Tag Archives: health citizenship

New project description

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I have finally fleshed out the research agenda:

Citizenship has been at the fore of political struggles since before the Haitian Revolution in Saint Domingue, and later Haiti. Beginning with the tightening of colonial citizenship conferral on people of color in 1769, followed by the struggles over the granting of full (, or French) citizenship rights to freed blacks in 1792, thus began a long history of citizenship as a project of exclusion (Garrigus, 2006; Popkin, 2010; Carolle, 2011). American interventions (dating back to the first occupation in 1915) have been particularly successful in reifying these exclusionary practices, often through aid and development projects – particularly in medicine. While much has been written about Haiti as the NGO Republic (World Bank 2008), there has been little excavation of the very processes of economic, political and social negotiation, or citizenship, that have made the NGO’ization of Haiti so pervasive and successful. This project seeks to examine the discourses through which outside aid and development programs have exploited the deeply historical project of exclusion that colours not only Haiti’s history, but more importantly, its present. While these exclusionary processes have been in place for 250 years, and interventionist projects for nearly 100, the 7.0 earthquake on 12 January 2011, has opened this devastated island nation even further to these exploitative interventions.

This project is explicitly interested in the transnational mediation of the health citizenship project in Haiti. Health citizenship is the economic, political and social negotiation related to the rights and responsibilities of individuals to and within the nation-state and of the nation-state to the individual with regard to healthful living. This is not limited merely to access to health care, but includes all that is incumbent in letting live well. That is to say that this research project is interested in the ways in which transnational aid and development project organizations – in this case, USAID (and their role in guiding the redevelopment of Haiti), the CDC (and their role in rebuilding Haiti’s public health system), and Save the Children (and their role in managing health services within the post-earthquake humanitarian context) – are engaging with and mobilizing understandings of Haitians’ health citizenship. Further, this research is interested in considering how these understandings are being mobilized to construct an imaginative geography which has materialized, on the ground, as health enclaves through the international patchwork of health service provision sites and internally through displaced people (IDP) camps. This research is employing an explicitly top-down approach to these questions, meaning, this research will investigate the discourses that drive aid and development projects in Haiti and the impact they have on the geography of health citizenship, from afar. This research project seeks to answer the following questions:

1. In what ways have American and other international aid and development programs been dependent upon the uneven and unequal citizenship rights of Haitians, and (how) did these projects re-inscribe and reify this unevenness – both in the past and currently?

2. In what ways do USAID, CDC, and Save the Children, who have all been charged with managing the mechanical aspects of mediating the health citizenship of Haitians in both the humanitarian crisis and in the rebuilding efforts, understand, articulate, and work toward an even and inclusive health citizenship project in Haiti (or do they?)?

3. How do programmatic understandings of the needs of Haitians translate into geographical demarcations of differential health citizenship? Particularly, how do imagined geographies of need become materialized through the micro-territorialized IDP camps, and how will these be further inscribed as health service areas, or health enclaves?

Implicit in this project is an exploration of the continual exploitation of uneven citizenship projects through medicine and health in Haiti by the U.S. over the past 100 years. This research is specifically focused at the sites of power – among those who define and manage health needs – to explore the processes by which decisions are made that, in turn, will have real and every-day impacts on those experiencing the outcomes of those projects.

Researchers and practitioners have, over the last 20 years, been heavily interested in the impact of international aid and development projects on the lived experiences of the Haitian population, particularly with regard to health (Farmer, 1999, 2004; Chomsky, Farmer & Goodman, 2004; Brodwin, 1996; James, 2010; Schwartz, 2010; Maternowska, 2006). And while examining and understanding the lived experiences of those most affected by aid and development interventions in health in Haiti are extremely important, in the words of Ananya Roy (2010: ix), “It [is] not enough … to understand poverty at the ground zero of lived experience. It [is] also essential to make senses of this management of poverty.” So it is that this research project proposes to engage precisely in those centers of power that manage health.

Nation, health and citizenship

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Our nation-centered view of citizenship can only comprehend the predicament of minoritarian ‘belonging’ as a problem of ontology – a question of belonging to a race, a gender, a class, a generation becomes kind of a ‘second nature,’ a primordial identification, an inheritance of tradition, a naturalization of the problems of citizenship – Homi Bhabha, The Location of Culture

I had a chat with my wonderful committee member, Vicky Lawson, today. She made a great point in the midst of my flustered self-analysis of what i thought was an utter disaster of an oral exam portion of my comprehensives (,or generals). In the context of the work that i’m doing, even as i refuse to engage in the de-/re-territorialization debate around the nation state, there is the issue of what work, exactly, “citizenship” does, particularly with respect to global health projects.

We started by discussing her question: Is “health” the new “progress” of millennial development? My response was wildly off-mark for two reasons: 1) i thought it was Matt Sparke’s question, and i was determined to not simply give him the answer i thought he was looking for, but to get there of my own accord, and 2) to do that, i did what i always do – i back-tracked into the history of it all (all the way back to 1947). What i ended up doing, in the course of answering the question, was giving myself a short course in Latin American macro-economics up to 1973.

It turned out that her question was really an inquiry as she is not familiar with the health discourses around development. After hours of trying to pull apart what the Washington Consensus is, the post-Washington Consensus is trying to do, and what the Millennial Development project (a la Ananya Roy) is trying to do, i blurted out:

Clearly, I’ve not even broached whether “health” is the new “progress” in Millennial Development. What is the new “progress”? It is, I would argue, too early to make too fine a point on it. From the view from nowhere, it’s a dizzying array of highs and lows, promises and failures – a collection of Plans (with a capital P) to end homelessness, eradicate hunger, abolish poverty. Millennial Development reads like a confused MTV moment – torn between the confessional post-Washington consensus moment of blame-shift , the mea culpas of IFIs and the celebratory instance of democratization of development. “Progress,” it seems, depends on the position of the asker.

But the view from Seattle holds a distinct frame of Millennial Development – here, the new “progress” is “health.” Seattle has been home to health innovations for at least 50 years, and has moved from scandalous non-professional patient selection for dialysis to highly-celebrated home of the new frontier of global health. “For Seattle’s global health sector, the party is only just beginning,” touts the Washington Global Health Alliance. The Bill and Melinda Gates Foundation, the Program for Appropriate Technology for Health (PATH), Infectious Disease Research Institute, Children’s Hospital’s Global Alliance to Prevent Prematurity and Stillbirth (GAPPS), Seattle BioMed, and the University of Washington Department of Global Health are the new development centers.But there is an underlying current present at meetings like the ones I attended last summer. Beneath the benevolent face of ‘health for all’ is a recurrent message of security – of our security (oh, well, and theirs, too). There has been a sudden upturn in global health and global health governance as academic terms in recent years (Sparke, 2009). But, although prior incarnations of global health, such as colonial health and cold war health projects were all part of modernizing projects, today, global health is less about the infallibility of technology and its hand in progress and more about a “shared vulnerability” (Brown, 2010; Fidler, 2007). Just as Rose and Novas (2008) have pointed out, biocitizenship has gone molecular – but it is not just about the management of the individual self, the taking responsibility at the genomic level – it is also about the securitization of developed nations against the specialized microbes of the underdeveloped, the transformation of poor societies to manage and contain disease (Braun, 2007).

So what, then, does that do to citizenship? While Marshall was all a-twitter about the growing inclusion of people in citizenship, the emergence of health citizenship would seem to be both inclusionary and exclusionary. No longer the purview of the nation-state, health citizenship has become a frame for understanding the political negotiations of the self within the context of health seeking behaviours. But citizenship is not limited to a set of rights and responsibilities, rather, it encompasses a whole range of social practices that mediate inclusion (or exclusion) in society and the polity of distribution of resources (Lake & Newman, 2002). Since the rise of neoliberalism, geographers have pointed to the “rolling back” of citizenship (Marston & Mitchell, 2005; Sparke, 2006) while others have simultaneously examined the employment of citizenship as a technology of governmentality (Mitchell, 2006; Staeheli & Mitchell, 2005).

Health citizenship, as a frame for thinking about the politicization of health matters, (re-)emerged in the 1990’s in relation to AIDS activism (Brown, 1994). (Health citizenship was first employed in pre-War Britain and Russia by those seeking to shift medicine out of the so-called hard sciences into social science, but that’s a topic for another day.) This early intervention into the involvement of HIV/AIDS patients and activists in the construction of training and health advocacy and access policies was extremely important in developing a democratization of biomedical knowledge as alternative communities worked to share knowledge and resources within the frame of HIV/AIDS activism, creating a new kind of “citizenship” among the participants (Brown, 1997; Robins, 2004). This frame of health citizenship through activism and self-care has developed more broadly, in the last 20 years, to encompass behaviors that speak to individualization of health-seeking behaviors, in general, and biopolitical understandings of health and the body more specifically (Rose, 2001; Braun, 2007). Health citizenship is a dynamic relationship with the body and with civil and social society, transcending binaries of social-political, private-public, and, ultimately, health-sickness (Brown, 1997).

And just as national citizenship is struggling under the uncertainty of a deeply networked and shifting set of power relations, so too is health citizenship. As Sparke (forthcoming) puts it: “the global reterritorialization of governance driven by market-based globalization has also clearly led to a series of reappraisals of the national territorialization of health governance” (4). With the blossoming of philanthropic designs toward global health, there has also emerged a discourse of a different kind of “global citizenship” – one that touts global justice as its underpinning. But these understandings of global justice are within a restricted frame of strategies that are geared not toward the democratization of health processes, rather, through the frame of economic development (Sparke, 2011).

So here we are – we return to the issue of the economic actor. Built into global health programs in the post-Washington Consensus, and even the Millennial Development, frame is really a pedaling back of original designs – to get those ‘underdeveloped’ countries On the Right Track of Development. What these programs do, then, is offer a more humanistic and less economistic frame from within which to begin. These are still about creating the appropriate global citizen – the kind of economic actor who can then claim his or hier citizenship through engagement with the market – not through engagement with the nation-state.

So it is that i return to the question, framed slightly differently: is health citizenship even a useful frame for thinking about negotiations for health within the frame of the meta-narrative of the post-Washington Consensus / Millennial Development / health-as-security frame?

PhC’d

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I’ve passed. Four weeks of non-stop writing, thinking, scribbling and worrying culminating in three hours of my stuttering, stammering, going blank, scribbling notes, laughing nervously and generally willing time to speed up (oh worm-hole, where were you?!), and i got four signatures.

I promptly wandered out, in a daze, and thought quite thoroughly about crying, changed my mind, and went with a friend (a co-Geography-PhC just back from the field) to have a lemonade. And a few french fries. She generously listened to me prattle on and on abou what an ass i made of myself and how excited i am about Next Steps. Visited another friend, met another PhC, who kindly gave me the look of sympathy i needed. It helped that, although she’s in Literature (American Lit), she also knows Geographers (Matt Willson – what-what!). She gave a sympathetic, “I cried my eyes out, afterward.”

It is what it is…

Two things came out of the exam (besides the utter horror at my inability to think on my feet) – i need to get going on that critical race theory that i’ve so inelegantly avoided and that i need to finish disentangling the strands of the capital-citizenship-place nexus.

How did we get there?

I do health citizenship geographies. So, what is citizenship, and how does health citizenship fit into this Millennial Development moment? The usurpation of state legitimacy – through so-called humanitarian intervention (Kosovo, Somalia, Haiti) as well as through global health programs (PEPFAR, USAID; Afghanistan, Hatiti) – has brought the legitimacy of the nation state as a territorially-bounded container into question. There’ve been politely ferocious debates about the de-territorialization and re-territorialization of the nation-state. Recently, there have been discussions of the transnationalization of citizenship. All of this, even in the humanitarian and global health projects, has been driven by money.

Think: who is funding GH projects? Where does that money go? GHP is a $21 billion a year industry – and growing. How many national health systems would that build? How many jobs? Instead, that money is used to buy American or European supplies and expertise. So, here we have a growing industry that is transnationally managing health. What does that do to citizenship?

Taking TH Marshall’s three citizenship projects – his was a utopic vision of an ever-expanding inclusionary progression – health citizenship emerges as a late-capitalist project that is both exclusionary and inclusionary through the very ways that health has become a vehicle for extra-national social service delivery. Targeted health programs create variable health citizenships through enclaving – Who resides within a particular space (place?) – IDP camps, a remote African village, a city; What diagnosis they have – HIV/AIDS, TB, malaria; What demographic they are – women, children, mine-laborers, prostitutes, orphans – these are all markers for enclaving. So then what happens?

There is the inclusionary aspect in the provision of health services. (yay!) There is an exclusion based on a lack of particular specification (boo!). There is negotiation happening to identify through biological markers (citizenship? – see Rose and Braun’s discussion on this point). But to the detriment of political, social and economic citizenship (refer, TH Marshall)…

There’s something there…there is something emerging. But what? Where is that point of juncture…I think i know what i’ll be chewing on for the next several months. (Years?)

General exams the re-discovery of my roots

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I have a theory about graduate school – it only works if you’re humble enough to admit that you’re not perfect, if you submit yourself supple-y to the demands and admonitions, praises and critiques, mouldings and formations of the people you ask to take you on. At the same time, there is another process happening that i’m ever so grateful for – the constant re-examination of who i am and what is important to me: the Why I am Here question.

Today i’ve been writing the postcolonial section of my general exam statement. In some ways it’s been easier than i expected and in others so.much.harder. But the best part of it, even in the midst of the angst of realizing that i just haven’t read enough to be exam’ing, has been falling in love again with the depth of theory. Today’s gem: Gayatri Chakravorty Spivak. Who knew?

She describes the chapters of A critique of postcolonial reason: toward a history of a vanishing present, as not standing alone, but

They are loosely strung on a chain that may be described this way: the philosophical presuppositions, historical excavations, and literary representations of the dominant – insofar as they are shared by the emergent postcolonial – also trace a subliminal and discontinuous emergence of the “native informant”: autochthone and / or subaltern.

The native informant. That seems to be the theme today. Who is the native informant and how does the native informant retain her positionality when even as she speaks, her position shifts? Is there an undoing of her native-ness in her speech? It is in this space that she points to the shift from colonial discourse studies to the transnational cultural studies.

Transnational. What does it mean to speak of the transnational? I’ve been trailing along on the tail of cosmopolitanism over the past nine months – (t)reading lightly, nothing too heavy, as i try to grasp at the meaning of Kant’s cosmopolitan man. It’s been years since i’ve read Kant for Kant’s sake. Maybe it’s time for a perusal. I do need to re-read him before Stuart Elden and Eduardo Mendieta’s edited book, Reading Kant’s Geography.

But what has grabbed my attention is the attempt to theorize about a globalized world without diving headfirst into monolithic descriptions of what it is to be cosmopolitan. There is, of course, the fascinating conversation between Saskia Sassen and Matthew Sparke in Political Power and Social Theory over the new formations of citizenship. For Sparke, there is a transnationalization of citizenship that is happening – not so much a de-nationalization of citizenship, as Sassen would have it. I’m inclined to agree with him.

It occurred to me yesterday that citizenship comes in two forms (not necessarily a singular form) – a cosmopolitan citizenship and a rooted citizenship. These are rough notes on my thoughts (that i scribbled while sitting through a rather uninspiring lecture about health systems), so please forgive their incompleteness. These are not two completely separate iterations of citizenship. In fact, i think i’m imagining them as dynamic and in constant state of re-formation. I’m coming at this from the back-end. Most of my dissertation will be on health citizenship -  a newly emerging citizenship project to follow on the heels of the commonly held economic, political and social citizenships laid out by TH Marshall. This is not my fantastic idea – indeed, i’m borrowing heavily from Bruce Braun, Susan Craddock and Nikolas Rose (as well as Kaushik Rajan, Adriana Petryna, and Vinh-Kim Nguyen, to name a few), so it’s all still a bit wobbly.

Where i’m imagining it going, however, is toward a more geographically nuanced frame. The fixed and rooted point not only to citizenship construction but also citizenship enactment. Citizenship is as much about how a person is perceived as it is about how a person perceives him or herself, thus, the rootedness is the national citizenship (which can be multiple for particular people) both in space/place and in ideologies of nationalism. The cosmopolitan has to do with the transnationalization of citizenship – that citizenship is not only rooted and tied to a specific place but is informed by and works in tandem with transnational movements – of bodies, resources, ideas, etc.

Here is where i’m going with it:

Haitians are rooted in their Haitian-ness. Humanitarian assistance is as much about keeping the Haitian people on their island as much as it is about helping them. That the American military immediately took over the airport after the earthquake and that the Coast Guard stepped up its patrol of the International Waters between Haiti and the US is not surprising – containment. At the same time, however, their cosmopolitan citizenship (not necessarily of their own construction) is coming through international humanitarian organizations.

Health citizenship is the individual and collective negotiations in the politics of seeking and accessing health and health care. That the health (meaning, not just health care and treatment, but all things that encompass what it means to be a healthy person – physically and mentally) of the Haitian people is very much in the hands of outside organizations – that it is being meted and managed not at all through their own devising means that their health citizenship has taken on a decidedly transnational formation. In the crudest sense, for those living in IDP camps (or not, as the 100,000 IDPs outside the Camp Corail can attest), this means that their health citizenship is intimately tied to place – and not just any place – to the small and enclosed spaces (oh – i can hear Lefebvre turning in his grave) of camps. Their citizenship is out of their hands – or is it?

How does this all relate back to Spivak? I am reminded, in reading her, what wealth of insight we can be offered by reading the philosophers and literary authors of the 19th century – what they have to offer us in richness. But more importantly, i’m drawn to thinking of the nebulous identity formation that is not a singular act of an individual even as the ownership of identity is a very personal matter. It is the rootedness of intimacy with the colouring of a transnational world…

And i’ve chased that dragon into smoke…