Epidemic Illusions On the Coloniality of Global Public Health

Visit the link below to download the full version of this book:

https://medipdf.com/product/epidemic-illusions-on-the-coloniality-of-global-publ
ic-health/

Click Download Now

“The game is up for global public health. Richardson
delivers a withering critique of a discipline that has too long
systematically ignored the real structural and political drivers
of disease. If our analysis doesn’t account for class, race, and
colonial power, then we’ve missed the point. Fresh, creative,
and even tricksteresque—don’t miss this book.”
—Jason Hickel, University of London; author of The Divide:
Global Inequality from Conquest to Free Markets
“Far too many of our efforts to achieve equity in health
outcomes for everyone everywhere are underpinned by
dangerous but unexamined assumptions and premises.
Eugene Richardson shows us how to recognize them, take
them apart, one by one, and commit them to the dustbin of
coloniality where they belong. This book is set to become a
prime text for our efforts to decolonize global health.”
—Seye Abimbola, University of Sydney; and Editor in Chief,
BMJ Global Health
“An impressive deconstruction of global health’s colonial
roots. This fine book is as sophisticated in social theory and
history as it is in infectious diseases and medicine. The
author doesn’t just talk the talk of anthropology, public
health, and clinical medicine; he walks the walk, and is as
much at home as an ethnographer in West African Ebola
settings as in the seminar room discussing postmodern
theory, African history, and the imperial background of
global health institutions. A telling contribution!”
—Arthur Kleinman, author of The Soul of Care
Epidemic Illusions
 Epidemic Illusions
On the Coloniality of Global Public Health

Eugene T. Richardson
Foreword by Paul Farmer

The MIT Press

Cambridge, Massachusetts
London, England
© 2020 Massachusetts Institute of Technology

All rights reserved. No part of this book may be reproduced in any form by any electronic or
mechanical means (including photocopying, recording, or information storage and retrieval)
without permission in writing from the publisher.

This book was set in ITC Stone Serif Std and ITC Stone Sans Std by New Best-set Typesetters
Ltd.

Library of Congress Cataloging-in-Publication Data

Names: Richardson, Eugene T., author.
Title: Epidemic illusions : on the coloniality of global public health / Eugene T. Richardson ;
foreword by Paul Farmer.
Description: Cambridge, Massachusetts : The MIT Press, [2020] | Includes bibliographical
references and index.
Identifiers: LCCN 2020011240 | ISBN 9780262045605 (paperback)
Subjects: MESH: Epidemics | Global Health | Colonialism | Anthropology | Africa
Classification: LCC RA651 | NLM WA 105 | DDC 614.4—dc23
LC record available at https://lccn.loc.gov/2020011240

10 9 8 7 6 5 4 3 2 1

d_r0
To my parents
 Contents

Foreword: Gramsci, but More Pragmatic, by Paul Farmer

Preface

Part I: Carnivalization (карнавализация)

Introduction: Pr [Global Health Equity | Coloniality]

Redescription 1: Colonizer, Interrupted (Flash Fiction)

Redescription 2: The Allegory of the Warren (Platonic Dialogues)

Redescription 3: The Pacification of the Primitive Tribes of Lake Geneva

(Nacirema Ethnography)

Redescription 4: WHO’s Semiosis (Semiotics)

Redescription 5: The Ebola Suspect’s Dilemma (Call and Response)

Redescription 6: Not-So-Big Data and Immodest Causal Inference

(Symbolic Reparations)

Redescription 7: Ebola Vaccines and the Ideal Speech Situation (Border

Gnosis)

Redescription 8: The Race-PrEP Study (Counterhegemonic Modeling)

Pre-Appendices

Conclusion: The Epistemic Reformation

Part II: Use Your Illusion

Afterword: Pandemicity, COVID-19, and the Limits of Public Health

“Science”

Notes
Index
 Foreword: Gramsci, but More Pragmatic

One of the great challenges of any social movement is to develop new vocabularies.
—Angela Y. Davis, “Marcuse’s Legacies”

Of a raft of new publications about Ebola, Epidemic Illusions is the most

important I’ve read to date. That’s because Eugene Richardson is asking the
key questions of the day: What do racism and diverse forms of belittlement
and exclusion have to do with epidemics? How do we best understand their
progress and unequal toll? How are these virulent outlooks built into public
health and academic discourses?
These questions aren’t new ones. They’ve been around for centuries and
more, but are being asked, here, by a physician-anthropologist at a time
when many without such specialized training are posing them vehemently.
Richardson’s book appears as the world is covered—unevenly, as ever with
pandemics—by a new disease, and by an awakening to the perils of an old
pathology, his nation’s oldest one: racism has enjoyed a long run in the
United States, where neither public health nor epidemiology, argues
Richardson, recognize their collusion in reproducing it. But this is a global
pathology, as is the coloniality he dissects. These problems persist both here
and there, with “there” meaning (in this book) the former colonies. Which is
to say, the Majority World.
For years, I’ve argued that the discipline of global health equity
represents a sharp break with colonial medicine. But I find Richardson
presents a more compelling, if less materialist, argument. He doesn’t mince
words in arguing that, “as an apparatus of coloniality, Public Health
manages (as a profession) and maintains (as an academic discipline) global
health inequity.” There are several grammatical and formatting qualifiers
throughout the book, including capital letters and italics, but these seem to
be references, and there are many, to a previous century’s logics and styles.
He proposes novel connections, if novelty is defined as an application of
old ideas and insights to new epidemics: drawing on Mikhail Bakhtin, for
example, Richardson proposes a sort of textual “carnivalization” in order
“to unsettle webs of meaning and power in global health.” This, without
question, he has done.
Carnivalization works its way into most pages of this book, even its most
somber ones. Richardson’s prose is often carnivalesque, but he wastes no
time getting serious business out of the way. He acknowledges white
privilege—“You are a colonizer through and through. You can feel it in
your bones, which have never known stunting. It courses through your
veins, through which malaria never has. Every fiber of your being has been
nurtured by centuries of predatory accumulation”—even as he sends up his
own training in anthropology, which he turns on the strange culture of
“experts” in public health and epidemiology. At the World Health
Organization, for example, Richardson the anthropologist “was able to
establish sufficient rapport to examine their relics and join their rituals.”
Is this a joke? An inside joke? A philosophical exercise divorced, as so
many of them are, from the real-world challenges of countering epidemic
disease? It’s not a joke. (“When thousands of people start bleeding out of
their mouths and eyes,” as Richardson quotes in introducing Ebola as a
theme, “sometimes it’s best to take a step back and see where it’s all
going.”) With rare exceptions, global health inequality—and the noxious
ideologies that have been the blueprint for it—have marred most colonial
and postcolonial efforts to address epidemic disease. In a time when more
and more people make the connection between pandemics and social
inequality, with structural racism front and center, our flawed analyses of
outbreaks are too often a form of status quo propaganda, and a mediocre
one at that. For those outside of these circles and facing a heightened threat
from such epidemics, it’s not funny at all.
If the text of Epidemic Illusions is sometimes marked by japery, it’s more
marked by subtlety. Can one operate as an effective critic of modernity
while using its terms of reference? Borrowing from Edward Said,
Richardson approaches global public health as a form Orientalism—in
short, aiming to exhibit the discipline of epidemiology as a discursive space
amenable to cultural criticism. Some of its practitioners, he writes, “have
had their moral outlooks stunted by coloniality.” In these pages, a long riff
about an arcane Ebola debate is often followed by devastating empirical
insight about how such discourse is reflected in the stunted analyses in
much research, writing, and sundry official commentary.
 It can be a most trenchant critique. Why, Richardson asks, is there so
much attention to stigma, often parsed as a local and cultural response to
noxious events, but insufficient attention to structural racism? Why is he
able to find, logging on to PubMed, over 5,000 articles about AIDS and
“stigma,” while there are only 200 or so about HIV and racism? Is it
because the term “stigma” is often used, in practice and sometimes in
theory, to stunt our understanding of the forces promoting suffering among
the afflicted, diverting our attention to their alleged cultural or cognitive
deficiencies, whereas exploring racism, especially structural racism, turns
our attention instead to power—particularly the power of extractive colonial
rule and white supremacy, and the varied regimes of coloniality they
spawned?

2.
As Covid-19 slowed or halted much of everyday social life, and especially
since the murder of George Floyd, a broader audience turned tardily to
questions that have captured Gene Richardson’s attention for most of the
past two decades. I’d like to introduce this book by introducing him.
I got to know Richardson in 2014 in a makeshift Ebola Treatment Unit,
or ETU, at the height of Sierra Leone’s epidemic. After subsequent years of
working and writing with him, I knew this book would be informed by a
profound knowledge of epidemics, extensive personal experience in
responding to them in West Africa and elsewhere, and an enduring
commitment to pragmatic solidarity. What I didn’t expect was the degree to
which Epidemic Illusions would engage in logical and conceptual debates,
and even philosophical ones. Richardson, I thought in reading an early
version of his book, is like Gramsci but more pragmatic (in the Rortian
sense). And while Gramsci was an organizer, Richardson chose tending to
the sick as his praxis.
He was born to an upwardly mobile family in a New Jersey suburb in
1976 and grew up in Florida. His engagement in health and social justice
wasn’t sure back then—“I revered Nixon because Alex P. Keaton did,” he
said slyly when I asked about his childhood—but medicine, not politics,
was the profession to which he aspired. As an undergraduate at Duke
University, he majored in biology as a pre-med and, shortly after
graduating, traveled to Cape Town, South Africa, to continue studies in
anthropology and generally prolong his errant learning. But he “didn’t like
what was going on there, as the university was still hypercolonized. Rhodes
still sat demonically in front of the place, but the movement to fell him was
still sixteen years away.”
Something had happened, clearly, between venerating Nixon and
execrating Rhodes. Richardson next applied to a master’s program in
anthropology in Sydney, Australia. Upon arrival, he discovered that the
program in anthropology was closing. “What else you got?” he says he
asked. “Asian studies, Eastern philosophy, ancient Chinese Buddhism?” So
he surfed and read omnivorously, heading next for China (where he ended
up in, of all places, Wuhan) and then for another semester-long program in
India, where he played cricket with Tibetan refugees and furthered his
studies of esoteric Buddhist philosophy. On a hiking trip in Nepal,
Richardson was stricken with hepatitis E. When his parents came to collect
their son, they found him “terrifically jaundiced” and bought him a return
ticket the next day.
Back in Florida, Richardson “recovered, got a job at a record store and on
a radio show, and took oceanography classes.” His interest in “Eastern”
thought continued unabated, and he decided to go next to the University of
Hawaii to pursue graduate studies on the topic, but was unsure which
discipline to work in. His reading led him also to studies of how social
inequalities, including racism, got in the body. And his interest in health and
social justice, and in pragmatic solidarity, didn’t wither either. These fused
with the relational view of phenomena he had come to embrace, motivating
his application to medical school—against the recommendations of his
previous Buddhist teachers, who said he would destroy all he had learned.
Unconvinced, he ended up taking a master’s in tropical medicine. He
organized a practicum in Peru, where he had his first, if abortive, contact
with Partners In Health, the NGO we both work with. (“I got fired after a
month for being obnoxious—basically I wanted to join the teachers’
protests in Lima instead of doing the hard work of clinical research, tedious
work I now know saves lives” was how Richardson put it. I had no idea
he’d worked with us before the West African Ebola outbreak.) Aborting his
master’s a semester shy of graduating, he took up a volunteer position with
Doctors Without Borders, where he spent five months in strife-racked
Sudan, supervising the clinical lab at a field hospital.
 It was in Sudan, Richardson said, that he saw how even the best-
intentioned humanitarian efforts could unwittingly serve imperial ends. He
returned to the United States to attend medical school in New York City, at
Cornell. By then, it seems to me, Richardson was clearly enough on his
current path, even if the Upper East Side was a tough proving ground for
global health equity. He took a year off from medical school, returning to
South Africa at a time when global health policy fights centered less on
access to therapy—those battles were drawing to a close, even in the
country with the world’s largest number of HIV infections—than on
standards of care, which came to be one of the subjects on which he would
take a repeated and coherent stand.
The standard-of-care issues were anything but carnivalesque. At the
outset of the antiviral era, battles in Pretoria and other cities turned on what
to do to prevent transmission from mother to child during breastfeeding.
Exclusive breastfeeding remained a public health recommendation for HIV-
positive African mothers, but not for those who delivered infants in Geneva,
Washington, or Boston, for example. The alternative recommended to the
affluent world, formula feeding, was deemed by public health experts not to
be cost-effective, sustainable, culturally appropriate, or even feasible. Lack
of ready access to the wherewithal to prepare formula—running water, a
stove or a fire, clean receptacles—was readily documented in the villages
and neighborhoods to which many mothers delivering in public hospitals
across the continent returned. But couldn’t this wherewithal be found?
This and related dilemmas led Richardson to conclude that he needed “to
become better versed in the structural determinants of health and illness.”
Upon graduation from medical school, in 2009, he went to Stanford to
pursue clinical training in internal medicine and infectious disease—to
become a professional pragmatist—and a doctoral degree in anthropology.
He was soon dividing his time between HIV clinic and classes in northern
California. He did much of his doctoral research in South Africa, focusing
on AIDS and tuberculosis, the two leading killers there. In South Africa, he
turned to understanding pathogenic social forces—ranging from forced
removals and labor migration to gender inequality and persistent post-
apartheid racism—and how these might best be mitigated in efforts to slow
epidemics and to deliver good care to those sickened during them. “I
focused on structural violence,” he explained, “since there are
approximately twelve thousand HIV investigators in South Africa looking
at stigma, culture, psychology, local knowledge, and cognition; there
seemed to be even more looking at cost-effectiveness of this or that
narrowly focused intervention.”
I’ve underlined Gene Richardson’s pragmatism (both philosophically and
as praxis) in part because those focusing on structural determinants are
sometimes dismissed as being “impractical,” and in part because I met him
shortly after this stage of his career, at the close of his doctoral and clinical
training. The outbreak of Ebola that began in Guinea at the close of 2013
was first identified as such a few months later. He had maintained his ties
with Doctors Without Borders and volunteered for service, ending up in the
town of Kailahun, in eastern Sierra Leone—leveled by war a decade
previously and now home to an explosive Ebola epidemic. The epidemic
was heading westward to the large cities on the coast of Upper West Africa;
it was an awful time. Since that time is covered in this book, it won’t be
covered here, even though Richardson’s narrative is tucked in between
carnivalized asides about the logics of cost-effectiveness and clinical
nihilism: Ebola, we heard, is too operose to treat properly in such settings.
After arguments about whether or not intravenous fluids could be used to
resuscitate dehydrated Ebola patients in Kailahun, Richardson applied for
the Ebola work being conducted by Partners In Health, an organization he
works with to this day from Harvard Medical School.

3.
It wasn’t until after he joined our faculty that Gene Richardson traveled to
the eastern Democratic Republic of the Congo, where he and several of our
colleagues helped to respond to another large outbreak of Ebola. At the risk
of repeating myself, he is a thoroughgoing pragmatist, just the sort of
person you’d want by your side in the midst of an epidemic.
There are other reasons to be enamored of, and instructed by, Epidemic
Illusions. You will love not only its playfulness; you will love its devotions.
Richardson makes reference to a bit of verse by Bertolt Brecht, the German
playwright who brought us Mother Courage. In his famous “A Worker’s
Speech to a Doctor,” Brecht poses the following questions: