Tag Archives: Matthew Sparke

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?

Citizenship, institutions, and government

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Today, i’m writing on citizenship. I have a vague sense of it form all the prattling i do about health citizenship, but i’ve felt that my focus has been too narrow. So, in three sentences or less, i need to define citizenship and the ways in which it has been employed socially and politically.

In going through my bibliography, i came across a fantastic article by Robert Lake and Kathe Newman that i’d read a few years ago when i was trying to disentangle health citizenship for my master’s thesis: Differential Citizenship in the Shadow State (GeoJournal, 58: 109-120). Their work is what really turned me on to trying to understand it, and using the definition by Gershon Shafir (1998, 23) :

By ‘citizenship’…we need to understand not only a bundle of formal rights, but the entire mode of incorporation of a particular individual or group into society

They go on to say that:

On this view, we look for citizenship not in the citizen but as situated in the social practices of integration and inclusion exercised by institutions of the state (Young, 2000). Under conditions of state contraction and restructuring, however, the state increasingly relinquishes the integrative functions of governance and redistribution while retaining function of repression, exclusion, and social control (Gilmore, 98; Jessop, 93). It is thus increasingly left to the shadow state to provide the arena, the mechanisms and the points of institutional access through which the offer of citizenship is extended and social integration can be accomplished.

Institutions of the state. I’ve been struggling lately with understandings of the state. On the one hand, massive state bureaucracy and surveillance is dastardly. Social services in this country are used as a telescope through which to examine, define, and control the poor. So the exercise of their citizenship right within this frame means that they also lose a rather large portion of other rights. On the other hand, if the state does not provide social services, then who does? and within what frame – with what accountability and to whom? De-democratization of the social services demobilizes the political power of the poor.

But that idea, in and of itself is a bit condescending – as if that is the only way to mobilize politically for the poor – through their collective bargaining for a meaningful social safety net. Then again, people who are struggling simply to survive hardly have time to engage politically or even socially – there is a whole host of much more complex questions that arises at this point.

It’s a question i’ve been struggling with for a few years. Less government vs. more government. What is the role of government? If the government is creating an economic climate that creates greater disparity, doesn’t it then have the responsibility to provide social safety net?

I found in my Master’s thesis a kind of utopia that i was feeling rather brazen to be so gloriously positive about. It was about the Model Cities Program funded by Johnson in 1965 (ish). What evolved from this was not only local institutions (community-built programs) that were tailored to meet the communities’ needs, but through whose process of building created political mobilization – written into the mandates were a return of citizenship to some of the most-disenfranchised populations. I worried that i was being overly optimistic until i met Jenna Lloyd, who at the time was at the CUNY Center for Place Culture and Politics. She had written her PhD on a similar project, also funded with Model Cities money.

This model was a great mixture of government bureaucracy and community involvement. At the time that the clinic i studied was dreamed up, there were 11 major hospitals and clinics within or adjacent to the model neighborhood (not one would was more than 2 miles from anyone within the bounded space), yet all were closed to the people who lived in the area. The only option for children was 11 miles away – it required at least two buses to get to. The clinic was dreamed up and built by the members of the community – and in this process taught the 100′s of people who were involved how to mobilize their citizenship toward concrete action with real consequences. All with minimal involvement from the government.

There is a balance in there that is hard not to fantasize about. Part of the fantastic-ness of it all is the historical legacy of the place – the community remembers and the people who work there and who attend there are reminded every day of the importance of dignity within this social service institute. Jenna’s dissertation did not end on quite so happy a note, from what i understand. Unfortunately, we weren’t able to discuss it in too much detail (i blame that on my own social ineptitude).

So how does this apply internationally? What if, in the transnationalizing of citizenship (see Matt Sparke’s discussion with Saskia Sassen on this), we also transnationlized the model cities project? Or is that too radical?

In the end, the conservatives managed to slowly strangle the program till it died of asphyxiation. A point that has stayed with me and still gives me chills stated that this program had provided a “blueprint for revolution” and “mayors across the nation charged the federal government with financing an attack on city hall.” I feel compelled to note that most of the model neighborhoods (including the one here in Seattle) were African American. Ah yes – citizenship…whom exactly is actually allowed to exercise citizenship and in what ways?

On that note, i am leaving off today with two videos that pose the same question: What if the Tea Party were Black? The first video is a rather inane “discussion” (insultingly so, i have to say) on CNN that fails to actually address the question (let’s not get too radical, now, CNN). The second is pointed and incredibly powerful in its exploration of the topic.