge and the processes through which the relations that inhere in ‘things’ are made explicit appear as key features of current political and scientific domains.3 Just as in responses to the ubiquity of digital imaging technologies mentioned above, developments in biotechnology are seen either to presage (global) business as usual, entrenching familiar inequalities, or to offer the possibility of transcending and destabilizing traditional hierarchies of, for example, expertise and value (e.g., Haraway 1997; Jackson 2002; see also Edwards 2005). But while we can point to evidence that backs both of these responses and while individual scholars may lean towards one or the other, neither is the starting point for this collection. Instead its commitment is to ethnography, and the ethnographic examples presented here both disrupt and instantiate the social theory that has been influential and informative to our understanding of contemporary social worlds mediated, formulated and, on occasion, fixed (albeit temporarily) by visual technologies.

Vision and the Body 1: The Emergence of the Modern Subject 4 Since Michel Foucault published The Order of Things in 1966 (1973), there has been a widespread recognition that the regime of knowledge which characterizes the contemporary natural, physical and social sciences is a

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historically specific configuration, tied to broader social and cultural bases for engaging with the world.5 Some of the most compelling work to expand our understanding of how the enlightenment period was the point of emergence for these contemporary knowledge formations has drawn its insights from an analysis of how changes in visualization practices were integral to this shift. The Order of Things itself starts with an analysis of Velázquez’s painting ‘Las Meninas’, and illustrates the emergence of new ways of seeing, or a shift in ‘scopic regime’ (Crary 1990; Brennan and Jay 1996).6 The shift had profound implications in relation to the history of the emergence of the modern subject, and fundamental concepts such as the externalization of ‘nature’ as something upon which Man now saw himself as able to act and to transform, and the distinction between observer and observed that underpins the experimental practices of modern science. Barbara Stafford (1999) argues that the Western aesthetic imagination saw a move from an analogical mode of representation, whereby painting was an attempt to describe a world in which the physical and the spiritual were interrelated and at one with each other – being two aspects of the broader cosmos – to a contemporary, allegorical imagination which works through separations and categorizations so that, for example, man and nature are made to occupy distinct realms.7 Francesco Panese (2006) takes similar insights about the analogical nature of pre-Enlightenment thought into the field of science to show how the invention of modern science (and the modern subject) was effected through a transformation in ways of looking and seeing which were implicated in the emergence of what he calls, after Shapin (1994), a new ‘regime of credibility’ (Panese 2006: 85). Late fifteenth-century texts describing the natural world tended to combine ‘empirical fact, practical magic and alchemy, secrets and folk knowledge’ (Panese 2006: 68, emphasis in original) into their imagery, but this mixing of genre was soon replaced by an organization of nature according to classifications of class or species. Scientific illustrations that had previously presented images of fantastical creatures now started to depict bodies as separable into constituent parts that could be categorized and hierarchized according to a universal scientific/analytic logic. Subsequent shifts in representational possibilities have been well charted, including the emergence of pictorial realism (Baxandall 1972; Snyder 1980; Alpers 1983), the place of form and its dissolution in avant-garde art (Bois and Krauss 1997), the implications of the emergence of photography (Benjamin 1936) and, more recently, digital photography (Lury 1998; Kember 1998) on the visual imagination. These insights have come alongside writings on the historical specificities of instruments of expert knowing and their capacity to generate politically powerful visibilities.8 At each step, these writings, whether about the production of art objects, new media forms or tools of governance, tell us that the problem of modern

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knowledge in any historical era has been provoked by and encapsulated in the technical and conceptual challenges of new kinds of visualization (Poovey 1998; Daston and Galison 2007). Photographic technologies have been central to the exploration of the diverse ‘scopic regimes’ ( Jay 1988) that characterized modern fascination with the visual.9 The history of photography is powerfully illustrative of the debates that have surrounded image-making practices, and the social uses to which such images have been put in the twentieth century. For many, photography is a direct extension of previous visualization technologies such as eye-glasses, magnifying glasses, microscopes and telescopes, whose fundamental importance to the history of vision has been in relation to their capacity to reveal that which is otherwise invisible to the eye, or to produce images from otherwise inaccessible places (outer space, under the oceans, exotic locations, underground, inside the body). Photography also allows the leisurely contemplation of movement at speed, allows people to see in the dark, and to witness, as if at first hand, dangerous events (war, pornography, sport) or otherwise inaccessible people, places, events. In the documentary tradition, then, photography has established image-making as an exploration of the world, an exploration that does not necessarily carry a transformational agenda, but simply allows people better to appreciate and/or control ‘reality’ through the extended possibilities of vision. The extension of human vision produced a new sense of documentary practice that brought together the exploration of the previously inaccessible with a new fascination with the everyday. However while photographic observation has afforded access to previously inaccessible and/or unexamined ‘realities’, the documentary project has also been taken up as a transformational social practice, seeking to reveal the social world with a view to changing it. In their diverse ways the avant-garde movements, social realists and street-photographers have all engaged in projects of social intervention and in this respect have been perfectly in tune with the on-going elaboration of modern science and technology as an alliance to change the world. Modernity was underwritten by regimes of technological transformation and improvement – a transformative project in which the new photography was enlisted from the start in the spirit of the documentary tradition that could be used (i) to provoke the desire for change through a politics of revelation and (ii) to accumulate better, more disinterested knowledge through a politics of objectivity that challenged the flawed and value-laden observations of human observers. As Timothy Mitchell (1988) has shown, underlying such a politics of objectivity was a Western understanding that the world was divided into a realm of representation (image) and a realm of reality (original) and this distinction also corresponded to a division of the world into the West and

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non-West. His observations are on the particular regimes and methods of truth and order that allowed for the world exhibitions of nineteenth-century Europe which exhibited both the colonized and Europe’s capacity to colonize. He notes the similarity between the writer and the photographer. Both intended to grasp the world as if it were an exhibition and both from a place set apart. The photographer, hidden by the black cloth and viewing the world through the camera lens, typified the ideal European presence in the Middle East, whether tourist, travel-writer or colonial worker. ‘[L]ike the authorities in the Panopticon, one could see and yet not be seen’ (Mitchell 1988: 24).10 Foucault is clearly influential here and remains key to our understanding of the emergence of modern disciplinary mechanisms of control and surveillance, which include the Panopticon to which Mitchell refers. In The Birth of the Clinic (1973), Foucault also shows how the increasing ability to plunge into the inner recesses of the body, through dissection and on the operating table, is integral to the production of a unified clinical subject. Here the move is from surface to depth. And, as in Discipline and Punish: The Birth of the Prison (1977), his interest is in the relations of power and authority that underpinned the apprehension of ‘difference’ and of ‘visibility’ – relations that have been well documented in relation to colonial politics of vision. Another key text which begins to unravel the implications of visuality in early colonial operations is Mary Louise Pratt’s book on eighteenth- and nineteenth-century travel writing. The ‘civilizing mission’ as well as ‘the improving eye’ are central themes in her work. She is interested in how travellers and writers ‘produced’ particular visions of the world outside Europe which supported and legitimated the economic expansion of empire as well as reflecting back on its European readership a sense of its own distinctiveness and superiority. With the idioms of ‘civilizing’ and ‘improving’, Northern Europeans produced other people (for themselves) as ‘natives’, ‘reductive [and] incomplete’ and in need of ‘the rationalized exploitation that Europeans bring’ (Pratt 1992: 152). The ‘improving eye’ saw habitats and inhabitants as ‘empty’ and in need of improvement. Pratt draws out the essentializing discourse of those who come to ‘see’ as well as the insidious classificatory exercise of placing those ‘seen’ in one of Linnaeus’s six varieties of homo sapiens, or in one of a rank of castes defined by parentage and skin colour. Running through the travel writing analysed by Pratt is what she identifies as a ‘relation of mastery predicated between the seer and seen’ (Pratt 1992: 204, original emphasis). The power ‘to see’ and the position of ‘being seen’ are not simply separated out in relations of authority in the modern visual regimes, they are also and simultaneously gendered and racialized. The role of authoritative (and scientific) images in projects of classification and control emerges very clearly by looking at visualizations of race. Early

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colonial visual representations of race, while they sometimes portrayed European’s racialized ‘others’ – such as native Americans – as phenotypically very similar to Europeans (Pagden 1982; Poole 1997), nevertheless displayed them in subordinate positions, linked to ‘barbarism’ (such as cannibal acts) and associated with the realm of (uncivilized) nature. By the nineteenth century, a more explicit concern with superficial phenotypical appearance – which came to be expressed in new technologies of photography, whether in the style of studio postcard portraits or laboratory anthropometric profiles – paralleled a growing concern with underlying anatomy, pursued in the laboratory by measuring skulls and bones (Stocking 1982). Deborah Poole (1997) argues that the multiple reproduction of images allowed by photography fitted into a stochastic concept of type. Racial type, seen as an underlying structure, was thought to express itself in the diverse individual bodies – and photographs – that were variants of the typological norm for a given ‘race’ (Stepan 1982: 93). Visual images such as photographs and drawings of skulls, with and without fleshy faces, provided enhanced access to data and evidence of racial hierarchy. Affinities between the retreat of scientific racism in the early and middle twentieth century and burgeoning visual technologies of film and photograph are harder to trace – although Anne Lorimer’s chapter in this volume argues that the Chicago Museum of Science and Industry’s 1989 ‘Brain Exhibit’ tapped into anti-racism (or at least race transcendence) with its focus on the disembodied mind/brain. These powerful depictions of external worlds required both the abstraction and generalization of particular realities, and the crafting of the visual representation. As Rose (2007) notes, the crafting of the image has always been an interdisciplinary practice, relying on a combination of technical, literary and social skills. The ‘objectivity’ will be successful where the framing devices ensure the appropriate distinctions between subject and object, identifying an enduring/stable state of affairs (nature) which can subsequently be acted upon and improved (Mitchell 1988; Pratt 1992; Jordanova 1999). One of the great contributions of contemporary science studies has been to show the work involved in achieving this stability, revealing the relations of authority through which expertise and objectivity are established. Documentary and imaginative traditions have always gone hand in hand as politicians, philosophers and scientists envisioned new social arrangement in relation to the specific imaginings of the social configurations they sought to transform. Shapin and Shaffer (1985), for example, discuss the dispute between Hobbes and Boyle over the reliability of the eye, which at a deeper level was a discussion about the separation of expert knowledge from opinion. In Boyle’s view the capacity of experiments to yield ‘matters of fact’ depended not only upon their actual performance but essentially upon the

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assurance of the relevant community that they had been so performed. Witnessing had to be a collective act, and experiments thus had to be performed in social spaces, at that time the Royal Society’s Assembly Rooms (the notion of the operating ‘theatre’ dates from this time). Witnesses also had to be credible, morally as well as in relation to their own expert, scientific formation. Gradually there was a move to other techniques of witnessing to the point where, in the contemporary world, peer-review in expert journals obviates the need for direct witnessing, and scrutiny is focused instead on the ‘inscriptions’ (including but not limited to written texts, graphs, diagrams and photographs) produced by scientists in the course of their experimental work (Latour and Woolgar 1979; Latour 1987). In the field of science studies, the place of visualization technologies is thus central to the theorization of how scientific truths come to be produced. Indeed Lynch has argued: ‘it might be said that an attention to the practices and documents through which researchers visualize phenomena is a way to gain a perspective on the whole field of scientific practice instead of singling out a particular aspect or phase of it’ (2006: 27).11 The histories of the ways in which objectivity is crafted and facts stabilized and/or given social purchase have become one of the central intellectual projects of science studies, establishing that objectivity is grounded in intersubjectivity – in relation to both the production and the validation of knowledge forms. Scientific illustrations were originally produced by artists, who worked to particular conventions both about what could be seen and how it should be depicted. Svetlana Alpers (1983) has shown how seventeenth-century Dutch painting developed in parallel with English empiricist science, both drawing on the assumption that the basis for certain knowledge was to be found in the project of bearing witness to nature, that is in the attempt to mirror nature through art. This realist project was based in craft techniques which developed and changed over the centuries. However, making something appear life-like whether in the laboratory, artist studio or taxidermist’s workshop (Haraway 1989) always required a combination of technical, literary and social skills (Daston and Galison 2007). This focus on the crafting of knowledge has led science studies scholars to focus on the social and cultural conditions of image production, rather than approaching visualizations as texts from which meanings can be derived through semiotic analysis.12 One effect of this interest in the materiality of image production has been to highlight the technological dimensions of the visualization process, and the investments made in such technologies by those seeking a more stable, reliable and extensive ‘mechanical’ objectivity (Daston and Galison 1992).

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Vision and the Body 2: Problems with the Modern Subject The ‘change’ that has been identified between modern and post-modern regimes of truth relates to the increasing awareness of the instability of ‘nature’ and of the contingency (and cultural specificity) of the ‘modern settlement’ (Latour 1993). Such awareness provoked the two divergent positions which characterized the so-called ‘science wars’ in which ‘scientists’ and ‘critical theorists’ battled over the status of the scientific object and the scientific fact.13 In the fallout from the ‘science wars’ we can discern two countervailing forces. On the one hand, a push for more robust, reliable and more extensively machinic objectivity – and reasoning capacity – with a move to metrics, and increased (political/scientific) investment in technological instrumentation. On the other hand, a questioning of the value of ‘objectivity’ and a call for the recognition of the inherent relationality of knowledge production (including the sociality of the non-human world) – and of the value or utility of relational knowledge (with an attendant recognition that the sociality of knowledge production does not render such ‘knowledge’ worthless). These two positions exist in political tension around questions of ‘utility’ and ‘authority’ and bring a new chapter to the story of visual regimes and the emergent modern subject. Indeed analyses which posit ‘the clinical’ or ‘the medical gaze’ (Foucault 1973), ‘the master gaze’ (Pollock 1988), ‘infinite vision’ (Kember 1998) and so forth seem to be at odds with the crumbling of certainties, the technological failures and the questioning of ‘science’ that characterized the end of the twentieth century. Views from contemporary science studies that reveal the competing and jostling authorities within the world of ‘science’ appear to belie a homogeneous ‘god-like’ perspective, or ‘a view from nowhere’ (e.g. Fujimura 1996; Knorr-Cetina 1999; Mol 2002). Post-modernism is, however, vulnerable to its own limits – particularly with respect to the difficulties of theorizing power and fully engaging the social significance of diverse scopic regimes. ‘The gaze’ has always been an analytic concept that acknowledges power – and it is clearly precipitous to dance on the grave of the ‘god-trick’: the trick of ‘transcendent, disembodied vision’ or ‘seeing everything from nowhere’ (Kember 2003, after Haraway 1991). Institutional capacities for seeing without being seen are greatly enhanced by networked information technologies – the CCTV camera, store cards that track purchases and desires, the mining of internet data and tracking by cookies, biometric information at borders and even in school dinner queues. Contemporary informational structures of surveillance also introduce new sites for manoeuvre (i) in their contingent effects, (ii) in their complexity that renders centralization pragmatically unlikely and (iii) in the requirements for compatibility across domains which leads to the sidelining or indifference towards (and subsequent invisibility of) huge areas of

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everyday life. The ‘god-trick’ is still being played and, in particular institutionalized settings, capacities for control are greatly enhanced, but ‘god’ through these systems is also strangely disconnected from all those areas of practice that the systems fail to encompass. Post-modern sensibilities have also re-introduced the body of the observer: ‘the body returns to dethrone the disinterested gaze of the disincarnated Cartesian observer’ ( Jay 1988). Also, a re-discovery of visual fluidity, haptic vision and the baroque fascination with the intrinsic opacity of the visible, has displaced the singular, transcendent and stable gaze of the prototypical modern observer. In addition, Actor Network Theory has provided analytical tools for considering how objects elicit attention, while the influence of psychoanalytical theory can be seen in renewed interest in the reciprocity of vision. The way in which Foucault posits a somewhat singular subject position has been challenged with the demotion of technique and technology to one amongst other actors which might include, for example, persons (differently positioned), bodies (parts and processes) and diseases. Thus, Annemarie Mol (2002) shows how a disease object, in this case atherosclerosis, is constituted in different ways by diverse means. Her focus is on how the disease is performed, in her term ‘enacted’, by the various social and material practices in the clinic and the laboratory. Measuring the thickness of an artery wall by x-ray or the velocity of blood by ultrasound (two visualising technologies), or dissecting an affected limb in the pathology lab, or recording the patient’s experience of pain and restricted mobility, each enact different versions of the disease. For Mol, this indicates an ontological multiplicity where ‘no object, no body, no disease, is singular’ and ‘reality is multiple’ (2002: 6), but where a coherence is achieved (albeit fragile) between different versions through clinical and administrative effort. Hannah Landecker, in this volume, provides a compelling example of the internal diversity of ‘science’, which curbs the tendency to lump together under the rubric of ‘science’ or ‘biomedicine’ diverse practices, materials, institutional arrangements and social relations. Her chapter reveals the overlapping and diverging practices and preoccupations of molecular biologists and biochemists, colloquially divided into ‘plant people’ and ‘animal people’ and cross-divided, by analogy, into ‘gardeners’ or ‘shoppers’ depending on how they source their cell lines. Other authors have challenged the idea of a totalizing vision or an allencompassing surveillance. Lisa Cartwright (1995) draws on Foucault’s analysis of the emergence of biology and ‘life’ in the shift from eighteenthcentury natural history to nineteenth-century biology (which entailed a change in the relationship between representation and ‘thing’) in her analysis of the marriage of modernist art and modernist science at the beginning of the twentieth century. She shows how developments in radiography and the

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use of X-ray images and of medical film also shaped and built the ‘life’ they were used to study. For Cartwright, ‘twentieth-century medicine does not so much “flay” the body as it does away with the distinctions of interior/exterior or object/ground’ (1995: xiv). This has a flattening effect, which we have reason to return to below in the context of contemporary brain imaging technologies. Cartwright’s examples include harrowing film (from the viewpoint of twenty-first-century sensibilities) of the gait and demeanour of people suffering various mental disorders (shot between 1918 and 1948) and of patients suffering epileptic seizures (the New York Epilepsy Biographies, 1905). She charts the emergence of both ‘surveillant cinema’ and a ‘profilmic body’. Running uncompromisingly through her commentary is the relationship between knowledge, desire and ‘the place of death, life, and pleasure in the medical gaze’ (1995: xiv). Her interest is in the kind of body shaped by particular modes of visualization and methods of surveillance and in the work required to stabilize it for ‘professional’ and/or other purposes. Yet surveillance, in Cartwright’s examples, is neither total nor evenly enacted and while cinema and X-ray functioned to shape and build the ‘life’ they studied, they also revealed the ‘uncontrollable’: X-rays in their destructive potential and film in the portrayal of bodies that could not be stilled. Cartwright concludes her account by acknowledging that a less totalizing condemning story could have been told which would have included diverse medical ‘cultures’ and subjugated histories of ‘those who were the objects’ of the surveillant gaze. Similar possibilities are suggested (although subsequently rejected) by Pratt (1992) in her exploration of ‘reciprocal vision’ within the terrain of the racialized and gendered colonial gaze, mentioned above. Commenting on the writing of Anna Maria Falconbridge, whose account of a trip to Sierra Leone was published in 1802, Pratt writes: ‘As a woman she is not to see but be seen, or at least she is not to be seen seeing’ (1992: 104). This entails the lowering of the eye, the side glance, the looking without seeming to. Mungo Park, by contrast, travelling in the Niger basin between 1796 and 1797, ‘affirms plausible worlds of African agency and experience’ (Pratt 1992: 84). His narrative is an account of reciprocity between himself and those he meets along the way: reciprocity not only in material goods but also in knowledge and vision. He offers himself up for scrutiny and portrays himself as the object of seeing. But, as Pratt notes, ‘reciprocity has always been capitalism’s ideology of itself’ (1992: 84). And ultimately, ‘[t]hrough his anticonquest, Park acts out the values that underwrote the greatest nonreciprocal non-exchange of all time: the Civilizing Mission’ (1992: 85). Pluralism and reciprocity had, by the late twentieth century, become commonplace in discourses around race, but the increased malleability and culturalization of race continued to exist in tension with reiterations of

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hierarchy and power. Visual technologies were giving rise to the possibility of manipulating racialized imagery to create, for example, blackened representations of Queen Elizabeth II (Lury 2000) and the creation of a new ‘Eve’, a computer-generated female face, morphed out of fourteen phenotypically (read ‘racially’) diverse ancestral faces and displayed on the cover of Time magazine in 1993 as the future face of America. The images of the new Eve have been criticized as, at one level, reproducing stock notions of racial types as seen in the ancestral faces, and, at another, homogenizing diversity into the bland, whitened face of Eve (Hammond 1997; Haraway 1997). These critiques already alert us to underlying reiterations of racial hierarchy. But it is also clear that these digital visualizations fit squarely with (popular and academic) ideas of race as culture, race as re-writeable, DNA as recombinant and racial identity as constructed, at least in part, through performance and consumption. These images seemed to provide hard visual evidence of the new malleability of race (however much that was disavowed by the operations of the market place and the criminal justice system). They also envisioned new futures: some (Eve) held out the promise of a future without race, while others (the black Queen) projected a transformation in the imagination of the nation. True to the transnational circulation of these images and their resonance in supra-national regimes of meaning and knowledge, the images invoke pasts and futures of migration: the picture of Eve was produced in a special issue of Time focusing on immigration, while the picture of the black Queen makes obvious reference to Britain’s colonial past and current postcolonial diversity. As Michal Nahman argues (this volume), ‘the national body is made transnationally’, whether by importing ova from a transnational circuit of gametes or allowing adult working bodies into the country: in both cases, the appearance of cosmopolitanism is belied by the reproduction in practice of national chauvinism and racism. In contrast to the perhaps utopian, or at least partial, interpretations of race purveyed in some visualizations, the advent of DNA testing has given a new lease of life to racial profiling in criminal justice systems – until recently the province of forensic anthropologists working on anatomical remains (Duster 2002, 2003). DNA testing does not now work with simple visual matching techniques, but there are strong affinities with visualization technologies, born of notions of ‘mapping’ DNA (Haraway 1997), of the imaginative link between fingerprinting and DNA matching and of the clear association of such technologies with new forms of biometric data gathering, which codes for phenotypical traits such as iris patterns. With DNA racial profiling, as with older racial typologies, a link is established between the visible surface (phenotype) and the hidden interior (genotype) and between unique individuality (a given DNA sequence) and generic types (sample populations with specific genetic traits, labelled as, say, Afro-Caribbean or

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Caucasian). With biometric data gathering, as yet incipient, the process is different and yet parallel: a unique individual visible iris pattern is linked to other personal, less visible, but nevertheless categorical characteristics, such as national origin, by means of integrating different databases. Vision, technology and science have also been closely entangled in histories of gender differentiation. Thomas Laqueur’s argument about the emergence of an oppositional, binary division between male and female, out of a prior ‘one-sex’ model in which women’s bodies were seen as an outsidein version of the same basic anatomy as men’s inside-out arrangement, is laden with visualizations, underwritten by anatomical investigations (Laqueur 1990). Anne Fausto-Sterling (2000) shows how visual images of the brain – using measurements performed on slices of the brain to define the apparently vital corpus collosum – are an important means for neurobiologists trying to create a clear differentiation between hypothetically male and female forms of this piece of brain tissue. The twodimensional appearance of the slices worked to simplify the complex threedimensional nature of brain connectedness, but even then a great deal of work was necessary to make the data give up the sought-after interpretation. Rose (2007) presents an example from a more open (less overtly racialized or gendered) realm of bio-medical practice. A shift to biomedical manipulation at the molecular level has relied on images, including DNA sequences and PET scans. Writing of the mind, Rose points out that during the nineteenth-century emergence of clinical medicine which looked for disorder inside bodies, mental medicine confined itself to the surface of the body – it assessed disorder through posture and pallor, gestures and demeanours. Freud (and Kraeplin working in Germany) presaged a move away from the eye to interpretation, relying as he did on talk. The mind could not be seen but only interpreted, and psychiatry, through the first half of the twentieth century, focused predominantly on the psychological space between the organic brain and behaviour which could be tapped via the talk of the patient and the interpretation of the psychiatrist. With developments in neuroanatomy the brain and its activity have been ‘opened up to the eye of the doctor’ (Rose 2007: 196) and not only mental illness but also desire, anxiety, depression and so on can now be ‘seen’ in brain activity. ‘When mind seems visible within the brain, the space between person and organs flattens out – mind is what the brain does’ (Rose 2007: 198). In the reading of the brain scan, the interpretation is fused with the image and the image becomes the brain. This is a similar effect to that described two decades ago by Rosalind Petchetsky (1987) who analysed the anti-abortion film The Silent Scream. Here the interpretation of the ultrasound image was fused with the image and the image became ‘the baby’. The chapter by Simon Cohn in this volume addresses the way in which images of the brain confer authority and are used by a range of actors as

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evidence of particular disorder. Cohn argues that the image itself changes the nature and quality of the illness, but he avoids an over-determined and crude polarization between scientific and lay understanding. While the reality of the image is not the same for the clinician as it is for the patient, Cohn’s analysis questions the familiar but problematic contrast between scientists who biologize, medicalize and otherwise reduce disorder, and non-scientists who complicate, complexify and otherwise mobilize more creative causal and explanatory models. In his ethnographic example there is evidence of scientific complexity and lay reductionism, and he argues that it is a mistake to automatically assume that novel biomedical technologies are axiomatically reductionist – why should what is considered to be significant necessarily be ‘considered primary or elemental qualities of the body’ (this volume)? In Cohn’s account, it is the patient who carries the image away from its place of origin (the lab) and puts it to work in ways which reduce the complexity of mental illness by locating it in specific areas of the brain. The image is used as evidence of a simpler truth about the cause and aetiology of a person’s suffering than more messy and subjective assessments of behaviour. But the twist in the tale is that the image fails to convince those that matter: those that, together with the patient, co-define the mental illness in the context of their quotidian social interactions. Ultimately the brain scan fails to convert the disorder from a moral to a biological disease as the sufferer had initially hoped. Indeed, as the brain scan travels further away from the imaging laboratory, to the hospital ward and GP’s surgery, for example, it will increasingly be seen as an image of the ‘real thing’ and will increasingly become disengaged from the social and moral aetiologies of mental illness produced in social interaction. Cohn’s account provides texture to what can at times appear as over-determined social scientific arguments which suggest a homogenous science and a generic scientist. Moreover, his work, amongst others, shows it is equally reductionist to consider biology as always deterministic and the social as always free.

Vision and the Body 3: Plurality and Expertise The shifting awareness of the complexity of visual regimes outlined above played through the documentary disciplines in different ways. In anthropology, there was a sustained challenge to ethnography in the 1980s, which came to a head with the publication of Writing Culture in 1986 (Clifford and Marcus 1986), but which was prefigured by a critique of visualism (Fabian 1983), calls to ‘demystify fieldwork’ (Marcus and Cushman 1982) and a critique of the ‘representational distance’ integral to the colonial project (Mitchell 1988). There was a focus on ethnography as text and the changing relationships (historically) in ethnography between

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author, reader and subject which led to a heated debate on ‘persuasive fictions’ (Clifford 1983; Clifford and Marcus 1986; Strathern 1987b). A second challenge to ethnography came in the wake of this with the pervasive awareness of relational knowledge and the exploration of new collaborative possibilities (both inter-disciplinary and between diverse expertise); both were linked to the recovery of the project of imaginative futures alongside that of documentation. These moves in anthropology parallel Rose’s project of not simply revealing the contingency – the artifactual basis of ‘reality’ – but to look also at the modes of collaboration (reciprocal vision) and the forms of assemblage that could have been otherwise. The task is to open different ways forward, and to document what is/was attuned to the imagination. One strand of this endeavour is to pick away at the enduring self-evidence of the visual (i) in relation to specific aesthetic choices and what they enabled and disabled and (ii) in relation to the ‘separation/segmentation’ of vision from the wider range of human sensibility in the training of the expert viewer.

Aesthetic Choices in the Crafting of the Object Sarah Kember invokes Mitchell’s reference to the ‘smug apartheid’ (Mitchell 1992: 16) between objective scientific photographic discourse and subjective artistic discourse, and notes that there has always been leakage between these traditions. STS has been interested in how these divisions are created, how they operate and fold in on each other. The boundaries are more overtly open in the current era of digital manipulation where techniques of sampling, scanning and electro-bricolage are commonplace, where realistic images can simulate reality through the manipulation of digital code, where the object world is now not simply mutable but totally malleable, marking the realization of subjects’ desires and imaginations as strongly as it marks an exterior world on which much high-tech visualization work also focuses its quest for objective truths (Kember 1998: 22). Lynch and Edgerton (1992) look at the processes by which photographic images produced by astronomers are manipulated to produce particular kinds of aesthetic and scientific effects. Light and colour are manipulated, and ‘noise’ is extracted to allow significant aspects of the image to become more visible, with the effect that the final product is far from an objective copy of the stellar bodies represented. Yet despite these manipulative and qualitative practices, which scientists themselves fully acknowledge to be an important part of their craft, belief in the objectivity of a science which communicates its knowledge through visual media remains a central aspect of its claims to knowledge and power. To understand how this might be requires that we combine an analysis of the sites where science is performed,

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with broader understandings of social and cultural knowledge practices that we outlined in the previous section. Joe Dumit (2004) is interested in the ways in which brain scans operate as resources of ambiguity, opening up the possibility of exploring how visualizations operate as ‘boundary objects’ in the complex communicational fields of intersecting expertise and interest that characterizes the broad field of neuroscience. He is interested in how PET (positron emission tomography) scans function in the world: how they are ‘desired, laboriously generated, selected, captioned, published, read, interpreted, argued over, referred to and forgotten’ (Dumit 2004: 10–11). He explores the implications of choosing to visualize data in images of the brain in different colours. Colour coding is arbitrary and different laboratories have different colouring conventions, but a reading can be radically altered by the choice of palette. Following his interviewees’ lead, Dumit calls these ‘pseudo-colours’ because they do not correspond to ‘real colours’ of the brain. Nevertheless, the boundaries between colours which mark different brain activity create the illusion of discrete areas of the brain. The colouring of brain activity creates the impression of bounded, discrete and monofunctional areas of the brain. Donna Haraway (1997) makes a similar point in her discussion of map-making. Maps (whether of land, people, resources, genes) readily turn processes into ‘nontropic real, literal things inside containers’ (Haraway 1997: 136). She rails against the technocratic fetishist who sees maps as purely technical and representational. Turning to the mapping of genes, she argues that it is ‘a particular kind of spatialization of the body’. Anne Lorimer’s chapter in this volume furthers our discussion of aesthetic choice in the crafting of objects by looking at the designers, materiality and media of a museum exhibit ‘Learning and Learning Disabilities: Explorations of the Human Brain’. She disentangles the elements that provoked a reading of a museum exhibition that was neither intended nor foreseen by ‘the scientists behind the exhibition’. Lorimer shows how the choice of materials – the actual media of the exhibit – as well as their physical crafting by artisans were implicated in the message conveyed. In this case white plaster mannequins and a photographic mural featuring persons dressed and painted in white, lent a ghostly atmosphere which, while aesthetically pleasing to the designers and artists, was disconcerting for the scientists. A biomedical imaging technology that has received much attention, particularly from feminist perspectives, is foetal imaging. A number of scholars have analysed and commented upon the early images of the foetus which were produced by Nielson and published with much fanfare in Life and Time magazines in the early 1960s. These images showed the foetus as solitary, dangling in the air, and captioned as ‘the baby’ and as ‘he’ (Duden

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and Hoinacki 1993; Stabile 1994). It was argued that, from the start, the images represented the foetus as primary and autonomous and the woman as peripheral or absent. Such analyses were important in revealing what was, in effect, coded in the image, and the focus was on the image per se as both representation and aesthetic object. These early analyses were less interested in how the image travelled, accrued meaning or generally engaged audiences differently. Carole Stabile (1994), for example, draws the reader’s attention to the way in which the image of the isolated foetus ‘looks’ like an astronaut or extraterrestrial, free-floating in space and vulnerable. Although the focus of much of this work was on the erasure of women, the early images of the foetus which circulated widely were clearly moulded by cognate political and cultural events and joined the ranks of other ubiquitous images of the era, including floating astronauts and Neil Armstrong’s first steps on the moon; like them, the foetal images became aesthetic icons. By 1990, with developments in electron microscopy, images of the foetus at seven weeks, the embryo at three and half weeks and the blastocyst two hours after fertilization, joined the ranks of the ubiquitous foetal-astronaut, but now there was no background, no amniotic sac, no placenta, no woman. For Stabile (1994), this gave an unprecedented means of showing images that separated wombs from women and foetuses from wombs. The history of art is likewise littered with the figure of the dismembered, fetishized, silenced and passive woman (Pollock 1988). While for Stabile the woman had been ‘shot through’ and for Duden and Hoinacki ‘erased’, we might also see her as invisibly present. From the glossy and ethereal images produced by Nielson and colleagues, feminist scholars turned their attention to the foetal images created routinely through ultrasound scans in biomedical prenatal care regimes, which can also become aesthetic objects in public and private domains of social life. Although from various professional perspectives the scans were perceived to encourage ‘bonding’ between mother and child (again picking up on the zeitgeist of the time), it was argued that they displaced women’s own knowledge of pregnancy. So while ‘quickening’ was once accepted as a guide to the progress of the pregnancy, now more ‘objective’ (and thus supposedly more accurate) data were to be seen on the screen. Furthermore, in consultation the doctor needed only to refer to the evidence provided by the technology rather than rely on the experience of the pregnant woman. Analytically these observations have often been placed within the wider problematic of ‘men attempting to control women’s bodies’ and specifically their reproductive capacities – what Kember (1998) refers to as ‘masculinist’ science’s attempt to ‘father itself’. For her, the ability of medicine to ‘simulate, capture and seemingly re-create the human body in cyberspace’ is another facet of this ‘autonomous reproduction’ (Kember 1998: 78). Important as these studies are in providing concepts with which ethnographic detail can engage,

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such readings do not always allow for an appreciation of the shades of difference and similarity between and amongst ‘medics’ and ‘patients’. When anthropologists have turned their attention to foetal images they have tended to focus more on their social lives: less, that is, on the image per se and more on the social relationships they reveal, congeal and mobilize (see for example Georges 1997; Mitchell and Georges 1998; Rapp 1999).14 Inevitably, perhaps, the universality implied in feminist analysis is punctured in ethnographic comparison (an aspect of the ‘awkward relationship’ that Strathern [1987a] described so well). Rayna Rapp’s fieldwork in New York ante-natal clinics stands out here (Rapp 1999). Her account embraces the perspectives of different actors without pitching them against each other, at the same time as showing how ‘choice’ and decisions following ultrasound scans are dependent on more than either the image itself or its interpretation. Rapp shows how the wider social relationships in which pregnant women are embedded, including those of kinship and community, as well as their own reproductive histories and the social and economic conditions in which they live, shape the way in which the foetal image is ‘seen’, interpreted and acted upon. Taking the idea of the social life of the image further, both Cohn and Lorimer (this volume) draw inspiration from Arjun Appadurai’s (1986) collection on the social life of things. Cohn analyses the way in which images of the brain travel and accrue meanings in different settings. Like the foetal image mentioned above, it is the social life of the brain scan, as an aesthetic object reproduced on T-shirts and tablemats, sitting on mantelpieces and carried in pockets and wallets, that draws our attention. Lorimer focuses on the lives of the media and the ‘production stream’ or ‘commodity chain’ along which the production of meaning flows. Recent ethnographic work combines the debates about images as crafted representations of reality with an interest in the image as a point of assemblage with particular communicative and transformational capacity. As we have seen, a number of scholars have explored the complex fields of power and precision as well as expertise and trust, which have surrounded the production and interpretation of brain images. These are cutting-edge, high-tech visualizations that seem to promise a clarity of form that will enhance the understandings of both the expert professional and the patient, and transform their capacity for action in relation to the conditions they are attempting to diagnose and treat (Dumit 2004; Rose 2007; Cohn, this volume). Cohn shows that, while social aspects of illness are solidified by these technologies into a definition of the self, such conversion is partial and highly contextual. It is clear that even those who welcome the images of ‘illness in the brain’ are still left with managing the social ramifications of their condition, and with the realization that that which is identified visually is not necessarily accessible socially in ways that make sense to the individual concerned.

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These are visualizations that combine the effective and the affective power of images, images that are used to both produce and negotiate the boundaries between the mental and the physical, the real and the statistical, the ‘normal’ and the pathological – rendering these boundaries more explicit and more explicitly contingent in the process. Of interest are the ways in which the visual technologies come to be taken as revealing facts about the world, and in the conversion capacity of these images in relation to how the individual conceptualizes their relationship both to their own body (and mind), and to the wider social world. The recent studies mentioned here have, amongst others, taken earlier Foucauldian insights about the authority ‘to see’ a step further by looking more closely at alternative translations of the same visual form. They alert us to the difficulties of controlling interpretation, to the re-emergence of powerful, differently authorized, alternatives, and to the way in which images accrue different meanings as they move around social worlds and mediate relations between beings. The point to underline from this discussion of aesthetic choice is that aesthetic conventions and their effects constrain but do not determine – for a more solid control of ‘interpretation’, more powerful social institutions, regulations, hierarchical conventions, and so on are required. It is these that we turn next.

Expert Vision The authority of the image is a theme that runs through many of the papers in this volume. The image is a communicative device that mediates or moves between socially differentiated actors: for example, between the body of the patient and the diagnosis of the expert. But in these scenarios this work of translation across perspectives is not carried by the image alone. The image (or inscription, to use the term deployed by Latour [1987]) requires the expert to speak about what is visible, and who gets to see and who gets to explain are carefully circumscribed and protected through professional and institutional protocols. Stefan Ecks (this volume) shows how endoscopy in India both visualizes the gut and also shores up the truth claims of gastroenterologists. The images of the gut mobilized by experts are both armour and ammunition against the personal understandings of the patient and are used to diminish and reject alternative patient diagnostics. Ecks works through the trope of enlightenment: lighting up the inner recesses and dark corners of the gut feeds gastroenterologists’ understandings of themselves as enlightened, global players in contrast to their local and ‘parochial’ patients. To return to the example of brain images, like the foetal images produced by Nielson, and the endoscopic images of the gut described by Ecks, they are also authorized by caption. Viewers needs to be told what they are

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seeing: it is not, for example, self-evident that the brain they are looking at is ‘smart’, ‘depressed’, ‘obsessed’, or indeed has criminal tendencies (Rose 2000; Dumit 2004; see also Roepstorff 2007). The brain image may be used as evidence or as ‘demonstrative illustration’, but as with other medical images, such as ultra-sound, photographs and X-rays, ‘skilled vision’ (Grasseni 2007) is required for pertinent interpretation. Awareness that images do not speak for themselves draws attention to the ‘cultural effort’ ( Jordanova 1999) required to stabilize and fix specific meanings long enough or adequately enough to persuade the viewer of the ‘correct’ or most pertinent reading. The process of learning to see what is meant to be seen (and by implication ignoring that which is not) engages the viewer in an ongoing series of decisions regarding the relevance of visual information in relation to the task at hand.15 In scientific as in artistic worlds skilled vision hinges on the discrimination of the expert. The capacity for such discrimination is formed over time as the novice learns to interpret in relation to a field of relevance that is not accessible to the untrained.16 Recent work on skilled vision discusses how expertise is established not simply in relation to authorized interpretations of what is seen (as in the expert reading of a brain scan or an X-ray), but also in the practices through which visual data are abstracted from the more complex sensory environment of lived experience, thereby producing/objectifying what is there to be seen in the first place. Alison Shaw draws productively, in this context, on Lave and Wenger’s figure of the ‘legitimate peripheral participant’ who through apprenticeship learns to see (Shaw 2003; Lave and Wenger 1991). Her ethnographic example is from the field of diagnostic genetics where phenotypical characteristics, in this case physiognomy, offer clues to the genotype. The weekly learning event revolves around photographic images of patients (often showing only their face). Senior members of staff take it in turns to present slides with a running commentary on the dysmorphic features of the patient.17 The apprentices, the ‘legitimate peripheral participants’, listen (but rarely contribute) to discussion about the syndrome that the specific facial features indicates. For the apprentice (and in this case also the anthropologist) the dysmorphology is initially indiscernible, let alone nameable. The learning event, including the ‘diagnostic performance’, reveals to the apprentice the skill of the experienced clinicians who ‘can identify a syndrome in just a few seconds, without analysing each feature, and before the rationale for the diagnosis is developed’ (Shaw 2003: 50). As well as scientific knowledge being formed around the capacity to ‘see’ instantaneously, it is also formed around the capacity to abstract and circulate visual objects. Bleichmar (2006), for example, discusses how botanical drawings systematically dislocated specimens from the particular material conditions in which real plants live, thereby rendering the

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‘specimen’ transportable. The drawings also re-format the plant in ways that render them more easily comparable to other specimens. This process of abstraction and relocation for purposes of systematic comparison and analysis mimics the work of the laboratory (Latour and Woolgar 1979; Latour 1999) and the museum (Macdonald 1998, 2002), spaces deliberately created to facilitate the abstraction and to provide the conditions through which ‘objective knowledge’ can emerge. It is these abstracted (sensually truncated) visual objects that require reanimation for re-introduction to the social world from which ‘scientific process’ purposefully removes them. Hence the importance of captions, narratives, ‘trial and error’, or appeal to cultural repertoires, expectations or traditions for the effective mobilization of such images in specific social processes. Indeed one of the key tensions between ‘science’ and ‘society’ in relation to skilled vision lies in the difficulties involved in maintaining a firm distinction between the visual object and the wider sensorium. Maryon McDonald, for example, discusses how medical students learn to ‘see’ the anatomical body through the models and images which systematically separate the body from the person (McDonald 2007). Yet in the practice of learning anatomical dissection, students continually have to address both their own physical sensations in relations to the smells, textures and sight of the flayed corpse, and their emotional sensibilities in relation to the personhood of the cadaver, never sufficiently abstracted from ‘life’ to become simply a site of medical knowledge, to be approached simply through the skilled vision of the observer. And while new visualization technologies offer possibilities for training and for surgery at one remove from the body – with the interactions mediated by the computer screen – the rich experiential associations that human beings acquire with their physical environments always threatens the integrity of the abstraction. People can be told what to see, but of course this does not preclude alternatives. As contributors to this volume show, as images move from their points of origin, as they travel in the social world, mediating, enabling and disenabling various relationships, they both accrue and shed meaning. Indeed they may be used in ways that confound original expectations of them and in the case, for example, of medical images in ways which trouble clinicians. As we know, the recalcitrant public is an absent presence in many of the ‘problems with the public’ that underline programmes for the public understanding of science (e.g., Irwin and Wynne 1996; Edwards 2002, 2004; Degnen 2007; Harvey and Knox 2007; Wynne 2007). This recalcitrance, linked to the capacity of some objects to resist abstraction, accounts for the power of images in the non-scientific domains of film and advertising. Here a purely visual entity is used to evoke other sensory dimensions and the power of cinema is utterly dependent on the combination of image and sound to provoke bodily sensations in the

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viewer – of fear, disgust, laughter, etc. This capacity of the image to evoke a wider sensorium returns us to the point that vision is a learned skill, that is fully embodied, never isolated from other senses, and never disentangled from the ideological and intellectual assumptions which it then necessarily carries, expresses and reproduces in practice. Of course the argument is complicated by the fact that one such ideological assumption is that vision ‘can’ be separated from the other senses – hence much earlier work within anthropology repudiating vision (as a problematic modernist abstraction), and the more recent move to reclaim vision (as embodied skill) or to elaborate on Deleuze and Guattari’s (1987) distinction between ‘long-distance’ or ‘optic’ vision and ‘close-range’ or ‘haptic’ vision. The instability of the visual abstraction also accounts for the tensions between skills and standards in relation to scientific practice. Science studies has begun to detail the ways in which the powerful abstracted images and the skilled visions of modern science are utterly dependent on specific bodies, networks, institutions and histories, that in turn entangle professional, political and economic interests, producing a ‘science’ that understands itself as somehow under siege from a problematic (ignorant) public, and in need of greater public awareness of scientific process, and greater investment in the technological potential for abstraction. The impossibility of ever fully guarding the image from ‘inappropriate’ interpretation fuels these concerns, and again reconnects us to the power of images to evoke diverse responses and oft-times unwelcome responses in viewers. Gyan Prakash (1999) has written of the problems the British colonial regime experienced in India as they sought to convince local people of the importance of modern scientific knowledge by mounting displays of agricultural science, only to find that they had in fact persuaded them of the magical dimensions of modern technologies, and the inferior persuasive power of reason in relation to the dynamic possibilities of rumour. This account is echoed in Michael Taussig’s engagement with Benjamin’s notion of dialectical imagery (Taussig 1986), elaborated by Susan BuckMorss (1989). The key idea here is that images and imaginaries have histories and that these histories create fields of ambiguity that also lend the images their potency, their capacity for reconfiguring the dominant orderings of the social. Images, saturated with dominant meanings, can be freed from their normative associations and opened up for other purposes. This is the work of the critic and the artistic avant-garde and was a project self-consciously adopted by the Surrealist movement. Taussig’s argument was that this opening up also happens in everyday life, producing a focus for ethnographic interventions. His particular interest lay in shamanic visions and also in religious icons as both visions and icons act as sites where

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differing imaginings come together in ways which stimulate new relationships between viewer and viewed. The move to link the image to the less visible realms of cultural imagination returns us to a point made earlier concerning the ways in which images act on us through what they make visible, but also through their capacity to invoke that which is not seen. The ethnographic work of Mariane Ferme (2001) offers a broad framework for describing this relationship between visible and invisible worlds by looking at how the flatness or intrinsic superficiality of the image relates to other modes of dissimulation or uncertainty. She attends to how the boundaries between visible and invisible worlds are drawn and transgressed, the ways in which visual ‘clues’ become ‘facts’ as they get tied into normative interpretations and the ways in which they get tied into people’s lives via their materiality, by the indirect forms of reference they entail and by the practices of narration through which they are consolidated. The ways in which the social significance of the image emerges in material and discursive relations over time frames our approach to the new visual technologies and connects our work to Foucault’s impulse to excavate the broader conditions that prompt change in a particular field, such as biomedicine or public administration, by drawing out the connections between social domains that appear unconnected. However, by contrast to many general accounts of what has become known as ‘audit culture’, ‘late capitalism’ or ‘knowledge societies’ we start from a descriptive position that is cautious about the extent of such changes: aware of the totalizing ambitions that characterize contemporary regimes and anxious not to reproduce capitalism’s own self-image. Contemporary capitalism, of course, both produces and is sustained by an image-saturated world and the body is a pervasive subject of such imagery, used to sell goods, lifestyles, a sense of who we are and who we could be. Furthermore, capital offers cosmetic surgery, assisted reproductive technologies, prosthetic limbs, organ transplants, sex changes, cochlear and retina implants and more, to those with the need or desire to fix, enhance, reduce or ‘enable’ their bodies. But anthropological and historical scholarship has shown the immense variation in human awareness of what the body is, or could be and how this ‘body’ corresponds (or not) to what it means to be a person. Detailed ethnographic and historical analysis allows us to ask with more precision about the current configurations of visualization technologies and technologized bodies. What specific problems do these new configurations throw up? How might these problems be approached? The philosophical/intellectual project also changes with this changed awareness: from a quest for conditions of ‘truth’ (attempt to stabilize) to a quest for new ways of imagining, of getting beyond cliché and stereotype, of being open to the possibility of productive non-cynical

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engagement with contingency and process. The enduring anthropological interest in the ambiguous, opaque, unreadable, ghostly becomes more accessible, more useful. *** The chapters in this volume each in their own way reveal complexly situated and contextual images which shape and are shaped by the social relations they mediate. They address the ways in which ‘vision’, like all human activity, is mediated by artefacts and by other people in complex, emergent social contexts. In this respect images are (and always were) complex assemblages of material and immaterial processes, relationships, histories, imaginaries and desires. Our contributors address questions of the body, visualization and technology in diverse ways. Some have a more obvious emphasis on the visual than others: Ecks, Cohn and Lorimer, for example, all foreground the process of visualization – the technological crafting of material (albeit digital) images and the way they circulate. Yet all the papers concern technologies of visibility and invisibility in relation to bodies. For example, Dumit’s analysis of the grammar of pharmaceutical companies’ advertising is not only about visuality because the PR material in question is distributed on TV and the Internet; it is also about how this grammar and these visual images allow previously unrecognized ‘symptoms’ to become visible to people as manifestations of an illness and how the advertisements encourage individuals to see themselves as sufferers through a process of ‘pharmaceutical witnessing’. Although the immediate emphasis in such witnessing – modelled on evangelical witnessing – is on language, the broader emphasis is on a ‘mode of attention, cognitive and emotional, embodied attention’ and there is a key process of visualization here as people identify with other sufferers on the screen, often through specific visual forms, such as a checklist of symptoms, or, most powerfully, footage of subjects embodying those symptoms. Dumit’s paper addresses a key theme of this book, which is how images are crafted into authoritative representations of and around bodies, images that are legitimated by scientific expertise, but may be adopted, adapted, resisted and, at least, mediated in complex ways to produce unpredictable results. It is not Dumit’s aim to explore how viewers of these images react, so we need to be careful not to assume the seamless suturing of interpellation and subject that the companies would doubtless like to achieve. Ecks’s paper on visualization in Indian gastroenterology clinics is concerned with the scientific authority of images, but also with how they function in the clinic setting. The ‘enlightened’ vision of the gut that the endoscope provides becomes the unquestioned diagnostic tool, even for alternative, non-

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allopathic practitioners; the visual evidence it provides appears self-evident, although the doubleness of the image is evident here too in the powerful emotional reactions such images can provoke in patients whose intestines betray evidence that the doctor can ‘see’ (i.e., interpret) as symptoms of cancer. The ‘simple’ images produced by the endoscope are not so simple in other ways. They are located in a distributed network of agency and responsibility of global dimensions: producing these images in the quantity and at the speed that Indian doctors produce them – largely for economic motives – is recognized by these doctors to constitute dubious professional practice by the standards of Western medics, as too little time is allowed for sterilization of the endoscope and time-consuming pain relief is not offered to patients. When it comes to visualizing the causes of gastrointestinal disorders, even greater complexity ensues, as patients have a whole set of images of the body and its functioning that the gastroenterologists dismiss as folk knowledge. There is nothing as convincing as the endoscopic image that the doctors can deploy when it comes to aetiology. Cohn’s paper shows a different aspect to this process. The images of the brain produced by scientists using modern scanning technologies are known by them to be complex, provisional and unstable constructions, derived via statistical selections from huge masses of digital data. These images have the stamp of authority, lent to them by their origins in the most up-to-date technologies of visualization, but they are still seen as interpretations. Meanwhile, some of the people – research subjects in scanning experiments – to whom these images are given eagerly adopt them as solid evidence of their brain’s functioning which can act as visual witness to their individual mental health problems. Authority and scientific legitimacy here is rather the opposite way round from the examples described by Dumit and Ecks. But Cohn’s material shows very vividly the social embeddedness of these judgements of authority. With time, some of the people who lit upon the brain-scan images as solid evidence of the anatomical nature of their illness lost faith in this apparent self-evidence: they had still been left with the everyday reality of their condition. Some other sufferers, in patient support groups, explicitly rejected the value of images, arguing for the social character of these mental conditions. Questions of expert authority are intimately linked to big issues about the overall social consequences of shifts in visualization and biological technologies; about whether these tend to reproduce hierarchies and regimes of power and capital accumulation or provide ways to enhance alternatives and empower individuals and collectivities. Many of the papers in this volume address this issue in one way or another. The papers by Dumit and Ecks tend to show that existing hierarchies of knowledge and processes of capitalist production are reproduced, although Ecks indicates some of the complexity involved in that. Cohn’s paper is more equivocal:

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the ethnographic complexity of the image’s social life belies a simple answer here. Cohn gives us a good sense of the image as a material object embedded in complex social networks which open different avenues and possibilities, albeit, one might want to argue, that this is happening within an overall trend towards the ‘biologization’ of mental illness in mainstream Western medicine. Landecker’s argument directs our attention to the risks of thinking in terms of epochal social shifts which are seen as opening up simple conceptual avenues for conceiving of social change. The apparent hiatus marked by the advent of cloning, with all the furore around its possible extension into human reproduction, was actually embedded in a long and complex process of learning how to manipulate the cells of simpler life forms, which dates back to the 1950s. Vital to this was controlling the temporality of cell life, by freezing cells (cryobiology) and by making different cells all reproduce simultaneously (cell synchrony). Landecker alerts us to the complex and extended mediations of science-in-practice that make it harder to identify straightforward answers to questions about whether social hierarchies are being reproduced. If the study of bioscience is about Foucauldian ‘biopolitics’ in regimes of power in which ‘life’ is managed, then, Landecker argues, we need to know what ‘life’ consists of for scientists – and the answer is that, for many life scientists, it consists of the cells of worms and plants, slime and mould. Norms and ethics are about the ‘right’ way to handle cell cultures, the ‘right’ ways of laboratory practice that produce ‘healthy-looking’ cell cultures that are not put at risk of contamination by the sloppy, rushed techniques of scientists who do not know enough about the life of cells, but want to use them for their genetic experiments. As we argued earlier in this introduction, the internal diversity of science, the plurality of ‘the scientific gaze’ is foregrounded in this chapter. Also important is a broader notion of the visual. While Landecker does not address visual imagery and visualization directly, she opens up ‘the visual’ to include its materiality – just as Cohn draws our attention to the brain scan image as a material object in the social world. Lorimer’s chapter on the ‘Brain Exhibit’ at the Chicago Museum of Science and Industry makes similar points in a different context. For her, it is important to take seriously the material media in which scientific abstractions are made concrete for the purposes of representation – in this case to a public that needs to be both educated and entertained, edified and engaged. This focus – like Landecker’s focus on the cell and its culturing – brings us to the extended networks across which agency and responsibility are distributed and which include the physical, material forms of the visual representations (statues, photographs, TV monitors, models, etc.), the people who actually craft these forms (designers, technicians, etc.) and the chains of money and power into which the physical media, the exhibit and

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the museum are inserted and which bring funding, materials and ideas to the exhibit. Lorimer traces the multiple processes that led to the Brain Exhibit ending up as it did: with a layout that modelled an over-sized brain, but with a birthday party theme as a ‘vehicle’ which would allow people to travel around the concepts of the exhibition, providing a familiar way into ideas about child development, memory and learning for diverse audiences; and with a huge mural of ‘ghostly’ mannequins that were thought to provide a universalist (and anti-racist) message of underlying human commonality. For Lorimer, the unintended ‘ghostliness’ of the exhibit, as perceived by many visitors, was evidence of the power of longstanding cultural frameworks for interpreting imagery. The connections made from brain to mind and thence to spirit and ghost were part of such a cultural framework, which reappeared despite the intentions of the exhibit designers. The public life of science, understood by her through ‘its conditions of actual existence’, reproduced some standard assumptions about humans. For Nahman, processes of assisted reproduction in Israeli IVF clinics also reproduce ideas about the ( Jewish) nation, invoking ‘old’ ideas of a multicultural yet also racially exclusive society based on ethnic nationalism, while also bringing in ‘new’ elements of consumerist choice and privatized markets in body parts (sperm and ova). Women who use IVF clinics fill in a Preferred External Features Form, in which they specify how they would like their ova donor to look; the choices reproduce ‘narrow ideals of beauty and national selfhood and family in Israel’. Like Landecker and Lorimer, Nahman shows how this technological process is linked into a wider network – in this case, the global trade in gametes. ‘The national body is made transnationally.’ As in Landecker’s case, temporality is important: the temporal shift between embryo and baby is ‘abridged’ to create an economy of hope for the couple who want a baby (which will allow them to be seen as legitimate citizens) and for the nation which needs (proper) citizens for its future development. The visual is given an important temporal dimension in both Landecker’s and Nahman’s studies: both involve technologies for being able to see – to see imaginatively – the past (frozen cells) and the future (a healthy baby) for purposes related to the material present. Agency, control and responsibility are key themes in the chapters by Scheldeman and by Viseu and Suchman. Like several of the other authors, they emphasize the distributed character of agency and responsibility, which in these cases derives from the enhancement of the body through wearable augmentations – insulin pumps, highly portable work computers, intelligent clothing, body-monitoring devices and reinforced military bodies. Viseu and Suchman share with Dumit an interest in bodies that hide important signs, emitting data that are invisible because they have not been recognized for what they are – in Dumit’s case, symptoms; in Viseu and Suchman’s, useful information that could be deployed to enhance productivity, well-being,

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health and military capability. Technological mediation, in the form of wearable IT devices, can be used to transform these signals into useful data. Making these signs visible, as useable information, means making the person wearing the device visible in new ways. Viseu found that workers who used a highly portable computer to record and transmit data about jobs, spare parts and their movements may have improved productivity and even made their jobs easier, but they also feared that their employers would reduce worker autonomy and even use increased productivity to downsize the workforce. While wearable IT is often depicted in the media as increasing autonomy and freedom (often for people who already enjoy a good degree of autonomy), it can also of course be used to limit those qualities (especially for people who do not enjoy so much of them to start with). When the body begins to disappear into complex networks that distribute agency and responsibility, it becomes harder to make blanket judgements about where responsibility lies and at what point the body becomes a docile one. However, Viseu and Suchman conclude that wearable augmentations ultimately re-inscribe the mind-body divide that they seem to blur, by presenting technology as the thing that can reconnect these separate domains. Thus ‘the augmented body as imagined by these technologists is still, in the end, a docile one’, which is being made more visible ‘in the interests of contemporary regimes of selfimprovement and control’. In this sense, ‘dominant discourses of personhood’ are reproduced, albeit in reconfigured form. Scheldeman is likewise interested in control and freedom and the way wearable insulin pumps, which dispense with the usual routines of insulin injections for diabetics, are distributed in complex networks of people, technologies and objects, which do not form a coherent system, but participate in ongoing performances. The insulin pump was experienced by some young users as enabling and empowering, giving them freedom and autonomy, because they were able to ‘incorporate’ the technology into their practical body-mind competence, rendering the pump more or less invisible to them. For others, things did not work out that way and they felt encumbered. Overall, Scheldeman is more optimistic than Viseu and Suchman about the empowering effects of technologies, or at least ones that can be incorporated and embodied in this way (although she only mentions in passing examples where the pump did not function in this fashion). For Scheldeman, the mind-body divide seems to be overcome in the successful users of the pump, for whom knowing, seeing and doing meld into one practical competence. For Viseu and Suchman, the divide is re-inscribed, at least in the imaginations of the technologists. Cohn shows how the brainscan technology first separated mindful people from their brain-as-body diseases, but then often ended up reconnecting them with their illness as a social-moral condition which they had to live with in the real world of social hierarchies of well-being and health.

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The themes drawn from this collection here – how authoritative images and imaginaries of bodies are crafted technologically, how they operate in hierarchies of knowledge and power and what consequences they have for agency and autonomy – connect all the chapters in this volume. Their ethnographic focus reveals the materiality of technologized images and the distributed and socialized character of the technologized body. It also reveals that the technologizing of images and bodies takes place in a context of dominant discourses and capitalist accumulations which often harness this process without, however, always controlling it. The consequences of this technologizing, in the end, always retain an element of unpredictability, which ethnography is well placed to reveal.

Notes 1. Sunday Times, 22 July 2007. 2. Thrift coins the term ‘biodigital politics’ to encompass current collisions of biological, technological and cultural elements (Thrift 2005: 10). 3. There is now a large body of literature focusing on the way in which science and politics mutually inform each other at particular historical moments (e.g., Laqueur 1990; Martin 1991, 1994; Jordanova 1999; Pickstone 1999). 4. This and subsequent sections owe much to the literature review carried out by Hannah Knox to be published as a working paper for the Centre for Research on Socio-cultural Change (CRESC), University of Manchester (http://www.cresc.ac.uk/publications/papers.html). The editors thank her for allowing them to draw on this material. 5. It is worth noting here the singularity of Foucault’s formulation, contrasted with Knorr-Cetina’s (1999) presentation of a more plural science in which diverse perspectives do not necessarily add up to a greater whole. 6. Alongside the new techniques of perspective, new regimes of knowing through seeing came to replace the wider sensorium of previous regimes of knowing. In addition to Foucault’s discussion, see Deleuze and Guattari (1987) on the distinction between distant and haptic vision. 7. Latour’s analysis of Holbein’s ‘The Ambassadors’ – in Fyfe and Law (1988) – is illustrative of the transition between these two notions of subjectivity. 8. See for example Crary (1990), Daston (2000), Pickles (2004) and Grasseni (2007). 9. Key texts on the history of photography include Tagg (1988), Mitchell (1994), Schwartz and Ryan (2003), Edwards and Hart (2004). 10. As Mitchell reminds us, although Foucault’s focus is on France and northern Europe, the panoptical principle was devised on Europe’s colonial frontier with the Ottoman Empire (in factories run by Jeremy Bentham’s brother) and examples were built for the most part in the colonies. 11. The focus on visualization also links communications between experts to the ways in which scientific knowledge comes to be communicated to non-science publics (Bucchi 2006; Trumbo 2006).

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12. For a critique of a meaning-centred approach to images, see Messaris’s review of Van Leeuwen and Jewitt’s Handbook of Visual Analysis (2003). 13. We briefly explore the contours of the ‘science wars’ in our ‘Introduction’ to Anthropology and Science: Epistemologies in Practice (2007). 14. Alfred Gell remarks of art that the image mediates between two beings and ‘therefore creates a social relation between them, which in turn provides a channel for further social relations and influences’ (1992: 52). 15. See Sperber and Wilson (1986), Hanks (1996) and Bauman and Briggs (2003) in relation to linguistic as opposed to visual communication. 16. See Latour (2004) for discussion of the training of ‘noses’ for the perfume industry. 17. ‘Dysmorphic features are those that fall outside the range of normal variation, a construct defined by clinical observation and supplemented by statistical measures’ (Shaw 2003: 42).

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Shaw, A. 2003. ‘Interpreting Images: Diagnostic Skill in the Genetics Clinic’, Journal of the Royal Anthropological Institute 9(1): 39–56. Snyder, J. 1980. ‘Picturing Vision’, Critical Inquiry 63: 499–526. Sperber, D. and D. Wilson. 1986. Relevance: Communication and Cognition. Oxford: Blackwell. Stabile, C.A. 1994. Feminism and the Technological Fix. Manchester: Manchester University Press. Stafford, B.M. 1999. Visual Analogy: Consciousness as the Art of Connecting. Cambridge, MA: MIT Press. Stepan, N. 1982. The Idea of Race in Science: Great Britain, 1800–1960. London: Macmillan in association with St Antony’s College, Oxford. Stocking, G.W. 1982. Race, Culture and Evolution: Essays in the History of Anthropology. Chicago: University of Chicago Press. Strathern, M. 1987a. ‘An Awkward Relationship: The Case of Feminism and Anthropology’, Signs 2: 276–92. ———. 1987b ‘Out of Context: The Persuasive Fictions of Anthropology’, Current Anthropology 28: 251–81. ———. 2000. Audit Cultures: Anthropological Studies in Accountability, Ethics, and the Academy. New York: Routledge. Tagg, J. 1988. The Burden of Representation: Essays on Photographies and Histories. Basingstoke: Macmillan Press. Taussig, M.T. 1986. Shamanism, Colonialism, and the Wild Man: A Study in Terror and Healing. Chicago: University of Chicago Press. Thrift, N.J. 2005. Knowing Capitalism. London: Sage Publications. Trumbo, J. 2006. ‘Making Science Visible: Visual Literacy in Science Communication’, in L. Pauwels (ed.), Visual Cultures of Science: Rethinking Representational Practices in Knowledge Building and Science Communication. Hanover, NH: Dartmouth College Press, pp. 266–84. Walker, J.A. and S. Chaplin. 1997. Visual Culture: An Introduction. Manchester: Manchester University Press. Wilson, D. and J.V. Pickstone. 2007. ‘Making Way for Molecular Biology: Remodelling Biological Sciences at the University of Manchester, 1980–1993’, International Symposium on Public Knowledge: Redistributions and Reinstitutionalisations 28–29 June 2007. Manchester: ESRC Centre for Research on Socio-cultural Change, Social Anthropology, University of Manchester. Wood, D. and J. Fels. 1992. The Power of Maps. London: Routledge. Wynne, B. 2007. ‘Science and Governance: Taking European Knowledge Society Seriously’. Report of the Expert Group on Science and Governance to the Science, Economy and Society Directorate, Directorate-General for Research, European Commission.

CHAPTER 2 Pharmaceutical Witnessing: Drugs for Life in an Era of Direct-toconsumer Advertising Joseph Dumit

People come into my office, throw down an ad and say, ‘That’s me.’ Psychiatrist It’s a disease that often has no symptoms. Advert for Peripheral Artery Disease If you answered 7 or less for question 10, you probably aren’t feeling like yourself. Website for Depression Awareness As an anthropologist studying pharmaceuticals in the U.S., I am constantly tripped up by statements that seem to challenge my common sense, ones made by pharmaceutical marketers, advertisers, doctors and patients. A life on drugs is not alien to me, nor to most readers of this article. We often are on prescriptions and we might be on them for life. But the easy emission of these statements points to a cultural inflection that I want to investigate here using what Victor Turner called the method of processuralism in anthropology, attending to processes that we are involved in and to how actors perceive, mutate and communicate their embodied worlds (Turner and Turner 1992: 172–73). All of the opening statements, I want to argue, share a relatively new grammar of illness, risk, experience and treatment – one in which the body is inherently disordered and in which health is no longer the silence of the organs, but it is illness which is silent, often with no symptoms. In this article, I want to

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interrogate this grammar, examining how it involves an image of health as risk reduction, and an image of information as full of partial facts. Together, these images underpin a logic of accumulation of pharmaceuticals in the U.S. such that it becomes natural and imperative to treat one’s body with more and more drugs for life. In fact, it is so commonsensical that even critics of the pharmaceutical industry and advocates of alternative medicine share in this logical growth. This article is part of a larger, book-length study of ‘mass medicine’ in the U.S. Mass medicine refers to blockbuster pharmaceuticals whose yearly sales exceed one billion dollars and whose customers are measured in millions. My research included analysing hundreds of pharmaceutical TV commercials, as well as magazine ads and Internet sites; tracking patient discussion groups online; and interviewing and holding workshops with pharmaceutical marketers, doctors and patients groups. Here I examine advertisements for their grammar of facts and health. I also analyse the ‘grey literature’ written by pharmaceutical marketers to each other to improve their practices. I aim to show how our ways of talking articulate with theirs such that we may get what we want, but it may not be what we need. Pharmaceutical Executive (PE) is one journal that concentrates on marketing strategies towards doctors and the public. I trace a key shift in marketing towards what I call factual persuasion and what PE, in its first branding seminar in April 2002, termed ‘Pharma’s challenge to convert science into marketing’ (Shalo and Breitstein 2002: 84). Using tools from many disciplines, pharmaceutical marketers are building on a much longer tradition of public relations aimed at calibrating emotions for maximum effect in concert with the authoritative discourses of science and medicine that dissociate viewers from their own bodies and experiences (Tye 1998; Chomsky and Barsamian 2001; Herman and Chomsky 2002). I begin with an early pharmaceutical commercial.

Remaking the Body at Risk The following table shows a direct-to-consumer (DTC) television commercial for a Depression Kit (manufactured by Lilly), which begins as a checklist in the form of an interrogation.

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Table 2.1. Text of TV Advert for Lilly’s Depression Kit Voiceover

Audio-Visuals

Have you stopped doing things you used to enjoy? Are you sleeping too much, are you sleeping too little? Have you noticed a change in your appetite? Is it hard to concentrate? Do you feel sad almost every day? Do you sometimes feel that life may not be worth living? These can be signs of clinical depression, a real illness, with real causes. But there is hope, you can get your life back.

Sombre music playing over black-and-white stills of unhappy people.

Treatment that has worked for millions is available from your doctor. This is the number to call for a free confidential information kit, including a personal symptoms checklist, that can make it easier to talk with a doctor about how you’re feeling. Make the call now, for yourself or someone you care about.

Text on screen: ‘Depression strikes one in eight’ Text on screen: ‘Get your life back’ Woman looking at pamphlets, phone number on screen, pictures of checklists and other information pieces. Fade to logo for Lilly.

The commercial features simple questions that are very general: are you sleeping too much or too little? But their seriousness is transmitted in the follow-up: ‘These can be signs of clinical depression.’ This conclusion converts the questions into a medical algorithm, a logical process of following a series of steps. But the grammar arrests: ‘these can be signs’ is a peculiar phrase. It is retroactively transformative: aspects of one’s life are inscribed as symptoms. What you had previously thought of – if at all – as personal variations are brought into heightened awareness. The first implication is that you are, maybe, suffering from a serious disease and do not know it. Your body, in other words, is potentially deceptive, concealing its own decline. This is not a presymptomatic form of awareness. Unlike the situation in Nelkin and Tancredi’s Dangerous Diagnostics (1989), where a brainscan or genetic test reveals a disease before it manifests symptoms, here you find out that you have been suffering from symptoms without feeling them. The grammar of the phrase, ‘these can be signs of X’ or ‘you could be suffering from X’ are also not simple performatives. They do not assert that you have depression, they do not diagnose (Austin 1962; Kahn 1978). For

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legal, marketing, and health reasons, the grammar is explicitly modalized as possibility: ‘these can be’ ‘you could be’ ‘you might be.’ But they are giving you a new possibility. Information about the possibility of pathology transforms modalization into mobilization (Halliday 1985). You cannot ignore the possibility morally because your status has changed (Sacks and Jefferson 1992). This can produce a very strong duty to be healthy (now that you know you are not) and a rational ‘having to try’ (since you know there is something you can do), that is as deeply moral as the imperative to be tested identified by Nelkin and Tancredi (1989; see also Franklin 1997). You are now at risk, you now know that you have been at risk, you have to try to do something about it. Since treatments are available, ‘There is hope.’ From a marketer’s point of view, once you are aware of the disease in general, the question is how to get you to add depression, breast cancer, cholesterol to your lived anxieties, to your personal agenda, enough so that you attend to it, find out more information, and talk to your doctor about it. This is what they term ‘personalization.’ Their problem is how to get their particular facts into your head as facts that you come to depend on. This practice recalls and builds on an older generation of advertisements teaching you that you might be suffering from bad breath or be overweight and not realize it (Marchand 1986; Bordo 1993), but amplifying this personalizing effect by passing it through tests and diagnostic algorithms. For instance, another commercial begins with a scene of many middle-aged people on exercise bikes in a gym, working out but looking tired. The only sound is a ball rolling around and superimposed above them is a spinning set of numbers. Finally the ball is heard dropping into place; the number is 265. The cholesterol roulette is over. The text on the screen: ‘Like your odds? Get checked for cholesterol. Pfizer.’ The challenge of thinking through how these commercials work dialogically lies in the fact that they aim for a retroactive status change. Rather than illness punctuating ordinary life, the everyday conceals illness. Once this is identified, once you identify with it, then your true, real life can be returned to you. The process here is a counterpart to interpellation. Althusser’s process of interpellation involved the always, already self-recognition of the subject, where the teacher or policeman hails you or asks you a question, and your response confirms the self evidence of your being a subject: ‘I am I’ (Pecheux 1982; Althusser 1984). Here your self-evidence is directly assaulted. Your self-identity is called into question via the algorithm. You are not who you think you are. Your body is not what you think it is. Your feelings are not what you think they are. The algorithm offers in turn to identify your objective self for you. So instead of the interpellated response, ‘Yes, it’s me’, we instead say, ‘Oh! so that’s who I am.’ The challenge in studying pharmaceutical marketing is that the commercials do not usually work this easily. In fact they do not work well at all, but they do

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work well enough. Both the number of prescriptions and the amount of drugs per prescription are projected to continue to grow at 5–15 per cent per year for almost all classes of drugs for chronic conditions (Express Scripts 2006). For marketers, some people responding some of the time is all that they need: their processes of persuasion are designed to work in percentages, or market share. If they can get even a small per cent more Americans to consider the possibility that they might be depressed or have high cholesterol, and a small per cent of those people actually go to a doctor and request a prescription, the profits on these tens to hundreds of thousands of additional patients are more than enough to cover advertising costs (Kaericher 2007). It does not matter whether those people ‘believe’ that they are sick, only that they act in accordance with that belief as delineated by the marketing campaigns. The studies that have been done on direct-to-consumer advertising suggest that these commercials are successful at generating concern and anxiety, and that they drive pharmaceutical sales just enough to justify continuing to invest in them (Aikin 2002). My ethnographic challenge is therefore to account for this aggregate growth. I am thinking of this as an ethnography of the aggregate. Thus I begin with a study of how marketers imagine people to be manipulable enough. As businessmen, pharmaceutical marketers know exactly what their endpoint is: profit in the form of ongoing mass pharmaceutical consumption. This profit ultimately boils down to prescription maximization which can be achieved through growing the absolute number of new prescriptions, extending the time a patient stays on a prescription, or shortening the time between having a condition and getting a prescription for it (Bolling 2003). Most pharmaceutical marketing overviews start with the product cycle. A pharmaceutical in the U.S. must go through an extensive regulatory process in order to be approved for use. This process includes testing the drug for safety, first in animals, then in humans. Its potential efficacy is then assessed, and finally its actual efficacy is tested in a clinical population for a specific illness through clinical trials. When all of these have been successfully accomplished, the pharmaceutical company applies to the FDA for approval. If granted, the company gains a number of years of exclusive right to market that drug to doctors and public for that illness. Marketers therefore divide their strategies into stages: pre-launch, launch, market exclusivity, and transition to generic competition. Embedded in their articles about direct–to-consumer marketing, however, is also a complex theory of the mass market as potential patients who do not know that they are ill, and must be led, step by step, toward a prescription. I opened this article with a close grammatical reading of how some DTC commercials are constructed, arguing in effect that we as viewers are vulnerable to redescriptions or reclassifications of our everyday variability into symptoms, and that we can be led to identify with the possibility of disease and treatment through rhetorical persuasion. I will now continue to attend to the

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logics and grammars of pharmaceutical marketing as they are circulated, and analyse these in accordance with these explicit strategies outlined by marketers. Marketers have a highly developed language for articulating the steps of conversion through which non-patients come to see themselves as undiagnosed patients, then actively visit and persuade their doctor to give them a prescription. Using their terms, but focusing on how marketers approach a person as someone who does not even know that they require a drug, I have mapped their implicit strategy onto five distinct steps. They are: 1. Awareness through Education 2. Personalizing the Risk 3. Motivation to Self-diagnose 4. Seeing and Convincing a Doctor 5. Branded Compliance Most DTC commercials are aimed broadly at addressing people in any step, at reinforcing this step-wise progression as logical and natural, and at helping people move onto the next step. This process involves much more than just advertisements, it includes the design of clinical trials, arranging screening programmes, constructing databases, and monitoring compliance. As we, patients and potential patients, try to learn facts about our risks and illnesses and come to incorporate these into our identities and bodies, almost every aspect of the medical world we encounter is being modulated (not constructed, but adjusted) in accordance with profit motives. That is capitalism, you might say, but it is also an opportunity to understand how, in our capitalist culture, facts, risks and illnesses work in and on us, transforming how we experience, understand and measure health.

Awareness through Education So companies realize that an effective way to reach commercial goals is to cultivate long-term patients through education, rather than acquiring new consumers through brand-awareness advertising. (Hone and Benson 2004: 98) Medical sociologists have recognized how the neutrality of health information can be manipulated through selection and amplification, privileging one form of explanation over others. The idea that information empowers can be turned into a structured or controlled empowerment, what Dixon Woods has called ‘information for compliance’ in contrast to ‘information for choice’ (Dixon-Woods 2001, cited in Henwood et al. 2003: 591). One key strategy for producing a market is direct education of both doctors and the public. Even before the launch of a new drug, time is spent

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crafting messages about the disease that shape it towards market ends. In the U.S., advertorials are a technical term for this process: quasi-educational spots that function to teach about specific disease symptoms and mechanism. Advertorials are ads ‘designed to deliver the experience of reading an article’ (Prounis 2004: 152). They are used increasingly in the U.S. to build disease awareness, to ‘create an urgency to treat diseases earlier and more aggressively’, and to draw attention to underserved populations. The logical premise of education as patient cultivation is that the public, doctors and medical institutions are ignorant. The status quo is harming people in a most dangerous way because they are not even aware of the harm they are doing to themselves. Ilyssa Levins, chairman of GCI Healthcare Public Relations, underscored how public relations supports the ‘science and marketing connection’ by creating a receptive climate through advocacy and issue-oriented media relations. She said PR can facilitate awareness and adoption among regulators, payers, medical influencers, and patients alike by conditioning the market for acceptance of new concepts such as overactive bladder. (Shalo and Breitstein 2002) Being ignorant of medical issues justifies an emergency public health response: explicit manipulation or ‘facilitated awareness’. There are two main approaches to awareness through education: preparing the market and health literacy. At different levels of generality, each aims at changing the status quo of common knowledge through critical presentation: redefining what health is, what treatment is, what a smart person does to be healthy, and so on. They aim, in other words, to reframe how we see the world working and what we take for granted. In this manner, fact-based marketing creates a receptive climate. The premise of health literacy is that a large segment of the population cannot handle complicated information. They must be managed like children: ‘Limit the content. Make it easy to read. Make it look easy to read. Select visuals that clarify and motivate’ (Kelly 2003). With this kind of handholding, medical information is streamlined so that it becomes more efficient in producing more prescriptions. The aims of health-literacy campaigns as envisioned by marketers are to cement this relationship between knowing and doing. Targeting a sixthgrade reading level allows imagining a market of 110 million people who could be addressed with health information. The health-aware individual is thus presented as one who can and will act on medical facts. While facts are typically seen as descriptive, health education is only seen as meaningful and successful if its knowledge induces action. Non-compliance with facts is thus framed as a problem of literacy. Health literacy grammatically frames

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the public as well-intentioned but ignorant, illiterate, uneducated and disempowered. When health information is offered, people cannot understand or act upon it. When that happens, [often] low health literacy may be at fault. Health literacy is defined as the ability to read, understand, and act on health information, and it becomes more important as patients are asked to take a more active role in their own healthcare. (Kelly 2003) The moral grammar of ‘health information’ is that facts will of course be acted upon. This grammar precludes resistance: if you do not act on what you know, you must be doing so for psychological reasons. You are confused, embarrassed, intimidated or ignorant. Each of these reasons offers an opportunity for strategic intervention to fix the problem of people who have encountered the information but are not acting on it. In Europe, this challenge is acute because brand-name pharmaceutical advertising to consumers is not allowed. Sandoz (Novartis), with an antifungal agent Lamisil to promote, needed to find another way ‘to encourage patients to talk with their doctors about onychomycosis and its treatment options. So the company renamed the condition the more consumer-friendly ‘fungal infection’ and took out newspaper ads asking readers to call or write to ‘“Step Wise” for a free brochure on foot care’ (Hone and Benson 2004: 96). Besides capturing future patients through the informational relationship, the phrase ‘fungal infection’ became an indirect brand, an illness fused with Lamisil as its treatment. The challenge for pharmaceutical companies is managing education that is not directly branded without giving too much away to competitors. Their goals are to ‘employ prelaunch promotion to prepare potential customers for future product use, without generating new prescriptions for the competition’ (Bolling 2003: 112). Mechanisms include quasi-branded cues that will later be branded explicitly when the drug that works on just that mechanism is launched. Even the colour schemes and typography are tied into this process of managing awareness in anticipation of a future market (Prounis 2004).

Personalizing the Risk When its efforts to market to physicians had reached the saturation point, the manufacturer of a prescription health product for women decided to launch a DTC campaign to expand product sales. The company’s goal was to pull through new prescriptions by increasing the target audience’s awareness of the need for treatment to prevent the onset of osteoporosis. The first communication objective was to get patients to ‘personalize’ the risk so they regarded the disease state as important enough to warrant

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taking further action. If the company introduced the brand too early in the relationship, before the target woman considered herself to be at risk for the disease state, she would quickly dismiss the therapy as not appropriate for her. (Bolling 2003) Once a prospect is aware of a risk and accepts that it is possible, he or she must then be made to personalize the risk. Having been introduced to a fact, one needs to enter into a relationship with it. Personalizing involves having the risk become part of an existing internal and external dialogue. It has to become part of my story, how I talk about and represent myself to myself and others. Personalizing requires that the possibility of risk in general now becomes my possible risk. What is needed is that I worry about this possibility, that it go from being an object of my attention (awareness) to becoming an object of my concern. Medicalization is a term used by sociologists to describe the historical process through which conditions, complaints, normal variation and socially undesirable traits are turned into medical conditions and interventions (Conrad 1992; Klawiter 2002; Lock 2002; Clarke et al. 2003). Analysed as power conflicts, medicalization can be a coercive force making people into patients in order to control and manage them. Alternately, medicalization can be a tactic by sufferers to become objects of attention and care through becoming patients (Dumit 2006). Within DTC, these problems of ‘my status’ and ‘my bodily state’ are ‘offered’ to me as explanations for what I am and should now be concerned about. It appears non-coercive, even empowering. I am offered a gift to evaluate freely. However, as Ronald Frankenberg has noted, characterizing this process of medicalization is fraught with narrative and conceptual difficulties for everyone involved (Frankenberg 1993). How does medical identification happen? How can we ethnographically describe an encounter with an advertisement that is effective as documented in increased prescription demands, yet does not reduce the viewer to a judgemental dupe, to use a phrase from Garfinkel (1967), someone who is passively manipulated by the media. In order to investigate processes of identification, I will make a detour into the anthropology of religion and personhood, and draw on the work of Susan Harding, who studied Christian Fundamentalist followers of Jerry Falwell (Harding 2000). She analysed the techniques of evangelical witnessing, the explicit process of attempting to convert non-believers into believers through speech and dialogue. Her study offers a framework for understanding the active, participatory process of identification and persuasion that is going on in pharmaceutical advertising. Harding approaches conversion and status change from the inside, so to speak, as one who is involved in the situation, in the dialogue, struggling to understand. Harding notices this when driving home after interviewing a minister. She almost gets into an accident. In that moment of danger, she finds

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herself asking, ‘What is the holy spirit trying to tell me?’ Finding herself asking this question begins a key insight. She found herself beginning ‘to appropriate in her inner speech the evangelical language and its attendant view of the world’. Her modes of attention, cognitive and emotional, were drawn to the near accident as a gap in the ordinary, an event within the everyday where ‘the seams split’ (Harding 2000: 58–59). Harding argues that one moves from being an unbeliever to believer through a ‘process of acquiring a specifically religious language … If you are seriously willing to listen, and struggle to understand, you are susceptible to conversion’ (2000: 57) It is the unwitting, basic desire to understand that aids this process. It is specifically not a ritual in that there is no social sanctioning that bridges the two worlds. Rather, the listener gets ‘caught up in certain kinds of stories’ in which the personal referents, the pronouns, ‘Christ died for you’, slip up, and slip into one’s own language. Her description is deeply processual: the listener struggles to make sense of stories with uncertain references, stories that force attention onto events, past, present and future, which disrupt the normal flow of life, leaving those disruptions open and vulnerable, and making sense of them only through a religious grammar. Harding shows that the worlds of the believers and the unbelievers regarding fundamentalism are each clear and logical, but that evangelicals want to convert or save others. While it appears that from either position there is no middle ground, that you either believe or you do not, Harding insists that there is a substantial in-between position, which evangelicals describe as ‘being under conviction’. Harding describes ‘coming under conviction’ as a kind of individualized dialogic approach to status change. Similarly, the suggestion: ‘These may be signs of a serious illness’ and the question, ‘Is this a symptom?’ can be thought of as part of coming under a biomedical conviction. This ‘inner rite of passage’, Harding suggests, works ‘subliminally’ in that she and others who are witnessed to often have no idea what is happening. They are not changing status with a culture, however that is to be defined, but are instead switching cultures or worldviews.1 Finding oneself asking the question, ‘Is my cholesterol too high?’ is already such a switch. One has begun acquiring a specifically pharmaceutical language and worldview. In pharmaceutical marketing, this switch often turns on some sort of bodily hook. This is a facilitated recognition in which I come to understand that what I had previously taken for granted or overlooked in my body is in fact an object of concern. In this manner, my attention to a risk possibility and my selfconcern become linked, and the temporal fact that I had overlooked this before adds an emotional surprise and worry to the mix. The archetypal form of this identification is the ‘ouch test’ as described by virtual contributing editor Vern Realto in Pharmaceutical Executive:2

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Of course, in the world of DTC, it helps to have a product indication in which patients can point to a spot on their bodies and say, ‘Ouch!’ Prilosec [for acid indigestion] has such luck. And its DTC creative makes full use of the fact. Patient self-selection is the point. For a heartburn sufferer, looking at the campaign’s ever-present cartoon figures is like looking in the mirror. Does it hurt? Yes. Would you like 24-hour relief with a single pill? Yes! (Realto 1998: 14) The grammar of this concise description conceals the interpellation at work. ‘Patient self-selection’ is the retroactive effect of the campaign when it is successful. A person who does not consider herself a patient or even necessarily a sufferer comes to recognize a complaint as suffering and as treatable and therefore recognizes herself as a patient. Althusser called this process of coming to see oneself as having already been a patient a ‘subject effect’. I call this process, when it happens through a scientific fact, ‘objective self-fashioning’ because one’s new identity appears to have been verified as one’s real and objectively true identity (Dumit 2004). This retroactive effect can also happen at a bodily level, within a subject’s body, when an ache or complaint is reframed as a symptom. In the following description, by patient compliance expert Dorothy L. Smith, the headache is always already a symptom that the unaware consumer has mistakenly ignored. DTC ads can make consumers aware that symptoms they have tried to ignore, believing that nothing could be done, are actually the result of a treatable condition. For instance, a person who suffers from frequent headaches may learn from a DTC ad that those may be the symptoms of a migraine and that there is treatment available. Those ads can give us hope. They can help us identify positive steps to take. They can motivate us to talk with the doctor about subjects we find embarrassing. (Smith 1998) Furthermore, one recognizes that a third-party expert enabled this objective redescription of one’s ‘symptom’ as the truth of one’s experience. In addition to a subject-effect here, there is also a truth-effect. At this point in the DTC process, the target is common sense. First, in the awareness step, I recognize that heartburn is a treatable medical condition and also that I should have known this. As a fact, it should have been part of my taken-forgranted background against which I examine the world. ‘If we think there is no treatment available for our symptoms, we may decide it’s not worth spending the money on an office visit’ (Smith 1998). Now, with personalization, I see that I may be suffering from this treatable medical condition. I may be a patient. What I now know is that I am a possible patient. Realto’s account of Prilosec (above) notes that it is ‘lucky’ to have this built-in auto-identification ‘ouch’ test. Then, the problem is only one of

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medicalizing a portion of experience. The bigger challenge for marketers is producing identification with an asymptomatic condition, ‘making patients recognize themselves’ despite feeling healthy. Medical sociologists and anthropologists have long used a distinction between illness as lived experience framed by lay notions of suffering and disease as biomedical knowledge (cf. Kroll-Smith et al. 2000). The aim of risk and symptom personalization is precisely to fuse these understandings of illness and disease together so that one talks in terms of medical facts, risk factors and biomarkers, so that one literally experiences risk factors as symptoms. Will the same approach work for a cholesterol-lowering medicine? No. But if a way exists to make patients recognize themselves through any DTC communication, therein lies the first lesson in consumer heath care marketing. You can take it to the bank. (Realto 1998) The lived body must be reframed as no longer giving forth symptoms, but instead as naturally concealing them. One’s body itself, as marked or measured, then takes the place of a bodily symptom. Even a basic demographic attribute like sex, race or age can become the basis for risk personalization and marketing. In a commercial for the osteoporosis-prevention drug Fosamax, women are urged to recognize themselves first positively as healthy, active, successful and empowered, and therefore as at risk. It presents a number of such vibrant women saying, ‘I’m not taking any chances. I’m not putting it off any longer. A quick and painless bone density test can tell if your bones are thinning. If they are, this is the age of Fosomax.’ The commercial concludes with multiple female voices: Bone density test? Bone density test. Sounds like a good idea to me. Ask your doctor about a bone density test and if Fosamax is right for you. For a viewer, identifying as a positive, healthy woman becomes identifying with the risk, which must be tested since it cannot be experienced. A successful advertising encounter is one which accepts and internalizes this uncertainty under a biomedical conviction: that one might need Fosamax, and only the bone density test can tell. Targeting a slightly older demographic, a series of commercials for Zocor feature grandmothers and grandfathers, including the famous football coach Dan Reeves, discussing how much they enjoy their time but how much they want to see the future, their grandchildren’s graduations, etc. They narrate having had a heart attack and how diet and exercise were not enough to lower their cholesterol:

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I could dance all night back there. So I was thrilled when my grandson wanted to follow in my footsteps. But before our first lesson, I had a heart attack. I needed to lower my cholesterol. How will you take care of your high cholesterol and heart disease? Their doctor’s information about Zocor gives them a salvationary solution: ‘Be good to yourself. It’s your future. BE THERE.’ This mode of storytelling provides an image of a responsible rational actor who upon hearing a new fact incorporates it through concern and then action. The very act of reciting this tale repeats this process, passing on the informational possibility of risk to the listener, and the personalized possibility of taking it up responsibly. Rhetorically repeating a tale about a fact is a mode of passing on the grammar through witnessing. The tale is told in the exact words that the viewer can in turn state for themselves, to others, and to their doctor. ‘Because I want to be there.’ At the same time, the risk information is translated from an ‘odds’ sense of possibility to a powerfully imperative one of probability. If you too are a woman or middle aged, how can you not ‘be ready’, ‘get checked’’ and so on. Putting these tactics together requires a precise effort at timing the market – coordinating public relations campaigns including mass media articles and doctor awareness so that biomedical identification and pharmaceutical conviction successfully take place.

Motivation to Informing Self-diagnosis The goal during this pre-launch stage is not to motivate patients to see their doctors but to motivate them to respond for more information. (Bolling 2003) Once identification has taken place and the person accepts a possible risk as their own, marketers see the next step as converting the possible into actual risk, or in the case of symptoms, getting the patient to self-diagnose. The next step of motivation then confirms this personal possibility as a probability through some kind of objective self-assessment: a self-diagnosis through a checklist or another external tool. Self-help is promoted as a ‘free’ activity, it does not cost anything to ‘see’ if you fit the criteria. You do not risk anything, you just take this simple quiz. Ambiguities of language in ads and teaser articles aim to induce curiosity and concern about one’s apparently neutral and healthy status. Checklists and risk-factor charts are provided in DTC commercials, ads, news articles, on websites and in direct-mail pieces. The personalized patient is still a patient-in-potential, and these self-help techniques aim to create empowered self-identified patients whose next task will be visiting and convincing their doctors of their condition and need for treatment. Checklists

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empower and disempower at the same time. The paradox of checklists is that while they appear to be a form of self-help they take the question of diagnosis, ‘Am I sick?’, out of the subject’s hands. Even if feelings and experience are used to fill out the checklist, the algorithm then decides whether or not these count as objective symptoms. The score one receives thus takes the place of a lived experience of illness, the score can even become its own experience. In this manner, one comes to verify that indeed the possible risk or symptom is a true risk or symptom. One has gained not just a fact about oneself but also a vocabulary, rationale and moral judgement about the unfinished process. Checklists thus function as a kind of rite of passage. Anthropologist Victor Turner described rites of passage as liminal processes in which a person is socially unmade and then remade into a different person – a boy into a man. Within DTC campaigns, nominally healthy persons (prospects) become secretly sick persons – patients in waiting (Sunder Rajan 2007) – who are oriented towards becoming healthy again. In the DTC rite of passage, one gives up one’s sense of self and health — the body becomes a silent traitor that has concealed its condition. One then submits to the ritual of questions in order to discover that the body really is disordered. If one is sick, the promise is that one will then be treated and reunited with one’s true self and true community. This process is enacted explicitly in many DTC commercials. Figure 2.1 shows the visual images that accompany the commercial for Zoloft reproduced in Table 2.2. Pre-Pharma

Pharma Treatment

Separation

Liminality

Pharma Maintenance Figure 2.1. Zoloft Liminality (screen shot from TV)

Re-aggregation

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Table 2.2. Zoloft TV Commercial Voiceover

Audio-visuals

You know when you’re not feeling like yourself. You’re tired all the time.

Drawing of fuzzy egg (or neuron?) with sad face.

You may feel sad, hopeless, and lose interest in things you once loved.

Egg cries. A ladybug approaches egg and egg loses interest, sighing.

You may feel anxious, can’t even sleep. Your daily activities and relationships suffer. You KNOW when you just don’t feel right.

Nighttime, a crescent moon comes out and egg starts walking

Now here’s something you may not know: These are some symptoms of depression. A serious medical condition affecting over twenty-million Americans.

Text at bottom of screen: ‘Symptoms persist every day for at least two weeks’ Egg looks surprised, then then sad again.

While the cause is unknown, depression may be related to an imbalance of naturally occurring chemicals between nerve cells in the brain.

Shifts to picture labelled ‘Chemical Imbalance’, with ‘nerve A’ and ‘nerve B’ with little balls going from A to B. Text at bottom: ‘Dramatization’.

Zoloft, a prescription medicine, works to correct this imbalance.

Zoloft symbol appears as ‘chemical imbalance’ words fade, and black boxes appear on ‘nerve A’

When you know more about what’s wrong, you can help make it right.

Birds chirping, shift back to egg, who is happy and has grass growing near it.

Only your doctor can diagnose depression.

Butterfly comes and egg smiles at it, then chases it. Text at bottom: ‘Depression is a serious medical condition’.

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Voiceover

Audio-visuals

Zoloft is not for everyone. People taking medicines called MAOIs shouldn’t take Zoloft. Side-effects may include dry mouth, insomnia, sexual side-effects, diarrhoea, nausea and sleepiness. Zoloft is not habit-forming. Talk to your doctor about Zoloft – the number one prescribed brand of its kind.

Egg bounces past large Zoloft logo, chasing butterfly. Text at bottom: ‘Zoloft is approved for adults 18 and older’ then ‘See our ad in People magazine’ then ‘www.ZOLOFT.com’

Zoloft. When you know more about what’s wrong, you can help make it right.

Text says same thing with egg bouncing along. Then text at bottom: ‘1-800-6-ZOLOFT’

The story in the Zoloft commercial mimics a Van Gennepian rite of passage as delineated by Turner. The subject, ‘you’, begins separated, alienated by a series of descriptions that are aligned into accusations. The biomedical facts are then introduced in a reflexive, subjunctive voice, the voice of liminality. These may not be your fault, they may be symptoms of a biology. ‘You’ at this point in the story is in the liminal state of being both this and that, both mental and physical, accused and sick. You “know” you don’t feel right, but you need the commercial to tell you that the feeling is a real symptom. And the grammatical voice, as Turner observed, can then shift form the subjunctive to the optative, from hypothesis and possibility into emotion, wish and desire (Turner 1982). ‘There is hope’ a narrator explains, ‘treatments are available’. The conclusion of the story is of course re-aggregation, a return to society with a new status, a new, true ‘you’. These stories are sanctioning themselves through the model of the rite of passage. They have appropriated the frame of the rite and packaged it for consumption. From the point of view of Harding’s conversion, the viewer is first called on to attend to interpersonal tensions as patterned problems requiring solutions, and then offered a narrative grammar that makes sense of them. Within the story, the shifts in status function as what rhetorician Kenneth Burke (1984: 126) called a ‘conversion downward’ – in which the complex social situation of the distressed, struggling ‘you’ is given a much simpler rationality of motivation. Using a process vocabulary that overlaps in important ways with Turner’s description of liminality, Harding attempts to characterize the way in which one who is confronted by an evangelical who witnesses can ‘gradually come to respond, interpret, act, as if believing [in Jesus], with or without turmoil and anxiety’. This process is not a social ritual, but rather, it is ‘a kind of inner rite of passage’ that involves acquiring a new form of ‘inner speech’, a

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process in which one is gradually alienated from one’s old voices because they no longer satisfy the gaps one experiences. One is cast into limbo, ‘somehow in a liminal state’, she says, ‘a state of confusion and speechlessness, and begin to hear a new voice’ (Harding 1987:170). A number of commercials explicitly elaborate this concept, where a voiceover offers a diagnosis and treatment and the patient says, ‘I feel like me again’, or a loved one states, ‘I remember you!’ These commercials and hundreds like them engage in a form of biomedical informing we might call pharmaceutical witnessing. Through passing on facts embedded in stories where the subject of the story is potentially you, the viewer is put in a position of having to make sense of the story or ignore the risk it portrays altogether. Steve Kroll-Smith uses the self-test as an example in which the voice of experience and the voice of medicine are ‘beginning to converse outside of the once solid container of institutionalized medicine’ (Kroll-Smith 2003: 639). Kroll-Smith has studied the development, deployment and use of ‘excessive daytime sleepiness’ (EDS) as definite illness defined publicly through a Likert measure of excessive sleepiness, a self-test. He suggests that ‘a person who self-diagnoses with EDS after taking [self-test] ... is exercising, if only momentarily, an alternative authority [to that of modern medicine]’ (Kroll-Smith 2003: 640). Calling for a both-and approach to illness and disease, he suggests that popular media plays a crucial role in fashioning medicine and bodily knowledge. Stigma and social approbation are intimately associated with how persons come to think of themselves. Whereas Kroll-Smith uses contested diseases as examples, marketers see the same media empowerment as useful for emphasizing ‘outsider’ conditions and amplifying the power of the checklist over the consumer, and the consumer over the doctor. Marketers do not like stigma because they fear it will inhibit self-recognition of patient status and therefore reduce prescription demand. They call these stigmatized diseases, ‘diseases of denial’, implying that individual psychology is at the heart of the marketing problem. Diseases of denial can be broadly categorized as medical conditions that make patients feel excluded, rejected, devalued, inadequate, or guilty … That’s one reason pharma marketers should facilitate undiagnosed or untreated patients’ self-identification and encourage them to communicate with healthcare providers about treatment options. (Edlen-Nezin 2003) Marketers are here aligned with other sufferers who struggle to understand, accept and communicate their suffering as illnesses. Sufferers often form their own communities online in discussion groups, and offline in mutual-help groups. In these sites, they actively invent ways of living with

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their conditions (Dumit 2006; Martin 2007). Of course there are often many different groups with different approaches to the same condition. Marketers with treatments to sell actively court these groups whose interests align with their needs. They accelerate the circulation of these social innovations in ways that also help sell products. The result is often a public service ‘educational advertising’ campaign that draws attention to an illness by reifying it as treatable, and by destigmatizing it. The marketers I have talked with regularly monitor online discussions of pharmaceuticals, they hold focus groups with patients, and some of them have hired anthropologists to conduct ethnographies of diseases. They consider one of their greatest strengths to be finding a patient who eloquently expresses a private insight about an illness that accords with their mission to increase prescriptions. Their job is then to amplify that insight so that others may come to identify with it. Cutting and pasting is thus a fitting description of the general circulation and mediation of pharmaceutical experiences and practices. Communicational media, mass media, everyday discussions and research techniques feed back on one another (Strathern 1992; Melucci 1996). Turning worry into incipient action and navigating between hope and stigma thus requires precise attention to the live language of consumers as potential patients who are struggling with a concern. Perhaps more than at any other step, grammar matters when the personalized risk must become incorporated into the consumer’s identity as a patient. Individual differences among persons thus require careful scripting in order to produce a mass market. One marketer explained that the level of attention is increasingly precise: HealthMedia uses a combination of Healthcare technology and behavioral science to design ‘action plans’ that give patients tips, advice, and strategies to obtain a healthcare ‘goal.’ In essence, the action plans are the front end of a highly sophisticated customer relationship management program that can segment at the individual level so that each fragment of every sentence in the plan is customized and corresponds to how patients answer a constellation of questions. (Breitstein 2004) Michel Pêcheux, in his study of language, ideology and discourse, found that motivation and identification were mediated by specific word choices (Pêcheux 1982). In the above passage, marketers manage these processes through empirically verified texts. Questionnaires are ‘meticulously’ designed through ‘extensive market research’. Each question on surveys and checklists is a psychological tool. At the conclusion of this step, concerned consumers have become worried, self-diagnosed potential patients who know what they have and want treatment for it. From a marketing point of view, they are empowered patients ready and motivated to see their doctor.

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Convincing the Doctor, the Critical Moment Marketers can generate significant product sales by motivating physicians and patients to take action and by influencing their interaction. On the consumer side, that means * providing enough information to patients so they can convince a busy, uninformed, or disinterested physician to prescribe the brand * getting more patients to fill their initial prescriptions * motivating patients to comply with their medication regimen. (Bolling 2003) With self-diagnosis accomplished, the goal of pharmaceutical promotion is still only half-way done. The potential patient must now get to the doctor, convince the doctor to diagnose and prescribe treatment, and the patient must then take the drug and continue taking it. Marketing must now aim at ‘pass-through persuasion’, giving the patient the tools to convince their doctors. Doctors in turn, are seen as obligatory obstacles to be overcome without authority actually to make a diagnosis. Any resistance on the doctor’s part is seen as a lack of knowledge, of interest or of time. This reading may seem harsh, but it is constantly reinforced in DTC campaigns in spite of their required acknowledgement that ‘only your doctor can make the diagnosis’. Some campaigns make doctor incompetence a direct theme, where the patient has to diagnose herself through seeing a commercial and filling out an online checklist in order to convince the doctor of her true condition. The problem is that doctors also depend on these checklists which are essentially the only measure of an illness and treatment effectiveness that otherwise is not perceptible to anyone, doctor or patient. In many cases, checklists developed in order to conduct clinical research have become both marketing and self-diagnostic tools (Healy 2002). This blindness and disempowerment is all too visible in both the descriptions of emplotment of doctors by patients online – in which they discuss how to get what they want from their doctor by saying the right things – and in commercials which directly encourage such behaviour. The virtual world for the clinician is precisely the self-identified world of the advertisement grammar. As members of what Ulrich Beck calls risk society, we are prepared for the fact that many dangers are imperceptible to us, below our conscious perception, that we cannot trust our senses, but must trust instruments and other technologies of identification (Beck 1992). Medical anthropologists Cheryl Mattingly, Mary-Jo Delvecchio Good and others have shown convincingly that even as they appear to be offering patients a choice, many doctors ask questions and phrase responses that elicit the response that the doctor thinks is right. They have identified this process as ‘therapeutic emplotment’ (Del Vecchio Good et al. 1994; Mattingly

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1994). Similarly, when Martínez-Hernáez describes doctors’ conversion of patient stories into ‘a language of facts’, he was launching a critique of ‘the conversion of symptoms into physical signs; the suppression of authorship; avoidance of the message; and the meaningful intention of the complaint. In short, the intention of the reader comes to dominate, limiting the symptom to his own interpretation’ (Martínez-Hernáez 2000:248). These critiques are quite perspicacious. The reification of symptoms often results in the evacuation of the meaning of suffering and delegitimates the speaker’s authority. But as patient social movements and DTC marketing show, there is a counter-politics to this semiotics: patients often discuss in support groups and online the possibilities to take this increasingly mechanical form of diagnosis and use it to emplot their doctors, telling them exactly what needs to be said to get what they want (Dumit 2000, 2006). Martínez-Hernáez’s notion of the ‘reader’s domination’ here becomes the domination of both reader and speaker, patient and doctor, by the code or algorithm, or symbolic domination (Melucci 1996). Much DTC marketing, therefore, offers a consumer the precise language with which to accomplish this counter-emplotment. Through the focus groups, interviews and fieldwork, marketers attempt to fuse personal stories with the rules of diagnosis. Calibrated for maximum effectiveness, the scripts thus simultaneously dumb down and reify the patient’s experience into generic branded stories of suffering, and in so doing, empower them to translate these stories into effective action in their doctors’ offices — in order to get what they ‘now’ know they want. The doctors are in the end even more dumbed down and reified. For if a patient should arrive in the doctor’s office saying these words, the doctor will have little choice but to observe that the patient has stated all the right things in the right way (Kravitz et al. 2005). In a section called ‘Critical Moment’, Realto’s article describes how important this scripting is: All of the DTC communications for Prilosec aim at this crucial intersection of physician and patient. The campaign primes potential gastric reflux patients to report symptoms accurately and ask about treatment with Prilosec. (Realto 1998: 14) This situation of doctor-emplotment through witnessing was also illustrated by the Effexor XR antidepressant website (in its 2002 format). It was designed so that the first thing the viewer saw was a list of statements and was told to ‘Click on the link that sounds like you’. Choices were: ‘Maybe I’m just down’, ‘I think I should see a doctor’, or ‘I want to share my story with others’. Clicking one of these brought up a page that did nothing other than offer the words that best fit these feelings. There were no further instructions.

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Maybe I’m Just Down Does this sound like your situation? Please note: The following story is fictitious and describes a general situation. ‘After a few weeks, I knew something was wrong. Nothing really bad happened, but I was having more and more negative thoughts. At first, I figured it was normal to feel sad and empty (even hopeless) for a few days, maybe even a week. After all, I wondered, don’t most people feel down every once in a while? But I couldn’t snap out of it. I started to get concerned that something was seriously wrong. Why was this happening to me? I decided to look for some answers. ‘I learned that I was experiencing the symptoms of a medical condition –depression – and that my doctor could help me feel like ‘me’ again. I also learned that I should not feel ashamed or embarrassed because it was beyond my control. That’s when I called my doctor. ‘It didn’t happen overnight, but I really have come a long way. Recognizing that I was experiencing the symptoms of a medical condition and understanding that help was available was the best thing I could have done for myself.’ Do you feel sad and empty? Do you no longer feel like ‘you’ anymore? Perhaps you are suffering from symptoms of depression. You may find some helpful information in What Is Depression? or What Is Generalized Anxiety Disorder? and Symptoms of Depression or Symptoms of Generalized Anxiety Disorder. You might also want to use the Success Scale or see Evaluation and Treatments for Depression. www.effexorXR.com3 These pages are written in a non-reflexive manner. They are posed as fictional stories that tell your story better than you could tell it yourself. The situations are described in the past tense as personal testimony but they are grammatically precise such that in repeating them you would obtain from one’s doctor exactly what you think you want. The isomorphism of marketing is here aligned with that of patient groups against a healthcare system, that for good or ill is attempting to resist the costs of increasing pharmaceutical interventions and maintenance. The net result is the aggregate increase in patients asking for and receiving prescriptions for daily medicines. The final stage of marketing is then to have patients complete the purchase and to continue to refill these prescriptions as long as possible.

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Branded Compliance Companies are increasingly using physician-supplied patient starter packs containing user leaflets, tips, FAQ advice, and patient diaries at the initial prescribing consultation to help ensure the right patient/brand compliance from the start. Those packs create the basis of initial patient expectations with resulting patient treatment outcomes fostering repeat brand loyalty in terms of prescribing decision making and user preference. (Hone and Benson 2004:104) The final stage is the payoff – one prescription purchased and hopefully many more in the future. Compliance refers to patients staying on the prescriptions they are given and refilling them. For marketers, compliance also refers to the general gap between those who should be on life-long meds and those not. The aim at this point is to cement a relationship between self-assessment, diagnosis and branded treatment – to integrate the pharmaceutical into the everyday and reinforce a notion of dependent normality. The notion of a ‘healthstyle’, requires support from many different directions. The initial one is through community with other patients. Second, brands are proposed as anchoring a patient’s healing to future purchases. With brand loyalty comes ‘product advocacy’. Addressing those needs by providing valuable, customized information will not only foster product loyalty among patients, it will generate product advocacy. And there’s nothing more powerful than patient-topatient endorsements. Although a physician’s recommendation may be highly credible, it doesn’t carry the power of empathy and understanding that a fellow sufferer typically conveys. Great brands not only become part of patients’ health and perception of well-being, they become part of their lives. (Bolling 2003) Achieving this integration starts with knowing as much about patients as possible, and making sure that they understand ‘the need to take medication daily’, ‘how to convert education to action’, and to ‘associate their medication with being sick or well’. Above all, researchers need to determine: ‘Do patients accept that they have a chronic disease or condition and need to continue to take medication for it, or are they in denial that they need to do that?’ (Bolling 2003). Contrary to writing on chronic illnesses that stem from pain or fatigue or suffering, none of these issues are taken for granted with these lifelong pharmaceuticals aimed at asymptomatic conditions. This explicit manipulation of unfounded fears offers insight into the single-mindedness of marketing. The war here is between companies,

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branded versus generic multinationals, in which patients are the means, their minds the instruments used in waging the battle. Bolling goes to recommend: ‘Overall, the key is to increase consumers’ comfort level so they’re resistant to change if faced with the option to switch’ (2003:117).

Conclusion In liminal situations, Turner argues, we develop our grammar, ‘ways of talking about indicative ways of communicating … We take ourselves for our subject matter’ (Turner and Turner 1992: 137). Perhaps even in subliminal marketing experiences, we develop and refine our modes of expressivity, changing our minds in order to change our bodies. In addition to his careful attention to the grammar and creativity of process, Turner constantly attended to the role of the anthropological writer who must always make choices in where to locate agency in process: in the individual, the social structure, or to strive for some sort of balance. Here I have portrayed the pharmaceutical marketing encounters with an emphasis on how they can convict some people some of the time. In other work, I have stepped back, behind the focus groups to see how activists and everyday acts of creativity and resistance have shaped the terrain of the doctor-patient encounter and invented most of the forms of informing that marketing has in turn taken up and amplified (Dumit 2006). Health activist groups today are often in a dilemma as to whether or not to accept funding from commercial, especially pharmaceutical sources. Roddy Reid has described how even anti-smoking activists have been caught off-guard when they are offered money by Novartis who considers them to be helping to grow the market for nicotine patches and smoking prevention pills. Many drugs work, much of the time, for most of the people they are intended for. The issue at stake in DTC for marketers is how to continue to grow the market big enough and fast enough to keep up with investors’ expectations, often stretching the evidence from clinical trials. Many of the currently used pills do work to modulate our bodies in ways that we may not be able to describe completely, but which we nonetheless desire for curative, preventative, experiential or experimental reasons. However, we have far too little data and are not in fact collecting data as to the long-term effects and side-effects of most drugs, as to the interactions between chronic drugs, nor of the positive dimensional effects like enhanced school performance, mood brightening, and so on. Especially consider the increasing tendency to add drugs in treatment algorithms for the side-effects of a previous drug. The expressivity of the commercials, websites and marketing efforts remains my key concern. To the extent that they do posit objective self-

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identification of feelings and possible risks as symptoms, I wonder where, when and how self-talk adopts and deploys this new grammar within and alongside other modes. The topic of my ongoing work is the invention of ways of living within this pharmaceutical world. As much as marketing provides potential patients with the exact words with which to emplot their doctors into providing them with their pills of ‘choice’, people also share and disseminate counter-strategies to avoid certain drugs, to calibrate their own doses through splitting pills, and to explore alternative treatments, alternative diagnoses and alternative explanations. For the moment, though, the average patient, by which I mean the marketer’s average, comes to experience his or her body under pharmaceutical conviction. This body is silently disordered, counterexperiential, waiting to be evaluated and measured in order to speak. This body is always under construction. For more and more Americans, health is a sign of concern, health is something they must see a doctor for in order to ward off the invisible risk they have been taught to worry about. Treatment is neither an imposition or a choice, it is increasingly ordinary.

Notes 1.

2.

3.

Consonant with Turner’s distinction between liminal (pertaining to more traditional societies where rituals involve the whole social group) and liminoid (pertaining to industrial societies where individualization both flattens rituals into ceremonies and invents the social categories of leisure and the arts). The process that Harding describes is individualized and, more importantly, antagonistic. It borders on manipulation, and is not unsurprisingly called ‘brainwashing’ by those who are outside of evangelical culture and see only the external effects of conversion. Conversion as a practice, and coming under conviction as an experience, require an extension of liminality in the direction of the sub-group or competing groups within a culture – pointed to by the felicitous term, ‘subliminal’, a term that connotes a form of liminality at a sub conscious, sub-social, or social unconscious level. According to his by-line, ‘Vern Realto is a virtual contributing editor to DTC Times, a composite of regular staffers and other advisors’. As a composite, Realto thus speaks the collective wisdom of the pharmaceutical marketing industry, precisely the level of enunciation I am interested in analysing. http://www.effexorxr.com/p/p10.jhtml, accessed 4 May 2002.

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References Aikin, K.J. 2002. ‘Direct-to-Consumer Advertising of Prescription Drugs: Physician Survey Preliminary Results’. Division of Drug Marketing, Advertising, and Communications, Center for Drug Evaluation and Research, U.S. Food and Drug Administration. http://www.fda.gov/cder/ddmac/globalsummit2003/index.htm. Althusser, L. 1984. ‘Ideology and Ideological State Apparatuses (Notes toward an Investigation)’, in L. Althusser, Essays on Ideology. London: Verso, pp. 61-139 . Austin, J.L. 1962. How to Do Things with Words. Cambridge: Harvard University Press. Beck, U. 1992. Risk Society: Towards a New Modernity. London: Sage Publications. Bolling, J. 2003. ‘DTC: A Strategy for Every Stage’, Pharmaceutical Executive 23(11): 110-117. Bordo, S. 1993. Unbearable Weight: Feminism, Western Culture, and the Body. Berkeley: University of California Press. Breitstein, J. 2004. ‘A Billion Brochures’, Pharmaceutical Executive 24(2): 95–96. Burke, K. 1984. Permanence and Change: An Anatomy of Purpose. Berkeley: University of California Press. Chomsky, N. and D. Barsamian. 2001. Propaganda and the Public Mind: Conversations with Noam Chomsky. Cambridge, MA: South End Press. Clarke, A., J. Shim, L. Mamo, J. Fosket and J. Fishman. 2003. ‘Biomedicalization: Theorizing Technoscientific Transformations of Health, Illness, and U.S. Biomedicine’, American Sociological Review 68: 161–94. Conrad, P. 1992. ‘Medicalization and Social Control’, Annual Review of Sociology 18: 209–32. Del Vecchio Good, M., T. Munakata, Y. Kobayashi, C. Mattingly and B. Good. 1994. ‘Oncology and Narrative Time’, Social Science and Medicine 38: 855–62. Dixon-Woods, M. 2001. ‘Writing Wrongs? An Analysis of Published Discourses about the Use of Patient Information Leaflets’, Social Science and Medicine 324: 573–77. Dumit, J. 2000. ‘When Explanations Rest: “Good-enough” Brain Science and the New Sociomedical Disorders’, in M. Lock, A. Young and A. Cambrosio (eds), Living and Working with the New Biomedical Technologies: Intersections of Inquiry. Cambridge: Cambridge University Press. ———. 2004. Picturing Personhood: Brain Scans and Biomedical Identity. Princeton: Princeton University Press. ———. 2006. ‘Illnesses You Have to Fight to Get: Facts as Forces in Uncertain, Emergent Illnesses’, Social Science and Medicine 62: 577–90. Edlen-Nezin, L. 2003. ‘Breaking through Denial’, Pharmaceutical Executive 23(9): S18. Express Scripts. 2006. ‘Drug Trend Report’. http://www.expressscripts.com/ourcompany/news/industryreports/. Frankenberg, R. 1993. ‘Risk: Anthropological and Epidemiological Narratives of Prevention’, in S. Lindenbaum and M. Lock (eds), Knowledge, Power, and Practice: The Anthropology of Medicine and Everyday Life. Berkeley: University of California Press. Franklin, S. 1997. Embodied Progress: A Cultural Account of Assisted Conception. London: Routledge. Garfinkel, H. 1967. Studies in Ethnomethodology. Englewood Cliffs, NJ: Prentice-Hall.

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Halliday, M.A.K. 1985. An Introduction to Functional Grammar. London: Edward Arnold. Harding, S. 1987. ‘Convicted by the Holy Spirit: The Rhetoric of Fundamental Baptist Conversion’, American Ethnologist 14: 167–81. ———. 2000. The Book of Jerry Falwell: Fundamentalist Language and Politics. Princeton, NJ: Princeton University Press. Healy, D. 2002. The Creation of Psychopharmacology. Cambridge, MA: Harvard University Press. Henwood, F., S. Wyatt, A. Hart and J. Smith. 2003. ‘“Ignorance is Bliss Sometimes”: Constraints on the Emergence of the “Informed Patient” in the Changing Landscapes of Health Information’, Sociology of Health and Illness (Print) 25: 589–607. Herman, E.S. and N. Chomsky. 2002. Manufacturing Consent: The Political Economy of the Mass Media. New York: Pantheon Books. Hone, F. and R. Benson. 2004. ‘DTC: European Style’, Pharmaceutical Executive 24(3): 96–106. Kaericher, C. 2007. ‘Pharmaceuticals and Direct to Consumer Advertising’. Manuscript. Kelly School of Business, Indiana University. http://kelley.iu.edu/cbls/research/articles.html (accessed 11 January 2008). Kahn, J.Y. 1978. ‘A Diagnostic Semiotic’, Semiotica 22: 75–106. Kelly, P. 2003. ‘Health Literacy: A Silent Crisis’, Pharmaceutical Executive 23(9): S6-8. Klawiter, M. 2002. ‘Risk, Prevention and the Breast Cancer Continuum: The NCI, the FDA, Health Activism and the Pharmaceutical Industry’, History and Technology 18: 309–53. Kravitz, R.L., R.M. Epstein, M.D. Feldman, C.E. Franz, R. Azari, M.S. Wilkes, L. Hinton and P. Franks. 2005. ‘Influence of Patients’ Requests for Direct-toConsumer Advertised Antidepressants: A Randomized Controlled Trial’, JAMA 293: 1995–2002. Kroll-Smith, S. 2003. ‘Popular Media and “Excessive Daytime Sleepiness”: A Study of Rhetorical Authority in Medical Sociology’, Sociology of Health and Illness 25: 625–43. Kroll-Smith, J.S., P. Brown and V.J. Gunter. 2000. Illness and the Environment: A Reader in Contested Medicine. New York: New York University Press. Lock, M.M. 2002. Twice Dead: Organ Transplants and the Reinvention of Death. Berkeley: University of California Press. Marchand, R. 1986. Advertising the American Dream: Making Way for Modernity, 1920–1940. Berkeley: University of California Press. Martin, E. 2007. Bipolar Expeditions: Mania and Depression in American Culture. Princeton: Princeton University Press. Martínez-Hernáez, A. 2000. What’s Behind the Symptom? On Psychiatric Observation and Anthropological Understanding, trans. S.M. DiGiacomo and J. Bates. Amsterdam: Harwood Academic Publishers. Mattingly, C. 1994. ‘The Concept of Therapeutic “Emplotment”’, Social Science and Medicine 38: 811–22. Melucci, A. 1996. Challenging Codes: Collective Action in the Information Age. Cambridge: Cambridge University Press.

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Nelkin, D. and L. Tancredi. 1989. Dangerous Diagnostics: The Social Power of Biological Information. New York: Basic Books. Pêcheux, M. 1982. Language, Semantics, and Ideology. New York: St Martin’s Press. Prounis, C. 2004. ‘The Art of Advertorial’, Pharmaceutical Executive 24(5): 152–64. Realto, V. 1998. ‘Prilosec Spot Hits All the Hot Buttons’, Pharmaceutical Executive 1 May, p. 14. Sacks, H. and G. Jefferson. 1992. Lectures on Conversation. Oxford: Blackwell. Shalo, S. and J. Breitstein. 2002. ‘Science + Marketing = Branding’, Pharmaceutical Executive 22(7): 84. Smith, D. 1998. ‘It’s Our Health ... And We Want More Than Advertising’, Pharmaceutical Executive 1 July, p. 23. Strathern, M. 1992. Reproducing the Future: Essays on Anthropology, Kinship, and the New Reproductive Technologies. New York: Routledge. Sunder Rajan, K. 2007. ‘Experimental Values: Indian Clinical Trials and Surplus Health’, New Left Review 45: 67–88. Turner, V. 1982. From Ritual to Theatre: The Human Seriousness of Play. New York: Performing Arts Journal Publications. Turner, V.W. and E.L.B. Turner. 1992. Blazing the Trail: Way Marks in the Exploration of Symbols. Tucson: University of Arizona Press. Tye, L. 1998. The Father of Spin: Edward L. Bernays and the Birth of Public Relations. New York: Crown Publishers. Vasella, D., N. Bloomgarden and K. Bloomgarden. 2003. ‘Courage under Fire’, Pharmaceutical Executive 23(4): S14–17.

CHAPTER 3 Picturing the Brain Inside, Revealing the Illness Outside: A Comparison of the Different Meanings Attributed to Brain Scans by Scientists and Patients Simon Cohn

Introduction Go into an average psychiatric ward and you will not see many physical objects that could be said to represent any ongoing therapeutic intervention explicitly. There are no specific machines, no white coats, no stethoscopes around the neck. There may be some frayed armchairs, a pool table in a common room perhaps, and a notice board or two, but these mundane, everyday things do virtually nothing to symbolise the focus of clinical care. And though there may well be a range of material and immaterial objects beyond the ward that serve this function for the staff, for the patients themselves there is remarkably little that could be said to tangibly demonstrate their ill status. Perhaps the only visible ones that embody psychiatry, although they are not frequently around, are the pills and tablets that circulate during the ward round – on the ‘shopping trolley’. The pills themselves confirm the presence of illness as much as treat it (Martin 2006); they serve to reproduce a label each time they are administered, for the psychiatric nurses, the doctors who prescribe them, and many of the patients who take them. But these are relatively ephemeral as they soon disappear from view. It is not surprising, then, that the illnesses have a precarious status for many patients, not in terms of the on-going distress and suffering caused but in terms of their existence – as a thing, or entity.

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This chapter is about new objects, brain scans, which are emerging in psychiatry and gradually into the realm of patients’ lives. Through recent detailed understanding of brain chemistry, genetics and the use of imaging technologies, illnesses such as schizophrenia and bi-polar depression, which traditionally have been identifiable only by behavioural symptoms, are potentially being re-assigned as physical brain disorders that can be isolated in the body. Advocates argue that this process will not only lead to more focused treatment options but, crucially, that the stigma and associations surrounding the old indistinct category of mental illness will be replaced by the moral neutrality of physical disease. At the centre of this process of reassignment is the way in which such conditions are for the first time being conceptualized as definitive objects for both patients and researchers. I will go on to explore, however, the ways many patients reinterpret the scans as they take them beyond the lab, not primarily because they fail to understand how the images are constructed by the scientists, but because their experiences of illness demand different things to be represented. My discussion is based on ethnographic research over two years conducted at both clinical and research imaging sites in London with my colleague Jo Bichard. Fieldwork was mainly in and around a limited geographical location, namely Queen Square London. Though an apparently singular site, the Bloomsbury square consists of a number of separate internationally renowned medical institutions and research organizations concerned with psychiatry, psychology and neuroscience. It has a long history in this area; the local pub originally provided the residence for the wife of ‘mad’ King George, while during the First and Second World Wars the hospitals were important places for the investigation and treatment of shell shock and combat fatigue. More recently, the square has attracted the collaborative research of a range of institutions; in particular the NHS, University College and the Wellcome Trust where resources, including staff, are frequently shared. Supplementary fieldwork was conducted at a number of significant satellite locations, including The Maudsley/Institute of Psychiatry, the Hammersmith Hospital Cyclotron Unit,1 Charing Cross Hospital and the Institute of Child Health, all institutionally connected to one or more of the organizations at Queen Square. For the neuroscientists, making images is ostensibly about doing science – gaining objectivity through the identification of definitive material things without having to resort to the messy external subjectivity of a behaviourbased classification of disease. This project has had a long history, but has gained new momentum as technology is emerging that allows the living, active brain to be subject to apparent objective scrutiny for the first time (Leigh Star 1989). Yet the researchers are fully aware that, in truth, these objects can only ever be statistically derived and are never the result of direct investigation. So, instead, they are accepted merely as devices with which to integrate structural and functional descriptions of the brain into a

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unified model that might serve to locate the disease ‘inside’ once and for all. However, for many of the patients suffering from a range of psychiatric conditions, the conversion is differently invested as an opportunity to redress previous distress and narratives of responsibility by reclassifying their condition as any other banal and external physical illness. The role of the visual images for patients is central to how they attempt to legitimize their conditions in a new way and make them ‘real’. Hence, though the medical scientists are both modest and reticent about their current understandings, for patients the idea that their own illness can finally be conceptualized as an apparently neutral ‘thing’ is already proving to have a radical impact. Where the research was conducted, volunteer patients are given their scans as part of the enticement to participate since they cannot be paid. They usually receive the scans as a print out, but sometimes also on a CD or even as a set of files via email. The images are always the structural scans that are done at the beginning of a session, because unlike the later ones taken during a session that capture brain activity, they invariably are the most impressive in terms of resolution. What is striking is how little interest the researchers have in why the volunteers want them, or what meanings are attributed to them, especially given the fact that a scanning session is a pretty uncomfortable and claustrophobic procedure. On one occasion, because of various delays and computer glitches, it was suggested by one researcher in the office that they not actually bother giving the volunteer a copy of their actual scan, since ‘they all look pretty much the same, and anyway, a structural scan doesn’t actually show what’s really interesting’. To that, the other two scientists in the room immediately reacted, arguing that they had no choice but to honour the agreement because the patient had done their part, even though they agreed that, in truth, the scans really did not show anything noteworthy. This small anecdote demonstrates just how the researchers perceive the value of the scans only in terms of the work in the lab, and view giving the patients a copy merely a contractual duty with no other consequence or significance. Comparing scientists and patients, I want to argue that there is an apparent inversion of a standard critique of medical science that has dominated for over thirty years; that is, that it forcibly objectifies the patient and their illness, and that patients desperately try to resist this process (see for example the classic work of Zola 1972). Instead, this account will illustrate a more complex relationship, in which the uncertainty of the scientists is regularly ignored by the patients who pursue an imperative to find definitive meaning and certainty beyond the lab. As a key dimension of this, I want to argue how the role of technology is crucial to mask the very human processes involved, making the materialized object appear sui generis – and with that, not only indisputable but also mysterious and powerful so that the images might instrumentally redefine patients’ everyday experiences of illness.

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At a broader level of debate, many theorists have suggested – drawing on the cultural impact of new biotechnologies such as genetics – that we live at a time in which there is a blurring of the categories of nature and culture; or rather, nature has become encompassed within culture (Franklin 2003). It has been said that with the rapid advances in biotechnology it is now increasingly presented as more malleable, more alterable, than culture – an inversion of the old order of things. Extending this argument, new biological knowledge is being used as the grounds for individual identities and forms of sociality (Rabinow 1992). Rose and Novas (2005), for example, discuss how genetic knowledge is constructing a particular form of biological citizen. But although there may well be new, creative ways in which human communities are established, there is also an overriding sense amongst some that these advances are violently forcing them to react and respond individually, dispersing their relationships with each other through technologies that divide and categorize. The last section of the chapter will raise this possibility by showing how the promise of a definitive disease object can effectively isolate sufferers from their old forms of social life, as new understandings of illness ultimately deny the kinds of social encounter which previously shaped its presence.

Inside the Lab The initial theme for investigation, then, is to address the claim that brain imaging technology will mean that certain diseases, such as depression and schizophrenia, will soon be fully located inside the brain, through what has been termed the rise of a neo-Kraepalinian era (Compton and Guze 1995). In Picturing Personhood, Dumit traces how the emerging technology of brain scans has met with controversy and conjecture, both amongst scientists and in broader cultural contexts as the images travelled beyond the lab. Dumit’s valuable work focuses on a different imaging technology called PET,2 which has largely been replaced by fMRI that similarly captures not only anatomic structure but also metabolic activity and thus, it is said, the ‘living brain’. This more recent technique may well be less invasive, and has become much more widespread, but is no less suffused with both local and international disputes over what the data actually shows ( Joyce 2008). I want to complement this previous work on the social significance of brain scans in many aspects of contemporary culture (Dumit 1997, 2003), by concentrating not on how they are now used to convey new claims of personhood but rather new notions of illness, and in particular what patients themselves quite literally make of them. As Lorimer describes in this volume, scientific images inescapably have layers of cultural meaning attached to them. She further points out that

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currently images of the brain seem to have a very special place in western culture; they seem to insist on having something immaterial, or ‘ghostly’, added to their materiality. This supplementary layer of significance may well be because images of the brain serve as iconic amalgamations of technoscientific accomplishment and an affirmation of ideological individualism. Though apparently neutral biology, they allow for a particular modern cultural fascination with the transparency of the self to be played out in popular culture (Van Dijck 2004). Yet one danger in such an argument is that it potentially suggests representations in science are in this way somehow ‘polluted’, that they can ever exist devoid of these cultural interpretations, or that scientific representations themselves are not, from the outset, constructed through negotiating and employing different sets of values. In contrast, the edited volume by Lynch and Woolgar, for example, presents a range of examples which reveal how the process of creating scientific representations is always about integrating multiple purposes and meanings (Lynch and Woolgar 1990). Throughout the text, via a wide range of examples, it is evident how often the resultant inscriptions hold in tension the tasks of assembling a variety of practices and knowledges – summarising only that information which is sufficiently stabilised. It is clear not merely that such representations are necessarily partial, but it is only through this that they ever convey meaning. Beyond this, the volume is also an invitation to think about the ‘looping effects’ representations inescapably have on objects of enquiry in science, and thus the extent to which it can ever be completely differentiated from that which it is charged to represent. As a result, I want to describe how the construction of brain scans is inevitably the result of values and ideals, as well as facts and data. In actuality, the imaging scientists are themselves largely aware of this, and perhaps it is this that explains why they are surprisingly reticent about the contribution their work may make to a new biological understanding of psychiatric disorders. Despite the expeditionary fervour that accompanied the pronouncement of the Decade of the Brain, and then the Decade of the Mind (Rose 2006), most neuroscientists are unexpectedly cautious about claims of any imminent widespread clinical application even though many assume that the technology will become a central means for diagnosis in the future (Liddle 2001; Morihisa 2001), and thus reconfigure the principles of the Diagnostic and Statistical Manual (DSM).3 The general daily sentiment of researchers contrasts with this rhetoric. The present-day application of neuroscience to psychiatry by detecting material disease objects, defined discretely, is necessarily uncertain because it challenges the dialectic between what is ideal and what is pathological, which currently operates as a key productive tension in the construction of the fMRI scans. It is the play of these two values that are at the centre of how the images are created, and

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consequently it is precisely an implicit awareness of this which creates the uneasiness amongst the majority of researchers. In contrast, for patients it is precisely this ability for the images to contain multiple values which makes them meaningful at all.

A Productive Tension A leading neuroscientist investigating schizophrenia explained, in conversation, how at present, all the research was being done on patients already diagnosed with conditions: ‘We’re currently just looking for the abnormalities in brain function that can reliably ... statistically ... be linked to the condition’. He went on to explain, however, that, ‘we’re continually trying to move, well, what I call “upstream” ... from merely finding associations to actually providing greater understanding of the condition ... and hopefully, eventually, to actually using this technology to make diagnosis itself’. He went on: ‘But it will always be a statistic diagnosis, one of probability, never certainty.’ In sum, this scientist’s view, which is shared by many, is that though at present the technology is merely replicating and endorsing current medical practice, the purpose is that it will rapidly shift towards becoming an instrumental part of clinical practice itself. Acknowledging probabilistic uncertainty, rather than claiming definitive certainty, is nothing new in medicine. Many ethnographic studies of medical students describe how they gradually learn and are socialized through lectures, texts, images, models and cadavers according to the identification of what is ideal and what is pathological (see, for example, Good 1994; Sinclair 1997). In the process, biomedical practice is constituted – each actual clinical case being negotiated according to evaluations betwixt. This echoes the work of Canguilhem (1991), which emphasises how diseases are historically defined according to degrees of toleration, in which measures of deviation and the identification of thresholds are always culturally sanctioned (Ernst 2006). The point is that medical knowledge of the body is always constructed through trying to establish this distinction and, in that process, it creates a space for what can be conceptualized as normal or deviant in daily practice. I wish to take up the argument that, with the recent rise of biological psychiatry, this tension is potentially being introduced in a very specific way in relation to how mental illness is conceived (Rose 2001). The traditional way of conceiving mental disorder is largely in terms of evaluating behavioural deviations that are present or absent, and so making judgements on the quantity and qualities of divergences away from a standard (Mezzich et al. 1996), as encapsulated in the DSM and its multiple types of criteria. Though mirroring the diagnostic practice of physical conditions, singular

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causes can rarely be established as the classification system means different aetiology can often lead to the same symptom pattern. Finding the biological basis for mental illnesses consequently promises to eradicate this open nature by establishing a more rigorous system based on the nature of the body and not the judgements of the person. Over the last twenty years there has been an explosion of very different neuro-imaging technologies, attracting not only hype but an increasing proportion of funds as the technology becomes ever more complex. This history is clearly a story of increasing detail and accessibility, and of rendering the invisible ever more visible. But the dissection knife traces divergent developments; in addition to the identification of specific structures of the brain, types of tissue, and the structure of cells, it also charts the recognition of networks and pathways. Correspondingly, on the one hand the technology is being used to investigate a huge variety of psychiatric and brain disorders, yet on the other it is dedicated to establishing the most clear, detailed whole-brain atlases of normal brain structure and cognitive function. But both projects contain contradictory practices, and serve to shape different research cultures based on what should be investigated and what can be known (for further discussion of different research cultures, see Knorr-Cetina 1999). Within investigations into the pathological, increasing anxiety revolves around the central validity of the exercise – to what extent mental illness can serve as a valid baseline from which to apply the materialist model. Research into the idealized healthy brain is no more secure; here, the main concern is with the ever-changing prototypes, averages and models. The normal brain is unsettlingly perceived as a variable entity, leading to a never-ending cycle of identifying and propounding the neurological standard through the inescapable variation of individual scans, and the gradual accumulation of data into a virtual ideal. Thus, there are two associated concerns which reflect the general tensions between the pathological and ideal; for some researchers it is articulated through negotiating the boundary between what is a physical pathology and what is a mental disorder, whilst for others the same tension is reconfigured in terms of what is the abstract ideal and what can be defined as normal. Such considerations are neither specific to contemporary neuroscientists, nor to this period of biomedical history. In obvious ways, the division is frequently reproduced within the remit of current research sites; some specifically investigate the normal brain, trying to map its complete structure in terms of heightened function and associations across regions, while others focus on pathology and illness, and try to establish the specific areas that give rise to specified diseases. But the productive tension also frequently exists at each site in daily practice; each normal scan is both compared to, and also contributes towards, a model of the ideal. Equally, the analysis of each variation of the brain serves to call into question the status of the

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pathological, the boundaries of health and the significance of traditional signs and symptoms of disease. The simple question arising from this is whether – with the new technology that captures activity and function as well as complex physiological form and delicate structure, highlighting variation as much as similarity, systems as well as parts – these themes of what is pathological or ideal are already being reconfigured as the technology potentially shifts ‘upstream’. In other words, to what extent can the production of an apparently stable and distinctive object of illness be classified with any certainty at all? Consequently, in private conversation, brain-imaging researchers are on the whole more wary about the relationship between the burgeoning technology, understanding the normal brain and the identification of disease, than the rhetoric that they may publicly extol. Central to their caution is a different conception of what the connection between functional images and a psychiatric condition may mean – what it actually constitutes. As one researcher said in almost an apologetic tone: ‘All we are trying to do at the moment is register statistically significant associations … It can never be definitive’. Another researcher stated: ‘The data, rather than the images, are open to different interpretations … You can do different analysis and get different results, within a certain range, I mean. It’s not straightforward.’ Though the pictures have an apparent direct simplicity to the outsider, the final image is, in fact, the result of many different decisions, calculations and manipulations. Since the advance of tomography in the 1970s, powerful computers have played the essential role of processing the vast amount of data obtained. The issue has throughout been a problem of determining what to do with the sheer quantity of data gathered that must be rendered intelligible. Thus, the development of new technologies and computer systems has in some senses been, counter to what one may assume, to provide less information: researchers spend much of their time ascertaining what may be jettisoned as noise, extraneous factors, irrelevant material, and so forth – processes of distilling, rendering and filtering. This integral ambiguity is, then, in contrast to the general view of a truthful photograph in which the fixed temporal order of its construction secures the authority of the image. This narrative no longer holds: it is not simply the fact that they are ‘digital’ that is the key, but that any one image constructed is only a small proportion of the information obtained by the scanner. Consequently, the neat linear authorial order no longer exists – it is ever flexible and malleable – a process that, from the outset, is a subset of the data collected by the scan that can be reconfigured and recast over time. The gigabytes are all carefully archived – available for new processes and new claims of representation in the future. The infinite degree of post-scan manipulation and interpretation has proved problematic; the technology not only allows, but virtually invites as many post hoc analyses and image

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generations as an investigator might want. As one neuroscientist argued: ‘It’s very frustrating, because you always have to make choices and choose thresholds … brain activity is always a continuum, its not that you see it in someone and you don’t in another, it’s just how you quantify the difference’. Though this potential fluidity is currently a cause for concern, and is generating a fairly hostile war for the standardization of software, methodologies and scanning techniques both in the U.K. and internationally, it also provides a beneficial degree of freedom; individual scans are not only related to the cohort conducted for a particular study, but can also be compared and conjoined to the growing bank of data that has been collected over time. In this way, contemporary neuroscientists are keen to encompass both reductionism and holistic paradigms to tie structure with function, and embrace the new emerging multi-disciplinary field. As one clinician put it: ‘I suppose I want to indicate to people that it’s not just looking at what part of the brain is used in this or that – you’ve got to put it into the context of how it can be used … it will give both an insight into how normal brains function and then why people have certain deficits and abnormalities.’ The productive tensions described between the ideal and the pathological, the living and the inert, the whole and the part are clearly being renegotiated in such comments. Though apparent in the experimental designs and research reports, the dichotomies can now be contained within the technology itself. Thus a researcher can switch between identifying a key site through subtracting one scan from another, or produce a generalized one through adding them together. Any clear distinction between what is normal and what reveals pathology collapses: there are no truly ‘normal’ brains because that is a developing ideal with which the mess of actual data is constantly compared and modelled. Equally, the degree of variation from the idealized normal, with which to demarcate any pronouncement of pathology, is also correspondingly less clear-cut. Different procedures and manipulations with the complex routines at each stage of image generation result in diverse things on display in the final image; frequently, researchers shift back and forth through various statistical and graphics packages in order to determine at what stage, and in what ways, a scan can be reliably said to exhibit pathology. Though regarded as a powerful tool, this effective collapsing of the two traditional positions can generate much anxiety. Researchers talk about ‘good’ scans not only in terms of the clarity of the image, or the focused localization of activity, but now also in terms of to what degree the scan can confidently be said to be of a normal or an abnormal brain. In everyday practice, researchers using the imaging technology therefore steer well clear from identifying illness per se, save for clear structural abnormalities. The pictures, sometimes even referred to as photographs, are therefore just as frequently dismissed as, in

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the words of one scientist, ‘merely window dressing’. And, as a final demonstration of prudence, every research claim is framed as a statistical result, a tendency, a matter of approximation.

When Patients See Their Illness In the second half of this chapter I want to explore a set of opposite themes. Overall, and in contrast to the scientists, for patients the central issue is not that the scanning technology might serve to locate illness within the brain, but that through biology the images can actually serve to make the illness external. Not surprisingly, non-experts being scanned see the technology and the images in very different ways, embedding them within existing beliefs about their body, mind and illness. All the people interviewed in this study were officially volunteers; that is, their scan was not intended to affect treatment options or diagnoses, save for the very rare instances of discovering a clear structural abnormality such as a tumour. These patient-volunteers had a range of conditions and participated in a range of research experiments. For the researchers, they are simply representative examples of people suffering from particular afflictions, whose scans might provide important understanding into one particular chemical or region of activity under carefully controlled conditions. But for the patients, the scans had a quite different, and personal, significance. At most sites the patient-volunteers are given a copy of the scan to take home as a kind of thank you gift, either in the form of a printout or sometimes on a CD. For them, the scans are frequently used to endorse a categorical separation from their disease rather than serving to blur any epistemological distinction between health and illness, or pathology and normality. Thus, unlike the more tentative position of the neuroscientists, for many patients the representations are already given an active role. As one patient suffering from depression reflected: ‘I’m curious … You know, people have parts of their body that are more or less important to them. Mine is always my brain … it’s who I am and my body to me’. Though virtually all are adamant that they see nothing ‘wrong’ with their condition being considered a mental or psychological condition, the imperative is clear: to establish a physical basis for their suffering, and in so doing to potentially find a way of re-conceptualizing their suffering – both in terms of cause and how it might be lived out through interactions with others. In this way, the distinction between the self and the body, the I and the other, is swiftly mapped over the division between mental and physical, necessitating the disease to be external, even if it resides on the inside. So, when someone holds their brain scan in front of them, they tend to assume, irrespective of the complex technical processes, that it is a straightforward picture

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of inside their head: ‘I think its weird – to think that that’s me, inside, [and] that those colours show what I’m thinking.’ The complexity of the imaging technology that forces the neuroscientists to resist definitive claims or identify singular sites of disease is not incorporated within the sufferers’ interpretations. Instead, they only respond to the hype and the awe of the technology to see the precise identification and location of disease, as a thing; something particular, bounded and separate from the self. A woman suffering from bi-polar depression relayed this conviction of gaining apparent medical certainty in the following way: I did think to myself, ‘would it show up on the scan? Which part of the brain is it that’s causing the depression?’ You know, can you just point to something and say, ‘That’s your depression’? But they know where to look for it, cause the brain’s been so thoroughly mapped … they’ll know where to look for the tell-tale things of whatever it is that they’re looking for ... I mean it’s not just a case of (points to scan) that big blue bit or that tiny red bit is – it’s, it’s like exactly where it is that’s gonna be the thing that gives it away. As this person so evidently expresses, for many people with a psychiatric condition the technology is valued because it is seen objectively to demarcate mental from physical illness. The image is uniquely useful to this process because it reveals the location of the illness with a directness that only an image seems to have – parting out, disembodying, and allowing it to be conceived as an alien pathological entity that hitherto had lurked inside. So it is that just as the images go on to have a life at the research sites, being standardized and averaged out, perhaps being used for illustrative purposes in a presentation or publication, and always being stored for future manipulation, they also take on a social life when taken out of the research sites by patients. Far more than mere trophies, for those suffering from an illness they are objects carrying immense significance; their illness is thought to be captured, contained by the scan on the surface of the paper. This itself is potentially therapeutic, a mechanism to redefine the whole well self from the diseased part. As one such person suffering from schizophrenia pronounced in front of me, ‘I just feel the need to do it, to make something of my illness – it’s like the illness is me, and it wants me to do it.’ In part, this is a simple story about the authority of science. But inaccessibility to knowledge is intertwined with the apparent veracity of the image, which despite its highly constructed nature takes on the appearance of a readily knowable source of representation. It is the very fact that patients are not aware of all the various stages in the image’s creation – the different technical steps essential prior to the scan, the software necessary to clean and filter the data, the statistical programmes that establish levels of probability from each threedimensional point in the procedure, and the different processes that finally

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model the information to generate a representation. But for the patients, the image, like any photograph, is invested with a kind of autonomy. The highly complex machinery provides a clarity of seeing and thinking about disease categories that hitherto had to be hazy. They see the images as proclamations that their illness can now be visually identified, pointed to and potentially acted upon in a way that contrasts with traditional methods of diagnosis and interpretation, and therefore potentially free from the illness they currently experience. As one forty-year-old man, who had had schizophrenia for most of his adult life, said staring at his scan for the first time: ‘This feels like something really important. A new beginning, in a way.’ Though the scans don’t actually influence their clinical encounters, the processes of diagnosis itself is imagined to have shifted from the realm of human subjectivity and interaction to one of apparent objectivity via the hardware and the vastly complex mathematical algorithms used to identify brain abnormality. It is not surprising, therefore, that many patients echo the sentiments of the following person, on seeing their MRI4 for the first time: ‘I am just really grateful that there is proof now about my schizophrenia ... It’s there, on the scan, and no one needs question it any more.’ This imbued sense of certainty emanates from the illusion, largely colluded with by the researchers themselves who are anxious to demonstrate their expertise to the volunteers, that somehow the images are divorced from the many people and technical decisions involved in their construction. The formation of a technology that appears to work independently, and the apparent disappearance of processes of interpretation and ambiguity, allows the transference of technological impartiality: the object-ness of the machinery is transferred to the object-ness of the condition. For many patients this logic is sufficient to feel that the image demonstrates the ‘discovery’ of a visible illness serving to authenticate their condition, even if no expert has actually said the image demonstrates any such abnormality and even if they can make little of the blurred shapes and unfamiliar outlines.

Outside the Lab However, for patients the apparent endorsement of a language of objectivity for their suffering is done not necessarily simply because biological reductionism tidies their illness construction and eliminates messy aspects of their lived experience but crucially because it allows them to introduce their condition into the social realm in new and innovative ways. For them, the technology allows a re-articulation of what is conceived of as internal, and thus only personal, with what can be made external and consequently an object with which to shape relationships with others. I asked one patient, a forty-three-year-old woman who had suffered from depression for over twenty years, about what she did with her scans. As she

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spoke she dipped down into her handbag: ‘I keep a small copy of this in my purse… it’s nice to have it with me all the time – on my person. … In fact, to be honest, I don’t really know what it shows or anything – it’s just really comforting to have it with me.’ People keeping the images with them is not uncommon, and suggests the very private meanings given to the images. Latour makes reference to this very act of carrying around a brain scan in a pocket in his discussion of how common it is to try and identify what might be considered primary or elemental qualities of the body (Latour 2004: 224). His argument is that finding ways to isolate what one considers most significant is not necessarily the same thing as subscribing to reductionism or objectivity at all; one could say it is more about finding a way of slicing through all the various potentials of the body rather than trying to establish what might lie definitively ‘underneath’. Similarly, for the patients here, the meaning attributed to the scan is complex and multiple. Certainly, through the image the illness takes the form of a concrete pathology that potentially frees patients, not merely from the stigma of their illness but from the conflation of the person and the condition, and other ways in which relationships with their bodies can be conceived. The image both locates and contains the illness but consequently allows it to move to the external, and in so doing can now be a social object. The illness, and the person, are consequently both relocated and divorced from each other. It is important to note that in my research I also came across patients who vehemently reject the current expansion of modern biological psychiatry, and who argue that their illness can only be understood and treated as a social condition. They would not participate in the neuroscience research, and were unconvinced by the idea that this knowledge might one day lead to a better understanding of their condition. By definition, they were not in the labs or research sites where we conducted fieldwork, and had to be contacted independently, usually through local support groups. These patients have no single feature in common – it does not appear to correlate with their illness, age or background. But they all see the rise of such things as brain imaging technology as a crude limitation of what constitutes their illness, and as pursuing a costly and restrictive model that will never be able to encompass their day-to-day experience. A number of user groups reiterate this position, which has catalysed a revised anti-psychiatry critique as new biotechnological developments have progressed (Crossley 2006). I do not wish to ignore their views at all, but instead I want to demonstrate how those patients who apparently endorse the new biological models actually do so according to their own interpretation of the knowledge and its potential to affect their lives. In this way, their position is not as far removed from those who reject the biological model as one might first assume. Rather than endorsing the reductionist model per se, the many patients who seem positive about current developments in neuropsychiatry are enthusiastic

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precisely because, for them, it offers a potentially steadfast and compelling means to reconfigure the illness in their social world. While neuroscientists are currently describing only how the new knowledge will eventually become an integrated part of psychiatry, as the technology and the research gradually shifts from merely description of current classifications to becoming instrumental in diagnosis itself, many patients are already using and interpreting the current claims to redefine radically the notions of their illness to themselves and others in their daily lives. It is this apparent inversion of the scientific project that I wish to explore through the rest of the chapter. Beyond issues of recognition and objectification, the images take on even greater significance as the patient takes them away. Like all other material objects, their meaning is contingent on their context, and in particular the social life that is threaded through them (Appadurai 1986). For those who are suffering, they are objects carrying enormous significance; their illness captured, contained, by the scan. But outside they lab they are also available as an external entity for themselves and others to comment on. Frequently the images are treated as though they are regular photographs, and put into albums or even framed and put on the wall. Scans might be lined up alongside photos of children, holidays or a wedding. In addition to this, though, what is striking is just how common the desire to do something actively with the image is, as though making the illness concrete and distinct at a conceptual level is not enough: ‘I’m going to frame it to keep it nice and hang it in the loo … It’ll become a talking point, although mates will think it’s just the kind of thing I’d do.’ And, ‘All my family are gonna get T-shirts with my brain on.’ The different creative things done to the scans frequently appear as therapeutic, a mechanism to publish or demonstrate. It is as though the many various activities serve as means both to appropriate them and convert them, so that they can be incorporated into some part of people’s life as something that is active and performative. Gell’s much cited discussion of the agency of art objects is particularly pertinent here (Gell 1998). Whilst not obviously a form of art initially, the work that many patients do to the scans can be interpreted as a method of applying their own personal agency to them, such that the appropriated image acts as an extension of themselves in the social life that then surrounds them. In this way, the scans become dynamic objects that can be used to initiate new ways not only for themselves to think about their own condition but also potentially serving as invitations for new ways to engage other people too. Talking to these patients in their homes about their scans invariably leads them soon not to refer to the images at all but to the ways in which they have catalysed new conversations with friends and relatives. By means of the images they are able to talk about the illness as an external object that exists

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not merely outside them but between themselves and the people with whom they are enthusiastically talking. The images are shown to friends and alongside other more regular family portraits. In this way the scan serves not simply as physical conversion but also as a vehicle that can convey private subjective suffering within the social world. Through these new opportunities to engage, the illness is mediated in a new way by the proximity that can arise by the very materiality of the scan that has been acted upon – that can be touched and held, carried and stroked. Yet also the agency of the object now means that it is something external and distant, providing a means for thoughts and communications to be reflected and refracted in the space between people. Unfortunately, however, for some this is not as stable a process as one might imagine. A few of the patients, who previously had been so enthusiastic about this technological intervention, gave later accounts that resembled narratives of betrayal. After these transformations the person is still not necessarily interpreted by others as healthy, even if they no longer regard themselves as intrinsically ill. Though apparently free from many of the dynamics that previously shaped their conceptualization of illness, the clear and static images can soon be layered with new more problematic social meanings. Although the appropriated scan promised to provide perhaps completely new ways of thinking about their illness, and new ways with which to relate to others, the idea that the illness is ever ‘contained’ or ‘material’ for some of the patients we followed up with some months afterwards proves to be ephemeral. For example, as one man suffering from bi-polar depression said in an anguished tone: ‘In the end, I’m not sure the scan really shows anything. I mean, people ask me about it, and I point to bits I’ve learnt, but it doesn’t really mean much to me.’ This despair suggests that what constituted the illness soon shifted from being a simple biological representation, since in the end it required the recognition and affirmation of others as much as the patient themselves. For him, and others, the drive to define their illness as organic opposes how in their social life this must be shaped as something that exists over time and through the encounters with others. This suggests that the boundedness created by trying to define a mental illness as physical can frequently become a trap precisely because for those who suffer, the limitations of adopting a biological model of their condition as an object prevents any further participation for it to be negotiated socially. One patient described this in detail to me. He had suffered from schizophrenia for over ten years, and had been more than willing to participate in the imaging research precisely so he would be able to have a scan at the end. But what he soon sensed was that afterwards others were not willing to accept the significance of the image as anything long-term, and disputed with him that it did in fact show his illness as, in his words, ‘something solid inside the brain’. He went on to describe at length the scorn

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he received, and his inability to understand why other people, including other sufferers were so hostile to his enthusiasm for the technology. Invariably it seems that these patients who are committed to using the scans as a way of radically rethinking their illness actually have new difficulties to face. For example, some continue to go to user- and supportgroups, but when they try to argue for this new biological claim for their suffering have new found social distances to deal with. As one told me: ‘I wanted to show everybody [in my user group] ... I thought it would help them, as well as me. But it made some of them angry – I still don’t know why exactly.’ Many of these patients speak about being frustrated and painfully disappointed that others do not acknowledge that their illness could so unambiguously be transformed. A paradox is frequently apparent; that patients wanted to use the images to find ways of divorcing themselves from the illness, yet the illness itself refuses to be redefined because in the end it emerges not from the internal body but the nature of the person’s social relationships. The result is that new alliances and associations are sometimes made; often against the clinical definitions of the illness, but following on from the investment made in the image, and the sense that it is an externalized object of their condition. Although only a few instances came to light, some patients, unbeknown to the researchers, tracked down other volunteers who had had a scan. Even though they may have been diagnosed with different conditions, they felt that, through the technology and their commitment to its transformative potential, they shared something important in common. As one female patient described, because her hope that the images might catalyse new relationships with her husband and children did not transpire she felt a special kind of affinity with other patients who had been scanned, whatever their actual condition. Her story, and others that have been mentioned, suggests that what frequently happens is not that patients’ illnesses are conceived in straightforward physical terms but that the particular hopes inscribed onto the image for circulation in the social world are frustrated. Mental illness, as a general cultural category, is as much a moral as a clinical one, and so invariably escapes being contained by a material representation of a brain. The image simply serves as a new nexus for cultural values without ever radically shifting the complex set of meanings that are associated with it. Perhaps these patients’ experiences in a sense parallel the method of obtaining a good scan – that the more it is framed and made sharp, the more things must be obscured or eliminated. For those patients who celebrate this opportunity, then, it is precisely the exclusion of certain dimensions of their illness that appears to give the biological promise its remarkable appeal. But old categories are soon active, as the apparent redefinition of illness through biological reductionism actually forces a renewed acknowledgement of the social nature of their suffering. Though the object appears to offer neutrality

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by escaping their own subjectivity, it nevertheless is soon overlain with meanings and interpretations – even if these are not immediately visible. Thus the image serves only to offer an appearance that masks and distracts the continued ways in which the illness is given a social, if frequently uncomfortable, meaning; the image merely serving as a vehicle of conversion not from subject to object – as is hoped – but from one cultural classification to another, in which it is less visible.

Conclusion Critics have been concerned that with the rapid increase in brain imaging techniques, the traditional basis of psychiatric diagnosis will be overtaken by crude biological reductionism. I hope to have indicated that the cultural basis of the categories themselves may, in fact, be revealed by the remarkable new techniques. Both in the lab where the new knowledge and resulting images are produced and beyond when patients take them home, the scans inescapably are an entanglement of both the moral and biological dimensions of what is identified as mental illness. Because of this, the scans can never present a condition free from the expectations and judgements that not merely surround but actually constitute the illness a person suffers from. To return to the ethnography in this chapter, whilst the neuroscientists may publicly extol a promissory rhetoric, in their everyday practice they are both more hesitant and conservative. Their reflections reveal an acute awareness of the multifaceted nature of the categories they are trying to pin down, and recognition that, in the end, what they produce are only ever probability maps between what is normal and abnormal brain activity. In this way, the notion of establishing a definitive disease entity, and an unambiguous biological description of a condition, is effectively denied. Yet, if this current hesitancy is derived from the proximity of the researchers to the methods of brain-image production, the real question is, as the technology becomes more widespread and distributed within the health service, whether this awareness is likely to decrease, and instead the knowledge, in the form of a final image, will be taken as unproblematic. In contrast, many patients initially embrace the scans with a greater optimism in their therapeutic potential. My central point, however, is not a straightforward one that they merely do not understand the complexities involved in the images construction. Rather, by exporting them from the lab to different social spheres, the scans are inevitably used to do much more than simply establish an incontestable disease entity, since this is only meaningful to them in terms of how it might potentially redefine their overall illness experience. But the hopes with which the images are imbued often prove all too ephemeral. As patients take the scans into a range of

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social contexts, it appears the representations have little lasting power to shift entrenched values and judgements of others, precisely because these emerge from the established relationships between people, rather than arise from the potential authority or otherwise of a single object. Overall, what I have recounted should be seen as a direct consequence of an inescapable logic, that a mental illness such as schizophrenia or depression can just never be converted into a single stable object, extracted from the entanglements of the person and their social world. To try and find a way of distilling out the condition from the person, the disease from the illness, is not only a theoretically flawed task but one that has a number of unintended consequences. It is not surprising that the patients discussed here only want a physical explanation; but in so doing, they are only ever making their illness take on the appearance of a disease object. The apparent clarity of the object is its very trick, since it appears to convey the materiality of something which only ever, actually, appears as such through the messy processes of social interactions. It is clear then, that my concern is that the object-ness of the scan is not only illusory but potentially damaging. The science of brain-imaging technology is advancing far more rapidly than our understanding of its consequences and patients’ attitudes towards it. The fear is that oversimplified neuroscientific representations will nevertheless take over traditional psychiatric practice and envelop various mental conditions within new claims of objectivity without ever ameliorating patients’ distress. The potential deletion of compounding socio-cultural features, through the hype associated with this technology and the starkness of the final images, must consequently remain a real current concern. That technology should not be considered merely physical equipment but rather a whole set of interrelated things, procedures and even values and beliefs, all put to work, is an obvious statement on which to end. But, as the power of penetrative visibility increasingly dominates the idea of what it is to know, it all too easily might dismiss the central role of subjective experience and social interaction in relation to suffering and illness through the creation of apparently definitive objects of disease.

Notes 1.

A cyclotron is a type of particle accelerator used to produce the radioactive tracers needed for a particular type of three-dimensional scanning technology, called Positron Emission Tomography (PET). Because of radioactive decay it is usually necessary to have the accelerator very near to the place of the scan; Hammersmith hospital has its large cyclotron in the basement.

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Positron Emission Tomography is based on the spatial detection in the brain of a radioactive tracer attached to one of a range of chemicals associated with neural activity which is injected into the body just before a scan. While it still has important advantages as a technique because it can help reveal the specific neurochemical basis of types of brain activity, its resolution is poor, and the delay between stimulus and visual representation often unavoidably slow. The Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Disorders, is a coded taxonomy that parallels the mental disorders sections of the International Statistical Classification of Diseases and Related Health Problems (ICD), published by the World Health Organization. The DSM has had major revisions since its initial publication in 1952; the last complete one, the DSM-IV, came out in 1994, while the DSM-V is due out in 2012. Of interest here is that each iteration has not simply been an augmentation of the number or hierarchy of categories but crucially has reflected changes in the underlying psychiatric reasoning concerning what constitutes an indicative clinical symptom, and how collectively they can serve to identify an underlying discrete disorder. Magnetic Resonance Imaging (MRI) is a type of medical imaging technology that does not use radioactive tracers but instead relies on the way water molecules in the body can be aligned by huge magnetic fields and then be made to release tiny amounts of energy when they revert their orientation. Computer software uses the data to create detailed three-dimensional images. A variation, fMRI, specifically registers differences in blood flow, and consequently is interpreted to indicate the actual function, as well as structure, of organs such as the brain.

References Appadurai, A. 1986. ‘Introduction: Commodities and the Politics of Value’, in A. Appadurai (ed.), The Social Life of Things: Commodities in Cultural Perspective. Cambridge: Cambridge University Press, pp. 3–63. Canguilhem, G. 1991. The Normal and the Pathological. New York: Zone Books. Compton, W. and S. Guze. 1995. ‘The Neo-Kraepelinian Revolution in Psychiatric Diagnosis’, European Archives of Psychiatry and Clinical Neuroscience 245(4–5): 196–201. Crossley, N. 2006. Contesting Psychiatry: Social Movements in Mental Health. London: Routledge. Dumit, J. 1997 ‘A Digital Image of the Category of the Person: PET Scanning and Objective Self Fashioning’, in G.L. Downey, J. Dumit and S. Traweek (eds), Cyborgs and Citadels. Santa Fe: School of American Research, pp. 83–102. ———. 2003. Picturing Personhood: Brain Scans and Biomedical Identity. Princeton: Princeton University Press. Ernst, W. 2006. Histories of the Normal and the Abnormal. London: Routledge, Taylor and Francis. Franklin, S. 2003. ‘Rethinking Nature-culture: Anthropology and the New Genetics’, Anthropological Theory 3(1): 65–85.

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Gell, A. 1998. Art and Agency: An Anthropological Theory. Oxford: Clarendon Press. Good, B. 1994. Medicine, Rationality and Experience: An Anthropological Experience. Cambridge: Cambridge University Press. Joyce, K.A. 2008. Magnetic Appeal: MRI and the Myth of Transparency. Ithaca: Cornell University Press. Knorr-Cetina, K. 1999. Epistemic Cultures: How the Sciences Make Knowledge. Cambridge, MA: Harvard University Press. Latour, B. 2004. ‘How to Talk About the Body? The Normative Dimension of Science’, Body and Society 10(2–3): 205–29. Leigh Star, S. 1989. Regions of the Mind: Brain Research and the Quest for Scientific Certainty. Stanford: Stanford University Press. Liddle, P. 2001. Disordered Mind and Brain: The Neural Basis of Mental Symptoms. London: Gaskell Press. Lynch, M. and S. Woolgar (eds). 1990. Representation in Scientific Practice. Cambridge, MA: MIT Press. Martin, E. 2006. ‘The Pharmaceutical Person’, Biosocieties 1(3): 273–87. Mezzich, J., A. Kleinman, H. Fabrega, and D. Parron (eds). 1996. Culture and Psychiatric Diagnosis: A DSM-IV Perspective. Washington, DC: American Psychiatric Press. Morihisa, J. (ed.). 2001. Advances in Brain Imaging: Review of Psychiatry. Washington, DC: American Psychiatric Publishing. Rabinow, P. 1992. ‘Artificiality and Enlightenment: From Sociobiology to Biosociality’ in J. Crary and S. Kwinter (eds), Zone 6: Incorporations. Cambridge, MA: MIT Press, pp. 190–201. Rose, N. 2001. ‘Normality and Pathology in a Biological Age’, Outlines 1(3): 19–34. Rose, N. and C. Novas. 2005. ‘Biological Citizenship’ in A. Ong and J. Collier (eds), Global Assemblages: Technology, Politics, and Ethics as Anthropological Problems. Oxford: Blackwell Publishers, pp. 439–63. Rose, S. 2006. The 21st Century Brain: Explaining, Mending and Manipulating the Mind. London: Vintage Press. Sinclair, S. 1997. Making Doctors: An Institutional Apprenticeship. Oxford: Berg Publishers. Van Dijck, J. 2004. The Transparent Body: A Cultural Analysis of Medical Imaging. Seattle: University of Washington Press. Zola, I. 1972. ‘Medicine as an institution of social control’, Sociological Review 20: 487–504.

CHAPTER 4 Embodied Brains: Why Science Studies Needs the Anthropology of Museums Anne Lorimer

Introduction Early work in the anthropology of science (Martin 1987, 1994) demonstrated that scientific representations of the body are loaded with implicit moral metaphors, metaphors that map between physiological entities on the one hand and socioeconomic formations or personae on the other. However, such work did not focus on explaining how those metaphors, which often are ones that would be disavowed by scientists, became part of these scientific representations. If we want to understand why scientific representations have the particular symbolic resonances they do in the public sphere, then we need to look at mediating processes, which involve the labour not simply of scientists but also of, for example, medical illustrators and photographers, taxidermists and big game hunters (Haraway 1984; Stafford 1991; Taylor 1992). We also need to examine specific mediating forms, such as computer graphics, preserved specimens or (in the case I am about to discuss) photographs and plaster manikins. This paper examines such mediating forms and processes in the case of a particular museum exhibit displayed at Chicago’s Museum of Science and Industry (MSI) in 1989. The exhibit was officially titled ‘Learning and Learning Disabilities: Explorations of the Human Brain’.1 To examine mediating processes is to go beyond metaphor: as Turner has argued, ‘the meaning is in the doing’ (1991: 151). Munn draws attention to

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how mediating processes can be usefully analysed in terms of the ‘symbolic distance’ they create between subjects and their mediated counterparts. In her Murngin example, contemporary witchcraft anxieties are reformulated as mythic ancestral events with which one can have a beneficial relationship (Munn 1969). Such distances between subjects and their mediated counterparts are given rich scope for play in the case of human anatomy exhibits, and especially in the case of the brain, insofar as the brain is construed as simultaneously the seat of our own subjectivity and the material object of scientific investigation. Such construal of our anatomy and of our relationship to the brain does not happen ahistorically. These construals occur in the course of various struggles, and perhaps especially in the course of attempts to impose or contest stigmas. By stigmas I refer to the marking of persons as possessing less than full human potential, as Goffman has attended to in twentiethcentury U.S. public milieux: An individual who might have been received easily in ordinary social intercourse possesses a trait that can obtrude itself upon attention and turn those of us whom he meets away from him, breaking the claim that his other attributes have on us. He possesses a stigma, an undesired differentness from what we had anticipated. … By definition, of course, we believe the person with a stigma is not quite human. On this assumption we exercise varieties of discrimination, through which we effectively, if often unthinkingly, reduce his life chances. We construct a stigma-theory, an ideology to explain his inferiority and account for the danger he represents, sometimes rationalizing an animosity based on other differences, such as those of class. (1963: 5) Insofar as stigmas are experienced as written on the outer layers of the body, and insofar as the mind/brain is construed as other than the body, locating self in the mind/brain can be a means of detaching self from stigma. Thus, twentieth-century U.S. anti-racism stressed that intellectual capacity is unrelated to corporeal markers of racialized identity, and in so doing, contrasted surface physiological diversity with the ‘psychic unity’ of humankind; this history resonates in the following account given by the senior developer of MSI’s ‘Learning and Learning Disabilities’ exhibit of why the team decided to paint displayed human figures a monochrome white: ‘we wanted to represent all races – but really stay kind of at a neutral position – not really looking at skin colour but more internal features of – that we’re all alike and we all have brains’ (interview, 25 June 1990). As Goffman’s commentary reminds us, the effects of racial or class marking are felt not merely on the skin but in the petty circumscription of ‘life chances’. Such circumscription can be at least rhetorically countered by subaltern

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discourse, discussed below, construing the brain as a realm in which a person may have agency and accrue wealth, irrespective of their powerlessness in political economic terms. Contrastingly, there are also of course longstanding ideologies that naturalize such political economic hierarchies by dichotomizing ‘mental’ from ‘manual’ labour. Recently, and with varying degrees of political commitment, anthropologists and close colleagues have worked towards undermining this dichotomy through finegrained analysis of productive practices.2 As Ingold points out, the dichotomy is especially recent and difficult to maintain in the case of art; Barbara Maria Stafford, an art historian of medical illustrations, illuminates how the professionalization of both art and science have been shaped by this struggle, and by an associated mistrust of that which is visually appealing or cunningly crafted (Stafford 1996, 1998). In line with this history, at Chicago’s Museum of Science and Industry during the time of my fieldwork, exhibit design was ideologized as divided between the initial ‘conceptual’ work in which ‘content’ is determined, subsequent design work in which forms are created, and finally ‘fabrication’, in which these previous decisions are materialised. This process is ideologized as causally unidirectional, rather than as a system incorporating feedback loops. Thus the senior exhibit developer narratively introduced to me the firm that created the material objects on which this paper’s analysis focuses by explaining: ‘we worked with a, um, studio in New York to execute this project for us of the mural’, and referred to this studio as ‘the, uh, company executing it for us’ (interview, 25 June 1990); such usage parallels the idea that one’s hands ‘execute’ the commands of the brain. Yet interestingly, as this paper will argue, it was this studio’s work (and in particular, its artwork) that solved the exhibit creators’ conceptual problem. As educators, MSI professionals took pride in basing the exhibit’s content on scientific research. But brain research has famously proceeded through case studies of the brain-injured, and the exhibit’s creators, including the senior exhibit developer, feared that this could have a negative impact on public perception. This problem can be understood at a more general level as an unfortunate side-effect of essentializing human subjectivity and locating it in the brain: such an investment risks making the self liable to all the contingencies to which an internal organ is liable, including death and injuries that may bizarrely transform one’s persona. As I will describe, the studio’s work offered a solution to this problem through symbolic distancing, making it possible to evoke a persona that seems both located in the brain and yet transcendent of fleshly mortality. This simultaneous attachment and transcendence was supported by the studio’s specific techniques of creating durable, circulatable human figures – with photography and casting from life, technologies which result in a product beyond the body, transcending its vulnerabilities, and yet based on intimately detailed connection with, the body.

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Technologies such as photography and plaster casting are thus nicely suited for creating forms that evoke a persona symbolically distanced from a more vulnerable human original. Their products partake in what Stasch calls a ‘principle of footprints’ (2009: 146): ‘Footprints’ semiotic force lies in the way they signify so directly the person who made them and also the perceiver’s separateness in time from the signified person’s actual act of stepping in soft earth’ (2009: 147). Stasch introduces this principle to discuss how the Korowai of West Papua orient towards children simultaneously as outcomes of parental actions, and as these parents’ ‘replacement or body match’ (2009: 147), making children a means of both indexing and compensating for parental mortality. More generally, this ‘footprint principle’ highlights how sign usage cannot be understood apart from people’s reflexive awareness of the temporally unfolding stream in which both themselves and the signs they produce are situated (cf. Lévi-Strauss 1969: 58–60; Bourdieu 1972; Voloshinov 1973; Munn 1986; Inoue 2004), even if this awareness is itself necessarily partial. Renewed attention to this temporally unfolding process has helped motivate cultural analysts, seeking to track and pin down meaning production, to explore the lives of media themselves (e.g. Appadurai 1988, Miller 2001), the production stream or ‘commodity chain’ (Conroy et al. 1996; Tsing 2004) along which they flow, and how their meanings resonate along this stream (e.g. Fraser 2006). Applying this approach to scientific productions (cf. Latour 1987, Shapin and Schaffer 1989) gives us a way of understanding the public life of science through its conditions of actual existence, rather than through its fetishized self-image.3 Science has since the early modern period been ideologized as operating through transcendent and universal signs (Bauman and Briggs 2003: 33–40 and passim). But all signs, in order to have a social life, must be embodied in particular material form (Irvine 1989; Keane 2003). Indeed taking material form is central to the scientific practice of experimentation, and even here, at the heart of science, the production process does not flow smoothly and unilinearly from conceptual intention to material execution to scientific outcome; rather, conceptual intentions become solidified and revised retrospectively when indeterminacies in how materially to set up the experiment are resolved (Collins 1985; Shapin and Schaffer 1989). Moreover, the concrete gains an additional layer of importance when scientific concepts, ideologized as semiotically transparent, are presented in public milieux governed by quite different semiotic regimes, such as those characterizing commercial entertainment. Here, the customary and folk usages that early modern scientists such as Bacon and Locke sought to exclude are reinstated, both through popular practices and through the mandates of institutions seeking to appear popular. In science museums mandated to ‘entertain’ as well as to ‘educate’ their publics, it is as if LeviStrauss’s engineers were forced to collaborate with his bricoleurs: unlike

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engineers’ allegedly specially manufactured concepts, the bricoleurs’ concrete signs draw on a messier history, each fresh occasion haunted by past usage (Lévi-Strauss 1966: 16–22). Technoscientific exhibits are thus doomed to translate concepts and engineering feats, ideologized as welldefined, into aesthetic and symbolic forms corrupt with excess. The pressures which formed the brain exhibit are political and material, both in the sense that these pressures are structured by larger politicaleconomic histories, and in the sense that particular actors’ histories, interests and loyalties led these actors to see material signs as haunted in either malign or benevolent ways. It was because of the exigencies and opportunities of a post-Fordist moment that the museum’s executives solicited funds from a resurgent elite of Chicago society families. In their role as exhibit sponsors, privileged parents empowered not only themselves but also the professionals closely allied with them in the project of de-stigmatizing learning disorders. This project sensitized professionals as to how neuroanatomical research findings, rather than operating as a transparent conduit to knowledge, could in public contexts evoke grisly images of vulnerability and mortality. A quest therefore ensued, among museum staff, for alternate imagery. This context enabled a chance glimpse of a single photograph to become consequential, allowing the exhibit to draw on imagery associated with U.S. anti-racist projects. Ironically or fittingly, tracing the story of the brain exhibit illustrates the primacy not of essentialized concepts, metaphors or conceptual design but rather of the dialectical processes through which embodiment enables re-conceptualization.

Figure 4.1. This is the entrance to the exhibit

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A Background of Brains Since around 1780, museums in the United States have been caught up in a shuttling of ideological emphasis between curatorial rigour and popular appeal, in tandem with other related economic and political struggles among the elite, the popular and the emergent middle and professional classes (Orosz 1990). This ideological tension has taken a particular form at Chicago’s Museum of Science and Industry (MSI). Although MSI had originally been funded by Julius Rosenwald – Sears Roebuck magnate and philanthropist of community-matched African American education – the institution’s early history was strongly influenced by Lenox Lohr, a pioneer of corporate sponsorship (Mann 1988). Lohr had been General Manager of the 1933–34 Chicago World’s Fair, from which MSI inherited many exhibits and personnel. Opening at the nadir of the Great Depression, the Fair procured technological exhibits by encouraging corporations to provide anxious and restless crowds with elaborately crafted glimpses of industrial production’s reassuringly well-coordinated ‘backstage’ (Goffman 1959; MacCannell 1976), glimpses which functioned as advertisements both for their products and for capitalism itself, which elites feared might be violently overthrown (Lorimer 1992). When Lohr in 1940 took over the presidency of the financially struggling museum, he employed the same strategy, slashing the curatorial payroll while explicitly marketing MSI’s visitors to corporate and military sponsors as a public without ‘sales resistance’, which could thereby be all the more easily influenced, particularly in its voting decisions (Mann 1988). During the Cold War, MSI emphasized its ability to attract large crowds, and became the Midwest’s most popular tourist attraction, claiming millions of visitors annually. As the Cold War ended and the U.S. middle class lost weight as a centre of gravity – increasingly dispersing into an underclass on the one hand and a highly trained class of professionals on the other – MSI shifted to target the latter, adopting in 1992 an admission fee which has been both criticized and vaunted for discouraging visitors from the Museum’s surrounding, largely African-American and frequently low-income communities. By this time, MSI perceived itself as in competition with attractions such as Walt Disney World’s Magic Kingdom, which offer expensive experiences stimulating visitors’ sense of personal potential (Spinelli 1992). Throughout the 1990s, MSI was ideologized by its visitors, its professionals, its floor-workers and its marketing department as combining ‘education’ with ‘entertainment’, a combination sometimes celebrated, sometimes problematized. For educators and middle-class parents, ‘education’ was generally identified with exhibits’ represented scientific concepts, or glimpses of an industrial backstage, held to underlie everyday life and consumer experiences; ‘entertainment’ was correspondingly identified with the concrete aesthetic forms that attracted children to engage

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with exhibits. MSI could thus claim superiority to Disney theme parks, which lacked ‘education’; however, this claim was vulnerable to critical accusations that somehow an exhibit’s underlying layer was being obscured, rather than transmitted, by its intended conduit, namely, the immediately accessible aesthetic forms. Such accusations were sometimes directed at the institution as a whole, sometimes at children who were failing to interpret exhibits in a properly disciplined manner, sometimes at exhibit professionals – a charge levelled by bosses or colleagues. I refer to such accusations as ‘semiotic discipline’ (Lorimer 2003). As an abstraction mediating between an exhibit’s intended scientific content and its necessary material components, museum education professionals involved in exhibit creation sometimes referred to an exhibit as having a ‘vehicle’. While intended as a conduit for ‘educational’ concepts, ‘vehicle’ refers not to the exhibit’s actual physical being but rather to a sort of trope structuring the translation of informational content into accessible form: an example used to describe this to me was an economics exhibit, created during the 1980s, whose vehicle was ‘a walk in the park’. ‘A walk in the park’, as an idiom, advertised that the exhibit would be easy to understand; as a vehicle, it shaped the exhibit environment, which took the form of a simulated park, with winding paths for visitors to follow, benches on which they could sit and signage on which they could read about various moments in this history of economic theory. In the process of exhibit production, the vehicle comes into being before the concrete aesthetic forms are crafted, let alone before any visitors enter the space; but the vehicle is imagined as their vehicle, in which visitors will be transported to a position allowing them access to the information the exhibit offers. The exhibit which is the focus of this study was officially titled ‘Learning and Learning Disabilities: Explorations of the Human Brain’, but has always been commonly referred to at MSI simply as ‘the Brain Exhibit’. Although it did not open until 1989, such an exhibit had been planned as far back as 1971 (Boshes 1971). After Lohr’s death in 1968, the Museum went through a transitional period, in which the presidency was filled first by Lohr’s director and ‘right-hand man’, Daniel MacMaster, and then in 1978 by Victor J. Danilov, who had joined MSI as MacMaster’s director in 1971 (Pridmore 1996: 124, 134–35). This transition in part reflects larger currents in U.S. culture surrounding museums: in the 1960s there had been a florescence of industrially unentangled science centres,4 and criticism of MSI’s corporate and military influences mounted, particularly during and after the Vietnam War. Danilov’s philosophy placed greater emphasis than Lohr’s on the role of scientific advisory boards, and when Danilov became president he created MSI’s departments of science, education and exhibits (William Pattison, personal communication). The brain exhibit appears to have been a pet project of Louis D. Boshes, M.D., a clinical professor of neurology,

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who together with other medical specialists and medical illustrators made a presentation to MacMaster and others at MSI. The exhibit Boshes proposed in 1971 involved a giant brain that visitors would enter, similar to another exhibit’s walk-through heart model that had proved enduringly popular since 1952. This device was retained in 1980s planning documents as a means of attracting visitors, but veered from a realistic, detailed model (Rush 1980) to an indirectly suggestive ambiance: Because the exhibit must attract visitors in order to be experienced, ‘Learning about Learning’ will present itself very dramatically. Approaching visitors will see a dark space with clusters of large white domes glowing overhead. Seemingly suspended within the domes will be networks of neurons. Subtle light changes will make them appear to transmit chemical and electrical signals. The effect will be a large glowing symbolic brain that encloses the visitors. Coming closer, they will see very large human heads positioned below the domes. The heads … are [horizontally] flat above the forehead. Visitor interactive demonstrations on learning processes are mounted in each head. In an intriguing way, each head appears to be ‘thinking’, and visitors will participate in those thoughts. Surrounding the cluster of domes will be dark, embracing walls … From the Rosenwald Court, visitors will be attracted by the skull-like domes, whose translucence reveals the ‘electrical’ and ‘chemical’ activity in the brain. From other places on the medical balcony, the domes will give the ‘Learning about Learning’ exhibit its special visual character. The overall exhibit environment will be glowing and enfolding, as if visitors were inside the mind itself, participating in its functions. (Danilov 1986a: 6–7) Traces of this image still remain in the final exhibit: the dark surrounding walls, the heads topped with interactive exhibitry and even the layout of the floor plan. The entire exhibit’s floor plan was laid out in the shape of an enormous cross-sectioned human head, such that moving into the central space of the exhibit enacts moving from the outer skull more deeply into the brain itself. The exhibit’s periphery is predominantly monochrome, dominated by white statues and, along the back wall, a black-and-white photographic mural: these monochrome elements correspond to the enclosing skull. The exhibit’s two front entrances are intended to represent eye sockets; a third, side opening is positioned at the left ear. The inner space of the exhibit, corresponding to the brain itself, is more colourful. Dotted around the carpet of this inner space are six large plaster heads, modelled from the eyes down. These lower heads each form a base for an array of educational and interactive materials, which thus visually stand in for the

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head’s upper portion. The heads are topped with crests, on each side of which are colour photographs. When the heads are seen in profile, each crest appears as if it were its head’s dome. Each photograph shows people engaged in activities that involve a particular cognitive function, captioned as, for example, ‘Recognizing Faces’, or ‘Perceiving Shapes’. Below this crest, the plaster head base supports pieces of interactive exhibitry, each intended to stimulate that very same cognitive function among visitors. Above each giant head a plaster brain hangs suspended, as if it had floated up from the lower head underneath. These various floating brains are each painted in a complex array of bright, pastel and metallic hues, showing how the exhibited cognitive functions can be mapped onto neuroanatomical sectors. However, once the exhibit was built, the exhibit creators found that visitors failed to perceive the symbolism of the exhibit’s floor plan as representing a skull-encased brain. This failure may have been due to the declining relevance of the walk-in brain as an explicit focus of backstage design. Instead, another thematic vehicle had been constructed by the exhibit creators: the brain exhibit as birthday party. All of the colour photographs topping the large scattered heads were of enacted scenes from a child’s birthday party; and at the eye-socket entrances, a plaster manikin named Joel explained to entering visitors that these were scenes from his own boyhood memories. I will discuss the significance of the birthday party at greater length below. For now, it should be noted that the birthday party did not appear as a vehicle until after there had been a significant shift in topic: from the brain, to the brain and learning. To understand this shift, it will be helpful to return to MSI’s institutional history. The pressures MSI faced during the 1970s were not only ideological but also financial (Pridmore 1996). In both cases the solution appeared the same: to lessen the Museum’s financial dependence on corporate and military exhibit sponsors. Once Danilov became president in 1978, he launched an extensive fundraising campaign, which took on a new twist in 1981 with the first Columbian Ball, which raised $250,000 (Pridmore 1996: 134–36). While MSI’s interior architecture, exhibits and staff had been inherited in various senses from the era of the 1933–34 Century of Progress fair, during which the Museum first opened its doors, the building’s exterior was its heritage from the first Chicago World’s Fair, the 1893 Columbian Exposition. Indeed, MSI was the only remaining building from that once vast parkland of Beaux Arts palaces dubbed ‘The White City’ for its spray-painted plaster exteriors. The Columbian Ball took advantage of these prestigious associations and aesthetic in both its name and its spatial positioning: the ‘formal gala … spilled out onto the South Portico’ (Pridmore 1996: 135), the site from which the former Fine Arts Palace’s exterior and the landscapes and waterways of Jackson Park, prepared for the 1893 fair by Frederick Law Olmstead, formed an impressive backdrop maximally evocative of the Columbian Exposition.

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Instituting the Columbian Ball also restored the site’s ties to Chicago’s social and philanthropic elite, ties that had been prominent in 1893 but lessened by MSI’s inception. While the 1893 Fair’s Board of Lady Managers was headed by Mrs Potter Palmer, illustrious wife of the hotelier and department store magnate, and the site had during the 1920s housed the Field Museum of Natural History, associated with Potter Palmer’s department store business successor Marshall Field, neither MSI founder Julius Rosenwald, nor his Sears Roebuck catalogue company, nor his industrial museum aspired to the same class status as the Fields and the Palmers.5 Now, however, the new Columbian Ball had been organized by Cindy Pritzer, a socially powerful Chicago philanthropist whose husband Jay was the most productive member of ‘one of America’s wealthiest families’, whose ‘showcase business’ was Hyatt Hotels (Weber 2003). Jay Pritzker had been among the potential brain exhibit sponsors Boshes had sent letters to without success during the 1970s (Boshes 1975, 1986). In the early 1980s, however, while lunching with Victor Danilov, ‘Cindy Pritzker … mentioned new work that was being done in the study of learning disabilities – she had two sons with dyslexia – and suggested that the Museum might consider an exhibit examining them’ (Pridmore 1996: 159). It was proposed that the two potential exhibits be fused. The resulting exhibit, ‘Learning and Learning Disabilities: Explorations of the Human Brain’ was sponsored by the Pritzkers and by Nikki and J. Ira Harris; Mr. Harris, who along with Cindy Pritzker was already a Museum trustee, later became vice-chairman of the Pritzker Organization. The two couples donated a combined total of $500,000 (Danilov 1986b). The exhibit’s opening received additional publicity from the attendance of First Lady Barbara Bush, another socially eminent mother of a dyslexic son (Chicago Sun-Times, 18 April 1989). The new focus on learning disabilities required the Museum’s exhibit creation professionals to consult with new outside experts, among them Dr Laura Lehtinen Rogan, co-founder and clinical director of the Cove School, an expensive private institution situated in a wealthy community just north of Chicago. After reading a draft proposal, Lehtinen expressed deep concern that the exhibit would trigger ‘feelings of anxiety and depression’ among visitors (Rogan 1986). It was in response to this fear that the MSI exhibit creation team constructed the birthday party vehicle, to which I now turn. First, however, it is necessary briefly to describe my research process. I began doing fieldwork among MSI visitors and employees in 1990, after the brain exhibit opened.6 Among my preferred methods of visitor observation are richly detailed ‘focal visitor sampling’ (cf. Altmann 1974), visitor participant-observation (in which I accompany a group of informant family or friends), and visitor memory-tours, in which one or more visitors guides me around the museum while reflecting on their past experiences.7

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However, these observational methods have not been thoroughly drawn on for the elements of principal interest in this paper, namely the plaster manikins and the photographic mural, which rarely provoke naturally occurring or explicit visitor interactions or commentary. Instead I rely here on ‘ad libitum sampling’ (Altmann 1974) and participant-observation within the exhibit (although, again, there is little data on the mural and manikins), MSI’s own visitor research and an outside exhibit evaluator’s critical commentary. I also draw on data from fieldwork with visitors and employees in other areas of the Museum that sheds interesting light on the exhibit’s aesthetic qualities, on ‘brains’ as a trope, and on MSI as a site for practices seeking to transcend racism through a more cosmopolitan identity. My preferred methods for researching exhibit creation include tracking and observation of various stages in the exhibit planning process, supplemented by interviews and ‘intimate, long-term acquaintance’ (Wolcott 1995: 76). For the brain exhibit, which was created prior to my research, I have relied on interviews with the Senior Exhibit Developer, Sara Lowenthal, and with outside fabricators Studio EIS, as well as documentation in MSI’s archives.

Figure 4.2. These starkly monochrome photographed figures and statues run around the exhibits back wall

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The Birthday Party as Trip to the Land of the Dead Using the birthday party as a ‘vehicle’ was a strategy designed to make ‘a bright and positive common environment’ (Lowenthal, interview, 2 July 1990) for a topic exhibit developers feared might alienate visitors. As Sara Lowenthal explained: Many television programs about the brain have a point of view of talking about the brain-injured … you’ll see someone on television … who can remember everything, or can remember nothing, or can see something on one side of his head but not understand it on the opposite side … those are pretty frightening things. … I felt that what we wanted to accomplish in part [was] having people feel that they could approach this subject … you know, ‘okay I’ll try this once, um, I’ll try and look into this subject’; we had to do something different from showing a lot about brain injury, because to the, um, it’s all pretty scary, what you see there and being such an unknown in your own head that you can … very easily wonder, well, what’s lurking in my own head? I’m not really sure I would wanna know. (Interview, 25 June 1990) In contrast to these threats of loss, stigma and lurking inner unknowns, the exhibit creators wanted to provide ‘a supportive … atmosphere’ (Lowenthal, interview, 2 July 1990). Yet the feedback the museum received on this point was not entirely unequivocal. The Museum’s visitor research, conducted in March 1989, found among their sample an ‘older couple’ who interpreted the exhibit’s bright palette not as cuing reassurance but rather as indicating the market sector to whom the exhibit would be of interest: ‘because of all the colors, I thought it had something to do with little children’, one of them is recorded as responding when asked why they had passed through the exhibit so hastily, and added: ‘Also, the characters on the wall looked eerie, like from outer space’. This begs the question of what people from outer space look like, but I would suggest two relevant characteristics here are ethereality and technological adeptness. A particular section of figures on the wall is intended to represent professionals who assist people with learning disabilities, and it seems possible that their clipboards, lab coats and medical accessories evoked images of extraterrestrials as studying and medically probing human subjects. Another sampled visitor, who had been observed closely interacting with this particular section, complained that the figures looked ‘threatening’ rather than ‘natural’:

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I would have preferred photos of natural people, they look threatening, why are they wearing wigs? Speech pathologist looks old and crotchety, most men who are speech pathologists don’t work in schools. It is possible that she is using an indirect speech style (cf. Morgan 2002) to object not only to eeriness but also to seeing herself misrepresented (this visitor is herself a speech pathologist). She has certainly objected to one dimension of demographic misrepresentation, gender (the dimension she likely shared with her interlocutor); it is possible she is objecting not only to the wigs per se, but to the figures’ overall monochromatic whiteness which the wigs enable and which, while it is intended to convey racial diversity, can also be read as having the opposite effect. (A child in the sample, coded as ‘B[lack]’, had asked her mother: ‘Why are they all white?’; African American visitors have expressed concerns about racial representation in other exhibits, for example the complete lack of African American scientists in the Sickle Cell Anemia exhibit.) Certainly the racialized dimensions of learning disabilities were something she highlighted, and directed MSI to highlight, as the visitor research report goes on to record: Comments: You should highlight with arrows or color: Public Law, many parents don’t know the law gives them rights. This exhibit is tremendous service. It’s well thought out, and interesting. I work in Gary, Indiana, [a Rust Belt city in Indiana, bordering East Chicago, with a mostly Black and Hispanic population]. You should have an inexpensive brochure to educate the public. A lot of kids are not tested. You should go out to the schools and tell them about this exhibit. To be labelled as learning-disabled is a form of privilege, conferring benefits to which racially marked families may not even have realized they are entitled (cf. Morgan 2002: 106–7 on the imperative to obtain one’s rights). For this visitor, racialized power struggles are not to be whitewashed (cf. Wells and Douglass 1893). Such variance in responses reflects not only differing sociopolitical positionings but also the semiotic complexity of the exhibit. I have argued elsewhere (Lorimer 2003) that in considering issues of mass-media production and reception, it is useful to think of such artefacts as a kind of manifold, composed of multiple frames. Contestation can be understood as a struggle over which frames become primary, subsuming other, contradictory elements. (Thus, to illustrate, we might analyse the ‘whiteness’ problem as an ambiguity over whether monochromatic uniformity subsumes racial difference, evoking it through models’ phenotypic diversity only to negate its importance ultimately; or whether racial difference subsumes monochromatic uniformity, so that we read whiteness as the mark

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of a particular group, and the apparent unity as really hegemony.) In such contestation, authorities such as parents and museum officials often do the work of reasserting the intended primary frame, as when the mother of the child quoted above responded: ‘Because no matter what color you are, you can have a learning disability’.8 I use the imagery of a manifold and of dialectical subsuming and transcendence in order to emphasize that contradictions are to be expected, rather than exceptional, when analysing complex and multivalent cultural productions. Indeed this multivalence, as Turner has argued (1958) and as Macdonald has emphasized with particular attention to museums (2002), is part of what makes such symbols powerful. In the rest of this article, I want to explore not the dual racial valency of monochromatic whiteness but rather the white figures’ eeriness, and how it connects to an aestheticization of the brain as technologically sophisticated, ethereal and/or disembodied. The supportiveness Sara Lowenthal wished to provide for visitors turns out to have come at an interesting cost: the exhibit seems to be haunted. Allegations of the photomural’s ghostliness inconveniently turned up in a critical review of the exhibit, by a professional exhibit evaluator, appearing in the Journal of Museum Education: Along the back wall is a black-background photomural of ghostly looking people (of different ages, genders, and ethnic origins), all painted stark white (including their clothes) except for their eyes, which look like spooky black holes. The figures have messages about learning disabilities. What was this mural meant to communicate? I missed the point. (Serrell 1991: 26) I will ultimately argue that this evaluator did, indeed, miss the point: that the figures’ ghostliness, which had struck me as well, operates in the service of the exhibit’s overall goals. My first interview with Sara Lowenthal left me trying to grasp how an exhibit environment might simultaneously be conceptualized as reassuring and yet suggest a place inhabited by ghosts. A step towards solving this puzzle came later that afternoon, when I happened to collect a text written by exhibit developers at another Chicago museum, also dealing with anatomy, mortality and the person: Monday 25 June 1990 – The Field Museum of Natural History Off the entrance hall to the left is an Egyptian tomb: a reconstruction of the Tomb of Unis-Ankh. The tomb is a part of ‘Inside Ancient Egypt’. A plaque says: ‘Anything that the spirit of the dead person might find useful or necessary in his new life could have been kept here. These jars and pots from our collection are typical, but there might also have been furniture, games, hunting equipment, cosmetic items and sealed jars containing oils, wine and beer ...

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‘The Mummy’s Life in the Afterlife. Many of us think the Egyptians were obsessed by death. That’s because most of what we know about ancient Egyptians, and most of the objects in museums, come from burials. We may feel that funeral objects are morbid, but for the Egyptians, the whole point was to create a life after death that was very much like life on earth. Our burial scenes will show you the many steps Egyptians took to assure a comfortable and joyful eternal life for their loved ones.’ (Extract from field notes) In the decision process as Sara Lowenthal was narrating it, much like the Egyptian funeral process as narrated by Field Museum exhibit developers, comfort and joy were to come first and foremost from familiarity, providing cognitive reassurance and hence emotional reassurance: We decided to, um, that still, that subject of the brain is so difficult, and so unknown to everybody that it’s like a terra incognita. Now if you’re gonna venture into someplace that’cha don’t know, you like to take some things with you that are gonna help you along the way. … And, um, feeling okay about things and the approach has something to do with feeling okay … Think of it really as … the birthday party we present gives people, um, something from their own world that everyone knows and can relate to and … enjoy, as a way to find out about their own brains. (interview, 25 June 1990) Narrating the series of decisions that the team made, Sara framed the team’s mission in terms that I, in transcribing the interview that evening after my first visit to the Field Museum, could not help hearing as evocative of preparing someone for a trip to the land of the dead. Here is a way in which ghostliness functions as comforting: unlike the other anatomical exhibits, in identifying with the forms of humanity exhibited in ‘Explorations of the Human Brain’ one remains a person – wearing clothes and jewellery, engaging in familiar activities and dialogue with others – and indeed that personhood is being celebrated. In the decision process as Sara was narrating it, the birthday party was appealing because its form was said to be familiar to all members of the museum’s public: Um. Now. We had been considering other subjects. Things like cooking, or driving your own car. There’s lots of eye-hand coordination things, or mental things, that … would work … but all … those didn’t reach the audience … the way we wanted it to. They might reach – adults. They might reach – um – you know, a certain level of education. They might reach a certain ethnic group, but none of them worked well enough for us to select it. So, um. So we came up with the birthday party. (interview, 25 June 1990)

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If birthday parties have meaning for so many persons, this is in part a function of their widespread statistical distribution: meaning is simply a matter of associative familiarity. But this distribution is in part a consequence of another kind of link between birthday parties and persons: birthdays are a cultural form in which to celebrate any person (or personification) appropriately. In this respect, the birthday party is a perfect rebuttal to the threat posed by other exhibits and television programmes: whereas brain injuries represent a threat to the person’s coherent subjectivity, birthday parties celebrate a personhood that is both continuous and culminating: ‘a birthday party is – really – a celebration of how … your brain has changed over a year’s time … you can be a whole new person based on the learning that you do’ (interview, 25 June 1990). The effect of this additional, unplanned level of meaning was experienced by the exhibit creators as ‘magical’, a term that I think refers here to the capacity of a concrete symbolic form to operate on multiple levels, resolving multiple conflicts perhaps even before these have been explicitly formulated. The notion of personhood appeared as an exhilarating solution at another crucial moment, in which the team envisioned the exhibit’s most ghostly element: its mural. Executing the mural was … really a delight, I mean it was … really a creative dream …. The fun, fun part there was getting the – before it didn’t really, see it didn’t have people on it initially. … through a day’s worth of thinking of what are we gonna do there and we came up here, and one of my colleagues said it just has to be people. (interview, 25 June 1990) Can the exhibit’s ghostliness be accounted for by simply considering the symbolic use of ‘personhood’ to circumvent the brain’s associated threatening images? Identifying the brain with personhood does not necessarily cancel the threat associated with the brain as a biomedical entity. Rather, it can increase the threat by pointing to the high stakes: your very personhood is at stake, all the more fragile for being located in a chunk of soft tissue. What is logically needed, then, is an image of personhood that transcends the flesh: in other words, in order to persuade visitors to approach the brain scientifically, it may help simultaneously to offer them images of ghosts. Indeed, the brain exhibit can be coherently read as offering just such an image, countering the corporeal threats that appear in other nearby exhibits – perhaps the ones which exhibit creators came through on their way ‘up here’ – particularly Body Slices and the now defunct, sinisterly titled Good Teeth and Good Health Go Together. Such a reading of these exhibits can be constructed by attending to a contrast between qualisigns (Munn 1986): on the one hand images of corporeal vulnerability, decay and stigma are

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identified with fleshy-toned cross-sections of human anatomy;9 on the other hand, endurance and invulnerability are marked by hard white bones and teeth. Visitors are frequently and loudly disturbed by the cross-sectioned cadavers, but not by their neighbour, the disarticulated skeleton. In sorting out the disparity in responses to various portions of the medical exhibits, I found it helpful to use as a formal analogue Hertz’s monograph on secondary burial, primarily in Southeast Asia (1907). As Hertz describes it, the dead are threatening and unhappy while still fleshy, but once reduced to bones, become benevolent, transcendent spirits. A similar logic seems to be at work here: through increasing symbolic distance and durability, human remains become able to convert anxieties of personal destruction into a more supportive idea of a departed person whose personality has transcended the flesh and become invulnerable, either as a skeleton or as a statue. One incident offered particularly striking evidence that statues can function as a solution to the threat posed by the sliced corpses: a young boy who hated visiting the latter exhibit, and whose father had drawn a line on his chest explaining ‘This is where they cut you, here’, kept pleading to be told that ‘they only do it to statues’ (field notes, 20 July 1990). Such a solution is what the brain exhibit offers: ‘from a distance, the first thing you encounter are people: the white manikins outside’ (Lowenthal, interview, 25 June 1990). While this link between the white figures and white bones may seem farfetched, it should be remembered that the exhibit’s monochromatic perimeter was designed to symbolize the brain’s surrounding housing – a human skull. But this notion of a personhood that transcends the flesh is not part of the decision-making process as narrated by Sara Lowenthal – even though it does logically resolve the predicament her account sets forth. How, then, did this spectral persona make its entrance? Who offered MSI a ghost to put back in the biomedical machine?

The Ethereal Afterlife of Studio EIS The exhibit’s photographic mural of white figures on a black background had been identified by Serrell as ‘ghostly’, and yet was also described by Sara Lowenthal as a favourite moment of the exhibit development process, a ‘creative dream’. This mural originated in the MSI design team’s visit to Studio EIS, a Brooklyn firm co-owned and directed by brothers Elliot and Ivan Schwartz, who specialize in crafting life-size figures, cast from human models, for corporate and museum clients, including the National Civil Rights Museum. During this visit, one of the brothers recounted, MSI’s design team happened to notice an image unintended for their eyes, which triggered a new imaginative possibility and practical solution:

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When they came to the studio there was a photograph above the door back in there which suggested to them a possible way in which to resolve one of their spaces. It’s a photo showing about thirty or so figures, very tightly grouped together. And there, there’s one running wall that was about seventy-five feet, and they said … we need to have something back there, it’d be great to have figures representing people; and we said well, it’s a great idea, but seventy-five feet of … figures, three deep would cost you, half a million dollars or something. So we said, well look you know it can be accomplished, ah photographically and, um, so why don’t we do that.… Um – and so that’s, that’s what actually happened. We then figured out how we were going to do this and we kind of sold each other on the idea that this was the way in which to go. (Interview, 1990) It is clear that both the clients and the fabricators were creatively open to the magic of contingent events, allowing themselves to be inspired not simply by the concept of ‘people’ but rather by a concrete sign (cf. LéviStrauss 1966: 1–33): a particular photograph of white statues against a black background. This photograph had been taken, not as part of the studio’s work, but for the brothers’ own aesthetic interest: about to send off a large batch of clientcommissioned statues, they were struck by the massed statues’ powerful presence – an impact which would inevitably be lost once the statues were dispersed into various museum contexts – and wanted to keep an image of this moment in which their creation amounted to something more than these separate purposes for which it had been created. While the brothers run Studio EIS as a business to support Ivan’s painting and Elliot’s photography, their fine and commercial arts are linked beyond mere financial ties. Indeed, when the director of exhibitions at the International Centre for Photography wanted to condense themes of Elliot’s art, he drew on a photograph that takes as its object a model being cast for one of the studio’s sculptures: When Schwartz photographs living subjects, he treats people as sculpture, presenting them as objects that seem at once alive and dead. In The Modern Prometheus, a man draped with protective cloth sits with plaster covering his eyes and much of his face … Schwartz … plays off Mary Shelley’s subtitle for her novel [Frankenstein; or, the Modern Prometheus], in which man defies nature in an attempt to reconstruct life using his own creative powers. (Hartshorn 1987: 2) Elliot Schwartz himself drew my attention to this exhibition catalogue as helpful for understanding the nexus of relationships between his work, the work of Studio EIS and Studio EIS’s contributions to the brain exhibit.

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The photograph’s resonance in this fine arts context reveals an aspect of the studio’s commercial work: like Frankenstein and his monster, it amounts to a use of technology to create a persona which is not human, but is made by and from humans, and which transcends the mortality of individual flesh. This same symbolic operation, in the context of MSI’s Human Body Zone, alters the nature of what it means to identify the self with anatomy. It does so by relying on a dual potential of human anatomical embodiment: on the one hand, anatomical embodiment defines us as mortal bodies, but on the other hand, it permits the self to achieve objectification in more durable forms, such as photographs and sculptures cast from life, that can linger and multiply in a kind of afterlife. Elliot Schwartz identified this value the statues have: They’re sort of dead, they’re not dead; yet they’re alive, they’re not alive; they’re here, they’re – you know, they sort of exist in a number of different planes. And I, I like that aspect of them … They really have a quality of a human being inside the clothing. They have a very, very, convincing, sort of, after-effect. You feel as if, a person has been there … They excite people. (Interview, 1990) It is as if the statues take the deadness of corporeality – and of corporeal absence – and transform it into a power to achieve transcendence, converting the negative value of bodily dissolution into the positive value of an after-effect that can circulate socially (cf. Munn 1969). The particularities of the Schwartz brothers’ work were not as available to project manager Sara Lowenthal, who did not make the trip to New York; in discussing the statues, she referenced a more famous American sculptor, George Segal, whose work raises a complementary set of concerns: the discourse surrounding his work emphasizes how casting technology transcends the evanescence of particular interpersonal moments, turning them into something that can be anatomized. Like Studio EIS, Segal specialized in monochromatic white figures cast from life, which the artist considered especially striking when positioned against a black background, and these figures too are often described as possessing ‘ghostliness’ (Edwards 1999: 5; cf. Time 1970; Prather 2000). Segal has suggested these sculptures provide an analogue for quotidian yet ineffable moments of human experience: What I’m trying to do in my work is somehow fumble around for the language to talk about what’s the equivalent of five seconds of consciousness. You and I sitting here, our legs are crossed, we feel the pressure of our foot, we have a physical sense of who were are; we also have all these ideas in our head, ideas it takes a lifetime to gather. (Segal, cited in Edwards 1999: 4)

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As this and other portions of the interview series suggest, Segal understood consciousness to be more than merely cognition or emotion: it is tied in with the body as intrinsically material, dependent on an individual mortal trajectory. Yet his sculptures in turn transcend lived moments of the organic body, attaining an enduring form in which they can circulate as objects of a more public consciousness.

Phantoms in Public The material introduced above has I hope begun to illuminate how, when persons are construed as embodied brains in this manner, symbolic distance allows a ghostly persona to appear: formed in the image of, and yet accruing value beyond, its owner’s body, it makes possible an imagining of a transcendent, invulnerable self, one whose existence is technosocially mediated, virtual rather than actual. In this section, I want to suggest an affinity between this persona and the way persons are understood to participate in the public sphere, and in particular to ideas about how such participation might lead to racial transcendence. This affinity arises through particular historical and cultural circumstances, including antiracist imagery, urban crowds, the gallery form and the particular forms of agency available to service workers. Let me begin by clarifying that although the mural Studio EIS created for MSI originated in a photograph of sculptures, the brothers did not feel the actual mural’s white figures to be merely statues manqué. Elliot Schwartz said: I don’t have any question, when I look at these pictures, I know there’s a person in there. They don’t represent sculptures to me. You know, the eyes cannot be painted, obviously, and you really sense, it’s sort of like looking through the mask, that there is a person in there. Even though they, they kind of look like some sculptural thing, the way they’re set up, black against white. Rather, the photographs of these figures linked to another lineage of publicly circulated imagery. Elliot Schwartz continued: The image that came to mind when we started working on that was, were images from Psychology Today a long time ago. (Ivan Schwartz: Mmm.) Where you would essentially obliterate the colour barrier, by – changing somebody to something, it’s not really neutral but it is a neutral colour when you think of, from black to white. You know, stark white as if painted as opposed to flesh.

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In twentieth-century American public culture, antiracist imagery and discourse sought to distinguish those outward signs, which functioned as social markers of ‘race’, from the mental states and capacities held to determine a person’s true worth. In so doing, such discourse and imagery drew on a longstanding moral prioritization of spirit over flesh (cf. Augustine 1950 [427]). However, insofar as any such explanatory ghost had been, in the course of the Enlightenment, expelled from its housing in the human anatomical machine (La Mettrie 1943 [1748]), secular antiracist authorities necessarily localized the spirit as mind, and the mind as functioning brain, in alignment with established scientific practice (e.g. Boas 1911: 102–4). But if a ghost lacks anatomical validity, it also possesses something that the brain lacks: ghostly images are socially recognizable as persons, possessing faces, clothing, speech, and so on. Insofar as a brain is an internal organ (‘wet and gray and mushy – and it’s just sitting there inside your head’ [Tomorrow 1995]), its public exposure functions as a kind of affront to personhood, reminding us of the grimmer ways in which we can be reduced to flesh. Wet, gray, mushy brains are for example displayed within the neighbouring exhibit of crosssectioned preserved cadavers, where they elicit from visitors loud disgust and horror; and these sections are legible as racially marked. The racetranscendent mind can be more safely shown by creating a composite in which the brain is represented by visual imagery of a social persona, while that persona is altered by abstracting from it the rhetorically salient feature of colour. Such imagery makes it possible to imagine the ghostly brain as itself a person. This ghostly brain manages a kind of personhood peculiarly adapted for the public sphere. Warner has argued that the distinguishing peculiarity of persons in the public sphere is their lack of embodiedness: they must have bodies that are unmarked, in correlation with their lack of interestedness (Warner 1990, 1993). Similarly, the persons in the brain exhibit have become spatiotemporally unmoored, as part of their strategy for addressing visitors. Consider the case of a woman I saw absorbedly attending to a manikin whose video monitor was asking her to simultaneously rub her belly and pat her head. She complied; but when the monitor said: ‘Uh huh, that’s good!’ as if to praise her performance, she suddenly became selfconscious, glanced around, caught my eye and that of her male companion, and laughed, as did we (3 June 1990). What was funny? I suspect the exposed absurdity was that the actor displayed on the video screen could not, in fact, be praising her individual performance: the human co-presence he seems to provide is really a trace of some prior time. It is as if, within the space of the exhibit, time flickered back and forth between that prior time and our own visit: the time of the professional recording and the time of visitor-exhibit interaction occupy the same place, but we can no longer alter

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that prior time. And if we cannot alter or experience intersubjectivity with our surroundings, then our represented presence becomes problematic, uncertain and evanescent. In this respect, a phantom public sphere makes phantoms even of the populace it claims inhabits it. If the public is sometimes described as a phantom (Robbins 1993), this is in part because, analytically, the public, being illimitable (Warner 1990), can never be fully present in any actual gathering. Such gatherings may however be ritually framed as revealing signs of, or acting upon, this larger entity – as when visitors to Chicago’s 1893 Columbian Exposition report their own participation as a sign of American racial progress (Reed 2000) or a 1993 MSI guide hopes his conduct will counteract racist beliefs among hinterland tourists – just as MSI exhibits claim to display other normally inaccessible forces underlying everyday life, such as human interior anatomy, or the industrial division of labour. Such framing is part of how, historically at MSI and Chicago’s two World’s Fairs, crowds of visitors have themselves been construed as among the attractions that make such sites worth visiting (e.g. Jenks 1893: 99, Shaw 1893: 38). Thus the December 1965 issue of MSI’s official magazine, Progress, counter-intuitively promoted the museum while featuring photographs of crowds and long lines. By the 1990s, however, such depictions had been replaced by images and slogans of mind and brain, rendering the Museum visit as a pleasurable learning event taking place within, or bursting out of, an individual person. Indeed, promotional graphics during this period focus on and treat analogously the Museum dome and the dome of the visitor’s skull, each seen lifting open. In such imagery, the brain functioned symbolically as a concrete abstraction (in Valerio Valeri’s sense): a physical object that could both thematize one aspect of a complex situation (the MSI visit becomes ‘learning’) and express all instances through a single essence (since each visitor is crucially equipped with a brain). When visitors described MSI’s efficacy to me during research there in 1994 and 1995, they too spoke of taking children there to ‘expand their minds’, or finding as an adult that its exhibits had become ‘embedded’ in one’s ‘brain’. One teenager explained that ‘the Museum … enlightens your brain’ because you ‘learn a lot’ of ‘things involving science’, and you learn it ‘in a fun way’. But this visitor also reported ‘watching people’: the crowds, which, like the exhibits, can be interpreted as privileged representatives of the ‘real world’ outside. MSI’s public, he commented, features ‘different cultures’, ‘black, white, everybody’, ‘and they’re all interested in what’s here’. By participating in pleasurable science learning, he experienced himself as participating in a community that transcends race. And indeed many Chicagoans, especially those living in or near low-income African American neighbourhoods, construe MSI as a rare chance to share space with a multiracial, transnational public: to measure oneself against racially

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privileged peers and know oneself a contender, entitled to safe public space and to spectacle; to go on racially proscribed dates; or to meet strangers, as one visitor, Tabitha Glass, recalled: ‘From all over the world. … It makes you a well-rounded person who can fit in, in any situation. … I have a lot of fond memories that I’ll take with me to the grave’. I can personally testify to Tabitha’s flair for recruiting strangers: her interest, perhaps sparked by my mongrel accent and my fiancée’s idiosyncratic wardrobe, easily drew us into the diverse rotation of welltravelled, artistic friends who would drop by for visits and special occasions at her workplace (where she defended the two of us from critics by drolly pointing out our cachet as ‘borderline professors’). At our first meeting, hearing of my research project, Tabitha had told me: ‘I grew up in the Museum!’ That this comment should have sparked a friendship amounts to a tiny indexical icon of how Tabitha presents MSI’s role in her life, as operating through characteristically intertwined subject formation and networking. In describing the Museum’s lasting effects, above, Tabitha’s imagery conveys how memory becomes an instrument for converting social situations into an inalienable possession, one that remains part of one’s personal identity through even the ultimate bodily hazard, death itself.10 Such construals of memory are consistent with nineteenth- and twentiethcentury American tropes in which the personal mind becomes a microcosmic container of impacts made upon it by jostling urban milieux, tropes which evolved in tandem with, and draw on, cultural technologies such as photography, exhibition galleries and World’s Fairs (Orvell 1989). Indeed her grandmother, Tabitha recounted, had attended and photographed the 1893 Columbian Exposition (whose only remaining structure houses the Museum of Science and Industry); and Tabitha considers co-presence with her relatives’ memories and their deliberately diverse acquaintance gave her a lived experience of history and society, contributing to her own cosmopolitan identity. Identification of personhood with mind or brain is thus consistent with a rich awareness of one’s social matrix, while simultaneously emphasizing autonomous agency even for those socially disempowered. This paradox was brought home to me by Keith Hughes, an actor and playwright whose artistic life, like Tabitha’s, centres on creating and renewing self-aware forms of cosmopolitanism from historic African-American identity. For his day job at MSI, Keith led visitors touring a future exhibit’s construction site. Between tours one day, he mentioned feeling frustrated by his inability to protect himself from the site’s dirt and dangers; in particular, he felt anyone on the site ought to be issued with a construction helmet. When I asked whether he had submitted a proposal through MSI’s ‘Bright Ideas’ employee suggestion box, Keith told me he had not invested much effort, since his previous suggestions had been stymied by bureaucratic inertia. I expressed

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surprise, having heard that demonstrators’ ideas do result in changes, for example changes in the tour’s script. Keith explained that while the script changed every day, outfitting tours with hard hats would require money and resources not directly accessible to himself and his colleagues; they can change the script because ‘your brain is accessible to you, and the ideas that pertain to the construction site are accessible’ (interview, 7 May 1994). Ironically, on the one hand Keith must rely on his brain as his prime asset, while on the other hand, guarding this asset carefully would entail using the means he defines as outside his brain’s scope: a construction helmet, to prevent head injury and brain damage. Within MSI’s power structure as Keith experienced it, bright ideas are insufficient to maintain the conditions of their own production. Through these commentaries by Keith, Tabitha and the anonymous visitor, as well as MSI’s promotional graphics, we can start to see an affinity between the image of the brain as ghostly persona and the (limited) forms of transcendence people experience through their participation in public space. Inhabiting MSI is said to stimulate the brain, creating immediate intellectual pleasure and expanding one’s mind through scientific knowledge and cosmopolitan savoir-faire. The resulting brain is socialized, not simply a biological organ which can be revealed by slicing tissue; to behold the brain’s contents and its capacities for cognition, we must watch actors projected on screens or in photographs, enacting an individual’s memories. This cultured yet individual mind is valued as an inalienable aspect of one’s persona – if one brackets biological vulnerability, and persons’ problematic agency over the material infrastructure in which they are embedded. But such bracketing is, after all, commonly characteristic of ghosts: they are invulnerable, because already dead, and so disembedded from the material world that they may pass through its walls as inconsequentially as nonvandalizing visitors pass through a museum exhibit.

Conclusion: The Praxis of Embodied Brains The brain exhibit team manager has since left MSI. When I briefly recounted the story she had told me, of the trip to Studio EIS and its consequences, to the man who had since become MSI’s senior designer, he responded disapprovingly, drawing on the ideology of semiotic discipline described above, saying these people had been led astray ‘by their eyes’, rather than being guided by their conceptual goals. An Enlightenment discourse resonates in this critique, in which sensorily experienced cultural forms are to be mistrusted insofar as they take on an autonomous agency, exceeding their proper role as transparent conduits for cognition, ‘obliterating the independence of physiological functions and thinking’

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(Stafford 1998: 5); in such an ideology, ‘design’ is indeed about cognitive intentionality, which disciplined imagery merely executes. Examining concrete instances of visitors’ and creators’ actual linguistic and aesthetic practices, however – including those of the new senior designer (Lorimer 1997) – reveals a more complex, multidimensional form of semiosis; a semiotics of the concrete, which creates hybrid readings, grafting together concept with form. The themes of eeriness, darkness, technology and human remains which art critics find in Elliot Schwartz’s photography (Hartshorn 1987; Haus 1991) were also evident to myself and other exhibit visitors unfamiliar with his art. Yet there were also limitations on the brothers’ agency, requiring them to confine the political impact of their work: Ivan: Basically, I think what happens with museums is that people are always afraid to go too far, for fear we will offend – someone. Elliot: The client in the background, though, you know, the – people, the museum director – you know if they wanted to, ah, talk about learning disabilities, I mean there’s – there’s no one who’s retarded,11 in this group, I mean there’s … Ivan: Yeah, there’s no one weird looking. (Anne: Yeah, yeah.) You know, that group should have had some weird looking people in it. (Elliot: Though this …) Would have been hard to set up, but – Elliot: Though this – though I think, their idea here was that there are learning disabilities that are in ... (Ivan: In our time box.) in our normal, yeah. That you don’t know it, that everyone appears normal and well, but – they have these things (Ivan: Right) that we average normal healthy people have; and that’s I think what that was about; but there, there was another element of this, uh, that could have been dealt with in a way, that might have been a little bit, you know, difficult. (Anne: Yes.) Ah, but they – for whatever reason they chose not to – deal with it that way. So, I think – you know, the museums tend to, uh ... they tend to walk a very sort of, uh, careful line. They don’t want to, they’re very sensitive to their constituency? In a way? And they don’t really wanna take, too many risks. And I think that’s pretty evident, in the kinds of exhibitions that one sees. At the same time they are ... uhmm, you know, it’s, it’s, it’s very – difficult, because they are interpreting – um, you know, history … And uh, if they are too, uh I dunno, editorial in some way, that they could get into trouble. Anne: Given these kinds of limitations, when you make an exhibit, what – what are you hoping for? What are you hoping – to achieve? Um, not just in the exhibit, but, I know money must play some kind of role ... And then there’s your own thing, your own reputation. Elliot: Mm-hm. Anne: …What kinds of result are you trying to bring about? Elliot: Well, you know fifteen years on the job tempers that.… Because,

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again, we are not, by and large, the designers. Therefore, it is not our intention that raised the spectre of any of this stuff to begin with. We are in a sense executing other people’s ideas, so, I think, we have to start with our limitation. If it was our project and we were designing it, our expectations and our desires would be different. Ah, the case being what it is, I think what we try to do is, is do the very best quality work that in – you know, in essence sort of, ah –delivers, to the client that which he has thought in his or her mind, they would be receiving. Which expresses their idea. So, we’re really kind of, illustrating, for them, an idea which they hope will be provocative. And I think that is, you know, that is one of the major flaws. We would like to go beyond this. We spend a lot of time talking about what we could do; we know we could do it. But, um, it’s a question of finding the right client. We have on occasion done it. Concrete representations are thus determined in part by the division of labour within the industry that produces them. In the process of their creation, however, such objects are always to some degree appropriated (in the sense used by Miller 1987), both by visitors and by those creators at different points along the path or network, as part of their ongoing praxes and projects (Pfaffenberger 2001). Examining mediating processes therefore requires us to question the adequacy of sociocultural models wherein those who craft such representations are considered as merely ‘executing’ concepts intellectually originated by scientists, artists or planners. Such models draw on a distinction between mental and manual labour, itself an example of a metaphor which maps between portions of human anatomy – the hand and the brain – and socioeconomically positioned persons. Critiquing this metaphor, Ingold (2001) has compellingly shown how inadequate it is to model skilled manual activity (such as engraving) as originating in mental phenomena such as concepts or intentions. Rather, he suggests (following Coleman 1988) that Plato’s use of the mental/manual distinction should be understood as an attempt to legitimate and naturalize the Greek institution of slavery, and the distinction’s persistence and intensification as complicit with processes of industrial control, Taylorism and de-skilling. We might similarly understand St Augustine’s division between the body and the soul, in which the postlapsarian, pre-millennial corruptible body, disobedient to our conscious intentions, was iconic of (and causally indexed) man’s failure to be obedient to God: since soul:body::God:man::church:laity, lay folk’s disobedience to priests was implied to be an analogous moral failing. But in the particular U.S. practices I have described, the notion of the brain, or of an enduring soul, is not used as a trope for a social position that legitimately allows one to control other people. Rather, it is used to invoke a sense of the self as maintaining and enhancing its own value while rising above oppressive or stigmatizing social

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or organic circumstances. While problematizing an identification of persons with disembodied minds,12 we can also recognize the value this notion has had to particular socially located persons and historical movements, including anti-racist Boasian anthropology. To understand science as popular culture, and especially how its representations become patched into people’s projects, we need to take seriously the media (and their surrounding praxes) through which science gets represented, and received. And we need these in order to recover political projects. If we take seriously the study of materiality, then sensory modalities and processes of translation become tools for observing concepts not as abstracted intentions but in the fullness of their social and material life. Museology thus crucially enlarges our understanding of the public, embodied life of science.

Notes 1.

2. 3.

4. 5.

This long-term project accumulated many intellectual debts; among those most relevant to the ideas presented here are benefits accrued from Nancy D. Munn, Michael Silverstein, Betsy Traube, Barbara Maria Stafford and Ira Bashkow. Sharon Macdonald, Tony Iaccorino and Janelle Taylor made it possible for me to present earlier versions of this paper to, respectively, the 2003 ASA meetings, Reed College’s American Studies Workshop and the University of Washington at Seattle’s anthropology department, where Trang Xuan Ta asked an insightful and crucial question; subsequently Lindsey MacAllister, Museum of Science and Industry archivist, helped me find the answer. Jeanette Edwards and anonymous reviewers provided helpful criticisms, as did Pete Wade, whose intensive engagement with my article’s claims I am even more grateful for than his extended patience. Penny Harvey enticed my argument out of its ghost-mystery shell, and Suzanne Menair decryptified it. See McNeill (1996, Ingold (2001), Suchman (2001); the present paper is intended to contribute to this project. By ‘public life of science’, I mean the manifold processes through which scientific findings ramify into the lives of non-scientists, and especially when non-scientists are construed as a ‘public’ for whom ‘science’ is being represented. By ‘conditions of actual existence’, I mean the production stream through which these findings are construed, translated and received, including the production of exhibits, on which this chapter focuses. And by ‘its fetishized self-image’, I mean the ideology through which science has been construed as a singular, and singularly unmediated, enterprise. I am indebted here and elsewhere to a series of generously initiated conversations with William Pattison. I am grateful to Ray Fogelson for this insight.

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My part-time fieldwork took place intermittently during the 1990s, and was supplemented in 1998–1999 by 14 months of full-time fieldwork funded by the Wenner-Gren Foundation. These observational methods are supplemented with other kinds of interviews, and long-term involvement in my informants’ lives outside the Museum. The Museum attributed her misidentification of learning disability professionals as learning disabled themselves to poor signage, which they immediately changed. In the dental exhibit, these cross-sections are enormous illustrations; in Body Slices, they are actual, imperfectly preserved slices of two cadavers. For Tabitha, death can be framed as another transformative experience, as when she formally announced over the telephone: ‘My grandmother made her transition this Saturday’ (15 January 1996). The extension of the term ‘learning disabled’ to those labelled as ‘retarded’ is potentially a political question, parallel in some respects to the questions that have emerged at various points for feminists, gay rights activists and others as to whether to openly ally themselves with groups oppressed for reasons that are connected to their own causes but more heavily stigmatized. Interestingly, such contestation emerged in the museum’s own market research: a West Asian teenager, exiting the exhibit, was asked: ‘Are you familiar with learning disabilities?’ He is recorded as replying ‘Yeah, my dad teaches mentally retarded.’ When the interviewer queried whether the mentally retarded have learning disabilities, he responded: ‘Yeah, they can’t do normal things’ (interview, 31 March 1989, MSI archives). There is thus a common-sense view that since those labelled as mentally retarded are disabled in ways that make it harder for them to learn, they should logically be included among the learning disabled: this view is in tension with the usage of U.S. advocates such as MSI’s consultant Dr Laura Lehtinen Rogan (although U.K. usage differs in this respect and the teenager’s ‘West Asian’ father would perhaps have been more influenced by U.K. usage). MSI’s exhibit was concerned to highlight the distinction, as this excerpt from an internal evaluation report (20 March 1989) makes clear: under the heading ‘Introduction and Definition of Learning Disabilities’, the report stated, ‘Results: Nearly half of the visitors tested thought that learning disabilities meant mental retardation before they read the text. After they read the text, several commented that they had changed their perception of learning disabilities. One person noted: ‘I will be more careful about how I interpret people’. Cf. Urciuoli’s critique of the adequacy of ‘ethnicisation’ as a response to racialisation (1996), or di Leonardo’s discussion of the limitations of identity politics (1994). Submitting ideas to the ‘Bright Ideas’ box proved an inadequate avenue to improved safety conditions in Keith Hughes’ workplace; I would suggest that the historically successful routes of organized labour, collective bargaining, sit-down strikes, and so on, involved a notion of persons that went beyond mere brains.

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Orvell, M. 1989. The Real Thing: Imitation and Authenticity in American Culture, 1880–1940. Chapel Hill: University of North Carolina Press. Pfaffenberger, B. 2001. ‘Symbols Do Not Create Meanings – Activities Do: Or, Why Symbolic Anthropology Needs the Anthropology of Technology’, in M.B. Schiffer (ed.), Anthropological Perspectives on Technology. Albuquerque: University of New Mexico Press, pp. 77–86. Prather, M. 2000. ‘Whitney Curator Interviewed for ‘Remembering George Segal’ on Newshour with Jim Lehrer, 14 June 2000. Transcript available at http://www.pbs.org/newshour/bb/remember/jan-june00/segal_6-14.html. Pridmore, J. 1996. Inventive Genius: The History of the Museum of Science and Industry. Chicago: Museum of Science and Industry. Reed, C.R. 2000. ‘All the World is Here’: The Black Presence in the White City. Bloomington: Indiana University Press. Robbins, B. 1993. ‘Introduction: The Public as Phantom’, in Bruce Robbins (ed.), The Phantom Public Sphere. Minneapolis: University of Minnesota Press, pp. vii-xxvi. Rogan, L.L. 1986. Memo to Anne Hornickel, Re: Brain and Learning Disabilities Exhibit, 10 March 1986. Chicago: MSI archives. Rush, R. 1980. ‘The Brain Exhibit: An Exhibit Concept Developed for Museum of Science and Industry and its Medical Exhibits Advisory Committee by Richard Rush Studio Inc’. Chicago: MSI archives. Schiffer, M.B. 2001. Anthropological Perspectives on Technology. Albuquerque: University of New Mexico Press. Serrell, B. 1991. ‘Of the Curators, By the Curators, For the Curators’. Journal of Museum Education 16(2): 26. Shapin, S. and S. Schaffer. 1989. Leviathan and the Air-pump: Hobbes, Boyle, and the Experimental Life. Princeton: Princeton University Press. Shaw, M. 1893 [1992]. World’s Fair Notes. St Paul, MN: Pogo Press. Spinelli, M.-L. 1992. ‘Fun and Power: Experience and Ideology at the Magic Kingdom’, Ph. D. thesis. Amherst: University of Massachusetts at Amherst. Stafford, B.M. 1991. Body Criticism: Imaging the Unseen in Enlightenment Art and Medicine. Cambridge, MA: MIT Press. ______. 1996. Artful Science: Enlightenment Entertainment and the Eclipse of Visual Education. Cambridge, MA: MIT Press. ———. 1998. Good Looking: Essays on the Virtue of Images. Cambridge, MA: MIT Press. Stasch, R. 2009. Society of Others: Kinship and Mourning in a West Papuan Place. Berkeley: University of California Press. Suchman, L.A. 2001. ‘Building Bridges: Practice-based Ethnographies of Contemporary Technologies’, in M.B. Schiffer (ed.), Anthropological Perspectives on Technology. Albuquerque: University of New Mexico Press, pp. 163–78. Taylor, J. 1992. ‘The Public Fetus and the Family Car: From Abortion Politics to a Volvo Advertisement’, Public Culture 4(2): 167–83. Time 1970. ‘Ghost Maker’. Time Magazine, May 11th 1970. Tomorrow, T. 1995. ‘The Trouble with Brains’. The New York Times Magazine, 3 September 1995, p. 60. Tsing, A.L. 2004. Friction: An Ethnography of Global Connection. Princeton: Princeton University Press.

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CHAPTER 5 Spectacles of Reason: An Ethnography of Indian Gastroenterologists Stefan Ecks

Spectacular Science In November 1999, I had the chance to participate in the ‘First Indo-US Gastrointestinal Endoscopy Workshop’, a transnational medical conference organized by the West Bengal Chapter of the Indian Society of Gastroenterology and co-sponsored by the American Society for Gastrointestinal Endoscopy (ASGE). The main venue of the two-day event was the Oberoi Grand Hotel at Calcutta, one of the city’s five-star hotels. In the large auditorium, a stage had been built to accommodate a white-clothed table for eight panellists and four video screens. The screens displayed live images transmitted from the operating theatres of two Calcuttan endoscopy centres. One screen showed doctors and nurses at work on a series of patients. The other three screens gave multiple views of the patients’ insides: live images from the endoscope, from an ultrasound machine and from an X-ray machine. Through a mediating ‘master of ceremonies’, the panellists and the audience could ask questions to the doctor at work in the operating theatre (OT) and to discuss the demonstration in progress. The procedures in the OT aimed at demonstrating how new equipment enabled the doctor to perform new types of diagnoses and surgeries. The language of the event oscillated between high-tech jargon and jokes. The live demonstrations from the remote OT were grouped around themes like ‘variceal band and loop ligation’ or ‘argon plasma coagulation’. Questions from the audience

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concerned the uses of the equipment, for example, if a particular kind of ‘prosthesis introducer’ manufactured by company X worked better than that by company Y. Asked about the health of the patient on the table, a doctor replied that ‘the performer status of the patient is very poor’ – meaning that the patient was in a bad state, but expressing it as if the patient was failing to play along with the procedure. Clearly, the presentation of the doctor and the equipment in use were more important than healing. The operating doctors’ comments sometimes even blamed patients for not having the ‘right symptoms’ for the equipment at hand: ‘This is not a good patient for this kind of treatment’. Jokes were also commonly made. For example, as one doctor appeared on screen with a red tika marked on his forehead, the MC greeted him: ‘Hey Vishal, you look pretty blessed this morning’. The doctor replied, with a suave smile and a thick American accent, ‘Yup, sometimes you need just that’. A joking attitude was especially prevalent in moments when the performance failed. Having no success with one of his intended demonstrations, a doctor remarked: ‘I guess I didn’t have my cornflakes today’. When one of the few participating female doctors appeared on screen with too little light from the video camera, the MC played on the Indian beauty ideal of fair skin by saying: ‘You’re looking pretty dark’, to the roaring laughter of the audience. The light went on, and the demonstration continued. To make visible even the darkest corners of the human bowels is the most fascinating aspect of gastroenterology, not only to the doctors, but also to the patients. The success of gastroenterology and of other visualizing techniques is partly attested to by the rapid growth of private diagnostic centres in India since the 1990s. These centres mushroomed in all larger cities and are increasingly found in smaller towns, too. They typically advertise all the diagnostic techniques on offer on billboards visible from the road, making up long lists of acronyms such as MRI (magnet resonance imaging) or CAT (computed axial tomography). Patients usually come to these centres by referral, but sometimes also go directly to a centre of their own choice. In the patients’ perspective, ‘getting a test’ goes beyond a regular consultation with a doctor and can signal to family and friends that ‘something serious’ is going on. A test from a lab is seen as much more objective than the impromptu diagnosis done in a doctor’s chamber. Indeed, to benefit from the power of visualization, healers of all medical specializations nowadays refer their patients to these labs. For many non-allopathic practitioners, specialized diagnostic centres are not even doing ‘allopathy’, but reveal the truth of the body independently of therapeutic specializations. Doctors of homeopathy or Ayurveda often see a fierce competition with allopaths in therapeutics, but not in diagnostics (Frank and Ecks 2004). For a scientific analysis of the belly and its diseases, allopathic diagnostic centres have achieved undisputed authority. The Endoscopy Workshop is one of the sites

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where this new form of biomedical hegemony is affirmed, celebrated and renewed. Without these visualizing powers, gastroenterology would not exist as a field of specialization.

Colonial Enlightenment Most of the words used for ‘truth’ in English – as in countless other languages – are based on images of light: someone who speaks the truth ‘illuminates’, ‘elucidates’ and ‘sheds light on’ a question that had so far remained ‘unclear’ or ‘obscure’. Bringing light into areas of darkness also became the key metaphor of modernity as an Age of Reason (see Jay 1993). But shining light onto something and making it visible is not enough for full ‘enlightenment’: whatever is seen must also be reflected in thoughts and words of reason. In his famous essay of 1784, Immanuel Kant gives the answer to the question of ‘What is Enlightenment?’ right in the first sentence. In the German text, Kant writes ‘Aufklärung ist der Ausgang des Menschen aus seiner selbstverschuldeten Unmündigkeit’. There are several translations of the original German text into English. Most of them render the word Unmündigkeit as ‘immaturity’ and translate this sentence as ‘Enlightenment is man’s emergence from his self-incurred immaturity’. Other translations speak of ‘tutelage’, ‘nonage’ or ‘childhood’. But none of these words translates the root meaning of Unmündigkeit, which literally means ‘unable to use one’s mouth’. Unmündigkeit has the double meaning of being unable to speak freely to express one’s opinion, and of being unable even to think rationally. This inability to think and to use one’s mouth to speak words of reason is, according to Kant, partly due to personal fault (for example, ‘laziness’ or ‘cowardice’), but also partly due to the socio-legal context of despotic rule. Unmündigkeit, and its opposite state of Mündigkeit, are legal terminology for having (or not having) all the rights of a grown-up and conscious citizen. Mündig are all those who are allowed to vote and to make decisions for themselves, as opposed to underage minors or mentally disabled people, who cannot decide their lives and are thus in a state of Unmündigkeit. Several other German legal terms are derived from the image of the mouth as a source of words of reason. The term for someone who cannot (yet) speak for himself or herself as a full citizen is Mündel (‘small mouth’), and a person who has the right to speak on behalf of a Mündel is a Vormund (‘the preceding mouth’). In all cases, Kant’s term Mündigkeit denotes using one’s mouth in the sense of ‘speaking with reason’ and ‘having one’s say’ as a full citizen. So, true Enlightenment is not only about seeing clearly, it is also about speaking clearly about what one has seen. Bringing Enlightenment to its colonial subjects was one of the British Empire’s key legitimizing strategies. Medicine, as a ‘rational’ and ‘modern’

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project, was used to lend credibility to colonial rule. As David Arnold argues in his work on medicine and colonial power in India, biomedicine was first a tool of British imperialism, but was later taken up as a legitimizing tool of the new Indian elite ‘as part of their own hegemonic project’ (1993: 294). Gyan Prakash (1999: 123–58) argues that Indian responses to Western medicine could not be reduced to simple ‘resistance’. Rather, members of the Indian elites quickly adopted Western medicine as their own domain and fashioned themselves as indispensable mediators between the British rulers and the unenlightened masses: ‘The Western-educated elite were quick to recognize this new space of mediation, and sought to intervene by placing themselves as agents of modern transformation’ (Prakash 1999: 144). Having adopted allopathy as the most rational system of medicine, this elite continually criticized the Indians’ neglect of their bodies and lobbied for a decisive scientific reform of everyday life. This space of mediation was opened by the colonizers’ split between an Indian elite capable of reason, and a passionate, unreasonable body of the masses. Thomas Hansen analyses this splitting of the Indian body as a ‘double discourse’ of colonialism (Hansen 1999: 32–43). In the post-Independence era, biomedicine was strongly supported by successive Indian governments and became even more powerful and prestigious than during colonial times ( Jeffery 1988). At the same time, the term ‘Western’ medicine quickly became obsolete and was replaced by ‘allopathy’ or simply ‘medicine’. Today, India educates almost as many medical graduates per year as the United States, and has become one of the world’s leading suppliers of pharmaceuticals and medical services. Allopathic physicians are at the top of the social and economic hierarchy and there is often less cultural distance between a doctor in Delhi and a doctor in London than between a Delhi doctor and a Delhi labourer (Gupta and Ferguson 1992; Appadurai 1996). If Arnold’s (1993) thesis holds true that the Indian elite has taken up biomedicine for its own hegemonic project, what has become of it in the city of Calcutta (renamed ‘Kolkata’ in 2000) at the beginning of the twenty-first century? To answer this question, I want to present results from interviews with allopathic doctors conducted in Calcutta between 1999 and 2000, with a special focus on ten specialized gastroenterologists. All the gastroenterologists whom I interviewed practiced in private chambers or diagnostic centres, all had been specialized in gastroenterology for at least five years and most had worked in the US or UK for some time. As for the doctors’ biographic background, all were from West Bengal. Only one among them was a woman. Given that Calcutta is a chief centre for medical education in India, it is not surprising that all the doctors interviewed came from West Bengal. The interviews with gastroenterologists formed part of a larger project on medicine in Calcutta (Ecks 2003). What drew me to gastroenterology was,

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above all, the fact that is it one of the fastest-growing medical specializations in India today. Given the centrality of digestion in popular Indian health practices, gastroenterology occupies a strategic position in defining a medico-scientific view of the body against ‘popular superstitions’. Gastroenterology is an intriguing subject also because it entails an unresolved tension between the ‘high’ and the ‘low’: it is ‘high’ in status for being a highly paid, highly specialized and highly technological activity that revolves around visualization. Just as much as in Europe or America, in India the sense of sight is also held in highest esteem when it comes to discovering the truth. On the other hand, gastroenterology is ‘low’ for what it sees: slimy masses of half-digested food and gastric juices, lesions, tumours and bits of faeces. Biomedicine has an internal hierarchy of specializations. Although not located at the bottom of the ladder, gastroenterology is not the most prestigious subfield. At social gatherings, neurologists or cardiologists usually find it easier to tell engaging stories about their experiences than gastroenterologists.1 In this sense, it could be argued that the division between an elite body of reason and an unreasonable body of the masses reappears in a new guise within the gastroenterologists themselves. When the doctors talk about their patients, they talk just as much about themselves as about them. They constantly try to assert a clear separation within themselves between the unreasonable ‘low’ ground of the belly, of superstitions and of darkness, and the reasonable ‘high’ ground of scientific reason, medical expertise and Enlightenment – both in the sense of the philosophical project and in the physical sense of shining light into darkness.

Endoscopic Enlightenment Calcutta gastroenterologists have a range of diagnostic technologies at their disposal, most of them producing results in written form, such as various forms of stool or urine tests. But their showcase technology is endoscopy, the live visualization of digestive interiors. The doctors highlighted visualization as the most persuasive technique they had at hand when dealing with patients. According to the doctors, patients were always concerned about the costs of diagnostics, for which most of them have to pay out of their own pockets. The faster a reliable diagnosis is reached, the less the patients have to pay, even if endoscopy is more expensive than other tests. The doctors felt pressured to find a convincing diagnosis as quickly as possible; otherwise the patients became irritated. As the doctors pointed out, if a series of tests was done without conclusive result, the patient or his relatives started to criticize the doctor: ‘If you haven’t found the problem after fifteen tests, the patient

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will switch to another doctor and start calling you names’ (Gastroenterologist #9). Endoscopy was even more convincing when it was not only used for diagnosis but also for therapeutic interventions. Technology enabled the doctors to perform treatments that earlier had been the task of surgeons. The endoscopic theatre of proof was at its most convincing when diagnosis and therapy were performed together. For example, even if a patient doubted that he had a gall stone, the doctor could prove him wrong at once: ‘You can take out a patient’s gall stone without general anaesthesia and hand it over to him right away’ (Gastroenterologist #3). Despite these spectacular powers of visualization, the doctors were ambivalent about letting the patients see the their own bowels. In one diagnostic centre where I was allowed to watch endoscopies, I observed that the practicing doctors sometimes concealed the monitor from the patients, sometimes put it right into their view. Depending on the changing angles of the monitor, the doctor and themselves, patients were sometimes able to see their insides, sometimes not. When asked whether they showed the live endoscopic images to their patients, some doctors argued that they liked to show their patients what is going on in order to convince them. However, the majority of doctors said that they preferred the patients not to see directly, and only showed the monitor if explicitly asked. For the doctors, the risk of triggering an uncontrollable response from the patient outweighed the gains of convincing them by letting them see inside themselves. In one doctor’s view, the lack of self-control in Indian patients – as opposed to idealized ‘Western’ ones – required that live images could usually not be shown: I’ve tried both, keeping the monitor inside the consultation room and outside. In my experience, it helps not to show the patient anything. One great thing about people in the West: They are not scared about the truth. For example, cancer patients want to know where exactly is the cancer located, ‘how long will I live?’ Here, people start crying first, and it becomes unmanageable. (Gastroenterologist #9) Other strategies could be used to avoid the risks of showing the images directly to the patient. For example, a relative could be brought into the diagnostic room who could look at the monitor instead of the patient. Another possibility was to take photographs through the endoscope and show them to the patient later, which allowed for presenting the images in a more controllable setting and for revealing only those images which the patient could ‘stomach’. Endoscopy not only bore the risk of shocking the patients through gross images, but also the risk of giving uncomfortable or even painful feelings. In contrast to the patients’ alleged lack of self-control in regard to the ‘truth’ of

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endoscopic images, the doctors pointed out that the patients took the endoscopic procedure itself fairly well – at least, once they had decided to go through with the examination, which only about half the patients who are told to take an endoscopy actually did. Some doctors found that Indian patients were more able to stand the bodily pain of the procedure than the visual truth of the findings. They said that patients in Western clinics were usually sedated before endoscopies, whereas in Calcutta, they were just given what the doctors jokingly called ‘vocal anaesthesia’: We don’t give any medication, painkillers, sedatives [before endoscopies]. Even for colonoscopy we don’t use, although it is supposed to be very painful. But my patients walk out of the room as if about to join office. It depends on your skills. We call it ‘vocal anaesthesia’ here: if a patient is moaning we say: ‘Shut up, there’s nothing wrong!’ [laughs]. (Gastroenterologist #8) As a medical procedure that produces live images of the body’s insides, which the patient can watch simultaneously as he or she is being operated on, endoscopy has an immediacy that few other medical visualization technologies can match. In the doctors’ opinion, the pain of the procedure can be easier to bear than the horror of seeing the images. There are conflicts between doctors and patients about how the images are generated, but the truth of the images seems beyond contestation. Indeed, the images are too truthful to be endured.

Doctors’ Perceptions of Patients’ ‘Bowel Obsession’ ‘Bengalis are bowel-obsessed’ was the most frequent statement in my interviews with allopaths about their patients. Even if other ethnic groups in Calcutta were also concerned with their digestive health, it was common opinion among the doctors that ‘Bengalis’ emphasized this concern to the extreme – and this although all the gastroenterologists I interviewed were themselves Bengali. What the doctors understand as ‘bowel obsession’ is a cluster of ideas and practices that are centred on the notion that if the belly is healthy, the whole body will be healthy, too. First, Bengalis were even more concerned about food than other groups in India – the happiest times of the day were the meal times. Second, Bengalis paid much attention to their digestive processes: how they feel at various times of the day, their appetite before meals and sensations after meals. Third, even illnesses that are not evidently linked to the digestive system, such as hair loss, headaches or heart disease, were explained as symptoms of a disease that lurked somewhere hidden in the bowels. Fourth, Bengalis loved to talk about their

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digestion and that of others. Far from being a dark and shameful part of the body, the bowels were a topic of everyday discussion, wide open to public scrutiny. None of the doctors had an explanation for why Bengalis were more bowel-obsessed than others. Nor did any of the doctors perceive either a rise or decline of bowel consciousness over time: ‘I cannot think of any social, cultural explanation for this. No, there is no historical change in perceptions of the digestive system. It has always been like that’ (Gastroenterologist #5). When the allopathic doctors talked about popular fixations on the belly, they usually did so in a mocking manner, as if to distance their worldview as far as possible from that of the lay population.2 As professional healers of the bowels, they did not deny the importance of digestive health for general well-being. However, they derided the lay beliefs as naïve and ill-informed. Popular bowel obsession was based on a fragmentary grasp of human anatomy and pathophysiology: ‘They talk about liver, stomach, “gas”, bowel movements. They are not bothered about pancreas, they are not bothered about gall bladder, they are not bothered about spleen. They are only bothered about stomach and liver. Everything else is just “down there”’ (Gastroenterologist #1). This gap between the doctors’ powers of accurately visualizing the entire digestive system, and what they perceived to be a rudimentary grasp of it on the side of the patients, was sometimes mapped onto a gap between knowing adults (the allopaths) and ignorant children (the patients): ‘[For the patients] everything is connected to the tummy. The patients are like children. As you know, when children complain about pain, they point to their tummy’ (Gastroenterologist #5). In this doctor’s view, popular ‘bowel obsession’ is not even credited as a form of knowledge of particular parts and processes of the body. Patients talk about their bowels because they are at the centre of the body. The patients’ ignorance of how to visualize the intestines was so complete that they could only distinguish the body’s centre from its periphery, but no details beyond that.3 That the exact topography of their bowels remained obscure to patients was not, as such, a problem for the doctors. Nor did the interpretation of the images produced by endoscopic examinations cause any significant friction between doctors and patients. The truth of the image was uncontested – but almost all other aspects of gastroenterological practice were open to challenge by patients. According to the gastroenterologists, some expressions occurred most frequently when patients describe their illnesses to them. The most common terms were ‘gas’ (flatulence, wind, or any pain in the upper body), peter byatha (abdominal pain), livere byatha (pain in the liver), ambol (sourness), acidity (heartburn), amasha (mucus in stool) and paykhana hacchena (irregular motions). Since these words were derived from patients’ subjective illness experiences, the doctors did not oppose their use. Indeed, doctors prefer

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their patients to use simple Bengali words instead of English or medical terms. Yet patients also employed medical language. Given their professional position, the doctors considered any such use a misuse. Patients who employed ‘professional’ terminology without knowing what it meant were seen as ‘complicated’, as more difficult to treat than ‘simple’ patients with ‘simple’ symptom expression. As one gastroenterologist explained: Simple people express themselves in simple ways and are simple to diagnose. […] More educated people say: ‘Doctor, I have “gas”, do something.’ They come up with medical terms, like dyspepsia or colitis. They have read the paper, they know a little bit. That makes them difficult. They just want me to confirm their own diagnosis. (Gastroenterologist #4) According to this doctor, patients’ uses of medical words such as dyspepsia or colitis made diagnosing more difficult, as more questions had to be asked about what patients meant when they used these words. Foreign words, when misunderstood, not only obscured the actual symptoms, but also created them. In the case of ‘gas’, this doctor observed that linguistic confusion could result in diagnostic confusion. Patients attributed the cause of headaches and other diffuse pains to the state of their bellies partly because of a linguistic misunderstanding. Patients conflated the Latin term gastro (‘related to the stomach’) with the English term gas (as air-like substance, derived from Greek ‘chaos’). When the excess of gas that originates in the stomach travelled through the body, it could pressurize other organs of the body and give diffuse sensations of pain. Other than the distinction between ‘simple’ and ‘complicated’ disease presentations, doctors also distinguished between those patients who liked to talk about their bowels and those who did not. In their view, Bengali patients met the stereotype of the ‘talkative’ patient, in contrast to other ethnic groups. In doctor-patient encounters, the patients’ desire to talk and the doctors’ shortage of time was highlighted as an area of conflict. For the doctors, the patients’ explanations were only of marginal importance to the diagnostic process. For the patients, on the other hand, talking about their symptoms was vital: ‘They talk at length. And expect us to spend a lot of time with them. If you give them time, they talk endlessly. The more you let them talk, the more they like you’ (Gastroenterologist #9). This conflict over consultation time was seen as a general conflict between the characteristics of modern/civilized/reasonable professionals and traditional/half-civilized/unreasonable patients, especially the Bengali ones. However, as much as the doctors might have made fun of the ‘Bengali’ lack of time-discipline, it was always light-hearted, like parents making fun of their children’s lack of good table manners. Moreover, the love for chatting

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was one of the characteristics that made Bengalis more ‘human’, hence less ‘mechanical’, than others. That the Bengali patient did not use his or her mouth to speak reasonable words was perceived as an endearing characteristic. When the gastroenterologists reflected on how patients diagnose themselves and what symptoms they focus on, the most common answer concerned bowel movements. The salient element of the ‘Bengali bowel obsession’ was the fixed idea that one must have exactly one motion per day, not one more or less, and that it had to happen right after getting up in the morning. None of the doctors had a theory about the origins of this anxiety about regular motions. Most of them thought that it was a cultural tradition, without deeper meaning: ‘That has been drummed into us from early childhood: First thing when you get up, you go to the toilet’ (Gastroenterologist #5). Some of the doctors associated this habit with the daily rhythms of peasant life. Other doctors related it with what they saw as Calcutta’s incomplete modernization: work routines forced people to leave the house without giving them the chance to come back when they wanted to. At the same time, the city infrastructure did not offer them toilets to make up for this.4 Women had to suffer more under these circumstances, as public defecation was not an option for them. The doctors always associated modern times not with normalized schedules, but with irregularity and disturbed rhythms. The link between bowel obsession and incomplete modernization was the theme of several jokes among the gastroenterologists. One was centred on the idea that, in order to stop employees from skipping a day of work because they could not pass stool in the morning, the government should distribute laxatives free of charge: ‘If the Indian government would distribute Isabgol [laxative] free of charge, the economy would boom’ (Gastroenterologist #6). Popular diagnostics also focused on the characteristics of the stool: its colours, textures and smells. Patients’ readiness to talk in vivid detail about this topic was often mentioned by the doctors, especially by those who had worked in the UK or in the US, where patients often felt too ashamed to talk about it. Comparing his experiences in the UK with those in Calcutta, one doctor said: There are days, when I’ve just woken up from sleep, having my morning tea, reading the newspaper, when a patient of mine calls up and tells me that he just had the most awful looking stool in his whole life, with the most awful smell. I just sort of manage to gulp down the tea! [laughs] I keep telling myself: why do they do this to me, in the morning? Really, they feel very free. (Gastroenterologist #2)

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Another facet of the ‘Bengali bowel obsession’ is, according to the doctors, that patients interpret any illness symptoms as one of disturbed digestion. Such a popular ‘holistic’ view of the body and illness was based on the patients’ lack of knowledge about how the body truly works. No matter if the problem was hair loss, impotence, headaches, skin disease or any diffuse weakness – at the root of the problem was an imbalance of the bowels. For the doctors, this over-attribution of symptoms was partly a harmless expression of ignorance (for example, when patients think that ‘gas’ causes headaches), but it was also partly a reason for disagreements with patients, especially in cases of severe diseases linked to the heart. First, patients presented heart and circulatory symptoms as gastric symptoms: ‘They don’t want anything related to the heart at first, so they say buk [Bengali, chest]’ (Gastroenterologist #4). Second, patients diagnosed with a heart disease often refused to accept this diagnosis. They hoped that, by going for a gastroenterological examination, the true cause of their symptoms would be found in their bowels: ‘Patients refuse to accept it is a cardio problem. I would tell them again and again, but they only go to a cardiologist after their first heart attack’ (Gastroenterologist #3). Patients always prefer to be diagnosed as a ‘stomach’ patient than a ‘heart’ patient, because heart diseases tend to be harder to cope with. Patients’ readiness to interpret illness symptoms as digestive disorders can be abused by doctors. In a private conversation, one GP suggested that doctors used the catch-all diagnoses of ‘gastric’ to get rid of patients. Whenever a doctor could not produce a convincing diagnosis for a patient’s symptoms, he could always appease him or her by diagnosing a ‘gastric’. This was usually enough to satisfy both the patient and the family. According to some doctors, a serious abuse of popular bowel consciousness also occurred when a doctor did not want to give proper time. For example, emergency calls in the middle of the night for ‘chest pain’ could be discarded as harmless ‘gastric’, even if the doctor suspected a heart attack. However, clashes between doctors’ and patients’ ways of diagnosing digestive problems never revolved around the images produced by endoscopes. If there were disagreements, they emerged from different types of speech that were authorized – or not authorized – by visualizing the intestines. The doctors saw their way of speaking as scientific and enlightened, because it was backed by truthful images, whereas all the patients had at hand were ‘subjective’ experiences and faulty imaginings of their insides, which only resulted in a pointless struggle with medical science.

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Doctors’ Reflections on Patients’ Aetiologies Endoscopic diagnosis went without contestation because of the evidentiary powers of images. Treatments that could not be accompanied by visualizing techniques were far more open to challenge. To determine the reasons why a patient was ill was one of these areas of conflict. When I asked the gastroenterologists about how patients describe the aetiology of gastric illness, a diffuse cluster of causes was mentioned. Two sets of causes were loosely distinguished: those that related to substances entering the body, and those of a psychosomatic character. Among the substances taken into the body, food was the most prominent. According to the doctors, patients commonly mentioned ‘spicy’ and ‘oily’ food as reasons for gastric troubles. The doctors generally agreed with the popular perception of such foods being dangerous for the digestive system. Yet the doctors disagreed with their patients on exactly why spicy and oily foods were risky. The doctors’ explanation was based on a biochemical model entailing enzymes, molecules and proteins – all of which could be visualized, if not by endoscopes, then by other biomedical technologies. In contrast, the patients’ model was based on ‘unscientific’ notions such as humoral hot/cold classifications, which were derided by the gastroenterologists because there was no visible evidence for them. The doctors distanced themselves from the popular notions so much that they portrayed hot/cold thinking as completely absurd and far removed from their own thinking, even if it was common in their families. Since all the doctors had grown up in Calcutta, one could expect that they had at least a basic familiarity with popular ideas such as hot/cold classifications. This distancing can be interpreted as an exaggerated expression of the gastroenterologists’ professional status. Such distancing is also a means to devalue patients’ anxieties about the side effects of medicines. When concerns were expressed in a popular idiom of hot/cold – for example, that ‘these tablets make my belly hot’ – it was easier for the doctors to shrug them off as unfounded lay perceptions. Obviously, the doctors were more ready to dismiss popular beliefs towards me than towards their patients, in order not to alienate them unnecessarily. Compared to food, water was rarely mentioned by patients as a cause for digestive illness. The doctors mostly said that the population did not know the risks of contaminated water. At most, people only paid attention to the appearance of the water, whether it was clear and whether it had no strange odour: ‘They just look at the colour of the water. If it’s clear, it’s OK’ (Gastroenterologist #1). Again, patients’ powers of truthful visualization fell short of those of medicine, leading to a host of problems not just for patients’ health but also for the doctor-patient encounter.

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Beyond illness aetiologies that focus on ingested substances, patients also mentioned ‘stress’ and ‘tension’ (cinta in Bengali) as plausible reasons for digestive illness. However, the gastroenterologists generally perceived their patients to be too little accepting of psychosomatic aetiologies. Given that the gastroenterologists derive so much of their authority from a materialist view of reality as visible reality, this finding must come as a surprise. Why would gastroenterologists subscribe to models of disease causation that are impossible to visualize? In a study of patients in a Boston clinic who were diagnosed with ‘psychosomatic’ problems as the cause of their digestive disorders, Cecil Helman (1988) concludes that doctors, when failing to determine an exact cause of the disease, ‘respond to the uncontrollable aspect by increasingly “psychologizing” the condition – that is, by shifting the responsibility for aetiology or flare-ups to patients’ emotions, personality, or early psychological experiences’ (1988: 117). The same process is behind the Calcutta gastroenterologists’ leanings towards psychosomatic aetiologies. The power of their discipline relies on making disorders visible, but in many of the patients they examined, no decisive image could be produced. The doctors affirmed that this was not a weakness of the visualizing technologies, but lay in the nature of bowel disorders. As they told me, up to half of all stomach patients were diagnosed with ‘Irritable Bowel Syndrome’ (IBS), a disorder of bowel movements with diffuse causes and without positive endoscopic evidence: ‘IBS is most common. Your endoscopic findings will be normal in it. Fifteen to twenty percent of world population, including me and you, suffer from IBS. Out of one hundred patients who come to me, fifty percent will have IBS. Fifty percent! See? It’s the commonest gastrointestinal disorder’ (Gastroenterologist #8). According to the doctors, IBS was a condition which could only be diagnosed after an endoscopy had been done and other possibilities had been eliminated. The common occurrence of IBS makes clear why visualization is so important: visual proof that there were no ulcers, tumours, or any other dangerous growths was far more convincing than a series of tests which yielded only written results. And even without visible evidence, it was still better to suspect psychosomatic causes than not to have any explanation. To diagnose psychosomatic reasons for digestive disorders did not mean, however, that the doctors would also advocate psychological therapies. Instead of psychotherapy, they mentioned the prescription of tranquillizers and antidepressants as the best way to control the patients’ symptoms. The ‘gas’ came ‘from the brain’, not from the bowels, and the best remedies were psychotropic drugs:

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I prescribe a lot of anti-anxiety medication, tranquillizers. Initially I never believed in these, but I found that the stress level is so high, even in people who don’t come across that way … So now I’ve come to believe that all the ‘gas’ is not really gas. The motion of the ‘gas’ is coming from the brain. Therefore you have to treat the brain if you want to get the stomach OK. (Gastroenterologist #2) Even if popular discourse stresses the need for a cool mind (mon in Bengali), patients do not commonly mention ‘tension’ or ‘anxiety’ towards an allopathic doctor (Ecks 2005). Once they decide to consult an allopath or even a specialized gastroenterologist, their expectation is that he or she will be able to determine a physical reason for their illness. The gastroenterologists played along with this expectation, preferring to prescribe psychopharmaceuticals without telling their patients that no ‘truly visible’ cause for their illness had been found.

Looking Backstage Like every stage performance, spectacular gastroenterology also has areas hidden from public view. It is there that medical malpractice takes place. If the doctors perceived their patients as lacking self-control, some of them were also critical of their own negligence. Given that ‘professionalism’ is the linchpin of allopathy, admitting one’s own breaches of conduct was rare. Nevertheless, one of the doctors I interviewed (Gastroenterologist #9) volunteered information about medical malpractice in gastroenterology. According to him, all the problems that beset gastroenterology in India revolved around money. Alongside radiology and cardiology, gastroenterology was one of the medical specializations that attracted many students because of the high financial rewards. There was little money to be earned in simple general practice, because it did not use expensive high-tech gadgets: ‘There was a symposium recently, so many new tools, I’d have loved to buy them all. So much fun’ (Gastroenterologist #9). Gains depended on turnover: once a machine had been bought, only maximum use ensured maximum profits. The machines used in India were imported from North America and Europe, and could only be bought at global market prices. For example, a colonoscope that cost US$4,000 in the US also cost that much in India. If the performance of an endoscopy cost US$500 in the US, but only about Rs.600 (ca. US$12) in Calcutta, the doctors were forced to treat about forty times more patients with a machine than in the US until they made a profit. Even if net prices per diagnosis were hard to compare because of different institutional overheads or insurance regulations, the dilemma was still the same. High patient turnover was one

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way of making the business of gastroenterology profitable. Other ways of cutting cost were to buy ‘ragged machines, cheap machines’ (Gastroenterologist #9) and to use them even when quality was compromised. The iatrogenic effects of using substandard equipment in haste were many. First, all endoscopies entailed the risk of serious injury to the patient if carried out neglectfully. Second, there were standards for the sterilization of endoscopes, especially in view of a rising prevalence of Hepatitis B and C, as well as of HIV/AIDS. For proper sterilization, an endoscope had to be left in an antiseptic solution for at least one hour. However, most doctors only owned one endoscope, and had to treat many patients in a row: ‘Colleagues from the West are amazed when they hear that I’m treating up to twenty patients an hour. That’s unbelievable to them. I own three gastroscopes, that’s more than anyone else has. But even with that, I cannot go by the book’ (Gastroenterologist #9). Third, doctors tried to cut additional costs of treatment as much as possible. Indian patients’ ‘high pain threshold’ was not only a product of environmental overstimulation, but also one of lack of money to pay for anaesthesia. If more than ‘vocal anaesthesia’ was given, the doctors had to provide nurses, oxygen and beds to take rest in. All such extra costs had to be cut as much as possible. Medical malpractice is tempting in India, where the state has not yet developed proper safety mechanisms and where health insurance is still the exception. Whereas patients could be fooled into believing that they got the treatment they were paying for, insurance companies were less gullible. Thus this doctor thought that a better insurance system was the best way out of the current mess, because insurance companies could make sure that the doctors did not treat too many patients and that costs for equipment were properly accounted for: ‘They want receipts’ (Gastroenterologist #9). Despite such misgivings about malpractice, not even this whistle-blowing doctor ever questioned the supremacy of allopathy. The current defects were not symptomatic of a fundamental failure of gastroenterology, but of its still incomplete development in India. Even if not all current practice was up to global standards, at least there were standards. By contrast, the gastroenterologists were unanimous in their opinion that other medical systems, including Ayurveda and homeopathy, did not even have proper criteria of professionalism, accountability, efficiency and ethical conduct. When asked whether they ever referred patients to other healers, all responded with an emphatic ‘No!’ – even if some of them also mentioned that members of their own families had a strong belief in homeopathy or Ayurveda. An accommodating attitude towards these other systems was that they were only ‘pre-scientific’ and had ‘not yet’ developed the professional rigour that characterized allopathy. More common was that they just scoffed at their semi-scientific competitors: ‘To practice homeopathy, or Ayurveda,

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you don’t need to be a doctor. Not even a graduate! [laughs]. So I think there is a serious problem’ (Gastroenterologist #2). Although the gastroenterologists perceived a ‘serious problem’ in the practice of non-allopaths, they tended not to warn their patients about them. To criticize doctors who regularly referred patients to them for endoscopy jeopardized their own business: a patient referred by a homeopath was better than no referral at all. Here again, the spectacular powers of the visualizing technique proved its superiority: even if the disease aetiologies and the treatments offered by gastroenterologists were rejected in favour of homeopathic or Ayurvedic approaches, the image itself remained as an object of truth that could not be produced by any other type of medicine.

Conclusion This paper analyzed how gastroenterologists evaluate and reflect on popular ideas and practices around stomach and digestion in Calcutta, and how these reflections are part of a legitimizing strategy that crucially depends on ‘enlightened’ practice. It is easy to see how these reflections also reveal hegemonic claims to socio-political power, as proposed by Arnold (1993) and Prakash (1999). Key to the doctors’ hegemonic claims is the assertion of a deep gap between themselves (as standard-bearers of reason) and their patients (as unreasonable quasi-children). For them, the patients are more or less ignorant of causes and cures of digestive diseases. The doctors ‘know’, whereas patients only ‘believe’ (Good 1994). The claim to be superior, not only to their patients, but also to practitioners of other medical systems, relies on visualization techniques. While their approach revealed the true nature of digestion, their patients only had a partial and culture-bound grasp of it. The perceived superiority of their own position extended from the medical domain to the domain of ethical conduct: while they portray their patients as only partially civilized, they themselves were the leading lights of modernity. At the same time, however, the ‘double discourse’ of an enlightened elite and an unreasonable body of the masses does not only run through the doctor-patient relation, but also through the body of the gastroenterologist. Self-criticisms of medical malpractice show that a ‘double discourse’ does not only structure social relations, but also causes an identity split within the body of the elite. The doctors themselves have, in their own view, not yet become as ‘enlightened’ as they should have. However, the relations between elite and masses are not static, and it might even be misleading to essentialize them as ‘different bodies’. Sketching the changing relations between Calcutta’s educated bourgeoisie and the masses of the urban poor in the post-Independence era, Partha Chatterjee (2004: 131–48) draws attention to transformations and

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realignments. For the most recent period (since 1999), Chatterjee argues that public life in Calcutta was shaped by two trends. Firstly, the city is more strongly dominated by business professionals and technocrats with global aspirations. As a consequence of this, middle-class people now stress the differences between themselves and the rest of the population more than previously: ‘While the new metropolis is globally connected, it is frequently locally disconnected from large sections of its population who are functionally unnecessary and are often seen to be socially or politically disruptive’ (2004: 143). Secondly, parts of the middle classes have been asserting ‘a new Bengali-ness’ (2004: 146) as a defensive reaction against globalization. The way that Calcuttan gastroenterologists speak about the ‘bowel obsession’ of their ‘Bengali’ patients can be read as a reflection on these two trends. The doctors are, I would argue, exponents of the ‘globalization’ trend within the Calcutta bourgeoisie. They define themselves as highly trained medical specialists who participate in the global circuits of professionalism and rationality, and who look down upon the low, superstitious world of the less enlightened members of Bengali society. This division between an enlightened head of society and its less enlightened underbelly is not the same as a division between lower and middle/upper classes. Rather, the doctors distinguish between a globalizing elite and a localizing group of ‘Bengalis’ that is not necessarily characterized by socio-economic class. Hence the apparently timeless image of ‘Bengali bowel obsession’ could also be interpreted as a commentary of one section of Calcutta bourgeoisie about another section of it. In step with the increasing globalization of medicine, it is possible that gastroenterologists will further disconnect themselves from the rest of the ‘Bengali’ population. On the other hand, the doctors can never become as disconnected from ‘low’ Calcuttans as other globalizing professionals, since their livelihood depends on their patronage. The belly might be low, dark and disruptive, but it can never be cut off.

Notes 1. The ambiguous status of gastroenterology also rubs off on any social scientific engagement with it. Similar to medicine, medical anthropology also has internal hierarchies of what is worthy of study and what is not. It seems less fashionable to study technologies of visualization in gastroenterology than, say, in neurology. Related disciplines, such as the medical history of Europe and America, show similar hierarchizations (Forth and Carden-Coyne 2005). 2. The distance between allopathic doctors and patients is a key theme in medical sociology. At least since Talcott Parsons’ (1951) writings on (allopathic) doctor patient relations, doctors’ paternalistic stance towards patients has often been described (for example, Freidson 1975; Mishler 1984).

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3. Medical professionalization has a profound influence on how doctors interact with people outside their profession. Towards a social anthropologist like me, the doctors had an ambivalent position. On the one hand, as I have no training in medicine, they perceived me as a ‘lay person’, and hence as an outsider. However, I could approach them as a researcher from a well-known university, wearing proper clothes, handing out business cards. I was perceived as a member of another profession and, as such, deserving respect (notwithstanding the low standing of social science research in India). Being European and English-speaking resonated both with their elitist habitus and their claim to be global players. That the doctors emphasized their remoteness from their patients was undoubtedly also an effect of me being the interviewer: a kind of ‘bonding’ between themselves and the Western observer further exaggerated the distance from the patients. 4. Michael Anderson (1992: 24) discusses how economic development and lack of sanitary infrastructure clashed in colonial Calcutta. Earlier, it was the labouring and dispossessed classes that were most affected by the politics of discipline and punishment against those who committed a ‘public nuisance’.

References Anderson, M.R. 1992. ‘Public Nuisance and Private Purpose: Policed Environments in British India, 1860–1947’, Working Paper No. 1, London: Law Department, School of Oriental and African Studies. Appadurai, A. 1996. Modernity at Large: Cultural Dimensions of Globalization. Minneapolis: University of Minnesota Press. Arnold, D. 1993. Colonizing the Body: State Medicine and Epidemic Disease in Nineteenthcentury India. Berkeley: University of California Press. Chatterjee, P. 2004. The Politics of the Governed: Reflections on Popular Politics in Most of the World. New York: Columbia University Press. Ecks, S. 2003. ‘Digesting Modernity: Body, Illness and Medicine in Kolkata (Calcutta)’, Ph.D. thesis. London: London School of Economics, University of London. ———. 2004. ‘Bodily Sovereignty as Political Sovereignty: “Self-care” in Kolkata (India)’, Anthropology & Medicine 11(1): 75–89. ———. 2005. ‘Pharmaceutical Citizenship: Antidepressant Marketing and the Promise of Demarginalization in India’, Anthropology & Medicine 12(3): 239–54. Forth, C. and A. Carden-Coyne (eds). 2005. Cultures of the Abdomen: Diet, Digestion, and Fat in the Modern World. Basingstoke: Palgrave Macmillan. Frank, R. and S. Ecks. 2004. ‘Towards an Ethnography of Indian Homeopathy’, Anthropology & Medicine 11(3): 305–24. Freidson, E. 1975. Doctoring Together: A Study of Professional Social Control. New York: Elsevier. Good, B. 1994. Medicine, Rationality, and Experience: An Anthropological Perspective, Cambridge: Cambridge University Press.

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Gupta, A. and J. Ferguson. 1992. ‘Beyond “Culture”: Space, Identity, and the Politics of Difference’, Current Anthropology 7(1): 6–23. Hansen, T.B. 1999. The Saffron Wave: Democracy and Hindu Nationalism in Modern India. Princeton: Princeton University Press. Helman, C.G. 1988. ‘Psyche, Soma, and Society: The Social Construction of Psychosomatic Disorders’, in M. Lock and D.R. Gordon (eds), Biomedicine Examined. Dordrecht: Springer, pp. 95–122. Jay, M. 1993. Downcast Eyes: The Denigration of Vision in Twentieth-century French Thought. Berkeley: University of California Press. Jeffery, R. 1988. The Politics of Health in India. Berkeley: University of California Press. Kant, I. 1999 [1784]. Was ist Aufklärung? Ausgewählte kleine Schriften. Hamburg: Felix Meiner. Mishler, E.G. 1984. The Discourse of Medicine: Dialectics of Medical Interviews. Norwood, NJ: Ablex Publishing. Parsons, T. 1951. The Social System. Glencoe, IL: Free Press. Prakash, G. 1999. Another Reason: Science and the Imagination of Modern India. Princeton: Princeton University Press.

CHAPTER 6 Technokids? Insulin Pumps Incorporated in Young People’s Bodies and Lives Griet Scheldeman

For us, in imagination and in other practice, machines can be prosthetic devices, intimate components, friendly selves. Donna Haraway, A Manifesto for Cyborgs

Preamble In 1981 Dr Pickup and his colleagues at Guy’s Hospital Medical School in London, pioneers in insulin pump therapy, published reactions of the first 15 diabetics after trying the ‘portable syringe pump’ for a period of three weeks (Pickup 1981). Most patients had better metabolic control with the pump, they also felt better, appreciating the greater flexibility of diet and insulin delivery rates. Many patients reported that carrying a device that was noted by others made them more aware of being a diabetic. Moreover, relying on a mechanical device for the delivery of a life-supporting drug caused uneasiness. Some patients were thought of – or thought of themselves – as robots. Twenty years later, in 2001, I conduct fieldwork alongside a pilot project re-launching insulin pump therapy at a paediatric diabetes centre in Millness Hospital, Scotland.1 William and Callum, both aged 15, are among the ten young people trying a pump for a year. I ask William how he feels about his pump. William says: ‘It’s strange. One friend says I’m a robot, he’s full of poo. I find it annoying; I don’t like the idea

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of being attached to a machine 24 hours a day. It’s just a circuit board with some plastic case. It’s more a gadget that helps me with my diabetes.’ I ask Callum whether the pump has made a change. Callum says: ‘On injections, diabetes was “Aw it hurts”. Now on a pump diabetes is thinking how much and remembering.’ * These three iterations inform what follows: an exploration in existential dynamics between young people, diabetes and insulin pumps. My aim in this chapter is to explore the impact of the insulin pump on the way young people live diabetes, in other words, the impact of a technological device on our modalities of embodiment.2 I touch upon two concrete aspects of this impact as highlighted in the quotes above: does a technological device worn on the body make us (feel like) robots? Can a technological device make us live a different illness? As these two aspects are closely related both in theory and in reality – for the second to work, the first should not be an issue – I discuss them intertwined. And I discuss them through ethnography, hoping to let people, events and practices speak for themselves. But first, before jumping into the ethnography, I sketch some ideas that informed my approach.

Robots – Cyborgs? It’s not just Robocop, it is our grandmother with a pacemaker. Gray (1995: 2) In response to Arturo Escobar’s 1994 call for an anthropology of cyber culture, Marilyn Strathern remarks that technology and cyborgs do not call for a new type of anthropology, as there is nothing post-human about hybrids. She points to ‘the cyborgs persons everywhere already make out of their dealings with one another, social relations and hybrid phenomena’ (in Escobar 1994: 226). While researching machines (insulin pumps) linked to bodies (of young people) leads me to specific literature on science and technology, at the same time, I realize that I am not studying a new topic in anthropology: people have always been hybrids, advanced technology only makes it more visible and explicit. To Latour’s ‘we have never been modern’ (Latour 1993), which states that unlike our theories, in our practices we have never been able to divide between the natural and the cultural/ social – however this need not be a bad thing as life is intertwined – I could add, paraphrasing Strathern: ‘we have always been cyborgs’.

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Indeed, cyborg scholar Gray’s statement above – though I do not fully agree with it, mainly because I doubt whether granny would define herself as a cyborg – draws our attention to the widespread nature of combinations between humans and technology. Gray points out that there is not just one kind of cyborg, the science-fiction cyborgs, such as Terminator or the Sixmillion Dollar Man, but he mentions ‘real’ cyborgs: ‘anyone with an artificial organ, limb or supplement, and anyone reprogrammed to resist disease (immunized) or drugged to think, behave or feel better (by psychopharmacology) is technically a cyborg’ (Gray 1995: 1). Following this lead, ‘technically’ people wearing insulin pumps can be called cyborgs. Interestingly, the first being to be called a ‘cyborg’ was a white laboratory rat with a tiny osmotic pump implanted under its skin injecting a continuous flow of chemicals (Haraway 1995: x). This is exactly the mechanism of an insulin pump, with the difference that – for now – some attention from the organism is required in addition to the continuous injection by the pump, though prototypes of a ‘closed loop’ system pump exist and are being tested. While I refrain from calling young people on insulin pumps cyborgs, as they would not classify themselves as such, the cyborg image informs my theoretical approach, as it allows me to overcome dualisms by blurring boundaries. As Haraway states: ‘[C]yborg imagery can suggest a way out of the maze of dualisms in which we have explained our bodies and our tools to ourselves’ (Haraway 1985: 101). Opening up the fixed categories of human and machine, blurring the boundaries, allows for more dynamic views on the relationships between the two (or composite one). While cyber culture (the omnipresence of technologies) can be seen as imposing ever more control, in Foucauldian style, over society and individuals, at the same time – since the organic and the technological are not necessarily opposed to each other – it can be seen as offering new possibilities, new configurations between humans, nature and machines.3 More technology does not necessarily mean a reduction of humanity, it can also enable us, make us ‘super’ human. While cyborg studies investigate how technologies participate as agents in producing social life and subjectivities – or, in this case, modalities of embodiment – the ‘technology-in-practice’ perspective takes a dynamic approach to study the dialectical relationship between technology and its users.4 It looks at what technologies ‘do’. Technologies are one actor among many, in continuously changing configurations. Though the actor-network literature lies at the base of the technology-in-practice approach, the latter has moved on over the last 20 years (cf. Law and Hassard 1999), now favouring ‘fluidity’, ‘mobility’ and ‘partiality’ over ANT’s ‘systems’ and ‘networks’. The appeal of this approach is that it allows us to see what is happening, without things having to fit into a coherent system governed by rules. Whereas the classic idea of performance sees people perform (surrounded by objects), these authors

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view both people, technologies and objects as actively involved in the performance. The crucial innovation is not only to see technologies as enacted but to realize that they could have been enacted in other ways. The technological device discussed in this chapter is enacted in a medical context. Amidst the abundance of approaches in medical anthropology centring on narrative, health beliefs, ideas and interpretations, I instead attempt an approach that looks at what happens. Medical professionals can too easily dismiss the qualitative approach as ‘mere stories’, and find truth and reality only in quantitative approaches. Perhaps ethnographic case studies can show doctors that social scientists can talk about an illness that is material and active. Disease is something that is being done.5 It is not just a matter of reflecting. And so let us turn to the ethnography; to see how diabetes is done. The main aim of the Millness paediatric diabetes team caring for adolescents is to keep the young people coming, to not scare them away by a demanding management routine, or by telling them what to do. Behind this ‘nonpatronizing’ credo lies the idea of empowerment. What informs Millness health carers in their adolescent policy is granting the adolescents autonomy and independence, and treating them not as children but as decision makers; treating them as people with a right to choose and who also have a right to enjoy life and normality, two things the health carers deem extremely important at that age. Hence no conditions of use are imposed with the insulin pump. Though pump nurse Sheila tells users they should do blood tests, most young people say they may have done them the first weeks but then stopped. The health carers do not harass them about it. Daily bolusing (adding insulin on the spot, at food times) is a matter of guessing instead of calculating, as users are not familiar with, nor instructed in, carbocounting (counting the amount of carbohydrates in the food eaten and thus knowing the necessary insulin dose). The philosophy guiding pump therapy in Millness seems to be: if users are happy with it, great, they keep wearing it; if they do not like it, they stop.6 Nurse Sheila tells me the pump is not for everybody: Only for a minority of young people the pump can be a tool to gain control over diabetes […] People who are willing to make changes in a positive way, to embrace technology. In young people with diabetes there is an opportunity to change. The pump at a certain time can give them control and the power to lead a normal life. I always say the pump is as good as the person who uses it. I ask how the pump can bring about that change. Sheila replies: ‘People are actively deciding what they want to do, like what to eat, when to get up, they can choose to eat three Mars bars …’. Not wanting to be prescriptive,

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the Millness health carers see the young people as the originators and deciders of their illness management and their insulin pumps. Then how do the young people wearing insulin pumps live diabetes? I could say: they live it less. I could tell you about how they use the pump as a tool to have diabetes interfere less in their lives, to do and eat what and when they want – this is how nurse Sheila promoted the pump. This would have me write about tool use and agency. Whose agency? The health carers’ or the wearers’? Both: the health carers see the pump as a way to reduce the hassle of diabetes and promote the pump as giving back freedom; (consequently) the wearers see the pump as the bringer of freedom, allowing them to do what they want when they want it, and they eagerly hand over diabetes management to the pump, relieving them of the need to inject, test and think. But the issue lies elsewhere: ‘tools’ and ‘agency’ are concepts belonging to a now often challenged ontology. They belong in a world where people are subjects – ‘agents’ – and machines are objects – ‘tools’ – that can be used by agents. This no longer holds in a world after actornetwork theory, with ideas on fluidity, performance, practices, multiple realities. The dynamics between wearer and machine travel both ways. Thus I aim to look at both wearers and pumps ‘doing’, or at least having an effect on, each other. For this I should start in the middle of things. I need to see the pump-in-action. In fact, I should see the young person-with-the-pumpin-action. And so instead of looking at how wearers use pumps – and talk about agency and tools – I prefer to look at how they do pumps: ‘pumps enacted’. While this focus on practices and individual experiences informed my theoretical stance before fieldwork, it was confirmed by the reality I encountered during fieldwork. As fieldwork progressed it became apparent that the young people did not have a discourse on their illness, rather they lived it. I relate this absence of a ready discourse mainly to their age. Firstly, they have not been socialized in it. Apart from short occasions in the doctor’s consultation, most young people are not invited to talk about their diabetes (at home or with friends) and are not in the habit of doing so. Secondly, in adolescent years it is not ‘cool’ to talk about something that debilitates you. Diabetes is mostly a sleeping lion, always present, but nothing spectacular to recount.7 The more I spoke to the young people, the more I looked for an approach that would fit with their experiences, their life-world. I thus resolved to focus on how they ‘did’ diabetes in their daily existence. Meet Callum, 15, diagnosed with diabetes since he was 9, and often referred to by the Millness health carers as ‘a success story with the pump’.

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Callum The first time I see Callum is at a focus group meeting about a website for young people with diabetes. Callum is a mature teenager, 15, teenage skin, chubby, cheerful and chatty. I know Dr Veronica had hoped Callum would come, as ‘he is a bright boy who is so much into technology and computers’. Callum is on a pump. I tell him who I am and ask whether I could come and talk to him sometime about his pump. No problem. Callum says he likes his pump and does not mind talking about it. After the meeting we happen to queue for the same bus home. I tell him how anthropologists normally, when they are abroad, tend to live for some time with people so they can see what they do in everyday life and try to understand how they live. Since I try to understand how teenagers live with diabetes and pumps that would mean, actually, that I would have to stay with them for a few days, to see what their everyday lives are like. Callum replies: ‘Yes, in Africa, but here nothing happens; we don’t do anything. My life is just like anyone else’s, there’d be nothing to see.’ During the ride home we arrange that I come to see him the next week; he gives me his mobile number, his phone number (he has a private line) and the phone number of the house. As he gets off the bus he puts his sleek headphones on, starts his minidisk and walks off into the night. A week later, I cycle into his street, rows of council houses. Callum lives here with his mum, an old people’s nurse. His bedroom has a bed and desk; pride of place is taken by large electronic piano keyboards, in front of the window. A second desk with a computer and printer, an impressive stereo, a large television (switched on), a complex looking phone with screen and I guess fax, another stand-alone phone. When I ask about two phones in one room, he shows me his mobile phone that is broken at the moment: ‘I probably cracked it because it is so small’. The mobile is metallic orange and indeed so small it looks like a chocolate miniature, in silver wrapping. Callum hands it to me saying it is even lighter than his pump, and smaller. Apart from the abundant mess (clothes lying around, papers, coke cans), Callum’s room looks like an office. It is very connected. He is the master conductor. During my visit he taps on the keyboard to go to internet sites, to show me which new pump model he is talking about, or to convert the dollar price into pounds, he deletes a few messages from his mailbox, turns off the television (remote) and switches on the stereo, adjusts the volume (different remote), all from his swivel desk chair. I sit on his bed and ask questions. His room, with the wiring, electronic equipment, noises and beeps makes me jumpy; I am focused on the pump I have not yet seen and am waiting to notice. As we talk, something starts to beep. Though the sound comes from the wrong direction, I ask whether it is his pump. Callum replies that it is the clock. ‘My pump beeped a while ago. The cartridge is almost empty.’

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Griet [concerned, thinking if the pumps beeps to tell you the insulin cartridge is almost empty, you better act on it]: Did you fill it? Callum [relaxed]: No, in a while, I wait, there’s still some in it. At the end of our meeting, Callum surfs to the website of an insulin pump company. We study their newest model, it costs $4500. Callum says it looks smaller and definitely must ‘do’ more things. Callum tells me he likes this pump (his is a different brand). I ask why? He leafs through his diabetes magazines to find the advertisement where he saw the picture. He does not find it. He surfs to the company’s UK website. There it is. ‘It looks smaller and it has a key ring’. I am nonplussed, a key ring on an insulin pump seems an unnecessary gadget to me. What else will they invent? Callum explains: ‘Yes, you see: you can do everything from there.’ Is the smaller the better? ‘Yes, and it might do more.’ Would you buy a pump yourself? ‘If I could I would buy a new one, ‘cause it’s very good.’ He tells me he would like to see the pictures of different pumps and what they do if he were going to buy one himself. We could be Internet shopping for a mobile phone. The same fashion categories seem to apply: as small as possible, a trendy look, and it should ‘do’ a lot. Over our next meetings and conversations, Callum will be the relaxed boy, in charge of his equipment, screens and buttons, constantly fiddling with them while talking. He will be master of the electronic world. I will be the technology-wary older person, not understanding how all these things work. I take my usual place on his bed, he sits confidently in his executive chair, all remotes and keyboards in reach. His mum says the clinic proposed the pump to him because they knew he’d be motivated, as he’s always doing things with technology and computers and reading on new development. ‘He likes gadgets so the pump is ideal for him.’ Throughout our conversations, Callum tends to divide his life with diabetes into ‘before the pump’ (five years) and ‘now with the pump’ (one year). For instance, when I ask what it means in actual fact to have diabetes he replies: ‘I have to remember to inject, do blood sugars, remember to eat something, but now with the pump …’. With the pump, then, Callum is more ‘in charge’ of his diabetes. He decides what insulin he needs and administers it. Several times a day he reacts to his diabetes; both when he eats or when he feels bad (high or low) he will address this with insulin. He is a 24-hour autonomous caretaker of his diabetes. The five years he was on injections, he would perform routines drawn up by the diabetes health carer. ‘Before I got the pump I wasn’t happy changing the amount of insulin, like I didn’t want to touch it. Every time I went to clinic the doctor said, “Well, what are you on” and they would look at my blood sugar diary. He would say, “Ah, a bit high here, we’ll increase that, they’re a bit low here, we’ll put that down a bit.” … I probably could

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have changed it around myself, but I just didn’t want to like, tamper with it.’ I ask him why, now he is on the pump, he does change it – what is the difference? ‘With the pump, you just put so much in at breakfast time, so much at night, it’s just flexible.’ I reply that it seems that he is more on top of his diabetes now, it’s more like his diabetes, not someone else who decides the dose? ‘Yes, you control it.’ The fact that Callum is relaxed about other people knowing he has diabetes is significant to his positive relationship with the pump. The pump can make diabetes visible and present 24 hours a day. Others can see the pump and ask what it is. Diabetes becomes public. In Callum’s case, diabetes has always been public. He is not ashamed he has it nor does he mind people knowing he has it. In fact he makes sure people around him, friends, schoolteachers, know he has diabetes, so they are aware in case something happens to him. If anything, the pump has made this public perception of diabetes easier. It has normalized Callum’s diabetes in a way, and fits it into his teenager attire and behaviour. The pump has made giving insulin for Callum almost invisible. ‘Sometimes I’ve known people for weeks and then I’d say “I just have to give my insulin” and they’d go “Oh you have diabetes, I didn’t know”.’ When he was on injections, it could be awkward when he was in a restaurant and many people were watching. He was not embarrassed ‘I just say “I have diabetes, what’s the big deal?”, but people have given me some very dirty looks sometimes, or about to call the police, because they thought I was taking drugs.’ Now, when he wore the pump on his belt – which he stopped because it kept falling off, it now lives in his pocket – even though people see it ‘they don’t care, and I’m a teenager, they’ll probably think it’s my music’. How did his friends react to the pump, did he show it to them? In his deadpan way Callum replies: “I said, here’s a pump. It’s cool”. Did they think it was interesting? ‘My friends are boring.’ Do people ask him what it is, when they see the pump? Callum says that people don’t care and that he can’t be bothered to explain it, he has done it so many times: ‘Everybody says: “What’s that then?”’ he sighs loudly. Callum’s pump has become second nature to him; he is at ease with it, he knows what it does. He trusts it and uses it as he wishes. While other people can feel very uncomfortable about machines and technology, especially when attached to their body, not so Callum. The pump is a device for him, like his minidisk, his mobile phone. These are things that are at his disposition and that he controls. When on several occasions Callum explains to me how to work the pump, he is so fast – how do you explain something you do not really think about any more, like riding a bike? – I always get lost half-way. A conversation would go like this:

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Griet: The pump says ‘Error 5’, what does that mean? Callum: It means ‘maximum bolus achieved’. I think you have to put over a 100 in bolus in or something because you can’t put in 25 units at a time. One day I just sat there seeing how high it would go, so you can put 25 in and it won’t go. Griet: And then you can cancel it? [Callum pushes the buttons to give instructions to the pump; we hear the beeps.] Callum: If you leave it to put that in, it gives you eight seconds, then it will start confirming it. Griet: You don’t have to confirm it? Callum: Right, for it to stop, you just push the top buttons. So either if you put too much or too little in, you want to cancel, just press. You push three buttons at the same time for resetting it, so you put a new cartridge in and then press the top two buttons. At this point I am lost and ask Callum whether he read the whole instruction book that comes with the pump, to find out how it works. He laughs derisively: ‘No. You just press the buttons and see what happens. ‘Cause you can always stop it.’ Does he then just go to the Menu on the screen? ‘Yeah, I mean, it’s pretty simple, there’s only eight things … and that one there [he points to an icon that appeared on the screen] is the one for priming in, that one here [he has made another icon appear] will only work when it’s off, when it is in stop mode, you can turn it on and off by pressing the two top buttons together.’ As I leave, his mum mentions how Callum is ‘so much happier with the pump. He has said to me it has made such a difference to his life, that he doesn’t have to be regimented about his life; he just does beep-beep-beep.’ Callum clearly combines the two aspects mentioned at the start of this chapter: so into technology, the pump becomes second nature to him, thus enabling him to live and embody diabetes in a different way from before. Or could I say he embodies a different diabetes?

Embodiment The concept of ‘embodiment’ allows me to foreground the young person with his/her individual experiences and practices involved with diabetes and wearing a pump. I take a broad approach to embodiment: the way we live life ‘embodied’: with and through our bodies. I see it as a road towards reclaiming the body in our lives, to making it present. However, how much and how it is present varies in every individual and at every moment. A constant to-ing and fro-ing.

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I combine phenomenological anthropologist Csordas’s interpretation of embodiment as a methodological attitude demanding attention to bodiliness – ‘an existential condition in which the body is the subjective source or intersubjective ground of experience’ (Csordas 2000: 181) – with Michael Jackson’s account of ‘bodily subjectivity’ when he elucidates the phenomenology of philosopher Merleau-Ponty for whom ‘human “being-in-theworld” is bodily being’ ( Jackson 1996: 31). Whereas phenomenology focuses on motility and perception, moments when our body is very present to us, I also want to include those moments when the body recedes, works in a tacit mode, moments when the body is absent. Hence, later in this chapter, I shall turn to philosopher-cum-medical doctor Drew Leder’s (1992) notion of the lived body. While it fits with a stress on practices and experience, my main reason to focus on embodiment is a practical methodological one. Lacking the opportunity to live daily life with young people on pumps, to observe the pump-in-action (the pump at school, during sports, with friends), I could only ask them about their life with the pumps. Though keen to talk, by now they were familiar with their pump and said ‘there is nothing to say’. As Callum put it: ‘I have a pump, it works.’ This was in sharp contrast to conversations about pumps with adults, who only needed one question from me – ‘Can you tell me about life with the pump?’ – to embark on a two hour pump saga, coloured with emotions (fear, apprehension, panic, satisfaction), physical facts (malfunctions, bruises, accidents) and medical results (blood sugar levels).8 Not so with these young people. I needed another approach. I decided to find out what it took (for them) for the pump to work. In order to get some conversation, my questions soon started to centre around the difference the pump made to their life and their diabetes, such as their diabetes management, their activities, their diet, how they felt physically and emotionally. We even discussed whether they felt they had ‘more or less diabetes’ with the pump. This was to my own surprise. How can there be such a thing as ‘more or less diabetes’, a chronic illness you have or not? The issue is the degree to which diabetes is present in their lives, or more precisely ‘interferes’ with their lives. This is the picture of diabetes formed in my mind through conversations with the Millness health carers, who also shaped my initial picture of the pump as the appropriate treatment to solve this interference; as nurse Sheila told William: ‘Giving you insulin all the time, it means you can sleep in and eat what and when you want’. The difference the pump makes to the young people is that they forget. They forget taking extra insulin, doing blood tests. They forget they are wearing the pump, and sometimes even that they have diabetes. I ask William (15) how he feels about the pump.

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William: It’s like, it’s there, but it isn’t. If I wasn’t talking to you now, I’d not think about it, I’d be doing stuff. As soon as I do my bolus I think about it and then I forget. When I first got it: I was 24 hours on a machine, the more I am used to it, I forget, only when I eat and give a bolus. Griet: What is the difference with injections? William: When I’m on injections: I have to Remember to Take insulin with me [he stresses the actions he needs to do, like summing up a boring list] I am more aware. I have to Take the needles when I go out, I have to Think more, I have to Count how many I’ll need. Now the insulin is just with me. Mum: The trouble with Willy is he is such an airhead, and he forgets his boluses, ‘cause his pump has become second nature to him so he forgets he has it. Griet: How come you forget your bolus? You didn’t forget your injections? William: Because I get insulin all the time, so I don’t notice it when I forget a bolus. Griet: You didn’t forget to take your injections? William: Because injections was work, and I would have to do it, and they hurt. Also if I didn’t take my injections I would feel terrible. Griet: So the consequences, if you forget to take a bolus, aren’t bad, and that makes it easier to forget? William: Yes. Griet: What about blood sugar tests, do you forget those? William: I forget a lot, I’d do them in the morning, before I get up. Griet: How come you remember that one? William: ‘Cause the needle will sit on the table and I see it, so I do it. My conversation with William tells us about the embodiment of an illness and how a technological medical device can modify this. William has a good reason to forget. Forgetting to take the bolus allows him to ‘forget’ he has diabetes, diabetes is now in the morning at breakfast and in the evening at dinner, during the rest of the day, out and about, he can ‘forget’ he has it. Nevertheless it is puzzling. How can you forget about having diabetes and having to give a bolus at mealtimes while the pump is always there to remind you visually, physically, tactually? As William says, he does not forget to do his test in the morning because the needle sits on his table, he sees it, he does it. Is that not so with the pump? He wears it, he feels it, he sees it? Or not? What happens with the pump that this is not the case? This brings me to a further reason to focus on embodiment: as another methodological device. Because I do not wish to take this talk about ‘forgetting’ as a throw-back to the mind-body dualism, it is tempting to take this embodiment as ‘talking about the experience of an illness’ and, as in other

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medical anthropology studies, it would then be a case of ‘mind over matter’: making sense of an illness, under the guise of embodiment; how we ‘feel’ about something. However, I think more is happening here, of a different order. Thus, in a final attempt to get something more out of our conversations, I decided to wear an insulin pump myself. I started from my personal embodied experience to arrive at the experience of the young people. I shared my own surprise, frustrations and worries about the pump with Callum, William and Sara. They talked, put me straight and said how it was for them. Now there was something to say.

Getting Started with the Pump Excerpts from my field diary: Monday Today is P-day, as nurse Sheila calls the day patients are put on the pump. My P-day. The table is spread with pump equipment: user manuals, canulas, tubes, plasters, syringes and vials, all wrapped in sterile plastic. We go straight into the workings of the pump. I hold the small box in both hands, push the buttons and focus on the display screen. In an instant the room shrinks to a 3 by 4 cm frame. From a sociable person interacting with the nurse and friend in the room, I am now a head bent down Game Boy addict. I still hear Sheila’s voice but even that moves to the background when the screen does not react to the buttons I push. I am talking to liquid crystals: ‘ach’, ‘hey’, ‘oops’. Sheila talks me through the main functions: ‘You push the Select button on the front to get new menus and you move around by the H (hour) and M (minutes) buttons on top. These two buttons double function as +

Figure 6.1. A well-stocked table (photograph by author)

Figure 6.2. Inserting the canula (photograph by author)

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Figure 6.3. The pump is attached, ready for use (photograph by author)

Figure 6.4. The pump in its bright red ‘scubadiving wetsuit’ (photograph by author)

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(up, more) and – (down, less)’. I program a 24-hour basal rate in the pump: I instruct the pump to give me a certain dose of insulin every hour of the 24-hour clock, so: 12pm–1pm: 0.5; 1pm–2pm: 0.4. This combination is saved in the memory but I can change and reprogram it at any time, when I notice that at certain times of the day I need less or more basal insulin. This basal hourly rate will be administered in tiny doses every three minutes, so every three minutes between 12 and 1 am I will get a 20th of 0.5 ml insulin, in my case, saline solution. Usually 50% of the daily total of insulin is given as hourly basal rate. The other 50% is administered at the time of food consumption, in the form of a ‘bolus’, given by pushing the bolus button as many times as units of insulin are needed to cover what one ate for lunch. I learn to lock and unlock the pump, by pushing all three buttons together. I put the pump in Stop mode by keeping the ‘H’ and ‘M’ button pushed down together for three seconds, I hear three short beeps and one long one, the pump is in Stop mode. It needs to be in Stop mode when I want to program it. To give a bolus the pump has to be in Run mode: select the number of units (by pushing ‘H’ button), wait eight seconds and the pump delivers the bolus. I am overwhelmed – I don’t know if I will ever manage this. And I have not even attached the pump. First I have to prepare the pump cartridge: I fill it with insulin (saline solution) from a vial, which I have to draw up through a syringe. I drop the syringe three times, spray half a vial over the table, the booklets and still I do not manage to fill the cartridge or get the air bubbles out. In the end Sheila does it for me. I admire teenagers filling their cartridges once a week, it is a skill. Now without further ado, I can attach the pump. I opt for the Silhouette insertion method. A plaster with a longer needle inside a tube, once inserted the needle is pulled out and discarded, the tube stays inside. It hurts, sticking a needle into you, slowly, all the way down. I click the pump on the tube, put it in Run mode. I proudly leave the room. In the hospital corridors filled with people on crutches, in wheelchairs, with plaster casts, doctors with pagers and stethoscopes, no one notices the trophy of my momentous initiation. Back home. I am now three hours on the pump. I feel a bit bruised. The biggest inconvenience so far is due to the fact that I forget I am wearing the pump: stepping out of the car, something heavy pulls my belly: the pump is dangling somewhere at my knees, the canula tugging at my skin. This happened three times in 1 hour. Another annoyance is the pump in my trouser pocket: my pocket feels full and I keep putting my hand in it to ‘take out my heavy keys’, only to meet the pump. I also have a constant heavy feeling in my belly area, but it is not clear whether this is inside: like I have eaten too much, or outside: like a plaster. My wearing a pump is only a detail: I don’t have to adjust the insulin dose or give a bolus. I don’t have to test blood sugars before taking a bolus. Most importantly I do not depend on the pump, what it does, what I do with it, how I use it, whether I know how it works, how to solve things about it. So I have no stress, no worry, no fear, no need. I am a free trier of this pump.

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Tuesday The night was OK. Though I kept feeling something in my belly and was annoyed that any time I got up I would have to remember to carry the pump as my pyjamas do not have pockets. Going to the toilet and getting (un)dressed is the biggest hassle, mainly because the tube is the minimum length of 30 cm, I now remember all teenagers I know use longer ones, from 60 cm to 1m10 cm, I guess for this reason, so you can leave the pump in your trousers when going to the loo, or you can deposit it somewhere, instead of having to hold it close. I think I would never want to use the pump, were I a diabetic. It is already annoying me that it is always there, with a tube connected to me, mainly because it doesn’t do much. If the pump had a closed loop system (built in blood sugar sensor and continuously measuring, injecting accordingly), this is something I would not be able to do, so yes, I would benefit from that machinery and might consider wearing it. Weighting its benefits against the hassle of being attached to it. Now the only thing this pump does is put insulin in me. I can do this perfectly myself. And when I do it myself, I have my own free body and don’t feel incapacitated by this umbilical cord with a weight. Already I want to be ‘rid’ of it, take out this tube, peel off the plaster and be whole again. Instead it is there: I feel it. Wednesday Annoyed with the pump today, I couldn’t get it to do what I wanted it to do. I wanted to lock it, but didn’t know how and the booklet doesn’t say. I push the S button and three other buttons at the same time, the screen flashes with different numbers, the pump beeps but I don’t know what’s happening. This morning I was shouting at the pump, when I pushed the S button once too often and I had to reprogram the whole 24-hour basal rates again. Last night in bed I had an ache in my belly and didn’t know if it was from the canula, the pump, or something unrelated to it. I was tempted to take it off. Am I giving myself an infection, is this salty water blowing me up? Were I on a pump for real, I guess I’d often be worried. Also worried about whether the pump is working and giving me insulin. Not being in control. Thursday The Pump is no more. I took the batteries out. A free belly again. My main issues with the pump are about being out of control, where is my agency, where does the pump’s begin? Mainly, I am continuously conscious this machine is attached to me. I am even more puzzled now: how can the young people forget? Trying out a pump has enabled me to find out more. However, it has done so by giving me new questions to ask, rather than by embodied knowledge. Of course not. My wearing the pump was merely a tenth of what it really is. No strings attached for me, just a tube I could detach whenever I became tired of the experiment. I am not a young person (33) nor do I have diabetes.

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In order to understand the experience of young people on a pump, to understand what diabetes and consequently the pump mean to them, I have to begin from their embodied experience. Like Leder’s tacit body that recedes in the background when all works well, when devices work, they are taken for granted. Instead I want to look at what it takes for the pump to work. More specifically, to work for the young people means to be able to forget, when diabetes interferes less. My point is that the pump works as it modifies how the young people embody diabetes. To make a bold statement: the pump can make a different diabetes. And it can do this when it is incorporated. I recall my own experience with the pump and I am puzzled. How can they forget about diabetes? Does this electronic device not act as a continuous reminder? When I ask Sara (16): ‘What’s this freedom with a pump, it’s always there?’ she replies: ‘Exactly, it’s always there. It helps you with your diabetes.’ I quiz Callum. ‘Indeed, so you don’t have to think to take insulin and pens with you.’ I persist: ‘But I found it annoying to carry that machine 24/7 to do something I can perfectly well do myself.’ Sara disagrees: ‘It does not do as little as you think it does’. Callum makes an apt point: ‘Maybe you should try injections for a month, then you’ll see the pump makes a difference’.

A Machine? When I wore the pump, the fact that it was a machine and always ‘On’ bothered me. This machine made a triangle between my body and me – very dualistic thinking, which appears to be our (adult) Western modality of embodiment. I did not want to hand over some of my agency to the machine. As for the machine’s agency: I would not trust it to do what it was supposed to do. My agency was encroached upon by the machine. A confusing experience. Both issues proved to be very different for the young pump wearers: they had limitless faith in the pump doing its job; and the pump helped them, giving them more agency. I share my worries with Sara. Griet:

Sara: Griet: Sara:

What about I would lie in bed and feel something in my belly and I’d worry, is that just the pump, or is something else wrong, nothing to do with the pump? No, I just know if it’s the pump. Yes, but what if it’s supposedly on, but not working? But it tells me if something’s wrong.

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I can’t shake Sara’s confidence. I try my worries on Callum: ‘What if the pump isn’t working?’ He replies similarly to Sara: ‘It tells you if it isn’t working, it beeps.’ Griet: Callum: Griet: Callum:

Not if it really isn’t working. That’s why there’s all those error messages. But if it doesn’t display error messages ’cause it’s not working. That’s why there is Error 7: saying the pump will stop working.

Callum thinks my worries are completely imagined. Why would a machine stop working? If the batteries are low, there’s an error message; if the cartridge is empty, another error message. I am thinking of complete failure: like a piece of dust in the mechanism that just stops everything. Is my reasoning out of time? I am jealous of his absolute faith in this piece of machinery in its plastic box, helping him in a matter of life and death. Even if the pump works as it should, what about having a machine so close to you all the time? But is the pump actually a machine for the pump wearers? Or has it become something else? In the preamble we saw how William feels about his pump. I ask Sara to describe the pump. Sara:

Griet: Sara:

My mum actually put it really well, she said, ‘It’s like a tamagotchi’ and it is.9 It communicates with me, tells me if I need to do something. This may sound strange but I see it as my friend. How does it communicate? It will go off.

Embodiment – Incorporation? When the pump works well, it functions in a tacit mode. Accordingly diabetes can recede into the background. Compare this with injections, when diabetes – either through discomfort or management routines – meant an almost continuous confrontation with the body, requiring attention and action. With a pump, young people can embody diabetes in an altered way. Diabetes, as it is lived, is no longer primarily a physical, painful affliction but rather is enacted as a more mental entity: forgetting, remembering and thinking. I suggest that the pump is incorporated. Drew Leder defines incorporation as ‘experiential disappearance’.10 This brings me to Leder’s ideas on the ‘incorporation’ of skills and technology. He writes about how we acquire skills through a process of incorporation (meaning to bring within the body): ‘A skill is finally and fully learned when something that once was extrinsic, grasped only through explicit rules or examples, now comes to pervade my own corporeality. My arms know how to swim’ (Leder 1990: 31).

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Incorporation comes with ‘experiential disappearance’. When we learn a skill, like swimming, our body is made explicit (not tacit anymore). As soon as we master the skill, the body recedes again. Explaining how to swim, to break up the process in separate movements again, is difficult. Leder sees the same process at work in our relation with tools and technological devices. While I find it easy to imagine skills (which are ethereal) becoming part of our body, Leder sees us also incorporating technology and devices in the sense that ‘in its use of tools and machines the body supplements itself through annexing artificial organs’ (ibid.: 30). Over time new skills and, to a certain extent, technological devices disappear from view, they recede into the background, become tacit and ‘enveloped in the taken-for-granted body from which I inhabit the world’ (ibid.: 32). Thus bodily processes, skills and devices all reside in Leder’s lived body, which, by acquiring new skills, and using tools and machines, is never stable but always shifting. In a way, the pump disappears from experience: the young people forget they have it. The I still intervenes, but in a less conscious way, in a tacit way, through automatisms. ‘Seeing’ carbohydrates in the food, automatically pushing the buttons on the pump, through the fabric of your trousers, listening to the correct amount of beeps. Operating the pump happens through embodied knowledge, no conscious thinking is needed. When the pump is incorporated, diabetes is lived in a more mental way. Because the young people can forget about diabetes – through the pump, which they can also forget – managing diabetes becomes a matter of remembering. Before the pump, with bruises and pain, they could not forget. The following drawings offer an illustration of this incorporation of the pump: being so present in the body, so much a part of one’s own body as one knows it, the pump disappears from experience. For while the youngsters say that, with the pump, they ‘forget about diabetes’ and they forget about the pump, the pump is actually very present. When asked by me to draw their pump from memory, Callum and William portray the pump in full detail with all buttons, symbols, inner mechanics in place, though they never take their pump out of their trouser pocket to operate it. In contrast two other young people, who were not very successful in operating their pump (one had quit) drew a pump with two lines, the box and the tube, no ‘working’ pump, just the material.

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Figure 6.5. William’s drawing (from memory)

Figure 6.6. Callum’s drawing (from memory)

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Figures 6.7 and 6.8. In comparison, drawings by two young people for whom the pump ‘did not work’

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In Conclusion By seeing boundaries not as solid but moving, and combinations of people and technology as challenging hybrids, the cyborg image and ‘technology in action’ approaches allow us to see more at play than merely people interpreting/using technology.11 Technologies also act, or at least are enacted, and are part of shifting configurations between them, people and objects. A technological device can enable or disable us; whether it does so depends on many factors. Knowledge is not only a mental activity but also being and doing. What I have tried to show here is how the activity of knowing is not only situated in people’s heads but spread across – and realized in enactment between – people, objects and technology: knowledge is performed in practices. This brings me back to Michael Jackson’s notion of bodily subjectivity with his emphasis on body praxis: ‘Our gestures and actions do not invariably depend on a priori cognitive understanding (on the contrary) in most human societies knowledge is a matter of practical competence’ (1996: 34).12 Though the present ethnography is situated in a society that on the whole favours theoretical knowledge and cognitive processes, as I discuss young people and close-to-the-body technology, a focus on practical competence proves appropriate. Looking through the lens of embodiment shows how we can live an illness in a different modality: the incorporation of a pump and of diabetes: the one through the other. This is not just a matter of using a pump to treat diabetes, but of a different modality of embodiment and thus a different way of being-in-the-world.

Acknowledgements The Ph.D. research (Scheldeman 2006) on which this chapter is based was funded by a research grant from Disetronic Medical Systems, an insulin pump manufacturer which also funded the pilot pump project at the paediatric diabetes centre in Millness. I am very grateful to the young people who shared their pump stories with me, and to the welcoming diabetes team at Millness Hospital. This chapter evolved from a paper presented at the ASA Anthropology and Science conference in Manchester, 2003. I thank Rachel GoobermanHill for inviting me to participate in her panel ‘the science of functioning bodies’. Some of the material in this chapter was presented in a paper titled ‘Primed for wellbeing? Young people, diabetes and insulin pumps’ at the Well-being: Anthropological Perspectives symposium at the University of Manchester, September 2004. A published version of this can be found in Alberto Corsin Jimenez (ed.), 2007. Culture and Well-being: Anthropological Approaches to Freedom and Political Ethics. London: Pluto Press.

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Notes 1.

2.

3. 4.

5.

6.

7. 8.

9. 10.

11.

12.

I was involved as a ‘social scientist’ alongside the insulin pump project at the large state-funded teaching hospital in Millness city. For one year I conducted fieldwork at this centre, observing clinic consultations, interviewing health carers and following patients to their homes and families. To protect the identity of the people involved, all names (of people and places) in this chapter are fictitious. As this chapter focuses on the interaction with a technological device, it does not discuss the health and physical and psychological well-being of the young people concerned, which are of course the main issues when talking about young people with diabetes. See for example Escobar (1994) and Downey, Dumit and Williams (1995). For example, analysing the usage of the metered dose inhaler (for asthma), Alan Prout uses actor-network theory to show how, in employing the inhaler, children are engaged in a process in which ‘technologies and people mutually constitute each other’ (Prout 1996: 200). Also studying asthma, Dick Willems (1998) suggests that different drugs, engaged in different practices, create different diseases. I refer, amongst others, to the inspiring work of philosopher-ethnographer Annemarie Mol (2002), who wrote what she calls a ‘praxiography’: an ethnography about different practices relating to the diagnosis and treatment of atherosclerosis in a Dutch hospital. In this chapter I chose to focus on those young people for whom the pump ‘worked’, as I look at how it worked for them. However, a different chapter could talk about young people for whom the pump did not work, which could be due to a multitude of reasons: technical hiccups, infection of insertion site, uneasiness with visibility of pump and with technology. In contrast are those heroic tales linked to their diabetes and readily narrated to all, the funny stories, or the dramatic ones that are made entertaining afterwards. A comparison between adults’ and young people’s experiences with insulin pumps would be another interesting route to take, as the few stories of adults I heard throw light on very different modalities of embodiment and different interactions with technology. A tamagotchi is a hand-held digital computer featuring a pet, which can be cared for by pushing buttons. He writes: ‘Heidegger notes that the “ready-to-hand” tool withdraws insofar as it functions unproblematically. Only when the tool manifests a certain “un-readiness to-hand” by virtue of becoming unusable, missing, or standing in the way, must we take explicit account of it’ (Leder 1990: 30). Nevertheless, I do have a sense of unease with a complete blurring of boundaries between humans and machines. While technologies enable things to happen and thus partly shape people’s worlds, it is important to keep in mind that, in this ongoing process, persons and artefacts do not constitute each other in the same way. In Human-machine Reconfigurations (2007) science scholar Lucy Suchman explores non-essentializing ways to re-introduce the difference between humans and machines, in order to recover the specific accountability of human actors. Here Jackson builds on Merleau-Ponty’s (1962: 138) concept of praktognosia, the practical knowledge my body possesses.

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References Csordas, T. 2000. ‘The Body’s Career in Anthropology’, in H. Moore (ed.), Anthropological Theory Today. Cambridge: Polity Press, pp. 172–232. Downey, G., J. Dumit and S. Williams. 1995. ‘Cyborg Anthropology’, in C. Gray (ed.), The Cyborg Handbook. New York: Routledge, pp. 341–46. Escobar, A. 1994. ‘Welcome to Cyberia: Notes on the Anthropology of Cyberculture’, Current Anthropology 35(3): 211–31. Gray, C. (ed.). 1995. The Cyborg Handbook. New York: Routledge. Haraway, D. 1985. ‘A Manifesto for Cyborgs: Science, Technology, and Socialist Feminism in the 1980s’, Socialist Review 80: 65–108. ———. 1995. ‘Cyborgs and Symbionts’, in C. Gray (ed.), The Cyborg Handbook. New York: Routledge, pp. xi–xx. Jackson, M. 1996. ‘Introduction. Phenomenology, Radical Empiricism, and Anthropological Critique’, in M. Jackson (ed.), Things As They Are. New Directions in Phenomenological Anthropology. Bloomington: Indiana University Press, pp. 1–50. Latour, B. 1993. We Have Never Been Modern. London: Harvester Wheatsheaf. Law, J. and J. Hassard (eds). 1999. Actor Network Theory and After. Oxford: Blackwell Publishers. Leder, D. 1990. The Absent Body. Chicago: University of Chicago Press. ———. 1992. ‘A Tale of Two Bodies: The Cartesian Corpse and the Lived Body’, in D. Leder (ed.), The Body in Medical Thought and Practice. Dordrecht: Kluwer Academic Publishers, pp. 17–35. Merleau-Ponty, M. 1962. Phenomenology of Perception, trans. C. Smith. London: Routledge and Kegan Paul. Mol, A. 2002. The Body Multiple: Ontology in Medical Practice. Durham: Duke University Press. Pickup J.C., H. Keen, G.C. Viberti, and R.W. Bilous. 1981. ‘Patient Reactions to Longterm Outpatient Treatment with Continuous Subcutaneous Insulin Infusion’, British Medical Journal 282: 766–68. Prout, A. 1996. ‘Actor-network Theory, Technology and Medical Sociology: An Illustrative Analysis of the Metered Dose Inhaler’, Sociology of Health and Illness 18(2): 198–219. Scheldeman, G. 2006. ‘Performing Diabetes: Balancing Between “Patients” and “Carers”, Bodies and Pumps, Scotland and Beyond’. Ph.D. thesis, St Andrews University. Suchman, L. 2007. Human-Machine Reconfigurations: Plans and Situated Actions. Cambridge: Cambridge University Press Willems, D. 1998. ‘Inhaling Drugs and Making Worlds: A Proliferation of Lungs and Asthma’, in A. Mol and M. Berg (eds), Differences in Medicine. London: Duke University Press, pp. 105–18.

CHAPTER 7 Wearable Augmentations: Imaginaries of the Informed Body Ana Viseu and Lucy Suchman

Introduction Almost all Marquesan art was attached to the human body (e.g., tattooing, adornment). Moreover, the art that was not intrinsically part of the human body (e.g., weapons, canoes, furnishings of houses, etc.) was conceptually treated as if it were. Thus, a chief’s canoe was part of his body, had a personal name which was one of his own set of names, if injury was done to it, injury was done to him, and so on. Alfred Gell (1998: 168) The intimate and meaningful association between persons, bodies and artefacts is a recurring theme across anthropological accounts, from classic ethnographic texts to contemporary discussions of art, agency and material culture.1 In his explorations of the agential power of artefacts, Alfred Gell emphasises through myriad examples the constructed and contingent nature of the boundaries between persons and things. Such human–artefact relations, moreover, form part of a repertoire of strategic resources through which one person’s body, or a collective of bodies, can engender specific effects in others. So tattooing, as one example, works simultaneously as a form of bodily protection, affiliation and differentiation. Whether for purposes of seduction or intimidation, artefactually augmented bodies are fundamental constituents of social agency. At the same time, Gell shares with Strathern (1999) an interest in the distributed nature of agency, as actions and effects are understood not as expressions of individual will but an outcome of mediated, social and material practices. The person is not

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isomorphic with the spatio-temporal coordinates of the body, on this view, but is effectively made up of ‘a spread of biographical events and memories of events, and a dispersed category of material objects, traces, and leavings, which can be attributed to a person and which, in aggregate, testify to agency’ (Gell 1998: 222). In the context of twenty-first-century technoscience and its commercial partnerships, these observations take on a new salience in the case of so-called ‘wearable’ technologies. Recent years have witnessed an increase in the number of research and development (R&D) projects carried out under the banner of augmentation, of both body and environment. Augmentation is understood to imply the coupling of humans with computational devices, taken to extend the body’s native capacities through information processing. Wearable personal technologies are a primary form of augmentation, intended not only to extend and enhance the body technologically but to treat the body as a kind of intimate host giving rise, at least in theory, to a symbiotic relationship between person and device. The growing commercial importance of augmentation is reflected in the increasing number of technologies that are designed to be used in synergy with the body. These include ‘smart’ running shoes (Associated Press 2004), armbands that monitor sleep (Wysocki 2001) and shirts that monitor heart attacks by sensing the body’s heartbeat (Nowland 2003). Despite the increasing number of companies and research laboratories devoted to developing wearable computers, little research has been done on the cultural imaginaries that inspire their design. Our aim in this paper is to explore the question of what familiar and emergent theories of the body – and of personhood – designers and engineers are drawing from and inscribing into these sociotechnical artefacts. We explore this question through the analysis of empirical materials generated in the course of an ethnographic study of the design and implementation of wearable computers (Viseu 2005). More specifically, this paper is drawn from interviews conducted with wearable application developers working in the four main areas of wearable research: work, leisure, medicine and the military. We begin by briefly introducing the concept of wearable computers, then turn to the four cases that constitute the bulk of the paper. Interviews done with developers in the area of work applications are extended through an ethnographic study of the implementation of one particular wearable vision, a pilot augmentation of telephone service technicians working for a major Canadian provider. We close with a reflection on the types of subjects, objects and entities that are in evidence in these initiatives. Among the various implications of wearable technologies that we might trace out, our focus here is on one issue in particular, resonant with others in this volume. That is the question of relations of self, embodiment and knowing in the context of a cultural imaginary dominated by the trope of ‘information’.

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We share with Dumit an interest in the ways in which certain commercial interests – pharmaceutical companies in the cases that he considers, technology vendors in those investigated here – assume the figure of a body that continually emits signs inaccessible without technological mediation. Rather than further articulating the body/technology interface (Latour 2004), however, we argue that the wearable within the imaginaries evidenced here drives a further wedge into the gap dividing the modern body from the knowing and acting self. Sold as technological solutions to this epistemological lacuna, wearable augmentations promise to enhance the legibility of bodily signs. At the same time, however, the greater visibility of bodily information implies an associated responsibility to act, and more specifically to act within intensified regimes of self improvement and bodily control.

Wearable Computers Precisely what a wearable computer is, or should be, is a topic of debate among researchers and developers themselves. A key issue in this discussion is whether to include or exclude technologies such as mobile phones, or personal digital assistants (PDAs) in the wearable computing category. Their exclusion, when advocated, is justified on grounds that these devices do not adequately meet the ‘always on, always ready, always accessible’ (Mann 1998) criterion for wearable computing. What is at stake in these discussions is the identity not only of the technologies but of the field of wearable computing itself, and the latter’s viability as a unique area of scientific research. For our purposes here, however, it is less crucial to delineate the boundaries of the field than to identify objectives common to research and development efforts that affiliate with the wearable project. The latter are indicated in one definition offered by prominent researchers in the field; that is, a wearable computer is a ‘fully functional, self-powered, self-contained computer that is worn on the body [… and] provides access to information, and interaction with information, anywhere and at anytime’ (Barfield and Caudell 2001: 6; see also Mann 1996, 1997; Bass et al. 1997; Barfield and Baird 1998). The aim, in other words, is to create devices that are intimately tied to the body, autonomously functioning and perfectly interconnected. In this respect wearable computers materialize and make visible values characteristic of contemporary Western societies since the mid-twentieth century, including a desire for mobility, combined with continuous connectivity, personalization and control. The leading ambition of wearable computer developers and their imagined users is that of personal empowerment: wearable computers are the path to the augmentation of human motor, sensory and cognitive abilities (Barfield and Caudell 2001; Mann 1998; Pentland 2001). Underlying this vision is the assumption that,

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as Barfield and Caudell (2001: 5) put it, ‘our senses are still limited in a number of ways,’ and that this deficiency requires remedy through computational and informational upgrading. If the actual development and implementation of wearable computers over the past decade has been slow, the dreams behind them have only become more ambitious. While initially wearable computers were considered tools designed to give wearers instantaneous and constant access to information, more recently the goal has become to make them proactive, that is, responsive, networked and ‘aware’ (Clarkson et al. 2002; Mann 1997; Barfield and Caudell 2001; Smailagic 2003). This shift implies much more than technical advances: it implies a shift in the wearable computer’s identity. No longer simply a tool, the wearable computer becomes a ‘second brain’, ‘a technological companion’, ‘an extension of the self’ or a ‘second skin’ that is connected to its owner in intimate, synergistic or symbiotic relationship (Mann and Niedzviecki 2001). In the future, we are told, a wearable will know its user better than she knows herself, being able to act preemptively on her behalf (Wood 2002; Viseu 2003a). Although figuring more in the realm of imagination than implementation, these concepts are key to understanding the design of wearable computers as at once a rhetorical and a technical project. The figure of the wearable as a second brain or skin is closely tied to the wearable’s imagined sentience or awareness. ‘Awareness’ in this context is meant to signify a computing device that can recognize, adapt and (re)act to its wearer, its location and the activity being performed. In technical terms, awareness is built through the development and incorporation of sensors such as infrared, accelerometers, temperature sensors and biological indexes. These sensors extract analogue stimuli from the body or environment and convert them into electrical signals that can be interpreted by a digital device with a microprocessor (Barfield and Caudell 2001). This information can be processed locally to perform ‘context aware’ tasks such as navigation and communication; or remotely, when the information is processed by a third party, for example when monitoring cardiovascular activity. In the latter case the wearer does not need to initiate the process of transmitting information, and consequently does not need to be conscious that information is being transmitted. Awareness then can be interpreted as a means to make the wearer visible and readable, whether to herself or to others. Awareness is also a harbinger of intelligence: in its implied combination of information processing abilities and communication/networking capabilities, awareness is deemed to give the wearable computer its ‘smart’ status. The scenario below is indicative: A full-fledged personal computer network woven into an individual’s clothing, [the wearable computer] will learn the preferences of its owner

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by watching behaviour and taking note of habits. It will manage a personal datebook and know where its owner should be even before departure. And by preemptively scouring Web sites, it will constantly be updating the best way to tackle the next task. Suppose a beach party is on the schedule. [The wearable computer] will know this because the event is in the calendar and there’s a note on a to-do list that says, for example: Pick up beer. When the system observes its owner getting on a bike, it immediately seeks the best directions to the party by way of a packaged goods store – taking into account that its owner hates heavy traffic. After calculating all of this information, [the wearable] displays a map to the beach on the owner’s glasses without even being asked. (Wood 2002) These notions of awareness and ‘smartness’ translate differently in the four areas of wearable computing considered here: 1. The stated goal of wearable work applications is to improve efficiency and productivity by providing hands-free manipulation of information and access ‘on the go’. Usually targeted at mobile workers, particularly those who perform their work outdoors, wearables have been hailed as the ‘killer application’ that will increase productivity and provide quick returns on shareholder investment (Sakurai 2002). Mobility in this context refers not only to workers but to information as well. Being able to access information ‘anytime-anywhere’ means that workers may be accessed in turn. Moreover, their visibility to the system effectively renders them informational, as the indicators of their work activity increasingly come to stand for them. 2. Developed for mundane activities such as music playing, and imagined in terms of ambitious goals such as experience or memory recording, wearables for leisure applications have also been described as (yet another) ‘killer app’ that will turn wearable computers into everyday apparel (Post and Orth 1997; Barfield and Caudell 2001; Barfield et al. 2001). Augmentation through leisure or life-style wearable applications poses issues similar to the ones mentioned above, yet here the benefits of increased machine awareness are equated not with improved health, efficiency or effectiveness but with increased human pleasure and, in a sense, with increased ‘humanness’. 3. Most health applications are devised to capture continuously, measure and interpret body-related information that would otherwise be concealed or go undetected. The relationship between the computing device and the body is imagined as a synergistic feedback loop with both entities transmitting and receiving information and acting upon one another’s signals. The expectation is that after being processed and analysed by the wearable (or a third party) the information can be reintroduced to the individual from whose body it was retrieved to be

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interpreted by a computing device (biological or silicon based), producing effects that can range from increased awareness to behaviour change, or more crucial interventions. As we shall see, such applications give rise to notions of augmented self-awareness and self-surveillance. However, they also pose questions of control and disempowerment, which are all the more important given the sensitive nature of health related information. 4. Military and security applications generally have as their goal the augmentation of the soldier’s physical and cognitive abilities. They are part of a suite of technologies being adopted by the military ‘to provide full-spectrum dominance through achievement of information superiority’ (Gentry 2002: 90; see also Machamer 1995). The augmented soldier is seen as a fully integrated information network, the central issue being to establish a balance between visibility and invisibility, access and control in military operations. How much information, for example, should individual soldiers be given without causing information overload, or a problematic degree of self-sufficiency? What is missed in informational or mechanistic representations of the body and of the battlefield? These brief characterizations introduce some of the issues that define the four major application areas for which wearable computers are currently being developed. In what follows we draw from material generated through interviews and ethnographic engagement to describe in more detail the relationship between wearable technologies and the bodies they aim to construct.2

Sonica: Wearables at Work We begin with the case of a company we call Sonica, developing wearables for work.3 The case of wearables at work evidences the ambiguous politics of the dream of mobility with connection. The wearer imagined by enthusiasts like University of Toronto’s Professor Steve Mann (Mann 1997; Mann and Niedzviecki 2001), or pictured in media representations of the upwardly mobile professional, is quite different from the one figured in projects financed by corporate investors concerned with a mobile workforce. While mobile phones, notebook computers and the like may be aimed at traditional ‘white-collar’ workers in areas such as management or sales, the prototypical wearable user in the imagination of industrial producers is one who is mobile and needs fast and reliable access to information, while having their ‘hands free’. This rationale is readily acknowledged by Victor, national sales and marketing manager for Sonica, a hardware manufacturer interested in developing a market for wearable products, who says:

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In our space a lot of the technicians, field service users, need to have their hands free to be working in an environment where they can do multiple tasks, and the PC just wasn’t usable when you would have it on a shoulder or perhaps in the vehicle only. By putting a strap around a small screen, the user could have access to a lot of information and do communication in real time. While the media feature products that feed on popular images such as those exemplified in Paul Verhoeven’s 1987 movie RoboCop, picturing individuals equipped with head-mounted-displays, a keyboard on their wrist, and sleek, almost-invisible computers attached to their bodies, existing implementations of wearable technologies evidence different and more practical concerns (see Figure 7.1).

Figure 7.1. Bell service technician, 2002 (Photo by Ana Viseu)

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The product developed by Sonica, for instance, is part of its ‘toughbook’ division, that is, it is constructed to withstand inadvertent dropping, rain, cold, dust and other forms of harsh treatment. It is a distributed computing device composed of two parts: the CPU and the touch-screen display. A third, optional component, the docking station, offers added functionality to the CPU, but remains chained to a desk (see Figure 7.2).

Figure 7.2. Sonica’s wearable computer (Photo by Ana Viseu) Victor imagines a user in need of ‘a rugged wearable solution’ to the competing demands of mobility and connection. This is an outdoor body, exceeding the bounds of the office and threatening to lose contact and disappear from view. To do the work requires that workers both travel out from the central office and, crucially, report back to it. And while information may be weightless, its production and use by an embodied worker requires a means of entering and accessing it. However small and powerful the ‘central’ processor, the writing and reading of information requires keyboards and displays sized to hands and eyes. The ability and willingness of mobile workers to encumber themselves – the embodied weight of information – limits its wearability. As Victor explains: [E]very customer we went to, we said ‘Here’s an interesting solution. What would your application look like on this?’ … We took the product to [a large telecommunications customer] ... and the first thing I asked the project team there was ‘What would your application look like on this?’

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They said ‘Give us a unit, load it, and we’ll take a look.’ And their immediate feedback was ‘No, it doesn’t work for us. Our application requires someone in their truck typing a report.’ On this account the truck serves as a mobile environment, a site midway between outdoors and indoors, the mobile body and the stable centre of the office. Mobility from the point of view of the central office interested in receiving a report is less about autonomous movement, and more about the worker as mobile agent acting on another’s behalf. For Sonica, however, the truck is not only an intermediary between the mobile worker and the office, but an interim step along the way to the full realization of wearability. Victor continues: What we were trying to eliminate was this movement between the truck and the job site, back and forth to get new information, or to communicate other information. Often you would see a technician with a cigarette package writing down numbers, nodes and various numbers for fixing a repair. We wanted it all on that tablet. The ‘cigarette package’, as it turns out, was a recurring figure in stories of current working practices. In Viseu’s travels with technicians from a major telecommunications company, conducted as part of an ethnography of the deployment of wearable computers, she did see technicians reach into their back pockets for a small piece of paper, onto which they wrote things as they performed a given task. And technicians did smoke, at a rate that was striking relative to the larger population within Canada. But she never saw a technician use a cigarette package as a notepad, which raises the question: Just what gives the cigarette pack example its mobility as a story? At least part of the answer, one suspects, circles back to the figure of the technician mentioned earlier. Imagined as a manual labourer, however professional, the wearable user is, not surprisingly, gendered as male and, like the solution that he requires, ‘rugged’. The phrase ‘often you would see’ in the quote from Victor, combined with the urban legend quality of the cigarette pack example, signals a frequent feature of stories like Victor’s; that is, while framed as eyewitness accounts of the present, their status as either real or imagined remains unclear. Similarly, reports of field trials in the use of wearables among technicians are characterized by conflicting accounts of incorporation and/or resistance. Victor imagined that: people out there who are doing day-to-day tasks that don’t require a lot of inputting through a keyboard … love the technology. They love being able to have it on their hip, take … their notes, detailed notes, and make some additional comments and finish a report and upload to a wireless network.

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This account contrasted sharply, however, with Viseu’s own observations of technicians’ concerted resistance – what Victor himself acknowledged as ‘the limited buy-in from the field’, and the ‘pushback from users who felt that this was a productivity tool’. The latter is hardly surprising insofar as the technology was presented to technicians as a way to streamline the work process and thereby increase productivity, efficiency and, possibly, their own salaries – though without mention of the consequent changes to their workflow, power relationships and autonomy, or of a likely reduction in the workforce. As technicians became acquainted with the technology they came to see it not as a device that enabled them to do their job more easily or effectively, but as one that effected such significant transformations to their work that it implied a new job and by, extension, different workers. Using a number of strategies, active and passive, discursive and practical, they resisted these transformations to their personal and professional identities. The case of wearables at work makes visible some contradictions built in to the wearable project. While wearables are depicted in the media as sophisticated devices for equally sophisticated, white-collar men, they are being produced for (and used by) blue-collar workers. Moreover, while wearables are publicized as materializations of mobility, thanks to informational connectivity, there is an enduring and unresolved tension built into their actual implementation, between autonomy and control. Equipped with a wearable computer, the user’s (male rugged) body is brought up to speed with the requirements of the electronic workplace, one that demands constant access by and to information. It is an efficient and effective body. Equally important, however, this is no longer a body out of reach with a potential to break loose, but rather a body whose ‘data shadow’ (Clarke 1994) is, at least in theory, always visible. This may help to explain why Sonica’s representative states that equipping a field worker with a wearable computer with wireless connectivity creates a new worker, or at least, allows managers to ‘think of the worker [in a] completely different [way]’. And it may help to explain workers’ resistance to becoming ‘wired’ as well.

I-Wear: Wearables at Play The I-Wear initiative is part of the I-Lab project, described on its own website as a ‘deep future research lab’ that does not engage in the actual manufacture of any products but focuses instead on imagining what these products will be and how they might work. At the height of its growth the ILab had campuses in two major European cities, and was, according to its website, ‘the home and playground of 70 original4 [sic] scientists from 28 countries’. In late 1999 I-Lab launched I-Wear, described in press releases as an initiative that ‘wants you to be able to wear your office, your gym, your

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medical clinic, the Department of the Environment and a policeman—and still travel light’. Two years later I-Lab went bankrupt. I-Wear’s central research focus was intelligent clothing, wearable technologies imagined as a ‘second skin’ but one that acts as well as a kind of ‘second brain’ for the wearer. As I-Wear’s Research Director explains: I got interested in wearables, because wearable computing, the way I saw it, is like adding a second brain to a robot’s body, which in this case is the real body, our body. It was interesting to try to find ways in which to couple the control which happens in the brain with the control that would happen in that wearable: to see how that wearable could start influencing the behavior of people. In a familiar modernist move, brain and body here are decoupled, as both become available for computational upgrading. The project of the augmented human and the humanlike machine trade places, however, as technologies imagined as robotic enhancements are returned to the ‘real body, our body’. The case for the wearable posits not only a mind separated from its body, moreover, but also a body separated from its skin, all in need of technological reconnection. The idea of a ‘configurable [or functionalizable] second skin’, epitomizes I-Wear’s vision: [The second skin] can be decompos[ed] in different resources [the power, display and sensor layers], that you can dynamically compose into particular functionalities, that is the first pillar. And the second one, is that this second skin has this awareness of self, environment and activity. And then the two pillars come together … [and] you can exploit that awareness to dynamically configure the functionality out of those resources embedded in the different layers of the second skin. The skin here becomes not an integral materiality of embodied being, nor even a boundary between being and the world, but a kind of ‘second self’ in a more literal way than that described by Sherry Turkle in the 1980s (1984). Mind, body and skin, moreover, are together alienated from a surrounding ‘world’, commonly figured in terms of ordinary objects and physical environments, which is itself in need of greater ‘awareness’ in order to be able to configure itself in a more accommodating way (see Chasin 1995; Suchman 2007, ch. 12). As I-Wear’s Research Director explains: The essence of wearable computing is that the computer that you wear, that thing you wear, shares the same contexts as the ones in which you find yourself … [a wearable computer] is something that is always on, is always trying to be of service, trying to help, and it does that so that it links

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into your needs because it understands the context in which you find yourself: it understands what you are doing, it understands in what kind of environment you are, it understands what your needs may be, it understands your emotional state. Awareness in the service of subservience is a recurring dream for wearable computing, repeatedly mentioned in the wearable literature, both popular and scientific. Coupled with its imagined ‘pro-activity’ on the user’s behalf, the aware wearable emerges as an intelligent, sentient companion. The Director continues: I think potentially [a second skin] can make us more aware of ourselves. … It’s not only the form of things that are going on, the external appearance of things by which we will be able to look at ourselves but also, at the blink of an eye, we will able to see much more about ourselves … So, I think it will give us a more complete image about who and what we are. I-Wear’s Research Director readily acknowledges that this merger of ‘skins’ and ‘brains’ is not without consequences. As ‘new way[s] of connecting with our bodies, and with the world’, wearable computers open the door to problems of control. I-Wear’s Research Director explains, It’s a whole category of interfaces that I call ‘behaviour bias interfaces’. Those are interfaces that will [do] just as the name says, they will bias [the user’s] behaviour. It is a bit what marketing people are doing too. You are not always conscious about the way marketing influences your consuming behaviour. The issue here is similar to that raised in Dumit’s discussion (this volume) of the ways in which direct-to-consumer psycho-pharmaceutical marketing strategies help to create and normalize selves in continuous need of new, selfenhancing products, a theme to which we return in the case of wearables for health. Together, the Director imagines, smart clothing and intelligent environments can even eliminate the need to relive one’s experience imaginatively, or recount it to others. Embodied activity can be transformed into a landscape of measurable elements, a ‘signature of the experience’, that can be captured and re-run as a kind of restored memory package, transmittable in turn to others. I-Wear’s Director is not alone in perceiving embodied experience as a play in which the roles of actor and spectator are interchangeable. In a documentary on his cyborg experience, that places him as the main actor in his own ‘reality-webcast’, Mann describes a future where his grandchildren will be able to ‘re-experience [his] life as [he] did’ by watching the reruns of his life on video (Lynch 2001).

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The long-term goal of I-Wear developers is that the resulting ‘smart’ clothing should move from novel to normal and natural, so that it can, says the Director, be ‘just [bought…] off the shelf and you don’t have to worry about the fact that it’s technology or not’. Like other aspects of infrastructure, I-Wear should ‘disappear into the woodwork’, in this case through a ‘FAN’ or ‘fabric area network’ protocol, enabling a ‘deeper’ integration from items of clothing, to fabrics and ultimately to the level of ‘fibres themselves’. One of the issues that we face as a society, says I-Wear’s Research Director, is that of whether we ‘want these things or not’. We must debate the ‘implications of intelligent clothing … because if [our] clothes are permanently somehow linked to the environment then there is a level of visibility, which is an information visibility and a presence visibility, [and] that will also [have an] impact on us’. Thus, he says, it is important that we discuss ‘the relation[ship] between the first and the second skins’. One possible resolution may lie in technologies such as I-Wear becoming not only ‘on-body’ but increasingly ‘inbody’ devices, a process that he suggests implies ‘a merger between the two’.

Infobody: Wearables for Health InfoBody was founded in mid 1999. Like many other high-tech companies of this period, it began as a ‘vision’ of technological possibilities, with a commercially plausible business model coming only later. Unlike many others, however, InfoBody is still in business and actively pursuing its vision, that of creating ‘continuous wearable body monitors’. InfoBody produces an armband, to be used on the upper arm, that contains a computer, memory and multiple sensors that continuously monitor certain physiological data, for instance motion, skin temperature, heart rate, evaporative heat loss and the amount of heat being dissipated by the body (see Figure 7.3).

Figure 7.3. InfoBody’s armband (By permission of Infobody)

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The ‘unsolved problem in society’ that InfoBody attempts to address, says the company’s CEO, is that of ‘mounting healthcare costs’. ‘Most of the costs,’ he explains, ‘come from people’s behaviours: whether they choose to take their medications, whether they choose to maintain their weight, whether they do the exercises that their physical therapist tells them to do, everything like that.’ Care for the body on this view falls into the category of personal choice, and a responsible person will choose to monitor her body to ensure her fitness. Commensurately, failure to engage in bodily maintenance comprises a form of free-riding, leaving to public remedy that which should be the province of the responsible individual. To reach a ‘proactive wellness society,’ according to InfoBody’s CEO, constant informational body monitoring is imperative. Moreover, with the added information extracted from her body by the InfoBody armband, the user can obtain scientifically proven self-awareness. The data extracted from the armband, the CEO explains, have been calibrated with data collected using the ‘medical gold standard’ to ensure their accuracy; that is, measures taken through proven technologies and accepted as normative references within the medical community. As InfoBody’s Chief Technology Officer puts it, ‘there is the truth and then there is our product’. Positioned as the medium through which the truth of the body is made accessible, in other words, InfoBody’s devices aim to bring physiological fact into the grasp of the experiencing subject. The objectivity of the InfoBody armband’s measurements, InfoBody’s Chief Technology Officer suggests, raises the body’s status to that of an object worthy of the same level of care given to others. With wearables, he explains, ‘you get a new dashboard for yourself, which you don’t have before. You have it in your car, you know when you go home [and] you look at the thermostat, [you see] what temperature it is; but you don’t know what’s happening inside [your body], or what your day was like, so that’s one aspect’. No longer idiosyncratic and intangible, the body obtains a recognizable value and identity. When asked about the shifts in personal identity that might accompany such an increase in self-surveillance, InfoBody’s CEO replies: I think [that is] exactly what needs to happen. If people treated their bodies at least as well as they treated their cars we wouldn’t be in the health care mess we are today… [W]e need to start thinking about our bodies as very delicate machines which need regular care and feeding and we have to watch over it like we watch over a manufacturing plant, like we watch over an organization we run or we watch our cars. Joe Dumit (2003; this volume) has detailed the ways in which pharmaceutical advertising for psychotropic drugs posits a ‘self’ in need of

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rediscovery and restoration. Like the pharmaceutical body described by Dumit, the informational body is one always already at risk. At the same time, this is a body continually emitting signs, albeit in forms inaccessible to the self that might act to maintain it. The InfoBody device enables a newly informated self, recognizing and so qualified to regulate her previously alienated body. The reconnection between body and person can only be achieved through objective data, biomedical facts extracted by new technology. Hence, the company’s motto, ‘You can only manage what you can measure.’ Encoded in the device, the ‘gold standard’ of the normal healthy body can be enforced and the vagaries of experientially based assessment eliminated. The augmented body is a body that reports to the self, in sum, which is thereby obligated to respond.

The Reinforced Body: Wearables in the Military Extending human abilities, both physical and cognitive, through the use of ‘on-body’ technology is the objective of military-related wearable projects. In the media these efforts are usually depicted as the creation of superenhanced, improved or amplified soldiers. For obvious reasons, this area of research has grown exponentially since the declaration of the U.S. ‘war on terrorism’ in 2001, and the subsequent wars in Afghanistan and Iraq. Reinforced Body started, ‘as all projects at DARPA5 start, as hallway talk’ says George, a former project manager. His colleagues and boss convinced him to pitch the idea to DARPA’s director, and the project got US$50 million in funding. However, George adds that he cannot take credit for the idea, ‘I believe it’s one of those great problems of engineering, like the airplane, or the horseless carriage, the idea of melding man and machine. It has been around for a while, people have never been able to do it.’ In the early 1960s, he recalls, the U.S. military awarded funds to General Electric to build an external protective skeleton, an exoskeleton (see Figure 7.4a). At the close of the project, ‘they ended up with about a fifteen hundred pound monstrosity that had a huge tether for hydraulic and electrical power’. But while the visions are old and persistent (see for instance Levidow and Robins 1989), the technological environment that informs them has changed considerably. Specifically, with the advent and ubiquity of networked information and communication technologies (ICTs) the U.S. military has adopted a model of ‘network-centric warfare’ that relies primarily on ‘information superiority’ defined as ‘the capability to collect, process, and disseminate an uninterrupted flow of information’ (U.S. Department of Defense 1996, cited in Gentry 2002). This turn to information is one expression of ‘the desire of contemporary martial corporeality to become intelligence incarnate’ (Dillon 2003: 129).

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Part of the U.S.’s network-centric warfare effort is the creation of an ‘integrated soldier-centric system’, a platform of which the Reinforced Body is key (see Figure 7.4b for an example of a system currently being developed). While rejecting the idea of the Reinforced Body as a ‘portable power plant’ that will power the electronic hardware of such a soldiersystem, George explains how the Reinforced Body contributes nonetheless to its realization: The [Reinforced Body will] increase lethality, increase protection, increase ability to carry logistics for longer trips, and increase the mobility. You could go faster [and] longer than you could with a plain foot soldier. Couple that with increased informatics, basically, about the battlefield or your situational awareness, video monitors, infrared detectors, multispectrum vision. So now the soldier becomes this more complete system […]. The [Reinforced Body] is foreseen as the base of a series of technologies that we would layer on the soldier, [to] see how formidable we can make that soldier.

Figures 7.4a and 7.4b General Electric’s Hardiman produced in 1963 (by permission of General Electric); and a full-scale mock-up of an Exoskeleton system being developed by Sarcos Research Corporation (by permission of Sarcos Research Corporation)

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The following scenario, written by a subcontractor, illustrates this longterm vision. When Sylvia joined her military unit, she didn’t realize that she was going to become faster, stronger, and smarter in a hurry. The military was training her to wear an early version of a Superman suit. Sylvia stepped into a ‘soldier amplification [Reinforced Body],’ which ‘lifted’ her weight and the weight in her backpack. As a result, she could run much faster and for much longer. With the [Reinforced Body]’s attached long arm, she could lift heavy objects that she would not normally have been able to hoist. Her smart [Reinforced Body] sensors would warn her if she was being exposed to hazardous gases or if enemy forces were nearby. Additionally, the information provided almost instantly by her wearable ‘talking’ computer boosted her memory, helped her solve mathematical problems, and guided her in making wise decisions. Her perceptive abilities were enhanced, too. She could see better in the dark and through fog and smoke, thanks to night-vision and multi-spectral goggles. (ORNL 2000)6 George recognizes that before this technology can be used in combat, not only do its ‘kinks and bugs’ have to be addressed but, equally important, it must be ensured that ‘it fits into the psychology and the techniques of fighting’. In this sense, reinforced bodies are part of what George calls a ‘doctrine changing technology […] a technology that is so enabling that you can actually change military doctrine’. Their deployment will require both training and new tactics that accommodate the physical and cognitive (i.e., informatics-based) augmentation of the body. Within this new regime, he imagines, the Reinforced Body soldiers may be used to spearhead ground attacks, to ‘do the most dangerous and hazardous work’. The issue of how the informational augmentation of the soldier will affect warfare was a topic of discussion in an interview conducted by Viseu with Kirk, a ‘military engineering psychologist’ who was involved in the development of a complementary U.S. military initiative. According to Kirk the ability to exchange ‘live’ information without making noise is of tremendous significance, as it is likely to enhance the safety of soldiers. However, he identifies what he takes to be a critical issue: how to distribute information among the soldiers on the ground without creating situations of information overload. Although Kirk believes that the Army’s hierarchical structure will protect ‘the privates, the infantry in the trenches’ by sending them information on a need to know basis only, he acknowledges that under rapidly changing conditions determining just what the soldier needs to know may itself pose a problem. Kirk points to another potential challenge as well: first-hand access to information, made possible by this computational

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embodiment, may lead to decision second guessing. On this subject Kirk says, ‘I think that when everybody has it then there is an egalitarian kind of thing, because they all have the right to second guessing, “Dummy, why didn’t he look in the computer, it’s right here, it’s obvious!” Given the Army’s organization, with strict hierarchical chains of command meant to ensure that orders from above are followed, such a level of information transparency is feared to be dangerous, if not deadly. George also reflects that the machine that incorporates the soldier’s body, this new embodied entity, is likely to dehumanize warfare further. He likens it to the process of shooting down a plane: the ground soldier will have the ability to shoot from his [reinforced body] to somebody else’s [reinforced body], and he may think he’s maybe not so much killing the person as killing the platform. Just like a pilot shoots down another pilot. Because you know, we have these heroic ideas that the pilot bails out and all that’s lost is the plane, but that is not typically the case. While recognizing that reinforced bodies will bring about a new form of warfare that will have to be accompanied by new tactics to accommodate both the physical and informatics-based augmentation of the body, George reiterates the place of human agency: ‘The human is still pulling the triggers here…. [T]he [Reinforced Body] is still a soldier centric platform, and the soldier is still at the centre in command.’ This human-centred understanding of agency is important as it distinguishes this technology from efforts in robotics and artificial intelligence. On this issue George says: There are people who discuss the ethics of having robots with automatic control systems, […] as the centerpiece for making decisions on killing human beings, and there are some people who have problems with that. Obviously things can go wrong, and they can kill the wrong people, but it’s more than that. It’s an ethical thing. It doesn’t have the ability to make a judgement. The idea that we can program machines to engage in combat without humans is something that there is mixed feelings over in the military. People have funny feelings about automated killing machines. The tension between the imperfection of the human and the amorality of the machine becomes apparent here. On one hand, technology comes to the rescue of humans, increasing their abilities; on the other, agency and its derived concepts of responsibility and accountability are still placed firmly in the hands of humans. Technology is both constitutive of the reinforced body and still just a tool. The ambivalent agency of the reinforced body is further reflected in George’s alternate accounts of bodies that disappear into the technological

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exo-structures that envelop them, and their reappearance as autonomous commanders of the ‘integrated soldier-centric system’. There is acknowledgement, in sum, that the merging of reinforced bodies and soldiers gives rise to a new entity that implies new tactics, intimidation and perhaps dehumanization, while agency remains the exclusive province of the human. The embodied metal creature that envelops the human body is simultaneously enabling of the super soldier, and subject to her control. But like her reinforced body, as the augmented soldier becomes more useful she herself is assumed to become more obedient as well (see Foucault 1979: 137–38; Hables Gray 1989: 57).

Conclusion Gell has proposed that in place of recourse to some overarching cultural aesthetic or ideology, we might understand particular families of artefacts in terms of an ‘inter-artefactual domain’, a kind of circulating and mutually referential network of discursive and material practices (1998: 216). This leads us to reflect on the kinds of subjects, objects and hybrid entities that are imagined across the projects considered here. As at least a preliminary analysis, we would note the following as connecting assumptions. First, the ‘natural’ body is taken to be incomplete, falling behind the demands and potentials of the information age. The desirability of wearable augmentations presupposes the separation, if not alienation, of minds and bodies, people and things, in need as a consequence of ever more intricate reconnection. Taking human and machine as ontologically distinct, discourses of wearable augmentation reflect a continuing tension between the imperfection of the human, and the amorality of the machine, such that one has always to provide a remedy for the other. Related to this, we find a continuing tension between passivity and proactivity in visions of the future machine – while wearable computing devices are themselves imagined as in need of greater ‘awareness’, they remain subservient to human needs and desires. In this and other ways, discourses of wearable computing are responsive to, but tend also to obscure, associated agendas of visibility and control. Wearable computing incorporates – figuratively and materially – the aims of both what Foucault named ‘docile bodies’ and of those regimes articulated in his later writings as ‘technologies of the self’. Since the eighteenth century, Foucault argues, desirable bodily forms have shifted out from qualities held to be immanent in the person to objects of bodily training such that ‘the machine required can be constructed’ (1979: 135). The useful body is also, and increasingly, an intelligible body, available for analysis and manipulation. In relations of labour and of service (the workplace, the military, the clinic), the aim is still the docile body, one that may be subjected,

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used, transformed and improved (ibid.: 136). Figured as augmentations of the self, in contrast, wearable technologies ‘permit individuals to effect by their own means or with the help of others a certain number of operations on their own bodies and souls, thoughts, conduct, and way of being, so as to transform themselves in order to attain a certain state of happiness, purity, wisdom, perfection, or immorality’ (Foucault 1988: 18). This is the ‘elite citizen’, motivated towards self-improvement and positioned as leader or manager of the rest. Yet while the body would seem to be the focus of the projects described here, on a closer look the body, translated as information, tends to disappear – to assume the position of the node in a network, the source or repository of data, or what Paul Edwards (1996) has characterized as the ‘machine in the middle’ of a larger technical infrastructure. Where we locate agency in these newly augmented bodies has implications as well for what we take the person to comprise (see Suchman 2007, Lambek and Strathern 1998). The agencies articulated in anthropological accounts of bodily augmentation involve always interdependencies and contingencies. We embrace Latour’s proposition ‘that to have a body is to learn to be affected, meaning “effectuated”, moved, put into motion by other entities, human or nonhuman’ (2004: 205, original emphasis). Against a figure of the natural body as the ground either of knowing or of ignorance, Latour posits a dynamic body for which further mediations enable ever more refined and elaborated sensoria of difference, of body/world articulations. Similarly, the forms of embodiment explored by Scheldeman (this volume) evidence corporeal experience as the ground of knowing, but not in the form of a purified body abstracted from technological entanglements. Rather, it is precisely because the lived body is inseparable from its prosthetic extensions that what Haraway (1997) characterizes as the material-semiotic configuration of bodies and technologies comes to matter. These understandings of embodiment imply an alternate standpoint to EuroAmerican assumptions regarding responsible action, recasting the latter from a matter of singular acts of will or decision, to a question of how action and its possibilities are configured, with what consequences, and for whom. There is, we would argue, both tremendous potential and urgent need for a critical engagement with the imaginaries of wearable augmentations. Anthropological approaches orient us to the fact that intimate and meaningful relations between persons, bodies and artefacts are at once longstanding and universal, and always historically and culturally specific. Wearable computing discourses and artefacts make evident the depth to which the Cartesian split between a material body and transcendent mind or soul has sunk into EuroAmerican cultural imaginaries. In what Foucault names the body-object articulation ‘[d]iscipline defines each of the relations that the body must have with the object that it manipulates. Between them, it outlines a meticulous meshing’ (1979: 152–53). The disciplinary ideals of the augmented body

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articulated by the proponents of wearable augmentations can in this respect be understood as the most recent materialisation of longstanding Western philosophical and political worldviews. Our effort here has been to show that while seeming to embrace the premise that ‘[l]anguage and materiality are fully embedded in each other’ (Butler 1993: 69), the new intimacies of bodies and artefacts envisioned by wearable computing enthusiasts instead reinscribe the separation of persons and things. The augmented body as imagined by these technologists is still, in the end, a docile one, and the project remains one of enhancing its visibility, in the interests of contemporary regimes of self-improvement and control. As technologies of ‘bodily permeability’ (Franklin 1995) wearable computers produce culturally specific bodily images that come to stand for the body itself, in the process acquiring normative dimensions. As such wearable computers operate to reproduce dominant discourses of personhood, at the same time that they aim to reconfigure them.

Notes 1. 2. 3.

4. 5. 6.

See, for example, Appadurai (1986), Miller (19887), Strathern (1988, 1999), Gell (1998). This research was conducted by Ana Viseu in 1999–2005. See Viseu (2003a, 2003b, 2005). Throughout the paper we use pseudonyms to refer both to individuals and companies. We do this not only to protect the participants’ identity but also because it is not our aim to provide an evaluation of the specific products that are being developed. Rather, we want to explore the cultural imaginaries that circulate through them. By ‘original’ we believe the authors mean ‘creative’ or ‘innovative’. The Defense Advanced Research Projects Agency. The female gendering of the imagined Reinforced Body, while readable as an orientation towards inclusiveness, might also operate to invoke the figure of the woman’s body as one in greater need of reinforcement.

References Appadurai, A. (ed.). 1986. The Social Life of Things: Commodities in Cultural Perspective. Cambridge: Cambridge University Press. Associated Press. 2004. ‘Adidas Creates “Smart Shoe”’. CNN. http://www.cnn.com/2004/TECH/05/06/adidas.smart.shoe.ap/ (accessed 6 May 2004). Barfield, W. and K. Baird. 1998. ‘Future Directions in Virtual Reality: Augmented Environments through Wearable Computers’. Paper presented at VR’98 Seminar and Workshop on Virtual Reality, Kuala Lumpur, April 15–24.

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Barfield, W. and T. Caudell. 2001. ‘Basic Concepts in Wearable Computers and Augmented Reality’, in W. Barfield and T. Caudell (eds), Fundamentals of Wearable Computers and Augmented Reality. Mahwan, NJ: Lawrence Erlbaum Associates, pp. 3–26. Barfield, W., S. Mann, K. Bair, F. Gemperle, C. Kasabach, J. Stivoric, M. Bauer, R. Martin and G. Cho. 2001. ‘Computational Clothing and Accessories’, in W. Barfield and T. Caudell (eds), Fundamentals of Wearable Computers and Augmented Reality. Mahwan, NJ: Lawrence Erlbaum Associates, pp. 471–509. Bass, L., C. Kasabach, R. Martin, D. Siewiorek, D. Smailagic and J. Stivoric. 1997. ‘The Design of a Wearable Computer’, Proceedings of CHI’ 97, 139–46. Butler, J. 1993. Bodies that Matter: On the Discursive Limits of ‘Sex’. New York: Routledge. Chasin, A. 1995. ‘Class and Its Close Relations: Identities among Women, Servants, and Machines’, in J. Halberstram and I. Livingston (eds), Posthuman Bodies. Bloomington: Indiana University Press, pp. 73–96. Clarke, R. 1994. ‘The Digital Persona and Its Application to Data Surveillance’, The Information Society 10(2). http://www.anu.edu.au/people/Roger.Clarke /DV/DigPersona.html (accessed 9 November 1999). Clarkson, B., S. Basu, N. Eagle, T. Choudhury and A. Pentland. 2002. ‘Learning Your Life: Wearables and Familiars’. Proceedings of the 2nd International Conference on Development and Learning (ICDL 2002). Los Alamitos, CA: IEEE Computer Society, pp. 235–39. Dillon, M. 2003. ‘Intelligence Incarnate: Martial Corporeality in the Digital Age’, Body and Society 9: 123–47. Dumit, J. 2003. ‘Is It Me or My Brain? Depression and Neuroscientific Facts’, Journal of Medical Humanities 24(1–2): 35–47. Edwards, P.N. 1996. The Closed World: Computers and the Politics of Discourse in Cold War America. Cambridge, MA: MIT Press. Foucault, M. 1979. Discipline and Punish: The Birth of the Prison. New York: Vintage. ———. 1988. Technologies of the Self: A Seminar with Michel Foucault. Eds L.H. Martin, H. Gutman and P. Hutton. Amherst, MA: University of Massachusetts Press. Franklin, S. 1995. ‘Postmodern Procreation: A Cultural Account of Assisted Reproduction’ in F.D. Ginsburg and R. Rapp (eds), Conceiving the New World Order: The Global Politics of Reproduction. University of California Press: Berkeley, pp. 323–45. Gell, A. 1998. Art and Agency: An Anthropological Theory. Oxford: Oxford University Press. Gentry, J. 2002. ‘Doomed to Fail: America’s Blind Faith in Military Technology’, Parameters, US Army War College Quarterly, 88–103. http://carlisle-www.army.mil/ usawc/Parameters/ 02winter/gentry.htm (accessed 2 February 2003). Hables Gray, C. 1989. ‘The Cyborg Soldier: The US Military and the Post Modern Warrior’, in L. Levidow and K. Robins (eds), Cyborg Worlds: The Military Information Society. London, UK: Free Association Books, pp. 43–71. Haraway, D. 1997. Modest _Witness @Second_Millenium.FemaleMan_Meets_OncoMouse™: Feminism and Technoscience. New York: Routledge. Lambek, M. and A. Strathern (eds). 1998. Bodies and Persons: Comparative Perspectives from Africa and Melanesia. New York: Cambridge University Press.

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Latour, B. 2004. ‘How to Talk about the Body? The Normative Dimensions of Science Studies’, Body and Society 10: 205–29. Levidow, L. and K. Robins (eds). 1989. Cyborg Worlds: The Military Information Society. London: Free Association Books. Lynch, P. (dir.). 2001. Cyberman. The Nature of Things. CBC Television Network. Canada. Machamer, R. 1995. ‘Welcome to the 21st Century’, FORCE XXI. http://www.army.mil/soldiers/april95/p36.html (accessed 22 April 2003). Mann, S. 1996. ‘Smart Clothing: The Shift to Wearable Computing’, Communications of the ACM, 39 (8): 23–24. http://www.acm.org/pubs/articles/ journals/cacm/1996-39-8/p23-mann/p23-mann.pdf (accessed August 2001). ———. 1997. ‘Wearable Computing: A First Step Toward Personal Imaging’, IEEE Computer 30(2). http://wearcomp.org/ieeecomputer/r2025.htm (accessed 6 March 2000). ———. 1998. ‘Wearable Computing as Means for Personal Empowerment’. Excerpt of keynote address given at the 1998 International Conference on Wearable Computing ICWC-98, Fairfax VA. http://wearcomp.org/wearcompdef.html (accessed 16 September 2000). Mann, S. and H. Niedzviecki. 2001. Cyborg: Digital Destiny and Human Possibility in the Age of the Wearable Computer. Toronto: Doubleday Canada. Miller, D. 1987. Mass Consumption and Material Culture. Oxford, UK: Basil Blackwell. Miller, D. (ed.). 1998. Material Cultures. Chicago: University of Chicago Press Nowland, J. 2003. ‘Smart Shirts to Revolutionize Healthcare’, The China Post. http://www.chinapost.com.tw/business/detail.asp?ID=42338andGRP=E (accessed 20 October 2003). O’Connell, P.L. 2001. ‘Online Diary: Dear Thermostat; Profane? It’s My Name; In Search of Marijuana’, New York Times, 23 August. http://www.nytimes.com/ 2001/08/23/technology/23DIAR.html (accessed 23 August 2001). ORNL (Oak Ridge National Laboratory). 2000. ‘Theme: Virtual Human’, Oak Ridge National Laboratory, 33(1). http://www.ornl.gov/ORNLReview/ v33_1_00/human.htm (accessed 14 February 2002). Pentland, A. 2001. ‘Wearable Information Devices’, IEEE Micro, 12–15. http://computer.org/micro/mi2001/pdf/m3012.pdf (accessed 6 August 2001). Post, R. and M. Orth. 1997. ‘Smart Fabric or Washable Computing’. Proceedings of the First International Symposium on Wearable Computers (ISWC ‘97). Cambridge, MA, pp. 167–68. Sakurai, J.M. 2002. ‘Ready to Wear’. http://www.destinationffa.com /APCM/templates/solution_set_template.asp?Articleid=647andZoneid=17 (accessed 4 January 2002). Smailagic, A. 2003. ‘Wearable Computers: A New Paradigm in Computer Systems and Their Applications’, IEEE Transactions on Computers, 52(8): 977–78. Strathern, M. 1988. The Gender of the Gift: Problems with Women and Problems with Society in Melanesia. Berkeley: University of California Press. ———. 1999. Property, Substance, and Effect: Anthropological Essays on Persons and Things. London and New Brunswick, NJ: Athlone Press. Suchman, L. 2007. Human-machine Reconfigurations: Plans and Situated Actions, 2nd edition. New York: Cambridge University Press.

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Turkle, S. 1984. The Second Self: Computers and the Human Spirit. Simon and Schuster: New York. U.S. Department of Defense and Chairman of the Joint Chiefs of Staff. 1996. Joint Vision 2010. Washington: Office of the Chairman, Joint Chiefs of Staff. Viseu, A. 2003a. ‘Simulation and Augmentation: Issues of Wearable Computers’, Journal of Ethics and Information Technology 5(1): 17–26. ———. 2003b. ‘Social Dimensions of Wearable Computers: An Overview’, Technoetic Arts 1(1): 77–82. ———. 2005. ‘Augmented Bodies: The Visions and Realities of Wearable Computers’, Ph.D. dissertation. Ontario Institute for Studies in Education, University of Toronto. Wood, C. 2002. ‘I, PC’, Popular Science. http://www.popsci.com/popsci/computers /article/0,12543,198188,00.html (accessed 20 March 2002). Wysocki, B. 2001. ‘In Sickness and Health, Biometrics Field Grows’, Wall Street Journal. http://startupjournal.com/columnists/challengers/bodymedia/20010810wysocki.html (accessed 5 May 2003).

CHAPTER 8 ‘Embryos Are Our Baby’: Abridging Hope, Body and Nation in Transnational Ova Donation Michal Nahman

Introduction In aid of the rise of modern nation-states, state forces were mobilized to control bodies, according to Michel Foucault, through ‘biopower’ or ‘techniques of the body’ (Foucault 1978). This included the technologies of counting, measuring and looking in order to control the bodies of populations. Such an account of the relationship between governing forces and people (individuals and populations) in poststructuralist theory has inspired much writing detailing instances of biopower (which are too many to list here). Foucault’s work has been useful for feminist critiques of the ways in which scientific practices of reproduction reproduce the ‘national body’ in quantity and quality (Yuval-Davis 1997), both imaginary ideals. Meanwhile innovations in science, biomedicine and technology have shifted the relations between the individual and the state so that social scientists no longer simply speak of the state managing populations (Novas and Rose 2000). In the anthropology of science in particular, attention has increasingly been given to shifting epistemologies of nature, science, technologies and collectivities, most notably with the work of Paul Rabinow on biosociality1 (Rabinow 1995; see also Gibbon and Novas 2007). An extension of this work has been the focus on the ways in which biosciences such as stem cell research reproduce and reflect epistemologies about Western subjects (Franklin 2005). Furthermore, analytical attention to the ‘global

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assemblages’ of bodies, science, capital and competing interests, has indicated important directions in the anthropology of science (Ong and Collier 2005). This has been a key methodological move (Wimmer and GlickSchiller 2002). While some earlier social scientists may have inadvertently worked in service of nationalism by focusing studies within discreet national domains, the global study of science has helped shift STS away from being the handmaiden of national governments (ibid.). This paper builds on Wimmer and Glick-Schiller’s critique of methodological nationalism and on others’ research into the globalisation of science and technology by illustrating that promotion of the idea of globally traded reproductive body parts and the hope for those body parts creates moments in which the nation is imagined transnationally whilst national boundaries are drawn that are not as ‘global’ or cosmopolitan as one might wish. This paper documents one instance of how in recent times the hope invested in IVF technologies by doctors and ova recipients has the tendency of shifting attention away from the process and source of procured ova towards the ultimate goal of simply getting those much coveted body parts. Such shift in attention away from the elaborate and sometimes illicit procurement of body parts has received significant attention from scholars looking at organ trafficking (see especially Scheper-Hughes 2002; and Cohen 2005). In ova donation this means that people’s hopes for a baby get shifted to hopes for embryos. The clinic subtly, through various technologies, reinforces this process. Through an analysis of a set of images, discourses and documents, which are employed by a private clinic to visualize bodies, this paper shows how global reproduction relies on both the movement of body parts, and the obfuscation of the actual process of that movement. Ironically, this obfuscation sometimes happens through actual description of the ‘process’ by the clinicians through empty signifiers (images, brands and narratives) such as the ones illustrated below. They happen through imagining bits of bodies as available, transportable and racially desirable among other things. These visualizations of the body offer ‘infertile’ Israelis the hope for self-improvement and are salvational ‘technologies of hope’ for ‘choosing’ ideal donor/embryo/baby traits. At stake here are the kinds of bodily imaginaries that are reproduced through the seemingly contradictory prosthetic possibilities offered by reproductive technologies: transnational, privatized and nationalist. Sometimes these imaginaries happen all at once and sometimes separately. By examining the hope invested in ova and embryos in the discursive practices of one private IVF clinic in Israel I argue that a hybridized version of Israeliness emerges, one that mixes Zionism with transnationalism and privatized medicine, within the logic of accumulative market ideals. If we were simply to look for ‘local’ manifestations of Jewish ideas and ideals we would miss the ways in which the Israeli state is and has always

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been enmeshed in global processes of mobility and markets, and how this operates in Israeli IVF clinics. This version of Israeliness that is imagined through the practices demonstrated here is one that is very much in line with the emergent cultural economies of Britain, the United States and other advanced capitalist states, though it has its own specificities, outlined ahead. So, for example, it is well known that if we are talking about the donation of female ova one must consider the fact that Israeli Jews are counted as citizens because of their relationship to a Jewish matriline. Yet important as it is, this ‘local’ dimension must not make us overlook the other equally salient aspects of Israeli histories, identities and bodies which may be equally interesting and relevant to an anthropological analysis of IVF and egg donation in Israel. Israeli IVF cannot, I argue, be examined outside the history and contemporary discursive practices of state Zionism. As others have shown, Israel is a settler colonial state (Yuval-Davis 1989) encouraging reproduction of Jews (Yuval-Davis 1997). In addition, Zionism ideologically and culturally fights to remain a viable vision of the world for its citizens (Dominguez 1989). Centrally of interest to my cultural account of ova extraction and exchange practices in Israel is an appreciation of the ways in which the cultural heritage of European Jews reproduces itself and remains dominant. An Ashkenazi identity, that is a European identity, confers upon one a right to legitimate citizenship in a manner different to any other in Israel. The fact that state Zionism officially declares it is a multicultural society is consistently betrayed by the social and cultural realities of the privileging of Europeanness (Shohat 1989; Alcalay 1993; Lavie 1996). Any discussion of Israeliness, in terms of bodies, nationalism and citizenship should take into account the myriad forms of exclusion and identification that prevail in this context. Another layer of this inequality is that despite official laws in Israel which deem all its citizens to be equal, in realities of everyday life it has been shown by many scholars that usually one must be Jewish in order to be a legitimate citizen with equal access to good jobs, healthcare and education (Dominguez 1989; Peled 2004). According to most of my research participants, in order to count as an equal member of the nation-state, one must also reproduce (see also Yuval-Davis 1997; Portugese 1998; Kahn 2000; Weiss 2002). It has been suggested that this social pressure emerges out of the anxiety regarding the perceived demographic threat to the existence of the Jewish state posed by the reproduction of Palestinians (Yuval-Davis 1997, 1989; Portugese 1998). It has also been argued that the pressure to reproduce is so strong that Jewish religious law and, consequently, Israeli state law are among the most permissive in the world for access to reproductive technologies (Kahn 2000). Indeed the Israeli government is well known for its generous funding of these technologies (ibid.). This has been identified as being part of the practices of creating a ‘chosen body’ (Weiss 2002). The idea of a chosen body derives from the biblical

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notion of the Jews as the ‘chosen sons’ of God. It is a central trope of Zionist ideologies (Almog 2000). According to Israeli anthropologist Meira Weiss the ‘chosen body’ in Israel is an imagined ideal that is Jewish, Ashkenazi (European descended), militarized, masculinized and reproductive. Yet, whilst the ideal national body is Ashkenazi, a majority of Israelis today selfidentify with Jewish-Arab and African diasporas, as well as with Muslim and Christian Palestinian national identities (with many additional complex and intersecting dimensions).2 The chosen body is also heteronormative, imagined-male, excluding straight women, lesbians, gay men, bisexual people, transgendered and transsexual people, and the myriad ways in which humans express themselves physically and sexually. It also excludes women who do not wish to or cannot reproduce.3 Several of my research participants at a fertility clinic said they were ‘second class’ citizens due to their lack of a child. These are some of the contradictions of Israeliness – a self-proclaimed democratic, multicultural state that somewhat contradictorily runs under the assumptions of ethnic nationalism and exclusion. The promise of embryos and eggs in this context then is their enabling power to make ‘chosen bodies’ out of some ‘unchosen’ ones.4 Yet to analyse simply the ethnic national dimensions of this would be to omit much of the story here. Indeed, the images and claims made by the clinic’s progenitors offer particularly Jewish, Zionist and neo-liberal kinds of ‘hope’ to ‘infertile’ people through transnational practices. This version of imagining national bodies promotes the reproduction of inequality and racialization and is part of Israel’s participation in global capitalism. Anthropologist Gay Becker (2000) who studied practices and attitudes to IVF in the US noted that the idea of ‘hope’ is a tool of IVF providers in the American context. In a chapter titled ‘Selling Hope’ Becker states, ‘[i]n the field of reproductive technology, hope has become part of the process of commodification, a marketing tool’ (Becker 2000: 117). Indeed, as I illustrate below, this is also the case in privatized IVF in Israel. Yet there is more to this: hope is not only sold, hope itself is a reproductive technology. Following Sarah Franklin (1997: 203) Marcia Inhorn argues that in Egypt reproductive technologies are ‘hope technologies’ (Inhorn 2003: 167). Franklin argues that it is not only the individual’s hope for a baby which is symbolized by reproductive technologies; she contends that a ‘collective hope [is] invested in the power of science and technology’ (Franklin 1997: 203). She argues that the hope in IVF is ‘devotional’ and therefore religious (ibid.). In the Israeli case it may be that this has consequences for equal citizenship as well – or for inclusion into the ‘chosen’ body. As I show below, the language of brochures, the imagery of posters and the selfrepresentations of the clinic by its head physician all suggest that the clinic provides people with embryos, which by elision are babies. Such babies, or attempted babies are what may recoup the ‘chosenness’ of the people at this

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clinic. The hope shifts from a hope in technology to a hope in the salvational promise offered by body parts. That salvation may at times take on a religious, civic nationalist or gendered form. In the end, however, since most egg donation cycles fail (Throsby 2004), there will not be a resultant baby. This means that the body people imagine quite often remains an ideal, or an idea of a body. Through the use of such hopes for a baby, private IVF clinics in Israel working within an increasingly global and privatised health system (Chernichovsky 1992; Chernichovsky and Chinitz 1995; Nitzan and Bichler 2002; Filc 2005) participate in the imagining of national bodies. They do so through methods of branding and the creation of potently, professionally rendered, company logos and glossy company brochures. These modes of visualising the embryo and the company’s stated ‘unique’ transnational method of acquiring embryos lend a kind of status or cultural capital to the clinic. Israeli society is part of a global culture and economy so, by extension, the company offers clients the ability to participate in those highly valued arenas (Carmeli and Applebaum 2004). In this case Israeli bodies are imagined within a privileged, privatized consumer economy of reproduction. Due to the transnational nature of the practices themselves and to their embeddedness in a global neo-liberal economy, the national body is made transnationally.5 That is, Israeliness must be seen as a relational category within these global transactions. This point has epistemological significance for the study of Israeliness as well as relevance for the study of global IVF more broadly within the social sciences. For the former, this claim works against any notion that Israeliness is simply a self-constituted set of cultural practices. It has a relation to the outside world that does not only relate to issues of anti-Semitism, or being a state under attack. Its relation also has to do with its very powerful participation in global market, and the history of Zionist Orientalism (this is detailed further below). This process depends on the successful operation of the notion of choice. In this case, what I am interested in is the choice of donor traits, which people are led to believe – by the clinic and by prevailing popular forms of genetic thinking – will bring about the desired phenotypic appearance of their future child. This has been indicated in other areas of reproduction. ‘Choice’ of sperm donors, surrogate mothers and ova donors reproduces particularly narrow ideals of beauty and of national selfhood and family in Israel (Birenbaum-Carmeli and Carmeli 2002; Teman 2003; Nahman 2006). There is enormous historical, medical and social pressure to conform to a militarized, masculinized, strong, healthy, European body in Israel (Ivry 1999; Almog 2000; Weiss 2002). The rich body of work on Israeli reproduction that focuses its examination within Israel and among Jews (Weiss 1994, 2002; Kahn 2000; Teman 2003) has been extended by writers who look at the discourses and practices of

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reproduction of Palestinians within Israel and in the West Bank (Kanaaneh 2002) as well as comparatively with places such as Japan (Ivry 1999). This research has crucially demonstrated similarities and differences within Israeli narratives and practice of reproduction, in different communities as well as comparatively across countries. This discussion can be extended towards seeing how these practices are embedded within global circuits of exchange. The Israeli state and its intimately linked privatized trade operate very much as part of a global economy and culture (Nitzan and Bichler 2002). Whilst it might be tempting to suggest that because of the transnationality of trade in gametes ‘Israeliness’ is more porous and cosmopolitan, such a conclusion would involve a misplaced ‘biologization’ and much historical forgetting. Acquiring ova from non-Jewish women in Romania does not alter notions of Israeli identities just because the eggs come from non-Jewish women. That is, my research found Israelis quite willing to receive biogenetic substance from non-Jews and still to confer Jewish identities upon their resultant children. Indeed, Israel has always been a ‘mixture’ of ‘cultures’. Such a notion of mixture, which ironically combine static notions of culture and ethnicity with a fetishization of mixture, are part of the fabric of Zionist rhetoric (Nahman 2006). As one leading member of the Israeli Ministry of Health stated when I interviewed her: there will no longer be Sepharadim, Ashkenazim…everything will become mixed … the truth is today it’s a lot less problematic [ethnicity in Israel] … there’s no social problem between the edot [ethnic groups]. (Interview, 24 June 2002) Yet, it is clear that despite this governmental perspective Israel is a cosmopolitan, multicultural society that experiences significant racial inequality (Peled 2004). Furthermore, in these exchanges of ova, the ideals of Israeliness do not shift towards an enduring or transformative desirability of Africanness, Arabness, Asianness or Russianness, to note just some diasporic and marginal kinds of Israeliness (Shohat 1989; Alcalay 1993; Lavie 1996; Peled 2004). The transnational flow of eggs involves techniques and practices which reinscribe the idea of the imagined ‘need’ for borders. The account provided here illustrates how a particularly narrowly conceived Israeliness is being reproduced by the transnational ‘flow’ of eggs.6 The examples are drawn from research in one private IVF clinic, south of Tel Aviv. This clinic is part of a network of six clinics, known as the Universal Fertility Centers (UFC).7 It is located in an industrial zone of one of the Tel Aviv suburbs and is housed in the building of a large chain of privately owned hospitals that has branches around the country. The network of clinics was spearheaded and linked together by two people: Dr Zer, the head physician, and Orit, the head manager. Five of the clinics are located in

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various parts of Israel, in the areas of Jerusalem, Tel Aviv, south, south central and northern Israel. (The sixth clinic is in Bucharest, Romania and is described in Nahman 2008). Each of the Israeli clinics is run by a manager, who organizes patient visits, meets with prospective patients and generally runs the clinic. In addition to this, each of the five clinics has a nurse, and an attending physician who visits once or twice per week. These physicians are usually linked to other institutions (generally state hospitals) in which they practice. The work they take on at this clinic is additional to their other medical obligations. The network of ova donation clinics was imagined by Dr Zer as an ‘all-in-one solution’ to couples’8 desire for children and has been running since 1997. While specializing in egg donation, the clinic also provides surrogacy arrangements, IVF, and Dr Zer has been considering adding a transnational adoption service. The satellite clinics around the country are centrally run via telemedicine, working on an ‘expert system’, which Dr Zer co-designed and is in the process of patenting. While his satellite clinics are for intake and prescription purposes only, the central clinic is where the clinical procedures are performed (uterine investigations, embryo transfer and extraction of ova in the cases of surrogacy). On a monthly basis, approximately twenty ova donors in Romania are hormonally induced to produce a large number of ova (usually between 15 and 30). An embryologist from the Israeli clinic travels with the head physician to Romania carrying with them a canister of cryopreserved sperm from commissioning couples. In Romania the sperm is thawed, ova are fertilized and incubated. After this, when embryos form, they are refrozen and taken to Israel, where they are implanted into Israeli women. This is obviously a very condensed account of the process (see Nahman 2005).

Embryos Are Our Baby The transnational, privatised and Zionist body emerges as conflated in one particular image found in the clinic itself and can be seen in Figure 8.1. Women who carry the baby are erased from this body, women who donate the ova are erased, but what is emphasised is the ability of the clinic to purvey embryos to its clients. If we read further into it, the language presented in the image in Figure 8.1 also gives us a uniquely Jewish sense of time and hope. So these different bodies and imaginaries are folded into each other. I suggest that this image collapses time and erases donors’ labour and agency. It will be argued that this image can be seen as a particularly Jewish visualising of Messianic time, and the ideas entailed within it are framed in ethnic/nationalistic tropes. It is this particular mix of ethnic nationalism and neo-liberalism that make the image interesting and presents

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a new view of Israeli reproductive technologies. This image might be one area in which one can heuristically see the convergence of the local and the global in Israeli IVF. Judging by its prominent placing in the centre of the waiting room of the central clinic of this network of ova donation clinics it can be seen as one way in which the clinic promotes hope for the procurement of ova and embryos rather than for a baby. It presents a narrative of scientific practices of reproduction that unabashedly portrays itself as being the ‘embryo business’. Whilst such a self-representation might seem crass in a British context, in an Israeli one, and possibly in others, to say you are a leader in buying and selling ova might not be seen as morally and ethically reprehensible.

Figure 8.1. ‘Embryos are our baby’ (photo by Michal Nahman)

Figure 8.1 is a photograph that I took of one of the many posters and boards on the clinics’ walls. The board is lined with photographs of babies, including one photograph of a physician holding a baby. One of the items on the board is a letter written to the clinic by a happy couple. The writing above the collage of photos translates from Hebrew as: ‘Embryos are our baby’. I wondered, ‘how can embryos be a baby?’ Who is the ‘us’ implied in ‘our’? Why is the English word ‘baby’ (in Hebrew script) used in the Hebrew sentence? How does the drawing of a baby next to this writing (at the top left of the image) relate to the statement ‘embryos are our baby’? What is the relationship between the statement, the drawing of a baby and the photographs of ‘actual’ babies in Figure 8.1? The viewer is perhaps intended to imagine a

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direct link between the statement, the drawing of an imaginary baby (wearing a baseball cap, sucking on a ‘dummy’ and carrying what can either be described as a baseball or a hand grenade), and the photographs of actual children. Condensed in this poster are fundamental questions of what Haraway (2003) calls ‘kin and kind’ – relationality and nationalism. The boundaries of the nation are discursively materialized in the poster. The slogan ‘Embryos are our baby’ seems to be about hoped-for babies, imagined selves and enterprise biomedicine. The clinic builds on clients’ desire for a baby through the ‘promise’ that embryos will result in babies. I suggest that the image on the wall is a complex, hybrid, ‘material-semiotic node’ (Haraway 1997) that connects individual desires for a baby, enterprising biotechnology’s aims of profit-through-promise, with particular aspects of the national imaginary. This is the Israeli ‘local’ folded into and with the ‘global’. This story unfolds below.

Erasing Labour The failure to distinguish between embryos and babies may perform an erasure of labour. Most obviously, perhaps, the labour of the woman who carries the baby to term and her embodied subjectivity is erased. Feminists writing in the context of reproduction have extensively examined such erasures of women’s labour. Most notably, Barbara Duden has written about the ways in which women’s bodies are effaced through the intense focus on the foetus (Duden 1993). Yet the specific kinds of erasure considered here are of the processes involved in extracting embryos from women’s bodies and inserting them into other bodies. This involves the transport of sperm to Romania where they are combined with ova, frozen, brought to Israel and also the ‘choices’ that people have to make to become ova recipients or donors. The mobility of capital, techniques and technologies of IVF and people are hidden or denied by the phrase ‘embryos are our baby’. As I illustrate below, they are also erased through the clinic’s self-branding. In thinking about how various kinds of labour are effaced, I enlist Charis Thompson’s (2005) idea that embryos are ‘promissory’, and involved in an economy of reproduction rather than production (or capital accumulation). Thompson’s work is based on research she conducted in IVF clinics in the US. As part of her study she examines the kind of capital that gametes embody. She states that an earlier version of capitalism involved measurable output and productivity, yet in relation to biotechnology and reproduction, new forms are emerging. According to Thompson, in the world of biotechnology, capital is not ‘accumulated’. Yet, in the Israeli clinic that is under examination here, there is accumulation of capital resulting from the selling of embryos. Biotechnology and reproduction are made into capital through the ‘promise’ that they offer about their future success. Thus, the

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existence and continued profitability of biotechnology depends on its ability to be taken seriously as a ‘stock’ or ‘future’. Similarly, the statement ‘embryos are our baby’ depends on the person viewing it believing in the idea of an embryo as a ‘future’ baby. What constitutes the ‘promise’ of embryos is their successful transformation into a signifying resource for the clinic, which results in the clinic’s accumulation of capital. Whilst they are promissory for recipient couples, embryos are accumulative for the clinic.

Americanization versus Neo-liberalism In part the statement ‘embryos are our baby’ also carries cultural capital. The phrase, in Hebrew script, reads: ‘ubarim hem ha’baby shelanu’. If the entire phrase was written in the Hebrew language it would be: ‘ubarim hem ha’ tinok shelanu’ – since the Hebrew word for baby is tinok. The semantic shift performed in the use of the English word for baby is, I would argue, quite an important signal. In addition to the use of an English word, the verb (are) is in the plural form whilst the noun (baby) is singular. Thus the noun and verb do not cohere. If the sentence does not make sense, grammatically, I would suggest that the word ‘baby’ is intended to imply something other than a baby. It could imply ‘specialism’, meaning that the company’s central project is acquiring, selling and implanting embryos. This turn of phrase, referring to a ‘specialism’ as a ‘baby’, is American rather than Israeli. Use of this sense of the word baby may be a way of lending the clinic status through affiliation with an Americanized manner of speaking. Avraham and First (2003) argue that elements of American culture connote high status and ‘the good life’ in Israel. They also cite the head of the Israeli branch of the international toy store, Toys R Us, who claims that ‘English is used purposely to create an atmosphere or a sensation reminiscent of America’ (Avraham and First 2003: 291). Avraham and First (2003) argue that there has been an increasing Americanization in Israeli society. Based on their extensive study of English language advertisements in Israel, Avraham and First found that, ‘In 1990, 118 ads … contained the English language motif, whereas in 2000, 437 ads did’ (Avraham and First 2003: 290). They use these figures to build on the argument of Liebes (2003), who claims that, in Israel globalization is the same thing as Americanization. They contend that Israel is ‘shedding’ its Israeliness and taking on an ‘American veneer’ (2003: 282). Yet, culture can never be ‘lost’. Globalization ‘never simply ingests difference, replacing it with a unified, coherent version: “a little version of Americanness”’ (Franklin et al. 2000: 4). Globalization in Israel is not the same as Americanization as Liebes argues. American monetary investment in the Israeli economy and military is crucial to bear in mind here (Nitzan and Bichler 2002). It has helped the Israeli market to become globalized, but

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this economic assistance has not meant a shift into complete Americanization, it is partial. Global consumer culture does not cause a loss of culture. It causes multiple ripples and shifts that are always about a complex negotiation between locality and something else. Consider that while Americanization may be involved in recent shifts in Israeli society, there is a fetishization of things that are ‘Eastern’ in Israel, signalling a prevailing Orientalism as well. This indicates that the flow of cultural desires and objects moves in contradictory ways, sometimes privileging Americanness as a source of comfort and ease, and sometimes privileging other cultural influences. Nevertheless an uneven and unstable privileging of Euro-Americanness persists in global culture. There is reason to suggest that, rather than an Americanization of Israeliness, what is being evoked in the image above, as in other practices of this clinic, is a shift towards privatized medical practices in which globalization and Americanization are standing in for deregulation and marketization-type thinking.

Hope, IVF and the Nation Taking this argument further, I want to suggest that in this image’s slippage between embryos, babies and hand-drawn images of babies, there is a skipping of time. This image taken as a whole – the statement ‘Embryos are our baby’, the juxtaposed photographs of babies and the drawing of a baby – fails to differentiate between embryos and babies, in such a way that makes it seem as if the process of egg donation is quick and direct. This implies that egg donation will happen quickly at this clinic, whereas at other clinics people often wait for several years. Indeed this is how Dr. Zer himself described it to me. The failure to distinguish between embryo and baby obscures the duration of time it takes to gestate an embryo and deliver a baby. Time is abridged. According to Benjamin, for Jews every second of time, past, present and future was a possible moment when the Messiah might arrive (1973: 266).9 Thus, every second of time was filled with hope and anticipation of salvation. This idea of hope is built in to Benjamin’s notion of abridgement. Similarly, the hope for future babies, and the elision of the time and labour it takes to make a baby out of an embryo are materialized through the phrase ‘embryos are our baby’. This abridgement is perhaps one way in which the clinic naturalizes the relationship between embryos and babies. It suggests that embryos always result in babies, as opposed to the many cases in which implanted embryos do not grow into babies.10 It defies the instances of at least 30 women I interviewed in Israel about their experiences of ova donation, which overwhelmingly included narratives in which embryos resolutely did not become babies (Nahman 2005). From my observations, it seems evident that the clinic puts much effort into managing the

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expectations and emotions of their patients. It does so in many ways, one of which is by encouraging attention on embryos. The clinic may be reproducing Jewishness through the mobilization of this particular kind of Messianic (time-abridging) hope. Further reproduction of Jewishness in the clinic can be found in what the head of the clinic, Dr Zer, himself had to say about the practices of the clinic. On one occasion he stated: Three years ago, well, more than three years ago, but three years ago it started to work ‘full volume’. And we saw it was good. There were many legal hurdles, but we received authorization from the Ministry of Health (in February 2002). … So we said, we’ll take the sperm there and bring embryos la’aretz.11 We checked [the legality of it] and it turns out that at the moment that embryos are formed they belong to the couple in treatment. The Ministry of Health told us there was no legal obstruction. Because, you know, there’s no such thing as ubarim mesoravei aliyah [embryos who’ve had their ‘right of ascent’ refused].12 (my emphasis) Dr Zer states that when he first opened his clinic he ‘saw that it was good’. This is a direct quotation from a biblical passage (from the first chapter in Genesis in which God is represented as creating the night and the day, animals, etc.), which injects a religious element into the privatized medical practice of IVF at this clinic. It is common in Israeli Hebrew to insert biblical phrases into everyday speech (see Dominguez 1989; Boyarin 1996). However, the quotation is interestingly placed here. The presence of biblical quotation renders it possible to see the clinic as something other than ‘merely’ a secular space where ova donation occurs, but also as a Jewish space, despite the non-Jews who access their services. Zer also argues that there were legal hurdles. Furthermore, the context of this particular quotation, coming at the end of seven days of God’s creation indicates the clinician may be playing God himself. The assertion that this was done despite legal hurdles places his endeavour within a narrative of ‘scientific progress’ through struggle (Franklin 1997). Its juxtaposition with biblical quotation places it in an ethnic-national narrative of struggle. It is through struggle that Israel is narrated as having achieved its status as a nation-state. This intersection of the national with the scientific continues most pointedly when he argues that there is no such thing as an embryo that has lost its right of ‘ascent to Israel’ (aliyah). This is one moment where the religious, the national and the scientific collide. This notion of aliyah is juridically associated with a notion of ‘return’.13 The ‘Law of Return’ guarantees the legal right of Jews to ‘ascend’ to Israel. It is encoded into the legal framework of the state; in this sense, it indicates the Israeli narrative of a ‘return’, after a two thousand year absence. Dr Zer is thus directly speaking about

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citizenship. In the Law of Return an historical link is made between Jews living in Israel today and Jews who lived in the Land of Israel in biblical times. This is the kind of ‘simultaneity’ that Benedict Anderson discusses when he describes how nations are imagined (Anderson 1991: 24). The imagined past is inscribed into the legal framework of the state. It is indeed true that embryos cannot lose their right of ascent, as Zer indicated in the passage quoted above, due to the fact that they are not ‘persons’ under Israeli law.14 In speaking with lawyers and representatives of the Israeli Ministry of Health, this notion of the ‘Right of Return’ of embryos was something mentioned and raised by my interviewees themselves. They spoke in this fashion because of a court injunction preventing the import of ova from Romania where lawyers took the approach of the right to ‘return’ embryos to their commissioning couples (this case took place in the months just prior to my research at Zer’s clinic and was already resolved at the time of my speaking with Dr Zer). It was legally decided in this case that embryos did not indeed constitute persons. Yet somehow the language of the case against him must have ‘stuck’. The embryos are, on the one hand, labelled by Zer as belonging to the commissioning ova recipients, and, on the other hand, to the nation. In part, this facility to speak about embryos as having or lacking a ‘right of return’ also makes it possible to speak of them as being, at least symbolically, a ‘baby’. This seems a unique instance in the global scene of IVF in which the legal system and doctors discuss and adjudicate citizenship based on rights of return to biogenetic substance. Whilst we have seen in other contexts such as Egypt the negotiation of religious acceptability of such substance, the Israeli state’s unique citizenship laws make it stand out. Here it is also about acceptable future citizens. But let us return now to the other dimension of ‘embryos are our baby’, namely that the clinic specializes in embryos. Indeed, the ‘embryo method’ is their attempt at a ‘brand’.

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The ‘Embryo Method’

Figure 8.2. UFC Company Logo (by permission) This is the UFC company logo. A faintly purple cloud of an embryo floats inside a purple sphere, encircled by two white, elliptical lines. It indicates the global aspirations of the company, its association with high-tech futuristic thinking and the centrality of embryos to its practice. This logo is found on all company letterhead and on office doors in the five Israeli branches as well as in the Romanian ova-extraction clinic. It may be an attempt to ‘brand’ the company, to create an immediately recognizable mark that will be associated with the company, such as the Nike ‘swish’ or McDonald’s golden arches. Whilst at the time of my research this was primarily an Israeli company, it is now a US-based corporation, with clinics in Latvia as well as Israel and Romania, and was at one point providing ova to a London-based IVF clinic. Its global aspirations are being realized. Perhaps the logo has performed the collapse between sign and referent that is hoped for in the production of brands (Haraway 1997: 74). In this ‘creation of a logo … which condenses a whole history of advertising … the object is ... brought into focus in relation to the logo; its properties reconstituted as effects of the brand’s repetition’ (Lury 2000: 167). This may be seen even more potently in another dimension of this brand, the product name. Accompanying this logo, in clinic brochures is the repeated phrase ‘the embryo method’. Initially, I was perplexed by this phrase and did not know to what it referred. The glossy brochure states:

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Based on the unique treatment approach of ‘the embryo method’, which guides the practices of the UFC, there’s a solution for those hurdles that are well known to any couple who has experienced fertility treatments. The centre functions in a comfortable, discreet, family atmosphere, with much attention to explanation and personal attention … The treatment will be matched to your needs in a manner that will not affect your daily routine and your work. … In case it is necessary, you will be referred to the clinic’s psychologist to receive emotional aid, support and professional advice.15 The text of this brochure indicates that, whereas IVF in other clinics may be cold and unwelcoming, this clinic is ‘like your family’. It invites couples to put their trust in the staff and their technologically facilitated expertise. These treatments are said to be tailored to an individual’s needs and routines, whereas it is contended that IVF as practiced in other places disrupts work life and does not meet the needs of the individual. The clinic seems to be presenting itself in vast contrast to the militarized medicine image (Ivry 1999) of the state-run hospitals, foregrounding its rigorous service that can only be derived from personal treatment and an ‘expert system’ such as the ‘embryo method’. When, after reading this brochure, I asked the secretaries and nurses to explain what the ‘embryo method’ is, they did not know. Orit, the head manager, told me that the term ‘embryo method’ referred to the ‘entire system’ that is focused on the embryo.

An Optimistic Medical Entrepreneur’s Perspective Dr Zer contrasted his clinic to state-run clinics stating that at state-run hospitals women must have various tests conducted, both in the hospital and at their own sick fund clinic,16 and must be very active in getting test results and pursuing treatment. He claims that his clinic makes things easier for ova donation patients by ‘provid[ing] all the treatments under one roof’. Dr Zer explains, ‘she does not need to chase after forms and results, because the UFC does it all at their ‘satellite’ clinics’ (my emphasis). The account that Dr Zer provided me of his clinic is one of ease and efficiency. He positioned his patients as consumers with a right to convenient treatment. This is a model of privatized medicine that complicates our understandings of the relationship between the Israeli state, nation and the individual body. In the excerpt below, ease, speed and affordability are modes of engendering hope in the success of transnational egg donation. The specificity of this is crucial. Dr Zer mixed religious references with allusions to national goals of the state. His account below combines ideas about class, and the economics of IVF and ova donation with ideas about selection of donors, their ‘availability’ and cultural ideas about phenotype.

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His economy of ova donation is not solely consumerist. Rather, the claims he makes about his motivation in performing ova donation combine a consumerist model with references to aspects of Zionism such as: struggle, selection and the right of return. In this sense he is imagining egg donation through metaphors of the nation. As we drove from one of his clinics in the south back to his central clinic, Dr Zer gave me his version of why this is the case: Now the main factors for this are the availability of willing donors plus the wide selection. Instead of being limited to one donor every now and then, I can recruit donors, sort them and decide ‘this one yes, this one no’ based on things which are very significant, like genetic diseases in the family, age (since we know that the chance for success depends on age). The younger the egg,17 the higher the chances of achieving a pregnancy with it.18 Whereas in other clinics people undergo ten, twenty rounds, I give them one or maybe two rounds and achieve a pregnancy. Plus (we have) the ability to match (appearance-wise) the donor and the recipient. And we see the results. And we see that the children who are born look a lot like the people who bear them. The idea that Dr Zer can recruit ‘willing donors’ – a ‘wide selection’ – indicates that a privatized, consumerist model of ova donation is operating there, similar to that in other places such as the USA. Yet the coupling of this model with references to the religious and national specificities of Israel makes his description of his clinic distinctive. On another occasion, while driving with Dr Zer from one of the other branch clinics, we spoke again about his business. He told me that initially he did not consider his business to be an ‘egg donation enterprise’. Yet the clinic’s glossy brochure materializes this consumerist model. In his explanation, Dr Zer alludes to the effectiveness of his ‘embryo method’. He does so through the language of expertise and through reference to ‘state-of the art’ equipment. Yet, both modes of explanation shift the focus away from the effectiveness of treatment towards intended effectiveness. This is done by an emphasis on the tools for achieving pregnancy rather than on the actual results of ‘take home babies’. The focus on the techniques and tools rather than the results indicates that the important aspect of the process for Dr Zer at least is his intention to assist. The focus is on progress through scientific assistance (cf. Franklin 1997), which is obvious from his use of phrases such as ‘state of the art’. This ‘positive assessment of natural science in the service of the natural family’ (Franklin 1997: 93) and in this case, the national family as well, effaces the actual results of IVF with ova donation. Again we have an example of the clinic’s notion that embryos are their ‘baby’. The contrast between relatively low success rates cited earlier and Zer’s description are compelling, indicating as they do some ways in which hope

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is mobilized in the service of private medicine. His description and history of the clinic is one ethnographic site that makes this explicit. He echoes and extends some of the promises made in the brochure. The company brand of the ‘embryo method’ encourages putting hope both in the embryo itself and in the highly technical practices of IVF. The processes of getting sperm, freezing sperm, thawing sperm, getting eggs, combining them with sperm, re-freezing them and returning them to Israel are full of moments where things can go wrong, require additional tests, overseeing by practitioners and recipients’ and donors’ obedient participation in injection and hormone intake. The fact that the company brochure refers to these practices as the ‘embryo method’ is a way of simplifying and condensing the procedures into a product that consumers can buy. The idea of the ‘embryo method’ obscures the likelihood that these procedures will fail. If the patient focuses on the promise of efficiency then the extremely low success rates of IVF with ova donation becomes obscured.

Choice, Variety and the Hope for Donor/Embryo/Child Traits One particularly noteworthy aspect of the ‘embryo method’ is the way it promotes the neo-liberal sense of ‘choice’. It has been argued that the notion of ‘choice’ operates in a problematic way in IVF, existing as it does in a neo-liberal era of the ease of choice, which reproduces market-driven assisted reproductive practices (McNeil et al. 1990; Strathern 1992). Indeed in some cases women can be almost coerced into going for IVF because they feel they have ‘no choice’ (Franklin 1997). In Israel the very proliferation of choice indicates the rapidly increasing consumer culture – sometimes enabled by the way the Israeli market has shifted and sometimes constrained by Jewish religious or cultural factors (Carmeli and Applebaum 2004). So, for example, many couples are not able to choose to marry outside the religious system but instead choose to fly to places such as Cyprus to have civil ceremonies. As well, abortions are not encouraged for Jewish women especially, except in cases where foetal anomaly is found in screening (Weiss 1994). Whilst it is tempting to view the flows of people and bodies across borders as free and unfettered, it is my contention here that in imaginaries of Israeliness in egg donation, the borders of national bodies are only semi-porous. Whilst a sense of cosmopolitanism is espoused in Israel, this is limited to consumption of food, art, travel and popular culture. What can ‘safely’ be incorporated into the Jewish Israeli body as acceptable is very particular. It is important to see that the desire for a child has a racialized geography, in the sense that desired ova travel to Israel from Europe. Romanian donors were seen as perfectly acceptable to most ova recipients in Israel. When I spoke to Dr Zer about this acceptability, he said,

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Look, in Romania the population is very similar to the Israeli one. There are dark ones, there are blonde ones, there are black ones. There’s everything you want. Don’t forget that there were two large waves of immigration (to Israel) from there, one of which was from Romania … so the population of Israel, not the ones who have recently arrived, and the population there are very similar. However, the main reason for going to Romania was the availability. To get eggs and not keep a 49-year-old woman waiting for five years.19 Three months’ wait and she has good quality eggs from which she can become pregnant. Ethnicity, nationalism, immigration and availability are brought together here. The availability of Romanian women as an inexpensive, young and racially desirable resource is the promise offered by the ‘embryo method’. Despite the model of privatized medicine as global at this clinic, the reproduction of Israelis and consequently of the Jewish nation is still what is implied here. A Europeanized Jewish body is envisioned as the ideal. This is best exemplified in the ‘Preferred External Features’ form. After their initial ‘intake’ meeting, ova recipients are asked to fill out a form labelled, ‘Preferred External Features’ (See Figure 8.3). I analysed thirty-two of these forms. This form enlists patients as ‘choosing subjects’. Through choosing traits of donors, ova recipients imagine what their hoped-for donor might be and what kind of baby they would like. I found that 26 out of 32 (81 per cent) women preferred light-skinned donors; 11 out of 32 (34 per cent) preferred brown hair, 4 out of 32 (12.5 per cent) preferred blonde hair, 10 out of 32 (31 per cent) preferred blue/green eyes, and 6 out of 32 (19 per cent) preferred brown eyes. These numbers and percentages would be meaningless if intended to be representative. However, they are indicative of how people imagine their egg donor, their intended baby and their commissioned embryos. (See Nahman 2006 for an analysis of comments patients wrote at the bottom of these forms.) The selections indicate the desire for light skin; this is the main distinguishing aspect of people’s selections. This can be seen as a desire for ‘whiteness’, the idealized appearance in the West (Dyer 2000, Frankenburg 2000). In the Israeli case, such a desire links very strongly with the ways in which Ashkenaziness (or European Jewishness) still dominates as a site for cultural emulation. A long documented fact in Israeli society is the way in which non-Ashkenazim were treated as more primitive, requiring civilising, and are discriminated against in Israeli society. The cultural roots of contemporary Zionism as a political movement emerging from Europe and driven by Europeans must not be forgotten here. These facts clearly influence the choices of individuals on the preferred external features form. As well as showing a preponderance of desire for whiteness (and this is a much more lengthy discussion I enter into in Nahman 2006) the documents I

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analysed are a technology of the clinic. The ‘preferred external features’ form seems to elicit ‘hope’ from the recipients. It asks them to project their expectation for a baby into the delineation of physical types for would-be donors, linked to particular phenotypic traits such as hair colour and height. The form, in effect, asks recipients to imagine that traits can be selected, and requires that they believe that such traits can actually be chosen. The percentages cited above are only indications that the clients of this clinic believed in the technology of the form; that it would get them what they desired.

Company logo Photo of Recipient Preferred External Features Mark an X next to the donor features you prefer Date: Name of Patient: Skin colour: light

Brownish

Dark

Very Dark

Height: 1.6

1.7

1.8

Hair Colour: Blonde

Brown

Black

Ginger

Eyes: Blue/green Brown

Dark

Comments:

Company name and contact details Figure 8.3. Preferred External Features Form (author’s translation from Hebrew)

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The head of the clinic, Orit, conveyed to me the idea that there is some sort of systematic pairing of recipient choices with donor traits. At our very first meeting, Orit told me: ‘The eggs at this clinic are brought in from a clinic in Romania [where] they are matched according to eye colour, hair, body structure, height, skin colour … we meshadchim20 between them and the recipients’. It seems that the clinic’s staff collect the forms and enter the details therein into a computer spreadsheet program, and then the forms are put away in a filing cabinet. In practice, however, the clinic does not seem to follow up on the ‘choices’ made by recipients. There is no systematic matching of recipients’ choices with donor traits either in Israel or at the clinic in Romania where the ova are fertilized, or at least I did not observe any kind of ‘matching’. An embryologist at the clinic told me that Nachum, the chief embryologist, matches the donor traits with the preferences expressed by couples. A few weeks later I spoke with Nachum and asked him how this ‘matching’ is done. He replied, ‘what matching? There’s nothing like that!’ A few months later when I went to the clinic in Romania where ova are donated I noticed that Nachum would list donor eye and hair colour in a spreadsheet program on a computer in the laboratory. I asked him again about matching and he did not change his answer. On one occasion as I watched data being entered, after having seen the donor myself, I noticed incorrect eye and/or hair colour being entered into the database. The fact that no one actually matches recipients’ requests with donor traits makes it even more apparent that the ‘preferred external features’ form is a technology of engendering hope. It telescopes donors into ‘donor traits’ on the preferred external features form, and again condenses embryos, traits and donors with imagined babies. This seems to be a common practice of both ova donation and sperm donation in other systems of privatized medicine (Birenbaum-Carmeli and Carmeli 2002). The process of ‘selection’ is interesting as it provides a different sort of narrative about biological reproduction of traits to the typical scientific one, which is about the complex biogenetic processes that determine physical features in people. The discourse here gives a sense that it is indeed possible to ‘choose’ a blue-eyed baby, with an expected height of 1.7 metres. It allows people to invest their hopes in science’s ‘ability’ to ‘know’ what will happen. These forms enact ‘new assemblages’ (Rabinow 1999) of Israeliness, by bringing together consumer choice, national bodies with transnational reproduction. By reinscribing desirability for particular phenotypic features they also perform ‘old assemblages’ of Israeliness (by this I am referring to the State of Israel’s history of exclusion, racism and the reproduction of whiteness, see Nahman 2006). While the ‘national’ is literally reproduced through ‘transnational’ exchanges of ova, the ‘national’ is also reproduced as Ashkenazi.

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Conclusion While ova donation at this clinic is practised through a global market of egg donation, some aspects of the ‘local’ are materialized through this very transnational trade. The practices and self-representations of the clinic materialize aspects of ‘the national’ that are both ‘old’, in the sense that they resonate with Zionism’s ideals of the ‘ingathering of exiles’, multiculturalism, racism, relatedness and religion; and ‘new’ in the sense that they involve privatization, neo-liberalism and consumerism. The possibility of selecting desired traits also turns individuals who are considered ‘illegitimate’ subjects, by virtue of their inability to have children, into legitimate subjects. The abridgement of embryo and baby in the phrase ‘embryos are our baby’ may also be one discursive node through which a sense of ‘chosenness’ is symbolically imparted to ova recipients in Israel. Since embryos may literally be the only offspring that recipient couples will have, the abridgement of embryos and babies may enable the recipients to become legitimate reproductive subjects. The clinic’s wall poster, ‘embryos are our baby’ presents the promise of redemption of the ‘unchosen’ body through a project of transnational trade and consumption. Recipients are encouraged to regain what they apparently lack in terms of the national idealized self and body (the ability to be parents and therefore proper ‘chosen’ citizens), through a consumer imaginary, whereby appropriate citizenship can be bought in the form of embryos. This is the ultimate ‘retail therapy’. This condensing, in imagery and practice, shifts attention away from the effectiveness of scientific technique towards intended effectiveness. In terms of its local significance, this example indicates how the privatization of Israeli medicine facilitates a global assemblage of nations, bodies and science (Ong and Collier 2005). This assemblage, of ‘embryos are our baby’, ‘the embryo method’ and the preferred external features form, mixes Zionism with hope and consumerism. It is a kind of messianic consumer economy that offers the ‘promise’ of a child, while glossing over the details of how the child is actually made. The synecdochal resonances in this account, between reproduction of individual bodies and reproduction of nation-states, are potent.21

Notes 1.

2.

Biosociality is a complex concept to sum up, and indeed an entire volume has been devoted to exploring this multilayered approach to studying the relationship between people, nature, knowledge, science and governance (Gibbon and Novas 2007). I use the term diaspora here instead of identity in order to invoke Avtar Brah’s (1993) sense of diasporic spaces, a much broader concept that encapsulates

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5. 6.

7. 8.

9.

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11. 12.

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histories, movement, politicized ethnic identification and relationships to the state. In the analytical move towards diaspora in this moment it is hoped that there will be a momentary and partial undoing of racialization of the diasporas mentioned. A contradiction here is the fact that these supposedly second-class citizens are being supported in many ways by the state through free IVF, and that even single women have such access to free IVF (Kahn 2000). This indicates that perhaps something more complicated is going on between non-reproductive bodies, the demographic crisis and IVF funding in Israel. I hedge this with the word ‘some’ because there were many instances in the clinic where people were excluded or treated differently due to their being perceived as ‘different’ (‘Arabs’, ‘Ethiopians’, ‘Bedouins’). This could be extended to other arenas and markets, as well as other contexts of reproductive technologies. This work draws on a four-year study, funded by the Wenner-Gren Foundation for Anthropological Research, of Israeli reproductive technologies in private, public and Romanian clinics. Ethnographic research was conducted in laboratories and clinics in all of these locales. Images and narratives about ovum extraction and donor choice were collected and analysed using anthropological, feminist, sociological and science studies approaches. This is a pseudonym. Single women are clearly eligible for IVF, but it is generally imagined in Israel in strictly heteronormative terms as indicated here by the physician’s allusion to ‘couples’ rather than some other less restrictive formulation. Benjamin was arguing about the importance of an historical materialist approach to understanding the state in which ‘the oppressed’ live. He was arguing that ‘salvation’ for the oppressed would only come through resistance. A study by the Medical Facilities and Equipment Licensing Division of the Israeli Ministry of Health found that in 1999 there were 16,536 IVF treatment cycles. Of these, 14,933 continued to the embryo transfer stage. This resulted in 4,051 pregnancies, 2,468 deliveries and 3,190 live births (the number of births is greater than the number of deliveries due to the high incidence of multiple births with IVF treatment). The percentage of pregnancies per treatment cycle is thus 24.5 per cent, and the percentage of deliveries per treatment cycles is 15.9 per cent. Interviews with various IVF physicians have indicated that the rates of live births with ova donation is significantly lower than this. ‘La’aretz’ is a colloquial formulation which literally means ‘to the Land’, and is the everyday reference to the Land of Israel. This right, conferred to all Jews by the State of Israel, to ‘ascend’ to Israel was one of the early legal measures put into place by the state to promote the Jewish demographics of Israel. It is viewed as a ‘natural’ right by many Jews around the world. Imagining that Jews were already there and that it is just a matter of them coming back is a central tenet of Israeli nationalism that obscures the colonial nature of the formation of the state. It is for this reason as well that in Israelis debates on embryonic stem cells research that embryos are not referred to as needing to have their ‘human dignity’ preserved, as is the case in some parts of Europe (Revel 2002).

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15. At the time there was no psychologist employed by the clinic. I was told by the head manager that this was due to relatively low uptake of psychologists’ services. Indeed I found this to be a claim in other clinics as well, which nevertheless set up well-attended group therapy sessions. 16. Each of the national sick funds runs their own clinics with services provided by physicians who work for that particular sick fund. Medication provided is specific to what that sick fund is willing to endorse and can afford based on their own cost-benefit analyses. 17. Note his slippage between donor and egg. 18. The age of the mother, the woman who will gestate and raise the child is erased in this formulation. 19. Dr Zer naturalizes the age of the woman waiting for the eggs as though it were not unusual for a woman aged forty-nine to bear a child. 20. By this she means donors and recipients are matched. The specific word she used is interesting. It comes from the word shidooch which means match-making, and is mostly used in the context of the traditional and contemporary practices of bringing together men and women for the purpose of marriage. This is a contractual relationship set up by a broker who is referred to as a shadchan, a match-maker. This clinic represents itself very much as a place where donor and recipient are individually matched. In this sense they represent themselves as egg brokers. 21. I develop the idea of synecdoche further in Nahman (2007).

References Alcalay, A. 1993. After Jews and Arabs: Remaking Levantine Culture. Minneapolis: University of Minnesota Press. Almog, O. 2000. The Sabra: The Making of the New Jew. Berkerley: University of California Press. Anderson, B. 1991. Imagined Communities. London: Verso. Appadurai, A. 1991. ‘Global Ethnoscapes: Notes and Queries for a Transnational Anthropology’, in R. Fox (ed.), Recapturing Anthropology: Working in the Present. Santa Fe: School of American Research Press, pp. 191–210. ———. 1996. Modernity at Large: Cultural Dimensions of Globalization. Minnesota: University of Minnesota Press. ———. 2002. ‘Disjuncture and Difference in Global Cultural Economy’, in J.X. Inda and R. Rosaldo (eds), The Anthropology of Globalization: A Reader. Oxford: Blackwell, pp. 46–63. Auerbach, E. 1957. Mimesis: The Representation of Reality in Western Literature. Princeton: Princeton University Press. Avraham, E. and A. First. 2003. ‘“I Buy American”: The American Image as Reflected in Israeli Advertising’, Journal of Communication 53: 282–99. Becker, G. 2000. The Elusive Embryo: How Women and Men Approach New Reproductive Technologies. Berkeley: University of California Press. Benjamin, W. 1973. ‘Theses on the Philosophy of History’, in H. Arendt (ed.), Illuminations. London: Fontana.

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Kahn, S.M. 2000. Reproducing Jews: A Cultural Account of Assisted Conception in Israel. Durham, NC: Duke University Press. Kanaaneh, R. 2002. Birthing the Nation: Strategies of Palestinian Women in Israel. Berkeley: University of California Press. Lavie, S. 1996. ‘Blowups in the Borderzones: Third World Israeli Authors’ Gropings for Home’, in S. Lavie and T. Swedenburg (eds), Displacement, Diaspora and Geographies of Identity. Durham, NC: Duke University Press, pp. 55–96. Liebes, T. 2003. American Dreams, Hebrew Subtitles: Globalization from the Receiving End. Cresskill, NJ: Hampton Press. Lury, C. 2000 ‘The United Colours of Diversity: Essential and Inessential Culture’, in S. Franklin, C. Lury and J. Stacey, Global Nature, Global Culture. London: Sage Publications, pp. 146–87. McNeil, M., I. Varcoe and S. Yearley. 1990. The New Reproductive Technologies. New York: St Martin’s Press. Nahman, M. 2005. ‘Israeli Extraction: An Ethnographic Study of Ova Donation and National Imaginaries’. Ph.D. dissertation, Lancaster University. ———. 2006. ‘Materialising Israeliness: Difference and Mixture in Transnational Ova Donation’, Science as Culture 15(3): 199–213. ———. 2007. ‘Synecdochic Ricochets: Biosocialities in a Jerusalem IVF Clinic’, in S. Gibbon and C. Novas (eds), Biosocialities, Genetics and the Social Sciences: Making Biologies and Identities. London: Routledge. ———. 2008. ‘Nodes of Desire: Transnational Egg Sellers as Theorists of Reproduction in a Neo-liberal Age’, European Journal of Women’s Studies. 15: 2 Nitzan, J. and S. Bichler. 2002. The Global Political Economy of Israel. London: Pluto Press. Novas, C. and N. Rose. 2000. ‘Genetic Risk and the Birth of the Somatic Individual’, Economy and Society 29(4): 485–513. Ong, A. 1999. Flexible Citizenship: The Cultural Logics of Transnationality. Durham: Duke University Press. Ong, A. and S.J. Collier. 2005. Global Assemblages: Technology, Politics and Ethics as Anthropological Problems. London: Blackwell. Paxton, R. 2004. The Anatomy of Fascism. London: Penguin. Peled, Y. 2004. ‘Profits or Glory’, New Left Review 29: 47–72. Portugese, J. 1998. Fertility Policy in Israel: The Politics of Religion, Gender, and Nation. London: Praeger. Rabinow, P. 1995. ‘Artificiality and Enlightenment: From Sociobiology to Biosociality’, in Essays in the Anthropology of Reason. New Jersey: Princeton University Press, pp. 91–111. ———. 1999. French DNA: Trouble in Purgatory. Chicago: University of Chicago Press. Revel, M. 2002. ‘The Use of Embryonic Stem Cells for Therapeutic Research’, Report of the Bioethics Advisory Committee, The Israel Academy of Sciences and Humanities. www.weizmann.ac.il/bioethics/myframeset. html?http&&&stwww.weizmann.ac.il/bioethics/s1.html (accessed 24 February 2004). Scheper-Hughes, N. 2002. ‘The Ends of the Body: Commodity Fetishism and the Global Traffic in Organs’, SAIS Review: A Journal of International Affairs 22 (1): 61–80. Shohat, E. 1989. Israeli Cinema: East/West and the Politics of Representation. Austin: University of Texas Press.

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Strathern, M. 1992. Reproducing the Future Essays on Anthropology, Kinship and the New Reproductive Technologies. Manchester: Manchester University Press. Teman, E. 2003. ‘The Medicalization of “Nature” in the “Artificial Body”: Surrogate Motherhood in Israel’, Medical Anthropology Quarterly 17(1): 78–98. Thompson, C. 2005. Making Parents: The Ontological Choreography of Reproductive Technologies. Cambridge: MIT Press. Throsby, K. 2004. When IVF Fails: Feminism, Infertility and the Negotiation of Normality. London: Palgrave Macmillan. Weiss M. 1994. Conditional Love: Parents’ Attitudes Toward Handicapped Children. Westport, CT: Bergin and Garvey. ———. 2002. The Chosen Body: The Politics of the Body in Israeli Society. Stanford: Stanford University Press. Wimmer, A. and N. Glick-Schiller. 2002. ‘Methodological Nationalism and Beyond: Nation-state Building, Migration and the Social Sciences’, Global Networks 2(4): 301–34. Yuval-Davis, N. 1989. ‘National Reproduction and the “Demographic Race” in Israel’, in N. Yuval-Davis and F. Anthias (eds), Woman-Nation-State. London: MacMillan Press, pp. 92–109. ———. 1997. Gender and Nation. London: Sage Publications.

CHAPTER 9 Living Differently in Time: Plasticity, Temporality and Cellular Biotechnologies Hannah Landecker

The plant and microbial worlds have long been targets for discovery of therapeutic drugs, but insects have been left virtually untouched … Among the substances found in insects are molecules that kill cancer cells, proteins that prevent blood from clotting, enzymes that degrade pesticides, proteins that glow in the dark, anti-microbial peptides and toxins. Cauchi 2002 Interest in biotechnology has been increasing in the humanities and social sciences, causing a proliferation of specific case studies of individual technologies or particular processes. This article offers ways to supplement these studies, identifying genres of technique common to biotechnological objects of disparate kinds, opening up avenues for research not organized by species (especially the human one) or a particular object. What is biotechnology, not as a scientific and technical field but as a field of social scientific or critical cultural inquiry? Different studies of diverse biotechnologies or biomedical developments are often linked by the theoretical claim that they are all contributing to an analysis of biopolitics, the movement of ‘life’ to the centre of contemporary political and capitalist processes. One difficulty with this Foucauldian use of ‘life’ is that it derives from an archaeology of nineteenth-century sciences, not twentieth-century ones. However acute Foucault was in elucidating the history of his present, that history for our present is as emergent as the sciences we are trying to

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study (Fischer 2004). Thus, an archaeology of twentieth-century sciences specific to the conditions of possibility operating in today’s research settings is a necessary complement to studies of the contemporary moment. Of course, life science in the twentieth century is a much different body of discourse and practice, of a much different scale than that analysed by Foucault; the very tools of such an endeavour require elaboration. What I suggest below is that contemporary studies of cellular technologies can be productively reconfigured by attention to their practical, material genealogies. This can be demonstrated historically or ethnographically. Here I retell a now familiar story of the cloning of Dolly in utterly different terms than those usually given to it, and follow out the historical method ethnographically, asking questions of cell culturists about how cells are cared for and grown, exchanged and stored, pushed and prodded. The historical perspective shows how practices of cryobiology (freezing and thawing of living things) and cell synchrony (artificial manipulation of cycles of cell division) of the 1950s and 1960s were constitutive to the developments in cloning in the late 1990s. These powerful techniques themselves belong to a genre of experimentation directed at making cells live differently in time, in order to harness their productive or reproductive capacities. The ethnographic perspective shows how these long-standing genres of intervention in cellular plasticity and temporality are now moving from the background into the foreground of biochemistry and molecular biology, disciplines previously focused on knowledge of gene sequences and molecules in a more disembodied, atemporal fashion. These two perspectives show how the discoveries of one generation become sedimented in the protocols and biological commodities of the next, thus revealing some of the objects most in need of excavation as enabling conditions for contemporary events. In both cases, the methodological result of a focus on practice is an altered set of historical and anthropological frameworks for understanding how seemingly banal, technical, unheralded approaches to esoteric corners of the living world determine what is eventually done to and with human biological matter. Understandably, many scholars interested in biotechnology and human life are drawn to study things that are already manifestly ‘human’ in some way, such as human genetics or human tissues or animals transfected with human genes; these categories and objects are readily available and already delineated by the professional specializations and diagnostic categories necessary to biological and biomedical research. While biological work objects made of human biological materials trouble any human/non-human categorization for everyone, particularly those interested in actants not actors (Casper 1994), my aim here is to extend analysis into the realm of the relationship between humans and animals by explicitly not privileging human matter as a more interesting or primary object of research because of

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its derivation or its cultural status as controversial or meaningful. Recent research in anthropology and science studies on interspecies encounters and transspecies relationships throws such anthropocentrism into question (Haraway 2007). When the object of analysis is isomorphic with analytics used, writes anthropologist Eduardo Kohn, ‘we are not able to see the many ways in which people are, in fact, connected to a broader world of life and the ways in which this changes what it might mean to be human … An ethnographic focus not just on humans or only on animals but on how humans and animals interact explodes this closed self-referential circuit’ (Kohn 2007: 6). Technique-watching would suggest that a characteristic temporal feature of the structure of contemporary life sciences is that work with human matter usually comes late into the process of problematization and reorganization of approaches to living matter. Put bluntly, how we handle nematode matter or yeast matter may be more formative for what we do with and think about human matter than any particularity of human matter as human. Hence the epigraph above on insects, which may seem a strange way to open a paper about cells – it illustrates avid interest in the previously abject, worthless or arcane of the earth, interest that is increasingly characteristic of the human relationship to living matter occurring today under the sign of biotechnology. ‘A feeling for the organism’ updated for the early twenty-first century might well shift attention to this biotechnological touch, about to descend on insects (Keller 1983). If this evokes for the reader the Midas touch, good. But this is about more than gold – it is about the touch itself, which transmutes something into another condition – fragments buzzing, swarming, virtually untouched forms of life into molecules, proteins, enzymes, glow-in-the-dark proteins, peptides and toxins, and reconstitutes them into products, tools, machines, therapies, subjects and objects of research and knowledge and profit. It is not just that we are mining the living world for useable bees’ knees but that a human relationship to living matter – not to insects per se but to living matter more generally – is established and concretized in these practices of transformation. Biological matter derived from human bodies is a subset of all the biological matter that is out there in the world – it is, in the logic of the life sciences, not endowed with any particularly special qualities other than the usual species variations. The more we develop ways to use insects, the more we develop approaches to human materiality that are continuous with the way we use insects, and this goes for all kinds of obscure organisms: when we change insects, we change what it is to be biological. We are most likely to develop these approaches prior to, or at least in concert with, using human things. Another way to put this is that the usual formula, ‘biotechnology changes what it is to be human’, should have an interim step included in it: ‘biotechnology changes what it is to be biological’. This interim step, I would

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suggest, is key to understanding the specificity ‘life’ after biotechnology rather than ‘life’ after nineteenth-century physiology. Although an archaeology of the twentieth-century life sciences is of course an enormous project, the focus here is on the development of the practice of tissue culture, as one thread crucial to understanding contemporary cellular biotechnologies. Tissue or cell culture is the practice of growing living cells of complex organisms outside of the body, often referred to as the in vitro culture of cells. Cells in this form are maintained continuously as indefinitely self-reproducing populations (called cell lines) as long as they are incubated and kept in nutrient media, or frozen at cold enough temperatures. It is a technique that first emerged around 1907, when the cell was a central object of inquiry in biology, physiology, embryology and even psychology (Landecker 2002, 2004; Schloegel and Schmidgen 2002). With the reemergence of the cell as ‘a central unit of action, temporally and spatially as well as functionally’ in biological research, tissue culture techniques take on renewed contemporary salience as the basis for the manipulation of complex living cells in the laboratory, from their maintenance and self-reproduction as substrates for engineered tissues, to their role as producers of useful molecules (Franklin and Lock 2003: 13). The examples that follow articulate the structure of that renewed salience, reconnecting apparently new objects such as cloned animals or embryonic stem cells to the conditions of their emergence.

Part 1. Before There Was Dolly There Was Frostie: Cell Synchrony and Cryobiology in the History of Cloning As observers of life science, we are constantly given highly visible, readymade categories of the relevance of biotechnology to the human by the burgeoning science popularization industry and the rhetorical underpinnings of funding structures in contemporary life science: health and homology. New biological findings in any organism are seen as significant to human life, even revolutionary, because they (a) introduce a new therapeutic product, which affects humans by changing their health possibilities or longevity, and/or (b) suggest that the same is true of human beings and bodies. The latter homology narratives affect people not by giving them something new to ingest but by changing their understanding of human nature via shared evolutionary history and structural or functional homology with other organisms. This implies the possibility of new processes or information being the same in human bodies. However, there are less obvious ways in which manipulation of mouse or chicken matter may become relevant to, or formative for, humans and human matter. These modes of relevance include genres of experiment and material

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infrastructures for exchanging and storing living matter. Sometimes the freezer matters more than the species, or the medium more than the type of cell cultured in it, in events that become important to how human life is thought about or acted upon. The now well-rehearsed set of conversations around the cloning of adult organisms in the late 1990s is a case in point. As Sarah Franklin has noted, the event that was Dolly has ironically produced an incredible proliferation of sameness in terms of responses about the so-called ethical or cultural aspects of cloning (Franklin 2003, 2007). Will parents clone their deceased children? Will adult nuclear donors be the twin-parent-ogre of nuclear recipients’ lives? Where will all those enucleated eggs come from, anyway? Because it raised these questions, cloning was cited as evidence of the thunderbolt of the new power of biotechnology hitting human existence at its core, helped along in no small measure by pronouncements by the scientists themselves of this experiment as ‘The Second Creation’ and so on. But what if we refuse the pressure, and do not make the leap directly from nuclear transfer to human nature? I suggest this event be read not as one which foreshadows the ability to clone humans or even clone human organs or even clone transgenic sheep producing human blood clotting factor in their milk. Rather, it is a tale of cell science and its attendant manipulations, which alters what it is to be made of cellular biological matter – a change which is very much still pertinent to the present and the imminent future. We have heard much about this experiment as the unprecedented creation of a new individual from the nucleus of an adult cell, proving that differentiation and perhaps ageing are not final, and the scientific and economic possibility of creating more identical organisms from individual, adult organisms. But these are not mandatory as terms of discussion, just because they are prevalent.1 Instead, cloning adult organisms may be retold as a tale of cryobiology and cell synchrony. Cryobiology is the science of freezing living things such that they are still alive when thawed. It is standard practice these days to freeze microbes, cells and embryos for later use. And how does one synchronize cells? This refers to the practice of forcing each individual cell in a population of cells that are growing in a culture dish to go through the stages of the cell cycle – growth, DNA synthesis and cell division – at the same time, something they would not do unless you deprived the cells of growth factors or subjected them to various other insults. If you deprive a whole population of some nutrient required for a stage of the cell cycle, they will all stop at that point, and then adding the withheld substance will cause them all to divide simultaneously, on cue. In 1949, Chris Polge and his colleagues at the National Institute for Medical Research in England somewhat accidentally discovered that when glycerol protected sperm was cooled slowly to below freezing, the result was that the sperm was still alive after thawing again. This spurred a flurry of

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research into adding things to the cellular medium as they froze, and before the 1950s were out, red blood cells, ovarian tissue, sperm and cell cultures were being frozen and thawed alive successfully. This was a boon to the agricultural artificial insemination business, as it would be later to reproductive biology more generally (Pegg 2002; Parry 2004). The ability to suspend and transport frozen cells meant much greater spatial and temporal flexibility for disembodied living cells.2 This was true also for the wider community of biologists using cell culture, since cell lines could be grown up, frozen, shipped, banked at a central location, referred to later, and preserved unchanged. The central storage of cell lines at the American Type Culture Collection, for example, dates from the early sixties. To keep large numbers of cell lines going by continuous culture, without outside contamination, over decades, was an unsupportable task; the freezer therefore acts as a central mechanism both within individual laboratories or companies and within the biological research community more generally to stabilize and standardize living research objects which are by their nature in constant flux. Freezing looped the line in lineage, making two of its points cross for sideby-side comparison. Peter Medawar wrote in 1952 that his principal object in studying the frozen storage of skin was to use it in experiments that would not otherwise be possible, such as the making of an ‘age chimaera’, by grafting tissue from a young animal ‘to its own self when it has grown older. Such an age chimaera (an organism whose parts are the same genetical constitution but of different developmental ages) can be realized by the appropriate use of storage methods’ (Billingham and Medawar 1952: 466). Freezing thus suggested modes of previously impossible comparison of different points on the same arc of biological time, in the same individual. Whether this ‘individual’ was an organism or a cell line or strain, one could put the older and the younger selves together in the same experimental moment. In 1983, embryologist Ian Wilmut was involved in work that produced the first healthy calf raised from a frozen embryo. Now famous for his leading role in the cloning of Dolly announced in 1997, Wilmut was a decidedly unknown biologist in 1983. In retrospect, Frostie garnered ever so little media attention, but may nonetheless be understood as continuous both with explorations of freezing in the 1950s and the more famous cloning experiments of recent years in two ways: at the level of material practice, due to the role that freezing plays, and at the level of something like genre – a genre of experiment directed at the controlled stopping and starting of biological time. In the case of the experiment that led to Dolly, tissue from the udder of a pregnant ewe that had been frozen since 1995 was thawed, cultured – which means the cells were plated on a petri dish and bathed in nutrient medium so they would start dividing again – and then used as ‘nuclear donors’.

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That the cells had been frozen for a few years was not significant to the main point of the experiment: the demonstration that the nucleus of an adult differentiated cell could be used to clone a whole new individual. But how, once Dolly had been born and was conveniently continuing to live despite the many insults visited upon her originating cells, could they actually tell that she was ‘genetically identical’ to the adult ewe from which the transferred nucleus had come, since that ewe was long dead? Well, the scientists went back to the freezer and got out another piece of the tissue they had used to start the cultures of nuclear donor cells. All this screwy generationality, the novel simultaneities, the gaps of time between death of one generation and birth of another with a suspension of continuity between them, all of these deeply unsettling temporal disruptions depend to some degree on the rather banal presence of a working deep freeze. But only banal because it has become so incredibly commonplace, where it was not fifty years before. Thus the story of making a cloned sheep has elements not just of suggestion for the possibility of cloning humans but of the conditions of its own possibility: the ability to freeze, halt or suspend life, and reanimate, as an infrastructural element of contemporary biotechnology. In short, to be biological, alive, cellular, also means (at present) to be a potential ‘age chimaera’, to be suspendable, interruptible, storable, freezable in parts. Cell synchrony similarly alters biological temporality. Cell synchrony was noted in dividing marine eggs for more than a century. The fertilized egg divides into two, and then the two cells both divide simultaneously to make four cells, and then the four cells also divide simultaneously to make eight, until a certain level of multicellularity is reached and the cells start dividing at different rates. In the 1950s, scientists working with simple single-cell organisms such as microbes and amoebae realized that a similar synchronization of division in all the cells in a population could be artificially induced by exposing the cultures to cycles of light and dark or raising or lowering the temperature sharply. In the early 1950s the significance of periodic DNA synthesis was of unclear significance. In a few short years, the movement of DNA to the centre of biologists’ attention as the hereditary material made understanding the process by which one cell became two with two sets of chromosomes a pressing task. Investigation of the cell cycle, as it came to be called, was the realization that cells were not just ‘resting’ between divisions as had been previously assumed but that the DNA in the cell was undergoing changes as the cell synthesized another copy of its chromosomes in preparation for division. These various steps are marked by biochemical changes – one could not investigate these changes in levels of enzymes or the increasing volume of DNA synthesis if all the cells in a test population were at different stages in the cell cycle. Furthermore, these things could not be measured in single cells, they had to be ‘amplified’ by making the same thing happen in

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lots of cells at once, so the molecules involved could be measured. Thus, ‘as an experimental technique, cell synchrony was developed primarily for the amplification of time-limited events within the cell cycle’ (Cameron and Padilla 1966: vii). The other major biologist in the cloning story, Keith Campbell, had for a good part of his career worked on cell cycle research in yeast and frogs, meaning that he was very good at the ‘amplification of time-limited events within the cell cycle’. He transferred this expertise to working with mammalian cells. Once the mammary gland cells had been thawed, they were cultured and synchronized by withholding growth factors from the culture medium. Thus the nuclei used as ‘donors’ to put in the enucleated eggs were taken from cells at a specific point in the cell cycle. Campbell and Wilmut claim that the age of the organism the cells came from – or the number of times the cells divided in culture – or the degree of differentiation of the cell – does not matter as much as catching the nucleus of the cell at this particular point in the cell cycle. It may not matter whether a donor cell comes from a young embryo, a foetus, or an adult animal, or whether it is cultured before transfer or not, or, if it is cultured, whether it goes through one passage or a dozen or more – that is, it may not matter as much as everyone anticipated. If you adjust the cell cycles of donor karyoplast and recipient cytoplast, you can produce viable reconstructed embryos from differentiated cells and perhaps, with better understanding and technique, from any kind of cell. (Wilmut et al. 2000: 105) They also manipulated the enucleated egg. Before injecting the cycleadjusted nucleus the egg was put in calcium-free medium. An egg penetrated by a sperm is ‘activated’ – that is, induced to enter the series of steps in which the fertilized egg divides to become an embryo – by the accompanying inrush of calcium. Normally, therefore, puncturing the egg to remove its chromosomes and inject a nucleus will cause activation. Withholding calcium delays activation – allowing for the adjustment of the cell cycle of the ‘recipient cytoplast’. The scientist may thus manipulate the egg by adding or withholding calcium in the medium, and both the giving and the receiving cell are kept poised in certain temporal states amenable to the wanted outcome. In other words, not just the matter of the cells is manipulated, great effort is put into controlling how they live in time. Importantly, the scientists put as much emphasis on the technique as on its refutation of what everyone thought would matter. Wilmut et al. (2000) indicate that a choice has been made between an idea of the immovable intrinsic age of living matter (according to whether it comes from an adult or has been living in the laboratory for a long time), and an idea of biological

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time as a moveable quality. Assumption of the malleability of biological time is an attitude to living matter more likely to be found in individuals who have spent decades freezing and thawing, stopping and starting cell cycles than in other kinds of life scientists. By the time it was put to use in this particular experiment, cell synchrony had become a relatively familiar technique of cell biology, as had the idea that cells have cycles. As had the various technical aspects of getting cells to live outside of the body where they can be experimented on, and the media in which they live can be fully controlled. The authors themselves admit that like so many other events in science, the novel combination of existing techniques resulted in something startling to all. For my part, pointing out that the experiment was constituted by these techniques of cell culture and cryobiology and cell synchrony is not to say that the actual origin of their work lies elsewhere or that the experiment was not important. There is no need to argue the long-term significance of this event as its aftermath is still unfolding. However, in order to pull the terms of analysis away from claims to revolution due to this single development, it is necessary to diminish the particularity of this event – to see cloning as an extension of an infrastructure that has been in the making for the better part of a century. This diminishment of particularity is in turn an effort to speak to cloning’s significance as part of (and not the cause of) the ongoing operationalization of biological time – not just its suggestion of the possibility of doing the same procedure in humans. These practices, now standard in contemporary biology and biotechnology, are also standard in that they assume and exploit a certain plasticity of organisms. That is, the ability of living things to go on living, synthesizing proteins, moving, reproducing, and so on, despite catastrophic interference in their constitution, environment or form. The very ability to grow cells outside of bodies in artificial environments or on scaffolds, to puncture eggs and inject foreign things into them, to cut and paste genetic material and so on without killing the organism in question altogether, are also good examples of plasticity. Where would biotechnology be if, after being spliced or frozen or fused or extracted from its original environment, the cell or organism just up and died? In my view, the history of biotechnology from 1900 to now may be described as the increasing realization and exploration of the plasticity of living matter. The manipulation of the plastic matter of the organism is often, if not inevitably, linked to a disruption of temporality, whether that be of lifespan or continuity or smaller-scale cycles of growth and metabolism. Whether halting something in a certain state, for example inducing stem cells to remain in a state of continuous potentiality as if they were blastocysts for eternity, or driving something to completion like a transgenic salmon, material interventions result in things living differently in time.

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As a subset of this longer twentieth-century course of biotechnology, the cloning story makes it matter differently to be composed of cells and cell cycles. Being a cellular entity after cryobiology and cell synchrony means being freezable and open to artificial synchronization; any live thing made of cells, after these interventions, becomes an object that can be stopped and started, suspended and accelerated. Being cellular after cloning thus entails a different sense of biological progression being yoked to historical time in any given, predictable way. Obviously, this story could be told in much greater detail but the point should be clear: the operationalization of biological time is a dominant characteristic of the interactions of humans and cells in technical environments over the last fifty years, and has been enabled by the infrastructural build-up of freezing technologies and cellcycle interventions and concepts (which have reached the status of unarticulated assumptions) of living matter as stuff which can be stopped and started at will. It is these changes that are at work in the production of novel cellular objects today, of which cloning is but one example. Methodologically, then, the approach via technique introduces specificity to understanding how biotechnology, with its characteristic interventions in plasticity and temporality, changes what it is, what it means, to be cellular living matter. As an approach to the living, biotechnology changes what it is to be biological, an interim step by which biotechnology changes what it is to be human. Detailing this step provides different avenues of analysis than the accepted links of therapeutic applicability or genetic homology, and gives the observer of the life sciences a way to cut across the structure of arguments and terms of debate already well-defined by other agendas and actors in the currently very public life of biotechnologies. A problem that arises with accepting high-profile entities or practices as given categories of analysis or boundaries of research projects is that one can easily mistake the thing as the origin of the phenomena which follow it or accompany it in the discourses under study. To pick just one typical example: in an article ‘on’ ontology and stem cell technologies, we read that ‘embryonic stem cell technologies introduce’ decisive disruptions in human biographical narratives, are ‘literally immortal’ and that they ‘effect a major redistribution of tissue vitality from the first moments of life to the end of life’ (Waldby and Squier 2003: 32, 35). This seems to make good sense; human embryonic stem cell technologies are new, they seem to be in the middle of unprecedented rearrangements of the manipulation and narration of human life spans, why not assume that they are, as powerful objects with their literal immortality, introducing and effecting this change? As should be indicated by the story recounted above, embryonic stem cells are an arbitrary starting point. It is actually more likely that major redistributions in tissue vitality were fundamental to the appearance and consolidation of what have come to be known as embryonic stem cell

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technologies, which are just one of many outcomes of a systemic change in the way living matter is manipulated and thought about. Immortality came into being as a scientific entity that could be researched in cells, and therefore as a technical descriptor of cells, in the course of these changes, not in the early twenty-first century but many decades earlier (Landecker 2000, 2007). Just as gene therapy and cloning have come and then diminished as high-profile scientific objects or processes, so will embryonic stem cells settle from their current prominence, but the conditions which produced all of these novel forms and objects will still be in operation, busily generating yet more new things and perturbing human biographical narratives.3 It is towards these conditions that analysis should be directed. Exclusive attention to things human is a result of mistaking material and efficient causes for formal and final causes, a difficulty perhaps particularly acute in the study of modern life sciences because of their scale and diversity, and the temporal feature of their reasoning in which the human application comes late in the process.4 Connections between the science done in the favoured model organisms of worms and fungi, and changes to or problematizations of human life, are not necessarily simple or already articulated. There are many kinds of connections, only some of which are visible from an outside perspective, are called revolutions, or are made otherwise obvious by practitioners. Keeping an eye on practice, protocols, methods, technique, touch or infrastructure is one way to access the actual complexity of ways in which work on some life (nematodes, insects, yeast) reshapes human life even when it does not take the form of a therapeutic product or a homology narrative but first introduces sweeping change into other facets of being biological.5 The scale, pace and nature of biological experimentation has of course changed greatly from the 1950s and 1960s when research in cell culture was primarily government or foundation-funded. The focus on practices of plasticity and temporality provide only a partial characterization of the conditions in which new biotechnical objects emerge today. Nonetheless, the genealogies given above map in interesting ways onto current practice. In particular, the material intersections of the operationalization of biological time with the temporal structures of capitalism in these settings opens up a further avenue of characterization of biotechnology (Franklin 1997; Fortun 1998; Sunder Rajan 2003). To this end, the discoveries of the first half of this paper will be followed as they sediment as the practices and commodities of the second half, which gives a brief ethnographic sampling of life as a cell culturist today.

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Part 2. Care of the Cells: Studying the Biotechnological Touch in the Present In 2002, I attended the annual meeting of the Society for In Vitro Biology. I wanted to talk to people about hands-on techniques of handling biological matter, techniques which cross between individual instances of biotechnological work, or generate the infrastructure in which different biotechnological projects operate. Having written an abstract for a conference which promised that I would track the fate of the adjective ‘human’ as it applied to biological nouns, material things well removed from the bodies of persons by years in the laboratory or layers of technical removal from its original state, I wanted to interview tissue culturists about this issue. I ran into two barriers. First, I kept meeting biochemists who were also there to learn about tissue culture. Apparently without irony, one biochemist from Pfizer said it was outside his usual field, but that there was no way around it any more – he simply had to learn to work with cells, now that he had a laboratory full of mouse stem cells – and since the meeting was being held at Disneyworld, he could bring his kids. Second, when I finally did find some tissue culture specialists to interview, they were, to a person, absolutely disinterested in my questions about distinctions between human and animal matter in their laboratories, responding with much more detail and emotion on quite separate issues of practice, many of them linked to infrastructural and economic changes in the field in which they work. In what follows, I will dissect in some detail one of these conversations, with the dual aim that frames this paper: to see how the use and conceptualization of cells is changing, and to demonstrate the methodological point that starting with questions of the human is not the only way to get at how changes in cellular practice will end up affecting human life. This is not ethnography in the sense of research based in longterm studies of tissue culture practitioners but a piece of interview-based research informed by the kind of genealogical work done in the first half of this paper. As biological research moves in the direction of cell-based technologies, more scientists are learning and revising tissue culture techniques to their own ends. During the course of the conversation analysed below, a number of themes came up around this rapid uptake of cellular techniques into fields such as biochemistry and molecular biology. The first of these was scientific research as itself a distinct market. That is, huge numbers of academic, industrial and medical laboratories require tons of materials, from Petri dishes to large machines to biological things such as cells or DNA pieces. Plasticity and temporality here become linked to packagability – freezing, shipping and storage enables the fast, industrialscale distribution of cell lines and their associated needs (specialized nutrient

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media, manipulation tools, etc.). The scientist as consumer was a figure addressed by my interlocutor in generational terms, indicating that the scientific problems of one generation turn into the protocols of the next, becoming sedimented as routines, unarticulated assumptions, and now, packaged commodities, a very particular kind of black box (Latour 1987). The second, linked theme that emerged in this conversation was conflict at the interface of biochemistry and cell biology around how to care for cells. This was simultaneously a practical issue of how to keep one’s research base alive and a normative issue of what counted as the right way to do science. This conversation about tissue culture practices was also one about ethics, but not the obviously controversial ones of using parts of humans or experimenting on living persons; other kinds of questions or problems are posed to human life by new technical forms of cellular life.6 Here then is a sample of a conversation about contemporary tissue culture practice, interspersed with my commentary on the implications of each statement for these issues of the research market and care of the cells. Wandering the confines of the Coronado Springs Disney Resort Hotel, between the biochemists and the hordes of plant biotechnologists, I found a scientist who described herself as a ‘die-hard’ attendee of the annual meeting of the Society for In Vitro Biology. Rita Elliott (a pseudonym) studies gastrointestinal diseases using cultured intestinal tract cells. She is a specialist in establishing cell lines, taking pieces of tissue from whole animals and coaxing them to live in the laboratory such that they maintain their specialized differentiated characteristics and may be used for understanding the functioning of the digestive organs at the cellular level. In her late 40s, she had been doing tissue culture work for 25 years – but biochemists were obviously on her mind. Reacting to my off-hand comment that there were more biochemists at the meeting than I had expected, she emphatically agreed. Her explanation of this phenomenon veered immediately into a reflection on how it had changed her own scientific life. Biochemistry is going cell-specific after years of being mass tissue. The molecular biologists down the hall treat cells as if they are just reagents, something to transfect into. People fail to understand that they’re complex living entities, not reagents on the shelf. They change over time. We grow old – so do they. Some dissection is in order here: ‘Biochemistry is going cell-specific after years of being mass tissue.’ Instead of taking a slice of liver tissue, grinding it up to release all the cell contents, and studying the molecules or molecular complexes such as enzymes or ribosomes, biochemists are now starting to understand how molecules interact inside the intact cell. It is one thing to study molecules floating free in solution in a test tube, it is another to

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understand where they are in the cell – on the surface of the cell, embedded in a membrane, sequestered in the mitochondrion, floating in the cytoplasm, and so on, in what numbers and when. Marker proteins that light up red or green are attached to antibodies specific for a particular molecule. Using markers of different colours, two or more proteins can be localized, and their relationship studied, in an increasingly nuanced topographical understanding of cell function.7 Measurement techniques for DNA and proteins are so sensitive that a single cell can be broken up for study and comparison with another cell. In short, the unit of the cell has become more technically meaningful in biochemistry. In order to work with cells, it is necessary to learn how to keep them alive. This is what it means to go cell-specific. ‘The molecular biologists down the hall.’ Elliott works in a university health sciences centre setting in the United States, and her funding comes from a mix of university, government and corporate sources. She studies the gastrointestinal tract and its diseases. The potentially wide therapeutic application for her research means that although she does so-called ‘basic’ biology of animal gastrointestinal cells, she is well funded. She is a cell biologist, and has been trained differently from biochemists or molecular biologists. Over the last few years, she has felt her situation changing; she feels pressured by the biochemists and the molecular biologists in her department to help them learn how to grow cells for their increasingly cellspecific experiments, and this interaction has damaged her own work in very tangible ways. ‘[They] treat cells as if they were just reagents, something to transfect into.’ In addition to the shift in basic cell science that sees biochemistry and molecular biology going ‘cell-specific’, there is the shift in applications for this knowledge. And here too, the words should be connected to the scene. The Society for In Vitro Biology has been in existence since 1946, when it began as the Tissue Culture Association, formed to standardize and teach the methods for growing cells in vitro and using tissue culture in research. Initially a close-knit community, animal cell culture people were most firmly in charge, and this was the case until the mid-90s. As we sat having this conversation surrounded by indoor palms and Disney paraphernalia, people bearing green nametags were streaming past us. This year, the ‘plant’ people (marked by green nametags rather than blue ones) outnumbered the ‘animal’ people ten to one. Judging simply from the volume of companysponsored hors d’oeuvres tables, the money was with the plant people. Why this shift to plant culture? A single word from Elliott’s sentence could suffice as answer: transfect. ‘Transfect’ encompasses all forms of directed insertion of ‘foreign’ DNA into the genome of a target cell, with the aim of having that cell produce a particular protein of interest. One enthusiastic graduate student, standing by his poster presentation, explained to me that ‘in simple terms’ his aim was to become the perfect parasite – by hollowing

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out the genomes of plant parasites but keeping the mechanism by which they inject their DNA into the host’s cells, he could harness and perfect this infectivity for the purposes of injecting ‘his’ DNA – this was his phrasing, not mine, and I presume he did not mean his own personal DNA. Once the ‘foreign’ DNA was integrated into the plant cell genome, he could culture plates of the cells and eventually regenerate whole plants from them. To date, one cannot regenerate a whole animal from a cultured somatic cell as one can with plants. He could then harvest these proteins from the growing plants, without the need to build expensive pharmaceutical factories. This imparts a new kind of relevance of in vitro plant cells to people, or at least their health and wealth. Transfection is a key tool for understanding how cells work, but increasingly the emphasis has been on its role in making cells do things they would not otherwise do. In other words, parasites also see cells as something to transfect into, there is a certain adoption of the parasite’s point of view in regarding cells and the organisms they constitute as DNA and protein factories. ‘People fail to understand that they’re complex living entities, not reagents on the shelf.’ A reagent is defined as a substance for use in a chemical reaction, and perhaps not surprisingly for people who have made a career out of understanding the chemistry of biological molecules, cells are seen as something to add to something else in order to get a third substance – something to use in the work of synthesis and analysis. Where does one get reagents? One orders them from a laboratory or chemical supply company. Where does one get living cells? One orders them from a laboratory supply company. In fact, many chemical supply companies are becoming suppliers of biologicals to this growing market. Take, just as an illustrative example, the Cambrex Corporation, which began in the nineteenth century as the H.L. Baker company, making castor oil from castor beans, moved into castor oil derivatives for the personal care, ink and coatings industries, as well as polyurethane systems for telecommunications, electronics and biomedical devices. In the 1980s the company that is now Cambrex began to move through a series of mergers and acquisitions and products, from inorganic salts to biocides for paint to synthetic organic chemicals, to cell culture products, including both the media in which to grow and freeze cells and the cell lines themselves. Now publicly listed, the company strategy is an explicit one: move deeper into the biologicals market. An ampoule of a human aortic endothelial cells, for example, goes from US$455 to US$1,300.8 One can indeed order biological products in exactly the same way, and in many cases from exactly the same companies that used to supply chemical reagents. Seeing a cell as a reagent is thus not simply a question of biochemists seeing the world as one big mass of chemical reactions but a new and growing infrastructural characteristic of doing research with living things, in which they very literally come in

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different packages than they used to. For my interlocutor, trained a generation ago in the specialized task of actually coaxing cells to live in the laboratory after excising them from the guts of laboratory animals, cell lines come first packaged as organs in organisms. For many others, these days, cell lines come as small ampoules in a Fedex package, smoking with dry ice. ‘[Cells in culture] change over time. We grow old – so do they.’ The most important characteristic that Elliott saw as being lost in the cell-as-reagent way of doing things was the sense of how cells live in time – as she put it, a cell in passage 10 is not a cell in passage 100 – passage number refers to the number of times that a cell population has been removed from the culture vessel and subcultured, in order to keep the cells at a sufficiently low density to stimulate further growth. It is a rough marker of in vitro age – indicating how long a cell population has been kept continuously dividing. And, I speculate here that this was also a generational issue – in the conversation she referred to the post-docs down the hall who were doing transfection experiments as ‘kids’ – she seemed to feel that her way of doing biology was ageing along with her and her cells, despite the renewed interest in in vitro cell techniques due to transgenics and stem cell research. When I asked Elliott what an example might be of this attitude to cells as reagents, she told me a story about mycoplasma. They [the molecular biologists’ cultures] had mycoplasma – and just doused them [the cells] with antibiotics. I don’t work with antibiotics because I want to know right away if my technique is sloppy. I say, assume nothing. Look at your culture, it’s a living system, like watching a child grow. Each cell line has a phenotypic characteristic, you have to observe them when they’re happy, because if you don’t know what a good culture looks like, you can’t recognize when something goes wrong. I like to do the tissue culture work at the end of the day (you know, like splitting and feeding), just close the door and everything’s quiet. The second thing she saw as lost was a certain level of skill, gained by observing one’s cultures and building up a feel for whether they are ‘happy’ or not. She put emphasis on the word ‘look’, stressing the necessity to see the cultures as living beings, to spend time simply observing them. This was not some abstractly moral or empathetic or caring thing to do but was in her eyes simply the right technique as opposed to sloppy technique, an attitude to cells that was not separable from a definition of good science. Forgetting something is alive is not good science. Forgetting that something ages and therefore changes over time and between experiments is not good science. Infection, such as with mycoplasma, spoils experiments because it means what is in the petri dish is no longer a controlled situation, ‘your’ DNA is not the only ‘foreign’ DNA in the mix, and you are not the only parasite around.

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Mycoplasma is particularly insidious – a form of bacteria but lacking a cell wall, it is very hard to get out of one’s cultures once it is in them, and the molecular biologist’s cultures infected her cultures, ruining months of work. In graduate school I grew African violets, then I got interested in orchids. And of course then, orchid cell culture – you can regenerate full plants, they’re much more flexible than animal cells. Anyway, I told them to just get a clean culture from ATCC, because it hadn’t occurred to them to freeze some down, but they don’t listen. They forget that the things they’re working with are living beings. I won’t let them store stuff with my cultures any more, I just can’t take the risk. At first it seemed extraneous that a comment on gardening should be sandwiched in here between doing tissue culture work at the end of the day and complaints about colleagues’ sloppy technique, but then I realized she was sorting biologists into types – or cultures, perhaps: are you a gardener, or are you a shopper? If you weren’t going to grow your own, you should call up the American Type Culture Collection – a central repository for all kinds of cell lines – and get a culture certified to be ‘clean’ of contamination. If you didn’t know enough about working with cells to know that you should freeze a ‘seed’ stock at the outset, in case you needed to recover from infection or mislabelling or in vitro ageing – then you should recognize your lack of technique, and buy what you need from people who know what they’re doing. Even here, the assumption that the place you would naturally turn to buy your cell lines is the ATCC, a public, non-profit, government institution – rather than, say, Cambrex corporation – speaks to a mode of practice that probably differs from that which happens in the laboratory down the hall. From this brief encounter, a whole set of questions opens up about science as consumption, the arrangement of gardeners and shoppers. In terms of the capitalization of biological matter, or nature, what do we know about the market that is scientific research itself? Scientists and laboratories, whether university, pharmaceutical industry, biotech start-up or whatever, increasingly purchase rather than make the infrastructure of their research, from machines to chemicals to reagents to datasets to assays to tissues to animals – to cells. Various configurations of all these products often come bundled together as kits designed to make particular procedures as rapid as possible. While the commoditization of human biological matter has received much attention (Scheper-Hughes and Wacquant 2003), one important but unstudied part of this story is the market in all kinds of biological matter that is research science itself. When scientists decide to work on cells, those cells have to come from somewhere. While sometimes they just use their own body as a source, or extract them from patients or laboratory animals, these

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days they are just as likely to order them from a catalogue, whether that of a non-profit cell bank such as the ATCC or a commercial source. Just as novel entities such as cloned animals or embryonic stem cells can be reconnected to the conditions of their emergence, research as a market in itself is an important condition for the production of biological entities as generators of value in the present moment. It is becoming increasingly clear that large twentieth-century chemical companies are becoming early twentyfirst century biologicals companies (Plotkin and Swanson 1999; Boyd 2003).9 The scale implied by the involvement of these companies speaks to the industrialization of biotechnology’s interventions in temporality and plasticity as ‘biologicals’. The ability to make cells live differently in time, so important to changing concepts in cell biology, connects at this juncture with the infrastructure of exchange through which the material base of research gets spread around the world. The techniques exploiting the malleability of biological time, which treat a living cell population as a thing that can be expanded in space and suspended in time, literally get packaged and delivered into disparate laboratories at disparate times. What is a narrative of loss for Rita Elliott is from another perspective the efficient collapse of years of conceptual and technical work into the condensed form of a tool that makes the kind of work and the scale of work being done today possible. Thus it is not just that the idea of the cell has re-emerged with all its fundamental-unit-of-life gravity but that a very particular kind of cell – a plastic, temporally adjustable, highly autonomous cell – is readily at hand to work with as experimental subject and substrate, one that often comes packaged with the conditions of its own in vitro existence. This is not to deny that many scientists are also continuously still working to establish (make) their own cellular research objects when they have particular problems or questions to answer, or that they do not continuously tinker with given conditions. The industrial scale of cells as biologicals is, however, one constitutive condition of this work today, both as a source of materials or as a potential goal for materials being developed. Many of the research questions suggested by my interview with Rita Elliott – such as the nature of research science as a market – are just that, open questions which represent research directions rather than detailed answers. How does the market that is scientific research itself fit into the more general capitalization of biological things? At what points do things exit ‘raw’ nature and enter the condition of ‘product’, and in what forms? Are there intermediary forms as tools, before things become therapies? Antibodies come to mind as a good example of this (Cambrosio and Keating 1995). Does the laboratory or research market work the way other markets do? What is its scale in comparison to the market of the general public, for the end products of research – genetically modified foods, drugs, and so on?

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What is the role of the laboratory market in making possible the longer-term development of these end-products for a mass market? In addition to understanding the infrastructural and economic role of the scientific market, we may also understand the gardener, the shopper and the perfect parasite as ethical or political modes of practice. Kim and Michael Fortun have proposed attention to ‘care of the data’ in doing ethnographic study of scientific practice, invoking Foucault’s The Care of the Self and the idea that practical works dealing with acts of everyday life reveal generally accepted principles that organize ethical experience, even though they are not works of moral reflection or prescription and make no explicit moral judgements on those acts (Foucault 1986; Fortun and Fortun 2005). They have shown how subject formation in the sciences may be followed and analysed via attention to the way new scientific machines and processes are connected to new articulations of what ‘good science’ is. Their ethnography follows scientists in the field of toxicogenomics, tracking what these scientists themselves articulate as worthy of care and ethical attention. Similarly, it becomes clear that there are many different modes of caring (or not caring) for cells currently at play in biological research, and that these are intimately related to the question raised above, of the nature of research science as a market in which scientists are also consumers as well as hopeful patentholders or industry participants. My interlocutor’s enthusiastic emphasis on good science as synonymous with ‘care of the cells’ – including respect for their existence as temporal beings and her contrasting marked disinterest in any of my questions about the sameness or difference of working with human materials as opposed to any other kind of biological materials – suggests that attention to laboratory manuals, protocol books, the training of young scientists on how and where to ‘get’ their materials and how to maintain them, how to operate in relation to other scientists’ materials and techniques, will often be more productive than explicitly moral or political questions in revealing the attitudes to the living that characterize biotechnology. We cannot stop at the laboratory door and engage only in explicitly political questions of regulation or prohibition. As years of science studies literature has demonstrated, technical practices are not abstract but occur in social settings, like a row of laboratories located on the same hallway. Conflicts over the right way to do things are also about the power relations between different constituencies and generations battling over the design and performance of experiments, the purpose of those experiments or their ownership.10

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Conclusion Speaking both of her refusal to share her tissue culture facilities and the changing economic conditions in which cell lines were increasingly privately sold and controlled rather than shared via ATCC, Elliott said: [shrug] ‘You do what you’ve got to do.’ These mostly unprompted comments – coloured as they are by a gentle nostalgia for previous times and one individual’s disgust for certain colleagues – are not repeated here in order to mourn the loss of a way of doing science or champion this particular perspective. Rather, they are offered as an example of empirical work that can delineate changes in those imperative but not necessarily explicit conditions for ‘what you’ve got to do’ in the life sciences today. A focus on technique, either in the contemporary or the historical sense, is one useful tool for characterizing the conditions of production of new biotechnical objects. Here it has revealed the importance of practices of plasticity and temporality to the formation of the technical cellular objects occupying so much attention today. The dreams of synthetic biology aside (to make organisms from scratch), biotechnology depends fundamentally on the cultivation of self-reproducing, productive life forms, and the harnessing of their life courses to human intention. These components of the biotechnological touch cross between individual instances of biotechnology, and between particular objects such as stem cells, transgenic organisms or cloned animals (as well as the much more numerous unknown, unheralded objects that escape public attention). Attention to these components opens up a set of empirical research questions about scientific research as a market, the interpretation of laboratory practices in the life sciences as ethical and political practices, and about the material techniques of caring for, exchanging and using biological matter that characterize contemporary attitudes to the living. Perhaps most importantly, this methodological focus on genres of technique and infrastructures of research allows room for the vast realms of contemporary biological practice and biotechnological intervention that are not based directly on human matter or health or reproduction. We thus gain better access to the question of how, specifically, altering any kind of biology – yeast, fruit fly, nematode, slime mould – is to alter what it is to be biological, without having to assume that their cultural significance derives only from their direct, one-to-one relation to human health and wealth. Gillian Beer writes of Darwin’s Origin of Species by Means of Natural Selection, as a text that spoke of ‘survival and descent, extinction and forgetfulness, being briefly alive and struggling to stay so, living in an environment composed of multiple other needs, coupling and continuing, ceasing to be: all these pressures, desires and fears are alerted in this work without any particular attention being granted the human person’ (Beer 1996: ix). Similarly, the contemporary texts of biotechnology, particularly the

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materials and methods sections of its thousands of constitutive publications, speak of mutation and revision, senescence and parasitism, multiplicity and infinitude, living in an environment composed of multiple other technologies, profit and proliferation, totipotency and replication, also without necessarily granting centrality to the human person. Certainly the focus is often on the implication for human health, and this is accentuated by the funding and investment structures of contemporary research. However, must the observer of the life sciences exclusively focus only on how biotechnology is always directly about human biology and human nature? My argument is that to do so is paradoxically to lose sight of much of its power in contemporary culture. Once we have a more specific grasp on how altering biology changes what it is to be biological, then we may be more prepared to answer the social questions that biotechnology is raising: What is the social and cultural task of being biological entities – being simultaneously biological things and human persons – when ‘the biological’ is fundamentally plastic?

Acknowledgements Thanks to Melinda Cooper, Christopher Kelty and Stefan Sperling for their input. Parts of this essay appeared in slightly different form in the journal Culture Machine, volume 7, 2005. Parts of the essay have been adapted and reprinted by permission of the publisher from the chapter “Epilogue: Cells Then and Now”, in Landecker’s book Culturing Life: How Cells Became Technologies, Cambridge, MA: Harvard University Press, 2007, pp. 219–237. Copyright by the President and Fellows of Harvard College.

Notes 1. A detailed and wide-ranging discussion of cloning, agriculture and the cultural significance of Dolly can be found in Franklin (2007). 2. ‘Reproduction in mammals normally involves contemporaneous and contiguous action on the part of the two sexes. The advent of artificial insemination abolished this requirement in principle, but in cattle at any rate the practicability of effectively using semen long-stored in the frozen state has enormously extended the scope of the technique. It may be said, in fact, that we have abolished time and space in cattle breeding’ (A.S. Parkes 1956, quoted in Smith 1961: 38). 3. Alberto Cambrosio and Peter Keating, writing about contemporary biomedical practice, have developed the idea of the ‘biomedical platform’, looking at the practices which link different laboratory, clinical and public spaces together, and

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keep bodies of patients, samples derived from them, test results and clinical entities functioning coherently across diverse disciplinary, technical and architectural spaces. Methodologically, the focus on practice, or on ‘activities that seek to stabilize existing practices and the entities they produce’ allows them to address not single novel objects or events but to ‘outline conditions for the production of novelty and routine’ within any given situation, and also to avoid the trap of always having to explain everything as a ‘paradigm-ordered or theorydriven activity’ (2003: 3). 4. My complaint with always only choosing human things for study as examples, or leaving their relevance to human life unproblematic, is sympathetic with, but not the same as the call first put forth by Bruno Latour to include non-human actors in stories of the history and sociology of science as a means of avoiding the assumption that all scientific or technical change springs from human thought (Latour 1987). Human genes are also non-human actors in his sense, as they are not (usually) endowed with thought. I wish to specify only that human biology and medicine is a subset of how the life sciences function, and is therefore not representative of the vast amount of non-human biological work in the past and present that forms the possibilities and concepts of action with human matter today. 5. A good example of this kind of work is that of Stefan Helmreich, who shows how molecular evolutionary theory has been altered by techniques of sequencing and large-scale computerized sequence comparison, practiced in large part on microorganisms that live in extreme environments such as deep-sea vents. Further, he demonstrates that these changes and arguments over the shape of evolutionary trees (to the extent that they are no longer trees at all), connect with particular practices in the bioprospecting and valuing of marine microorganisms, via the linguistic and legal configurations of patenting (Helmreich 2003). 6. As Andrew Lakoff and Stephen J. Collier have observed of the growth in anthropological studies of scientific, technical and administrative systems and their political regulation, these investigations are clearly not ‘to understand technical developments, per se’, but the question does then arise of what draws these studies together (2004: 419). The same query may be posed to anthropological, sociological, literary, historical and other critical studies concerning life science. Lakoff and Collier argue that what binds diverse studies of different instances of scientific and technical transformations, what makes them ‘anthropological’ questions, is a common interest in how, ‘in relation to these technical and political developments, ‘living’ has been rendered problematic.’ That is, technical change and technical reason problematize what individual and collective life is or should be, raising questions of ‘what is human life becoming? What conventions define virtuous conduct in different contexts?’ (2004: 419). Therefore, they suggest, anthropological methods should be directed at elucidating the elements of problematization of ‘living’ in the different localities traversed by global technological and scientific developments. The empirical study of ethics then is a Foucauldian one, directed at elucidating these elements – techniques, subjects and norms – through which the question of ‘how to live’ is posed. 7. Many of the prize-winning microphotographs in the Nikon Small World Competition involve multiple labelling of cell components; see beautiful examples at www.microscopyu.com/smallworld/gallery/ (accessed 22 October 2004).

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8. Company history, business plan and cell line product catalogue available at www.cambrex.com (accessed 22 October 2004). 9. These comments also raise the interesting question of what consumerism looks like in the laboratory, among scientists. A flip through any life sciences journal will indicate the advertising strategies designed to shape laboratory consumers. Just registering for a meeting of, for example, the Society for In Vitro Biology has been enough to produce an absolute flood of offers for probes, machines and biologicals, as well as telephone calls from various salespeople, slightly bemused when they find out they have called a cultural anthropology department and found someone more interested in asking them questions than placing an order for the newest apoptosis assay. Who buys what, and how does that affect the knowledge they produce? 10. In a different kind of paper, the local conditions around this particular case could have been explored in much more detail, including the institutional and economic hierarchy between different kinds of life science being done in the same complex, and the dynamics of age of gender at work in the relationships being reported here from a single perspective.

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Foucault, M. 1986. The Care of the Self. The History of Sexuality, Volume 3. New York: Random House. Franklin, S. 1997. ‘Dolly: A New Form of Transgenic Breedwealth’, Environmental Values 6: 427–437. ———. 2003. ‘What We Know and What We Don’t Know about Cloning and Society’, in P. Glasner (ed.), Reconfiguring Nature: Issues and Debates in the New Genetics. Aldershot: Ashgate, pp. 247–58. ———. 2007. Dolly Mixtures: The Remaking of Genealogy. Durham: Duke University Press. Franklin, S. and M. Lock. 2003. ‘Animation and Cessation: The Remaking of Life and Death’, in S. Franklin and M. Lock (eds), Remaking Life and Death: Toward an Anthropology of the Biosciences. Santa Fe: SAR Press, pp. 3–22. Haraway, D. 2007. When Species Meet. Minneapolis: University of Minnesota Press. Helmreich, S. 2003. ‘Trees and Seas of Information: Alien Kinship and the Biopolitics of Gene Transfer in Marine Biology and Biotechnology’, American Ethnologist 30(3): 341–59. Keller, E.F. 1983. A Feeling for the Organism: The Life and Work of Barbara McClintock. San Francisco: W.H. Freeman. Kohn, E. 2007. ‘How Dogs Dream: Amazonian Natures and the Politics of Transspecies Engagement’, American Ethnologist 34(1): 3–24. Lakoff, A. and S. Collier. 2004. ‘Ethics and the Anthropology of Modern Reason’, Anthropological Theory 4: 419–34. Landecker, H. 2000. ‘Immortality, in vitro: A History of the HeLa Cell Line’, in P. Brodwin (ed.), Biotechnology and Culture: Bodies, Anxieties, Ethics. Bloomington: Indiana University Press, pp. 53–72. ———. 2002. ‘New Times for Biology: Nerve Cultures and the Advent of Cellular Life in Vitro’, Studies in History and Philosophy of Biological and Biomedical Sciences, 33(4): 667–94. ———. 2004. ‘Building a New Type of Body in Which to Grow a Cell: Tissue Culture at the Rockefeller Institute, 1910–1914’, in D. Stapleton (ed.), Creating a Tradition of Biomedical Research: Contributions to the History of the Rockefeller University. New York: Rockefeller University Press, pp. 151–74. ———. 2007. Culturing Life: How Cells Became Technologies. Cambridge, MA: Harvard University Press. Latour, B. 1987. Science in Action: How to Follow Scientists and Engineers through Society. Milton Keynes: Open University Press. Maienschein, J. 2004. Whose View of Life? Embryos, Cloning and Stem Cells. Cambridge, MA: Harvard University Press. Martin, M.J., A. Muotri, F. Gage and A. Varki. 2005. ‘Human Embryonic Stem Cells Express an Immunogenic Nonhuman Sialic Acid’, Nature Medicine 11: 228–32. Parry, B. 2004. ‘Technologies of Immortality: The Brain on Ice,’ Studies in History and Philosophy of Biological and Biomedical Sciences 35(2): 391–413. Pegg, D.E. 2002. ‘The History and Principles of Cryopreservation’, Seminars in Reproductive Medicine 20: 5–13. Plotkin, J. and A. Swanson. 1999. ‘New Technologies Key to Revamping Petrochemicals’, Oil & Gas Journal 97 (51): 108. Rabinow, P. 2003. Anthropos Today: Reflections on Modern Equipment. Princeton: Princeton University Press.

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Rapp, R. 2000. Testing Women, Testing the Fetus: The Social Impact of Amniocentesis in America. New York: Routledge. Rheinberger, H.J. 2000. ‘Beyond Nature and Culture: Modes of Reasoning in the Age of Molecular Biology and Medicine’, in M. Lock, A. Young, and A. Cambrosio, (eds), Living and Working with the New Medical Technologies. Cambridge: Cambridge University Press, pp. 19–30. Scheper-Hughes, N. and L. Wacquant. 2003. Commodifying Bodies. London: Sage Publications. Schloegel, J.J. and H. Schmidgen. 2002. ‘General Physiology, Experimental Psychology, and Evolutionism: Unicellular Organisms as Objects of Psychophysiological Research, 1877–1918’, Isis 93: 614–45. Smith, A. 1961. Biological Effects of Freezing and Supercooling. Baltimore: Williams and Wilkins. Sunder Rajan, K. 2003. ‘Genomic Capital: Public Cultures and Market Logics of Corporate Biotechnology’, Science as Culture 12: 87–121. Waldby, C. and S. Squier. 2003. ‘Ontogeny, Ontology, Phylogeny: Embryonic Life and Stem Cell Technologies’, Configurations 11(1): 27–46. Wilmut, I., K. Campbell and C. Tudge. 2000. The Second Creation: Dolly and the Age of Biological Control. Cambridge, MA: Harvard University Press.

Notes on Contributors

Simon Cohn is an anthropologist who investigates ideas of health amongst patients and medical professionals, particularly in relation to chronic conditions. He has published work on diabetes, ME/chronic fatigue, gulf war syndrome, and most recently the impact of neuroscience in psychiatry. A central concern throughout his work has been to examine how sources of knowledge are used creatively by sufferers to provide meaning and legitimacy, and how consequently this is often at odds with the biomedical perspective. He is currently employed as a medical anthropologist in the General Practice and Primary Care Research Unit, Institute of Public Health, Cambridge University. Joseph Dumit is Director of Science and Technology Studies and Associate Professor in the Department of Anthropology at the University of California, Davis. His research interests are in the anthropology of science, technology and medicine, focusing on brains, drugs, movements, marketing and rationalities. He is the author of Picturing Personhood: Brain Scans and Biomedical Identity (2004); and the co-editor of three books: Cyborgs and Citadels: Anthropological Interventions in Emerging Sciences and Technologies (with Gary L. Downey, 1997); Cyborg Babies: From Techno-sex to Techno-tots (with Robbie DavisFloyd, 1998); and Biomedicine as Culture: Instrumental Practices, Technoscientific Knowledge, and New Modes of Life (with Regula Valérie Burri, 2007). Stefan Ecks is Director of the Anthropology of Health and Illness Programme and Lecturer in Social Anthropology at the University of Edinburgh. Before joining Edinburgh University in 2004, he taught at the South Asia Institute, University of Heidelberg. He has carried out ethnographic fieldwork in Kolkata (Calcutta, India) since 1999, focusing on postcolonial notions of body, health and healing. His current work looks at pharmaceutical uses, evidence-based medicine, and global corporate citizenship in India. From 2006 to 2009, he takes part in the ESRC/DFID-

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funded project, ‘Tracing Pharmaceuticals in South Asia’, that studies the trajectories of three key drugs (fluoxetine, oxytocin, rifampicin) through production, distribution, prescription and consumption in India and Nepal. Jeanette Edwards is Professor of Social Anthropology at Manchester University., She has carried out extensive ethnographic fieldwork in the north of England and has published widely on kinship, new reproductive technologies and ‘public understanding’ of science. She co-ordinated and directed the European-funded project ‘Public Understanding of Genetics: A Cross-cultural and Ethnographic Study of the “New Genetics” and Social Identity’ from which the edited volume European Kinship in the Age of Biotechnology has recently been published (2009). She is coeditor, with Penny Harvey and Peter Wade, of the volume, which complements the present one, Anthropology and Science: Epistemologies in Practice (2007). Penny Harvey is Professor of Social Anthropology at the University of Manchester. She has done fieldwork in Peru, in Spain and in Manchester, UK on the politics of communication, looking at language, exhibitionary forms, information technologies and most recently road building. She is author of Hybrids of Modernity: Anthropology the Nation State and the Universal Exhibition (1996), and editor of Technology as Skilled Practice (1997), special issue of Social Analysis 41:1. She is coeditor, with Jeanette Edwards and Peter Wade, of the volume, which complements the present one, Anthropology and Science: Epistemologies in Practice (2007). Hannah Landecker is an Associate Professor at UCLA in the Sociology Department and the Center for Society and Genetics. Her work is in twentieth-century life sciences, particularly the history and anthropology of the cell. She is the author of Culturing Life: How Cells Became Technologies (2007). Anne Lorimer has carried out extensive enthographic fieldwork in and around Chicago’s Museum of Science and Industry, exploring specific concrete objects and conversational practices through which visitors, staff and exhibit creators mediate their experience of industrialized capitalism and its socioeconomic disparities. Her archival research on Chicago business spectacles demonstrates how the aesthetic qualities used to represent prosperity change in tandem with shifts in political economy. Recently, she has become interested in the politics of commodities such as ‘union-made’, ‘fair trade’ or ‘local’ goods, an interest she first pursued with the help of the Oregon Fair Trade Campaign and her students at Reed College. She is currently doing political work in Harrisonburg, Virginia.

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Michal Nahman is Senior Lecturer in Sociology at the University of the West of England. Her research has primarily explored practices and discourses of transnational ovum extraction and exchange in Europe and Israel. Publications include articles on choice and selection of donor traits, Romanian egg traffic, the ethics of selling eggs and theoretical approaches to studying nationalism, race and reproduction. Griet Scheldeman is a Research Associate at the Lancaster Environment Centre, Lancaster University, where she is currently working on an EPSRCfunded project on urban walking and cycling. Her research interests centre on perceptive and creative processes at play in the relationships between people and their environments. She completed her Ph.D. (St Andrews University, 2006) on young people’s lives with diabetes and insulin pumps for which she carried out multi-sited ethnographic fieldwork across western health care settings. In her research, she portrays how a uniform technological device is always necessarily embedded in specific cultural and social contexts. Lucy Suchman is professor of Anthropology of Science and Technology in the Department of Sociology at Lancaster University, and Co-Director of Lancaster’s Centre for Science Studies. She spent twenty years as a researcher at Xerox’s Palo Alto Research Center (PARC) before taking up her present position. Her research investigates how human–machine relations are enacted in practice, and with what theoretical, practical and political consequences. She is currently engaged in a critical study of ‘innovation’, as a rhetorical invocation and as lived material practice, based on her years at Xerox PARC. She is the author of Human-machine Reconfigurations (2007). Ana Viseu is Assistant Professor in the Department of Communication Studies at York University. Anchoring her work on feminist technoscience and cyborg anthropology, she is interested in ethnographies of the practices of development and use of emergent (and contested) technologies, from both theoretical and material perspectives. Her research goal is to understand how particular notions of embodiment, agency, science and technology are reified, created and enacted in emergent technologies. She has addressed these issues in two complementary lines of research, wearable computers and nanotechnology, and is currently starting a project that will examine the bodies that are being produced within the field of nanomedicine. Ana has published in a number of venues, including the journals of Ethics and Information Technology, and Information, Communication and Society.

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Peter Wade is Professor of Social Anthropology at the University of Manchester and works on issues of racial and ethnic identity in Latin America and on practices of racialization in the context of new genomic technologies. His publications include Race and Ethnicity in Latin America (1997) and Race, Nature and Culture: An Anthropological Perspective (2002). An edited volume, Race, Ethnicity and Nation: Perspectives from Kinship and Genetics appeared in 2007. He is also coeditor, with Penny Harvey and Jeanette Edwards, of the volume, which complements the present one, Anthropology and Science: Epistemologies in Practice (2007).

Index

A abstraction accessibility and ‘vehicles’ at MSI 91, 96 instability of 23 relocation and 21–2 Actor Network Theory (ANT) 11, 139–40, 158n4 advertising, images in 22–3 aetiology doctors’ reflections on patients’ 128–30, 132 in gastroenterology 128–9 psychosomatic 129–30 African-American identity 107–8 Agamben, G. 4 age chimera 216 agency 28–9 agential power of artifacts 161–2 cognitive intentionality and autonomy of 108–9 core value of 2–3 distribution of 29 location of 161–2, 178, 179, 180 machine and human 152–3 Aikin, K.J. 41 Alcalay, A. 187, 190 aliyah (return), notion of 196–7 allegorical imagination 5 allopathic practice 124, 130, 131–2, 133n2

diagnostic centres 118 see also gastroenterology Almog, O. 188, 190 Alpers, Svetlana 5, 9 Althusser, Louis 40 Altmann, J. 94, 95 American Society for Gastrointestinal Endoscopy (ASGE) 117 American Type Culture Collection (ATCC) 216, 227, 228, 230 Americanization 194–5 anatomical dissection 22 Ancient Egypt 98–100 Anderson, Benedict 197 Anderson, Michael 134n4 anthropocentrism 212–13 Anthropology and Science: Epistemologies in Practice (Edwards, J., Harvey, P. and Wade, P.) 3, 31n13 antibodies 228–9 Appadurai, Arjun 19, 78, 88, 120, 181n1 Armstrong, Neil 18 Arnold, David 120, 132 artificial insemination 216, 231n2 Ashkenazi identity 187, 188, 190, 202 Association of Social Anthropologists (ASA) 3 atherosclerosis 11, 158n5

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Augustine, Saint and Bishop of Hippo 105, 110 authority images of, role of 8 questions of 10 scientific legitimacy and 26 auto-identification 46–7, 47–8 Avraham, E. and First, A. 194 awareness brand-awareness 42, 43, 44 education and pharmaceutical awareness 42–4, 47–8 human awareness of body 24 of images 21 presymptomatic awareness 39 reflexive awareness 88 scientific process, public awareness of 23 wearable bodily augmentations 164–5, 172 Ayurveda 118, 131, 132 B Bacon, Francis 88 Barfield, W. and Baird, K. 163 Barfield, W. and Caudell, T. 163, 164, 165 Barfield, W. et al. 165 Bashkow, Ira 111n1 Bass, L. et al. 163 Bauman, R. and Briggs, C.L. 31n15, 88 Baxandall, M. 5 Beck, Ulrich 55 Becker, Gay 188 Beer, Gillian 230 behavioural symptoms 66–7 Benjamin, W. 5, 195, 206 Bentham, Jeremy 30n10 biblical notation 196–7 Bichard, Jo 66

Billingham, R.E. and Medawar, Peter 216 biochemistry 212, 217, 222–3, 224, 225–6 cell-specificity of 223–4 biodigital politics 30n2 biogenetics 190, 197, 203 biological psychiatry 70–71 biological sciences developments in 3–4 experimentation, pace and nature of 221 Biomechatronics Group (MIT) 1 biomedicine biomedical conviction 46 biomedical explanation in gastroenterology 128 imaging in 13–14, 17–18 in post-Independence India 120 practice of 70 biometrics 13–14 biopolitics 27, 211–12 power and 27 biosociality 185–6, 206n1 biotechnology 211–14, 230 capital in transnational ova donation and 193–4 commoditization of human biological matter 227–9 contemporary thinking 222–9, 231 developments in 4, 77 tissue culture practice 223 Birenbaum-Carmeli, D. and Carmeli, Y. 189, 203 The Birth of the Clinic (Foucault, M.) 7 Bleichmar, D. 21 Boas, Franz 105 body artificial organs, annexation of 154

Index

bodily awareness, technologies of visualization and 2 bodily subjectivity 146, 157 body praxis 157 focus on 3 footprints, principle of 88 human awareness of 24 mind-body dualism 29, 147–8 mind/brain and 86 moral metaphors of 85 national bodies, transnational imagining of 189 person and 22 plaster casting from life 87–8, 101–4 Reinforced Body 175–9 in scientific illustration 5 scientific representation of body 85 stigma, human potential and 86 symbolism of 85–6 technology, visualization and 25 see also embodiment Bois, Y.A. and Krauss, R.E. 5 Bolling, J. 41, 44, 45, 49, 54, 58, 59 Bordo, S. 40 Boshes, Louis D., M.D. 91, 92, 94 Bourdieu, P. 88 Boyarin, J. 196 Boyd, W. 228 Boyle, Robert 8, 9 Brah, Avtar 206n2 brain accessibility of 108 activity, capture of 67 authority and images of 14–15 behaviour and 14 brain research 87–8 CAT (Computed Axial Tomography) 118

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Decade of the Brain 69–70 disorders of the 66–7 division of labour and 110–11 DSM (Diagnostic and Statistical Manual) 69–70, 71, 83n3 fMRI (functional Magnetic Resonance Imaging) 68, 70, 83n4 images of 26 images of, perspectives on 14–15 images of, production and interpretation of 19 material representation of 80–81 MRI (Magnetic Resonance Imaging) 76, 83n4, 118 PET (Positron Emission Tomography) scans 14, 17, 68, 83n1, 83n2 structural scans 67 unified model of 67 whole-brain atlases 71 brain scans 14–15, 17, 65–83 construction of 69–70 patients’ perceptions of illness and 74–6 social meaning and 79–80, 81–2 see also neuroscience branded compliance 58–9 Breitstein, J. 54 Brennan, T. and Jay, M. 5 bricoleurs 88–9 Bucchi, M. 30n11 Buch-Morss, Susan 23 Burke, Kenneth 52 Bush, Barbara 94 Butler, J. 181

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C Calcutta, medicine in 117, 120–21, 123, 126, 128–30, 132, 133, 134n4 Cambrex Corporation 225–6 Cambrosio, A. and Keating, P. 228 Cambrosio, Alberto 231n3 Cameron, I.L. and Padilla, G.M. 218 Campbell, Keith 218 Canguilhem, G. 70 capitalism 24–5 transnational ova donation and emergence of new forms of 193–4 The Care of the Self (Foucault, M.) 229 Carmeli, Y.S. and Applebaum, K. 189, 201 Cartwright, Lisa 11, 12 Casper, M. 212 CAT (Computed Axial Tomography) 118 cellular technologies 212–14, 214–21, 230 caring for cells 223, 228–9 cell banks 227–8 cell cycle research 218 cell-specificity in biochemistry 223–4 cell synchrony 217–21 Charing Cross Hospital 66 Chasin, A. 171 Chatterjee, Partha 132 Chernichovsky, D. 189 Chernichovsky, D. and Chinitz, D. 189 Chicago Museum of Science and Industry 27–8 Chicago Sun-Times 94 Chicago World’s Fair (1933-4) 90

Child Health, Institute of 66 choice chosen body, idea of 188–9 core value of 2–3 of donor traits in transnational ova donation 189, 201–4, 205 proliferation in transnational ova donation 201–4 Clarke, A., J. Shim, L. Mamo, J. Fosket and J. Fishman 45 Clarke, R. 170 Clarkson , B. et al. 164 Clifford, J. 15, 16 Clifford, J. and Marcus, G.E. 15, 16 cloning 212, 214–21, 228 cognition brain and cognitive function 71, 93, 108 cognitive abilities 164, 166, 175 cognitive attention 25, 46 cognitive augmentation 177 cognitive intentionality 108–9 cognitive reassurance 99 unconsciousness and 103–4 Cohen, L. 186 Cohn, Simon 14, 15, 19, 25, 26, 27, 29, 65, 237 Coleman, R. 110 Collier, Stephen J. 232n6 Collins, H.M. 88 colonialism 23 colonial enlightenment in India 119–21 visuality of 7 Columbian Exhibition, Chicago (1893) 106, 107 Compton, W. and Guze, S. 68 computers digital data 2, 26 portable work computers 28

Index

tamagotchi (computer pet) 153, 158n9 in tomography 14, 17, 68, 72, 83n1, 83n2, 118 wearable bodily augmentations and 162, 163–6, 168, 179–80 Conrad, P. 45 Conroy, M.E. et al. 88 control 28–9 modern disciplinary methods of 7 conversion, pharmaceuticals and 45–6, 52–3 Corsín-Jiménez, A. 4 cosmopolitanism 13, 95, 107–8, 190, 201 Craib, R.B. 2 Crary, J. 5, 30n8 CRESC (Centre for Research on Socio-cultural Change) 30n4 Crossley, N. 77 cryobiology 27, 212, 214–21 Csordas, T. 146 culture antiracist imagery 104–5 historical and cultural circumstances, affinity between 104 nature and 68 Culture and Well-being (Corsin Jimenez, A., Ed.) 157 Culture Machine 231 Culturing Life (Landecker, H.) 231 cyborgs 138–9 Cyclotron Unit, Hammersmith Hospital 66, 83n1 D Dangerous Diagnostics (Nelkin, D. and Tancredi, L.) 39 Danilov, Victor J. 91, 92, 93, 94 Darwin, Charles 230

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Daston, L. and Galison, P. 6, 9 Daston, L.J. 30n8 Degnen, C. 22 Deleuze, G. and Guattari, F. 23, 30n6 demographic threat, transnational ova donation and 187–8 depression bi-polar depression 66, 68, 74, 75, 77, 79, 82 pharmaceuticals and 37, 38–9, 51, 57 di Leonardo, M. 112n12 diagnosis checklists in pharmaceuticals for 49–50 diagnostic algorithms 39–40 ‘ouch’ testing 46–7, 47–8 self-diagnosis, motivation to informing 49–54 social approbation, selfdiagnosis and 53–4 dialectical imagery 23–4 diasporas 188, 206n2 digital data 2, 26 digital imaging 2, 4, 25 digital photography 5–6 see also photography Dillon, M. 175 Discipline and Punish: The Birth of the Prison (Foucault, M.) 7 disease denial, diseases of 53–4 illness and, distinction between 48 Disney, Walt 90 Disney World’s Magic Kingdom 90, 91 division of labour 106, 110–11 Dixon-Woods, M. 42 DNA (deoxyribonucleic acid) 13–14

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measurement techniques for 224 profiles and technologies of visualization 13 synthesis of 217–18, 224–5 Dominguez, V. 187, 196 DSM (Diagnostic and Statistical Manual) 69–70, 71, 83n3 DTC (direct-to-consumer) television advertising 38–42, 44, 45, 46–7, 48, 49–50, 55, 56, 59, 60n2 Duden, B. and Hoinacki, L. 17, 18 Duden, Barbara 193 Dumit, Joseph 17, 19, 21, 25, 28, 45, 47, 54, 56, 59, 68, 163, 172, 174, 175, 237 Dumit, Joseph and Williams, S. 158n3 Duster, J. 13 Dyer, R. 202 dysmorphic features 21, 31n17 E Ecks, S., Cohn, S. and Lorimer, A. 25 Ecks, Stefan 20, 25, 26, 27, 121, 130, 237–8 Edlen-Nezin, L. 53 EDS (excessive daytime sleepiness) 53 education brand-awareness advertising in 42–4 and entertainment at MSI, Chicago 90–91 patient cultivation, education in 42–4 Edwards, A. 103 Edwards, E. 4 Edwards, E. and Hart, J. 30n9 Edwards, J., Harvey, P. and Wade, P. 3

Edwards, Jeanette 22, 111n1, 238 Edwards, Paul 180 egg donation cycles 189, 206n10 Egyptian funeral process 98–100 electron microscopy 18 Elliott, Rita 223, 224, 226, 228, 230 embodiment concept of, insulin pumps and 145–8 embodied brains, praxis of 108–11 incorporation or 153–6 see also body embryology 216–17, 220–21, 228 embryos babies and, failure to distinguish between 191–3, 195–6, 205 centrality to UFC practice 198–9 commissioning in transnational ova donation 197 promissory nature of 193 purveyance of 191–3, 195–6 endoscopy 117, 119–21, 124, 127, 128–9, 130, 132 endoscopic images 20–21, 26 gastroenterology, endoscopic enlightenment in 121–3, 132 risks to patients in 131 enlightenment cognitive intentionality 108–9 colonial enlightenment 119–21 knowledge formations, emergence of contemporary 4–5 pre-enlightment thought, analogical nature of 5 spirit as mind 105 Ernst, W. 70

Index

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247

Escobar, A. and Downey, G. 158n3 Escobar, Arturo 138 Escolar, M. 2 ethnicity, transnational ova donation and 190, 202 ethnography, relationships in 15–16 European marketing of pharmaceuticals 44 Europeanness, privileging of 187, 188, 202 evangelical language in pharmaceuticals 45–6, 52–3 Exoskeleton system 176 expert authority 26–7 expert knowledge, separation from opinion 8–9 expert vision 20–25 external worlds, visualization of 8 eye-glasses 6

Fosamax 48 Foucault, Michel 4, 10, 11, 24, 27, 30n5, 30n6, 30n10, 179, 180, 185, 229 Frank, F.and Ecks, S. 118 Frankenberg, Ronald 45 Frankenburg, R. 202 Frankenstein; or, the Modern Prometheus (Shelly, M.) 102 Franklin, S. and Lock, M. 214, 215 Franklin, S. et al. 194 Franklin, Sarah 40, 68, 181, 186, 188, 196, 200, 214, 215, 221, 231n1 Fraser, A. 88 Freud, Sigmund 14 Friedson, E. 133n2 Fujimura, J.H. 10 Fyfe, G. and Law, J. 30n7

F Fabian, J. 15 Falconbridge, Anna Maria 12 Falwell, Jerry 45 Fausto-Sterling, Anne 14 Ferme, Mariane 24 Field, Marshall 94 Field Museum of Natural History 98–100 Filc, D. 189 film, images in 22–3 Fischer, M.M.J. 212 fMRI (functional Magnetic Resonance Imaging) 68, 70, 83n4 foetal imaging 17–19 Fogelson, Ray 111n5 footprints, principle of 88 Forth, C. and Carden-Coyne, A. 133n1 Fortun, K. and Fortun, M. 229 Fortun, M. 221

G Garfinkel, H. 45 gastroenterology 20–21, 117–34 aetiologies, doctors’ reflections on patients’ 128–30, 132 ambiguous status of 133n1 biomedical explanation 128 ‘bowel obsession,’ doctors’ perceptions of patients’ 123–7, 133 bowel topography 124–5 British colonialism in India and 119–21 consultation times, conflict on 125–6 diagnostic centres, spread of 118–19 disease presentations 125 doctors and patients, gap between 121, 123–7, 128–30, 132

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endoscopic enlightenment 121–3, 132 endoscopy 119–21, 124, 127, 128–9, 130, 131, 132 enlightenment in 119–21, 121–3, 132 food as cause of digestive illness 128 gastric symptoms, patients’ presentation of 127 hidden areas in 130–31 illness aetiologies 128–9 Irritable Bowel Syndrome (IBS) 129 jokes in context of 117–18, 126 medical malpractice, selfcriticisms of 130, 131, 132 popular diagnostics 126–7, 128 professional status of gastroenterologists 128, 131–2, 133-4n3 profitability in business of 130–31 psychosomatic aetiologies 129–30 self-diagnosis, doctors’ reflections on patients’ 126 stool characteristics 126–7 visible bowels 118 visualization in 25–6, 118–19, 121–3, 134n1 water as cause of digestive illness 128 Gell, Alfred 31n13, 31n14, 78, 161, 162, 179, 181 gender 97 brain measurement and 14 differentiation in 14 work, dynamics at 233n10 General Electric (GE) 175, 176 genetics 3, 13–14, 21, 27, 66, 68, 189, 200, 212 genotype 13, 21

Gentry, J. 166, 175 Georges, E. 19 Gibbon, S. and Novas, C. 185, 206n1 Glass, Tabitha 107, 108, 112 global reproduction 186 globalization 133 Israeli perspective on 194–5 of science 186 Goffman, Erving 86, 90 Gooberman-Hill, Rachel 157 Good, B. 70, 132 Good, Mary-Jo Delvecchio 55, 56 Grasseni, C. 3, 30n8 Gray, C. 138, 139 Gray, Hables 179 Gupta, A. and Ferguson, J. 120 Guy’s Hospital Medical School 137 H Hallam, E. and Ingold, T. 3 Hammond, E.M. 13 Handbook of Visual Analysis (Van Leeuwen, T. and Jewitt, C.) 31n12 ‘hands free’ operations 166–7 Hanks, W.F. 31n15 Hansen, T.B. 120 Haraway, Donna 4, 9, 10, 13, 17, 85, 137, 139, 180, 193, 198, 213 Harding, Susan 45, 46, 52, 53 Harris, J. Ira 94 Harris, Nikki 94 Hartshorn, W.E. 102 Harvey, P. and Knox, H. 4, 22 Harvey, Penny 111n1, 238 health health-literacy 43–4 information on, moral grammar of 44 proactive wellness 174

Index

wearable bodily augmentations for 165–6, 173–5 HealthMedia 54 Healy, D. 55 Heidegger, Martin 158n10 Helman, Cecil 129 Helmreich, Stefan 232n5 Henwood, F. 42 Herr, Hugh 1 Hertz, R. 101 Hobbes, Thomas 8, 9 Holbein, Hans 30n7 homeopathy 118, 131–2 Hone, F. and Benson, R. 42, 44, 58 Hughes, Keith 107, 108, 112 human life biotechnology and 211–14 commoditization of human biological matter 227–9 human and machine, blurring of boundaries between 139–40, 152–3, 157, 158n11 stigma, human potential and 86 hybrids, advanced technology and 138–9, 157 I Iaccorino, Tony 111n1 IBS (Irritable Bowel Syndrome) 129 ICD (International Statistical Classification of Diseases and Related Health Problems) 83n3 illness, disease and, distinction between 48 image-making practices 6 image-saturation 24–5 images affective power of 20

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of brain 26 of brain, perspectives on 14–15 brain scans, social meaning and 79–80, 81–2 crafted reality in 19, 25–6 cultural imagination and 24 effective power of 20 ‘improving eye’ 7 interpretation of 28 meaning and 22 power of 22–3 scientific images, cultural meaning and 69 scientific images, role of 8 social lives of 18–19 social significance of 24 India 23, 26, 117–34 Ayurveda 118, 131, 132 British colonialism in 119–21 Calcutta, medicine in 117, 120–21, 123, 126, 128–30, 132, 133, 134n4 Indian Society of Gastroenterology 117 inequalities, reproduction of 187–8 information for compliance in pharmaceuticals 42–4 informational augmentation, wearable bodily augmentations and 177–8 informational sciences, developments in 3, 4 Ingold, Tim 87, 110, 111n2 inhalers 158n4 Inhorn, Marcia 188 insulin pumps 29, 137–58 agency, machine and human 152–3 before and after, life experience 143–4

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cost of 143 cyborgs 138–9 embodiment, concept of 145–8 embodiment, incorporation or 153–6 experiential disappearance 154 human and machine, blurring of boundaries between 139–40, 152–3, 157, 158n11 hybrids, advanced technology and 138–9, 157 incorporation of 153–6 mind-body dualism 147–8 paediatric diabetes, treatment for 137–8, 140, 141, 142–5, 146, 157, 158n1 portable syringe pump, introduction of 137–8 practice in use of 149–52 project experience 137–8, 140, 141, 142–5, 146, 157, 158n1 pump-in-action 142–5, 146 relationship of users with 144–5, 146–7 intelligence, awareness and 164–5, 172 interdisciplinarity 3, 4, 8 intersubjectivity 9, 105–6, 146 Irritable Bowel Syndrome (IBS) 129 Irvine, J. 88 Irwin, A. and Wynne, B. 22 Israel 28, 185–207

Israeliness 186–7, 188, 189, 190, 194, 195, 201, 203–4 IVF (in vitro fertilisation) 28 technologies of, hopes invested in 186, 188–9, 195–7, 202–3

visualization technologies and 186 Ivry, T. 189, 190, 199 J Jackson, Michael 4, 146, 157, 158n12 Jay, M. 6, 11, 119 Jeffery, R. 120 Jenks, T. 106 Jewishness, reproduction of 196–7 Jewitt, Carey 31n12 Jimenez, Alberto Corsin 157 Jordanova, L.J. 8, 21, 30n3 Journal of Museum Education 98 Joyce, K.A. 68 K Kaericher, C. 41 Kahn, S.M. 187, 190, 206n3 Kain, R.J.P. and Baigent, E. 2 Kanaaneh, R. 190 Kant, Immanuel 119 Keane, W. 88 Keating, Peter 231n3 Keller, E.F. 213 Kelly, P. 43, 44 Kember, Sarah 5, 10, 18 Kirk, George 177, 178 Klawiter, M. 45 Knorr-Cetina, K. 10, 30n5, 71 knowledge crafting of 9 formation and practices of visualization 5, 9 inaccessibility of 75–6 micro-management of 4 and visualization, technologies of 3 Knox, Hannah 30n4 Kohn, Eduardo 213 Korowai of West Papua 88 Kraeplin, Emil 14

Index

Kravitz, R.L. et al 56 Kroll-Smith, J.S. 53 Kroll-Smith J.S., Brown, P. and Gunter, V.J. 48 L La Mettrie, J.O. 105 labour division of 106, 110–11 transnational ova donation and erasure of 193–4 Lakoff, Andrew 232n6 Lambek, M. and Strathern, A. 180 Landecker, Hannah 11, 27, 211, 214, 221, 238 Laqueur, Thomas 14, 30n3 Latour, B. and Woolgar, S. 8, 9, 22 Latour, Bruno 8, 9, 10, 20, 22, 30n7, 31n16, 88, 138, 163, 180, 223, 232n4 Lave, J. and Wenger, E. 21 Lavie, S. 187, 190 Law, J. and Hassard, J. 139 Learning and Learning Disabilities exhibit (MSI, Chicago) 17, 85–7, 89, 91–5, 101–4, 104–5, 108–11, 112n11 learning disabled persons 95, 97, 112n8, 112n11 Leder, Drew 146, 152, 153, 154, 158n10 leisure applications for wearable bodily augmentations 165, 170–73 Lévi-Strauss, Claude 88, 89, 102 Levins, Ilyssa 43 Liddle, P. 69 Liebes, T. 194 life sciences 211–14 Lilly’s Depression Kit 38–42 liminal processes 50, 52–3, 59, 60n1

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Lock, M.M. 45 Locke, John 88 Lohr, Lenox 90, 91 Lorimer, Anne 17, 19, 28, 69, 90, 91, 97, 238 Lowenthal, Sara 95, 96, 98, 99, 100, 101, 103 Lury, C. 5, 13, 198 Lynch, M. and Edgerton, S. 16 Lynch, M. and Woolgar, S. 69 M MacAllister, Lindsey 111n1 MacCannell, D. 90 MacDonald, Sharon 98, 111n1 Macdonald , Maryon 22 Machamer, R. 166 MacMaster, Daniel 91, 92 McNeil, D. 111n2 McNeil, M. et al. 201 magnifying glasses 6 A Manifesto for Cyborgs (Haraway, D.) 137 Mann, J.G. 90 Mann, Steve 163, 164, 166, 172 Mann, S. and Niedzviecki, H. 164, 166 Marcus, G. and Cushman, D. 15 marketing isomorphism of pharmaceuticals 57 of pharmaceuticals 37–60 strategy for pharmaceuticals, steps implicit in 41–2 Martin, E. 30n3, 54, 65, 85 Martínez-Hernáez, A. 56 Massachusetts Institute of Technology (MIT) 1 material-semiotic configurations in wearable bodily augmentations 180 Mattingly, Cheryl 55, 56 Maudsley Hospital 66

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Medawar, Peter 216 medicalization medical entrepreneur, perspective on transnational ova donation 198–9 pharmaceuticals and 45–6 medicine anthropology of 55, 133, 134n1, 140, 148 illustration in, art of 87 mass medicine 38 medical malpractice, selfcriticisms of 130, 131, 132 Melucci, A. 54, 56 Menair, Suzanne 111n1 mental illness 65–6 see also neuroscience Merleau-Ponty, Maurice 146, 158n12 Messaris, P. 31n12 Mezzich, J. et al. 71 microscopes 6 military engineering computational embodiment and 175–9 wearable bodily augmentations 166, 175–9 Miller, D. 88, 110, 181n1 mind-body dualism 147–8 see also brain Mishler, E.G. 133n2 Mitchell, L.M. and Georges, E. 19 Mitchell, Timothy 6, 7, 8, 15, 30n9, 30n10 Mitchell, W.J. 16, 30n9, 30n10 mixture, transnational ova donation and notion of 190 mobility, connection and 163–4, 165, 166, 168, 169–70, 176 modern subject, emergence of 5 modernity as Age of Reason 119 of gastroenterologists 132

social change and narratives of 2–3 technological transformation and 6 Mol, Annemarie 10, 11, 158n5 molecular biology 11, 212, 222, 224, 226–7 molecular level manipulation 3–4, 14 Morgan, M. 97 Morihisa, J. 69 MRI (Magnetic Resonance Imaging) 76, 83n4, 118 Munn, Nancy D. 85, 86, 100, 103, 111n1 Museum of Science and Industry (MSI), Chicago 85–7, 89 accessibility, ‘vehicles’ of 91, 96 birthday party, use as ‘vehicle’ 96–7, 100 Body Slices exhibit 100–101 brain, aestheticization of 98 brain, spirit as mind and ghost of 98, 100, 104–8 brain, surrounding housing of 101 Brain Exhibit at 91–5, 95–101, 101–4, 104–8, 108–11 ‘Bright Ideas’ box 107, 112n12 contestation 97–8 creative dreamworld in 101–4 education and entertainment at 90–91 embodied brains, praxis of 108–11 Good Teeth and Good Health Go Together exhibit 100–1 Human Body Zone 103 ideological tensions 90 learning disabled persons 95, 97, 112n8, 112n11

Index

multivalence 97–8 personhood 99–100 phantoms in public 104–8 photographs and statuary created by Studio EIS 101–4 promotional graphics 108 sculptures, people as 102–4 spirit as mind 98, 100, 104–8 supportive atmosphere 96 Tabitha Glass, visitor recollection 107–8 target audiences 90 visitor reactions to Brain Exhibit 96–7, 101, 105–6, 107 mycoplasma 226–7 N Nahman, Michal 13, 28, 185, 189, 190, 191, 196, 202, 204, 207, 207n21, 239 nation hope in IVF and transnational ova donation 195–7 simultaneity and imagination of 197 National Civil Rights Museum 101 National Institute for Medical Research 215–16 nationalism, transnational ova donation and 186, 187, 188, 192, 193, 202, 207n13 nature culture and 68 externalization of 5 Nelkin, D. and Tancredi, L. 40 neo-liberalism 194–5 network-centric warfare 175–6, 179 neuroanatomy 14

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neuroscience 66–7 brain-imaging research 72–3 data from scans, volume and reconfiguration of 72–4 neuro-imaging technologies, expansion in 71, 72 neuroanatomical research 89 objectification, issues of 78, 82, 103 pathalogical and ideal, tensions between 71–2, 73 personhood and 68–9 productive tension within 70–74 promissory rhetoric of 81 recognition, issues of 71, 78, 79, 81 tomography, computers and 14, 17, 68, 72, 83n1, 83n2, 118 visualization in 17, 19–20, 134n1 NGOs (non-governmental organizations) 4 NHS (National Health Service, UK) 4, 66 Nielson, H.C. 17, 18, 20 Nitzan, J. and Bichler, S. 189, 190, 195 Novas, C. 68 Novas, C. and Rose, N. 185 Nowland, J. 162 O object, aesthetic choices in crafting of 16–20 objectification of illness 67–8 objectivity establishment of 9 objective truth, visualization and search for 16 patients’ endorsement of language of 76–7, 78 politics of 6–7

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Olmstead, Frederick Law 93 Ong, A. and Collier, S.J. 186, 205 The Order of Things (Foucault, M.) 4–5 organ trafficking 186 Origin of Species (Darwin, C.) 230 Orosz, J.J. 90 ova, transnational donors and recipients, matching of 203, 207n20 willingness of 199–200 P paediatric diabetes, treatment for 137–8, 140, 141, 142–5, 146, 157, 158n1 Pagden, A.R. 8 Palmer, Mrs. Potter 94 Panese, Francesco 5 Panopticon 7 Park, Mungo 12 Parkes, A.S. 231n2 Parry, B. 216 Parsons, Talcott 133n2 patients aetiologies, doctors’ reflections on patients’ 128–30, 132 ‘bowel obsession,’ doctors’ perceptions of patients’ 123–7, 133 brain scans, perceptions of illness and 74–6 doctors and patients, gap between 121, 123–7, 128–30, 132 illness in, neuroscience and relocation of 76–81 images, risks of showing directly to patients 122–3 medical words, patients’ use of 125

objectification of illness and 67–8 objectivity, endorsement of language of 76–7, 78 patient cultivation, education in 42–4 self-diagnosis, doctors’ reflections on patients’ 126 self-selection in marketing of pharmaceuticals 46–7 truthful visualization, patients’ powers of 128 Pattison, William 91, 111n4 Pêcheux, Michel 40, 54 Pegg, D.E. 216 Peled, Y. 187, 190 Pentland, A. 164 persona, evocation of 87–8 personal technologies 162, 163–4 personalization 40, 45 risk, personalization of 44–9 symptoms, personalization of 48 personhood 29 celebration of 99 identification of 107–8, 110–11 learning disabled persons 95, 97, 112n8, 112n11 Museum of Science and Industry (MSI), Chicago 99–100 neuroscience and 68–9 persons and things, reinscription of separation of 178–9, 181 sculptures, people as 102–4 spirit as mind and 105 PET (Positron Emission Tomography) scans 14, 17, 68, 83n1, 83n2 Petchetsky, Rosalind 14 Pfaffenberger, B. 110

Index

Pharmaceutical Executive (PE) 38, 46–7 pharmaceuticals 25 auto-identification 46–7, 47–8 biomedical conviction 46 branded compliance 58–9 checklists for diagnosis 49–50 conversion 45–6, 52–3 depression and 37, 38–9, 51, 57 diagnostic algorithms 39–40 disease, illness and, distinction between 48 diseases of denial 53–4 DTC (direct-to-consumer) television advertising of 38–42, 44, 45, 46–7, 48, 49–50, 55, 56, 59, 60n2 EDS (excessive daytime sleepiness) 53 education, brand-awareness advertising in 42–4 European marketing 44 evangelical language 45–6, 52–3 facilitated awareness in marketing of 43 Fosamax 48 health information, moral grammar of 44 health-literacy 43–4 HealthMedia 54 illness, disease and, distinction between 48 information for compliance 42–4 Lilly’s Depression Kit 38–42 liminal processes 50, 52–3, 59, 60n1 marketing, isomorphism of 57 marketing of 37–60 marketing strategy, steps implicit in 41–2

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mass medicine 38 medicalization 45–6 motivation to informing selfdiagnosis 49–54 ‘ouch’ testing 46–7, 47–8 patient cultivation, education in 42–4 patient self-selection in marketing of 46–7 personalization 40, 45 physicians, motivation of 55–6 retroactive transformation 39–40 risk, personalization of 44–9 self-diagnosis 49–54, 55 social approbation, selfdiagnosis and 53–4 stigma, self-recognition and 53–4 subliminal processes 46, 50, 52, 59, 60n1 symptoms, personalization of 48 word choice in marketing of 54 Zocor 48–9 Zoloft 50–52 phenotypes 8, 13, 21, 97, 189, 199, 202, 203–4, 226 photography 5–6, 16–17, 21, 87–8 learning from photographic images 21 ‘reality,’ photographic vision and access to 6 Schwartz’s themes 109–10 Studio EIS 101–4 visualization, technologies of 6 writing and 7 physicians, motivation of 55–6 see also medicine physiognomy 21 Pickles, J. 2, 30n8 Pickstone, J.V. 3, 30n3

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Pickup, J.C. 137 pictorial realism, emergence of 5–6 Picturing Personhood (Dumit, J.) 68 Pistorius, Oscar 1 plant culture 224–7 plaster casting from life 87–8, 101–4 plasticity of organisms 212, 219–20, 221, 222–3, 228, 230, 231 Plato 110 Plotkin, J. and Swanson, A. 228 pluralism, reciprocity and 12–13 Polge, Chris 215 Pollock, G. 10, 18 Poole, Deborah 8 Poovey, M. 6 popular imagery of wearable bodily augmentations 167 Portugese, J. 187 Post, R. and Orth, M. 165 post-modernism limitations on 10–11 observation and 11 power agential power of artefacts 161–2 autonomy and power relationships 170, 229 biopolitics and 27 of biotechnology 215 and capital accumulation, regimes of 26–7 colonial power in India 120 of empathy and understanding 58 hierarchy and 13 of images 22–3, 28, 128 and knowledge, regimes of 2, 16, 30 of penetrative visibility 82 precision and 19

relations of authority and 7, 170, 229 of science and technology 188 theorization of 10–11 of visualization 118–19, 132 Prakash, Gyan 23, 120, 132 Prather, M. 103 Pratt, Mary Louise 7, 8, 12 Pridmore, J. 91, 93, 94 Pritzker, Cindy 94 Pritzker, Jay 94 Prounis, C. 43, 44 Prout, A. 158n4 psychiatric conditions 66–7 psychiatry 65–6 Psychiatry, Institute of 66 Psychology Today 104 R Rabinow, Paul 3, 68, 185, 203 race authoritative images and 8, 13 malleability of 13 partiality of visualization in 13 racial hierarchy 8 racialized imagery 13 radiography 11–12 Rajan, Sunder 50, 221 Rapp, Rayna 19 reality, realm of 6–7 Realto, Vern 47, 48, 56, 60n2 reciprocal vision 16 surveillance and 12 Reed, C.R. 106 Reeves, Dan 48 Reid, Roddy 59 Reinforced Body 175–9 relationality, nationality and 193 representation 5, 6–7 active role of 74–5 biological representation 79 in future 73

Index

image as aesthetic object and 18 image as crafted reality 19, 25 knowable source of 76 of life 11–12 mapping as 17 material representation of brain 80–81 neuroscientific representations 82 popular culture, representations in 110–11 purposes of 27–8 racial representation 97 representational distance 15–16 in science 69 scientific representation of body 85 visual representations 8, 83n2 reproduction control of 18–19 pressures for 187–8 responsibility 28–9 distribution of 29 retroactive transformation 39–40 Revel, M. 207n14 revelatory powers 20, 122 risk, personalization of 44–9 Robbins, B. 106 Roepstorff, A. 21 Rogan, Laura Lehtinen 94, 112n11 Rose, Nikolas 3, 8, 14, 16, 21, 69, 70 Rosenwald, Julius 90, 94 Rush, R. 91 S Sakurai , J.M. 165 Sarcos Research Corporation 176 Scheldeman, Griet 28, 29, 137, 157, 180, 239

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Scheper-Hughes, N. 186 Scheper-Hughes, N. and Wacquant, L. 227 schizophrenia 66, 68, 70, 75, 76, 80, 82 Schloegel, J.J. and Schmidgen, H. 214 Schwartz, Elliot 102, 103, 104, 109 Schwartz, Elliot and Ivan 101, 102 Schwartz, Ivan 102, 104, 109 Schwartz, J. and Ryan, R. 30n9 science anthropology of 85, 186 authority of 75–6 globalization of 186 internal diversity of 11 learning in, pleasure of 106–7 public life of 88, 111n3 representation in 69 ‘science wars’ 10 scientific truth, visualization and production of 9 signs, embodiment in 88 technoscience 88–9 scientific images, role of 8 scientific research economic role of scientific market 229 market for 222–3, 228–9 science as consumption 227–8 scopic regimes 5, 6, 10 security applications, wearable bodily augmentations 166, 175–9 Segal, George 103 self, embodiment and knowing, relationships of 162–3, 177–8, 180 self-awareness, visualization technologies and 2 self-diagnosis 49–54, 55

258

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self-surveillance, wearable bodily augmentations in 174–5 sensual truncation 22 sentience 164–5 Serrell, B. 101 Shalo, S. and Breitstein, J. 37, 43 Shapin, S. 5 Shapin, S. and Schaffer, S. 8, 88 Shaw, Alison 21, 31n17 Shaw, M. 106 Shohat, E. 187, 190 The Silent Scream (Bernard Nathanson video) 14 Silverstein, Michael 111n1 Sinclair, S. 70 skilled vision 21 slavery 110 smart clothing 172–3 smartness, notions of 165–6 Smith, A. 231n2 Smith, Dorothy L. 47 Snyder, J. 5 social approbation, self-diagnosis and 53–4 social change 2, 27 social consequences of shifts in visualization 26–7 social tension 2–3 Society for In Vitro Biology 222, 223, 224, 233n9 Sperber, D. and Wilson, D. 31n15 Spinelli, M.-L. 90 spirit as mind 98, 100, 104–8 see also brain Stabile, Carole 18 Stafford, Barbara Maria 5, 85, 87, 111n1 Star, Leigh 67 Stasch, R. 88 stem cell technologies 220–21, 228 Stepan, N. 8 stigma 96

de-stigmatization of learning disorders 89 human potential and 86 of illness 77 life chances and 86–7 self-recognition and 53–4 Stocking, G.W. 8 Strathern, Marilyn 4, 16, 54, 138, 139, 161, 181n1, 201 subliminal processes 46, 50, 52, 59, 60n1 Suchman, Lucy 111n2, 158n11, 161, 171, 180, 239 superiority claims of visualization technology 132 colonialism and sense of 7 information superiority in warfare 166, 176–7 of MSI over Disney theme parks 90–91 surgical applications for visualization technologies 22 surveillance all-encompassing 11–12 informal structures of 10–11 modern disciplinary methods of 7 modes of, visualization and methods 12 reciprocal vision and 12 self-surveillance, wearable bodily augmentations 174–5 symptoms, personalization of 48 T Ta, Trang Xuan 111n1 Tagg, J. 30n9 tamagotchi (computer pet) 153, 158n9 tattooing 161–2 Taussig, Michael 23

Index

Taylor, Janelle 85, 111n1 technology close-to-body technologies 157 modernity, technological transformation and 6 technological dimensions, process of visualization 9, 25 technologized bodies and visualization technologies 24–5, 121 see also insulin pumps; wearable bodily augmentations technoscience 88–9 telescopes 6, 203 Teman, E. 189, 190 temporality of organisms 212, 213, 214, 216, 217, 218, 219–20, 221–3, 228–30 Thompson, Charis 193 Thrift, Nigel J. 3, 4, 30n2 Throsby, K. 189 Time 13, 17 time, transnational ova donation and abridgement of 195–6 Tissue Culture Association 224 tissue culture practice 223 Tomorrow, T. 105 toxicogenomics 229 transfection 225–7 transnational ova donation 185–207 aliyah (return), notion of 196–7 Americanization 194–5 Ashkenazi identity 187, 188, 190, 202 availability and 199, 200, 202 babies and embryos, failure to distinguish between 191–3, 195–6, 205 biblical notation 196–7

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biosociality 185–6, 206n1 biotechnology, capital and 193–4 capitalism, emergence of new forms of 193–4 choice of donor traits 189, 201–4, 205 chosen body, idea of 188–9 convenient treatment, rights to 199–200 demographic threat 187–8 diasporas 188, 206n2 donors, willingness of 199–200 donors and recipients, matching of 203, 207n20 effectiveness of treatment 100–201, 205 egg donation cycles, effectiveness of 189, 206n10 embryos, centrality to UFC practice 198–9 embryos, commissioning of 197 embryos, promissory nature of 193 embryos, purveyance of 191–3, 195–6 ethnicity and 190, 202 Europeanness, privileging of 187, 188, 202 global reproduction 186 globalization, Israeli perspective on 194–5 inequalities, reproduction of 187–8 Israeliness 186–7, 188, 189, 190, 194, 195, 201, 203–4 IVF technologies, hopes invested in 186, 188–9, 195–7, 202–3 Jewishness, reproduction of 196–7

260

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labour, erasure of 193–4 medical entrepreneur, perspective of 198–9 mixture, notion of 190 nation, hope and IVF 195–7 nation, simultaneity and imagination of 197 national bodies, transnational imagining of 189 nationalism and 186, 187, 188, 192, 193, 202, 207n13 neo-liberalism 194–5 organ trafficking 186 proliferation of choice 201–4 relationality, nationality and 193 reproduction, pressures for 187–8 science, anthropology of 186 time, abridgement of 195–6 Universal Fertility Centers (UFC) 190–91, 191–7, 198–204 Zionism and 186–7, 199, 202, 205 transparency 4, 69, 88–9, 108–9, 178 Traube, Betsy 111n1 Trumbo, J. 30n11 truth, modern and post-modern regimes of 10 Tsing, A.L. 88 Turkle, Sherry 171 Turner, T. 85, 98 Turner, Victor 37, 50, 52, 60n1 Turner, V.W. and Turner, E.L.B. 37, 59 Tye, L. 38 U ultrasound scanning 18, 21, 117 Universal Fertility Centers (UFC) 190–91, 191–7, 198–204

University College, London 66 Urciuoli, B. 112n12 utility, questions of 10 V Valeri, Valerio 106 Van Dijck, Van 69 Van Leeuwen, T. and Jewitt, C. 31n12 Van Leeuwen, Theo 31n12 Velázquez, Diego 5 Verhoeven, Paul 167 Viseu, A. and Suchman, L. 28, 29 Viseu, Ana 161, 162, 164, 181n1, 239 vision, history of 6 visual imagery, materiality of 9, 27 visuality advertising and 25 of colonialism 7 seer and seen, relation of mastery between 7 skilled vision 21 visualization body, technology and 25 conceptual challenges of new kinds of 6 endoscopic enlightenment 121–3 in gastroenterology 25–6, 118–19, 121–3, 134n1 of gender, brain measurement and 14 IBS (Irritable Bowel Syndrome) and importance of 129 knowledge formation and practices of 5, 9 modes of, surveillance methods and 12 in neuroscience 17, 19–20, 134n1 process of, technological dimensions 9, 25

Index

of race, authoritative images and 8, 13 of race, partiality in 13 social consequences of shifts in 26–7 totalization in 11–12 truthful visualization, patients’ powers of 128 visual imagery, materiality of 9, 27 visualization, focus on 30n11 visualization, technologies of authority, scientific legitimacy and 26 bodily awareness and 2 brain images, production and interpretation of 19 DNA profiles and 13 hierarchies in medical anthropology and 134n1 in IVF (in vitro fertilisation) 186 knowledge and 3 objective truth, search for 16 photography 6 relationships to 2–3 revelatory powers of 20, 122 and scientific truth, production of 9 self-awareness and 2 superiority claims and 132 surgical applications for 22 technologized bodies and 24–5, 121 Voloshinov, V. 88 W Wade, Peter 111n1, 240 Waldby, C. and Squier, S. 220 Warner, M. 105, 106 wearable bodily augmentations 28–9, 161–81

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agency, location of 161–2, 178, 179, 180 awareness 164–5, 172 commercial importance of 162 computers 162, 163–6, 168, 179–80 engagement with imaginaries of, need for 180–81 ‘hands free’ 166–7 for health 165–6, 173–5 informational augmentation 177–8 intelligence, awareness and 164–5, 172 leisure applications 165, 170–73 material-semiotic configurations 180 military engineering, computational embodiment and 175–9 military uses 166, 175–9 mobility, connection and 163–4, 165, 166, 168, 169–70, 176 network-centric warfare 175–6, 179 personal technologies 162, 163–4 persons and things, reinscription of separation of 178–9, 181 at play 165, 170–73 popular imagery 167 preferences, learning of 165 proactive wellness 174 Reinforced Body 175–9 research and development (R&D) 162, 164 security applications 166, 175–9

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Index

self, embodiment and knowing, relationships of 162–3, 177–8, 180 self-surveillance 174–5 sentience 164–5 smart clothing 172–3 smartness, notions of 165–6 tattooing 161–2 working with 165, 166–70 Weber, J. 94 Weiss, Meira 187, 188, 190, 201 Wellcome Trust 66 Wells, I.B. and Douglass, F. 97 Willems, Dick 158n4 Wilmut, Ian 216, 218 Wilmut, Ian et al. 218 Wilson,D. and Pickstone, J.V. 3 Wimmer, A. and Glick-Schiller, N. 186 witchcraft 86 Wolcott, H.F. 95 Wood , C. 164, 165

word choice in marketing of pharmaceuticals 54 working with wearable bodily augmentations 165, 166–70 writer, photographer and 7 Writing Culture (Clifford, J. and Marcus, G.E.) 15 Wysocki, B. 162 X X-ray images 12, 21, 117 Y Yuval-Davis 185, 187 Z Zer, Dr. (UFC, Israel) 191, 196, 197, 199, 200, 201, 207n19 Zionism 186–7, 199, 202, 205 Zocor 48–9 Zola, Emile 67 Zoloft 50–52