REBIRTH OF THE CLINIC

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REBIRTH OF THE CLINIC
Places and Agents in Contemporary Health Care

C I N D Y PATTON, E D I T O R

A Quadrant Book

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An earlier version of chapter 4 was published in Suzanne Fraser and kylie val-
entine, Substance and Substitution: Methadone Subjects in Liberal Societies
(New York: Palgrave Macmillan, 2008); portions reprinted with permission of
Palgrave Macmillan. An earlier version of chapter 5 was published as Anne-
marie Mol, "Customer or Patient?" in The Logic of Care: Health and the Problem
of Patient Choice (New York: Routledge, 2008), 14-28; reprinted with permis-
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Library of Congress Cataloging-in-Publication Data

Rebirth of the clinic : places and agents in contemporary health care /
Cindy Patton, editor,
p. cm.
A Quadrant Book.
Includes bibliographical references and index.
ISBN 978-0-8166-7018-5 (he : alk. paper) — ISBN 978-0-8166-7019-2
(pb : alk. paper)
1. Clinics. 2. Medical anthropology. 3. Social medicine. 4. Foucault,
Michel, 1926-1984. Naissance de la clinique. I. Patton, Cindy, 1956- .
IL University of Minnesota. Institute for Advanced Study.
RA966.R43 2010
362.1 —dc22 2010033908

Printed in the United States of America on acid-free paper

The University of Minnesota is an equal-opportunity educator and employer.
16 15 14 13 12 11 10 10 9 8 7 6 5 4 3 2 1
 CONTENTS

Preface and Acknowledgments vu

Introduction Foucault after Neolifaeralism; or. The Clinic Here and Now ¡x
Cindy Patton

1 Clinic or Spa? Facial Surgery in the Context of AIDS-Related

Facial Wasting i
John Liesch and Cindy Patton

2 Implications of an Epistemological Vision Knowing What to Do in

Home Health Care 17
Christine Ceci and Mary Ellen Purkis

3 Where Is Community Health? Racism, the Clinic, and the Biopolitical

State 39
Jenna Loyd

4 Repetition and Rupture The Gender of Agency in Methodone Maintenance

Treatment 69
Suzanne Fraser

5 Freedom or Socks Market Promises versus Supportive Care in Diabetes

Treatment 99
Annemarie Mol

6 Clinic without the Clinic 121

Cindy Patton
7 Practices of Doctoring Enacting Medical Experience 143
Lisa Diedrich

Contributors 169
Index 171
 PREFACE AND ACKNOWLEDGMENTS

This volume treats clinical treatment. As members of this project we are

deeply concerned with what happens to the people, both patients and
providers, who enter into clinical transaction/interaction. As feminists
and activist researchers, we have all wondered how we got to this place
and where we might go from here; how, in this case, "the clinic" might be
treated—both in the sense of intelligently describe and of cure.
This project was born when several of us participated in an applied
anthropology conference. Although originally we had not thought to cre-
ate a book based on this event, we soon found ourselves increasingly frus-
tratedby research that used narrow definitions of "clinic" (and allied terms
such as "care") to explore the web of relationships between the sick, the
caregivers, and the institutions through which they meet—namely, the
clinic as perceived in Michel Foucault's broader sense. Although many
researchers invoke Foucault through terms such as biopowerand respon-
sibilization, the fundamental insights of Foucault's most sustained work
on the clinic seem to have drifted from view.
Our work in developing this volume grew more geographically diverse
as we explored the side channels carved by avant-garde researchers in
the humanities and social sciences who plied their crafts at the margins
of medicine. In particular, the research assistant and collaborator Helen
Loshny spent considerable time attending conferences and tracking
down new work in the intellectually aligned areas of history, the theory
of clinical practice, and the representation of shifting styles of health and
healthcare. We are especially indebted to Loshny's efforts in convinc-
ing authors to let us review their work for this volume. We are equally
indebted to Marguerite Pigeon, the staff editor at the Health Research
and Methods Training Facility at Simon Fraser University, for managing

vii
the contributed pieces from submission through completion. I thank Lisa
Weeks, also of the Health Research and Methods Training Facility, who
shepherded the project through its final stages before turning it over
to the publisher. Finally, we are indebted to Richard Morrison, editorial
director of the University of Minnesota Press, who has a keen eye for a
worthy project, and to his former editorial assistant, Adam Brunner, who
smoothed the process through every phase.

viii • P R E F A C E AND A C K N O W L E D G M E N T S
 INTRODUCTION

Foucault after Neoliberal/sen; or, The Clinic Here and Now

CINDY PATTON

THE ENLIGHTENMENT is OVER. Still, the inherited question of how to

mediate the macrostructural (society, now market) and the individual
(citizen, now consumer) lingers in the way of a really bad relationship:
we know it's over—there is no solution, likely it's the wrong question—
but we can't quite find an "exit strategy." We engage in deferral tactics. We
devote our time to requiems for our enlightenment lost. The broad space
of discourse and practice that Michel Foucault called la clinique lies in
tatters, while nations grapple with how to produce "health for all."1 It is
no surprise that I want to return to Foucault, the most rigorous chron-
icler of modernity's constitution. Followers of Foucault have developed a
set of terms to describe the "present" of la clinique, or rather they have
to some extent turned away from the broadest articulation of his idea
by intensifying their focus on a later set of his concepts: biopower and
governmentality, along with techne of the self and responsibilizing (the
latter as developed in genealogical works, which, Foucault [1971 (1970)]
insisted, complement but do not replace the "critical" or archaeological
works).2 Rather than "forget Foucault," as Jean Baudrillard (1987 [1977])
suggests, I want to remember his earlier work, which may contain a set of
utilities—possibly an exit strategy—obscured by the blindingly obvious
fit of the later terms with neoliberalism.
There. I've said the word. I'm now obliged to discuss its meaning in
order to forestall a misreading of the ensuing essays, which provide rich
descriptions of clinical contexts that exceed the concept.
Economic neoliberalism has a long history; indeed, the concept might
just slightly predate the global dominance of political liberalism. In its nar-
rowest sense in the contemporary era, the term refers to a set of policies—
sometimes called the "Washington Consensus"—that formed the basis

ix
for economic recovery policy in Latin America. Nascent antiglobaliza-
tion activists and theorists attacked what they saw as the inflection of an
economic logic (to which they objected) into a much broader social and
political agenda (to which they also objected). Internationally oriented
economic theorists sought to clarify their position, often by asserting the
semiautonomy of the political and the economic. A theoretical battle over
the relationship between the economic ("base") and the social/cultural/
political ("superstructure" and maybe ideology) was thus revived. The
North Americans and Britons who had assumed the mantle of second-
generation poststructuralism sidestepped that debate.3 Having already
rejected economic versions of Marxism (leaving aside the question of
whether other versions of Marxism survive that rejection), poststructur-
alists began to talk of neoliberalism as a form of governmentality,4 and
they soon used the term as an epithet for any plan to set foot on the slip-
pery slopes of individualization and of marketization.
There have been many efforts to clarify the underlying ideas of neo-
liberalism—in particular, to disaggregate neoliberalism proper from other
more explicitly political and moral frameworks that have become attached
to it in different national and transnational contexts. At a certain point,
we begin splitting hairs (or refining our definitions while Rome burns),
but two factors are important to note because they bear directly upon the
question of how to use Foucault's TheBirth of the Clinic: An Archeology of
Medical Perception (1973 [1963]) in the immediate historical context.
Wendy Brown in "American Nightmare" (2006) explains why American
commentators in particular conflate neoliberalism and neoconserva-
tism, the latter with its uneasy political alliance with the New Right. Neo-
conservativism, she argues, shares interests in common with neoliberals,
but recently the relationship of the two separate strands to electoral poli-
tics, along with their underlying motive for their policies, has diverged.
Beginning in the 1970s, after a few decades of cultural separatism, reli-
gious conservatives became attracted to policies like the devolution of
state functions (education, care of the needy) to smaller units like church
and family. Further, they began to find common cause with the conser-
vative wing of the Republican Party, which sought devolution of the state
for different reasons. This combination of forces brought us Ronald Rea-
gan, George H. W. Bush, and his son, George W. Bush. Moral conserva-
tives and neoconservatives differ on issues such as the globalization
of media ("smut on television" versus precondition for homogenizing

x - CINDY RATION
taste to create markets) and internationalism (consorting with commu-
nists versus reconquering the world through U.S. trade relations), and
they even differ on the overarching rationale for their politics. The self-
purported morally relativist neoconservatives primarily want to regain
American military and cultural dominance, while moral conservatives
want to solidify and make explicit America's Christian foundation. Neo-
conservatives are happy enough to go along with Christian fundamen-
talist ideas as long as they don't lead to government consolidation. For
example, abortion is complicated because banning it requires state inter-
ference in medicine, while home schooling is not problematic because it
tends to enhance the market competition for subjects to be educated.
Confoundingly neoliberalism also supports open markets and the
decentralization of some state functions, but it does so with the aim of
expanding the quest for a "good life" that yokes liberalism to democ-
racy; that is, the expanding market enhances democracy, and it is a not
unpleasant side effect that some people make money from it. Thus, pro-
gressives in the United States conflate neoliberalism and neoconserva-
tism because they do not like either mode. Or perhaps it is because the
two at present walk hand in hand; neoliberalism with its more progres-
sive moral politics and neoconservativism with its religious Right voting
base shadow box in the current debates about national defense and gay
civil rights. "Health care reform"—the Obama-era potentiality that is of
most interest in the context of this volume—is as of this writing freed
from the deepest anxieties about the administration's third-way politics
only because the reform plan has yet to detail coverage of medico-moral
techne such as abortion, sex reassignment, and the psychological label-
ing of antihegemonic gender alignments, a practice that remains the hid-
den linchpin of both the "don't ask, don't tell" policy and the Defense of
Marriage Act.
The second major issue in the context of this volume is the important
difference between neoliberalism in France and its practice in the United
States. Monica Prasad in "Why Is France so French?" (2005) argues that
while capitalism in France has undergone considerable adaptation and
development (indeed, perhaps housing the first "protoneoliberal" govern-
ment under Giscard d'Estaing), at the level of policy this change has not
been accompanied by the same confusing overlap with right-wing moral
agendas, despite the successful right-wing backlash that netted the elec-
tion of Jacque Chirac in the mid-1980s. In fact, Prasad shows that in France

INTRODUCTION - xi
neoliberalization has been successful only in some sectors (health care
privatization and the dismantling of unions have been resoundingly unsuc-
cessful) largely for three reasons: the existence of strong and successful
nationalized corporations, the unions' success with massive strikes, and
the fact of an electorate unwilling to support free-market candidates. From
our vantage point, the contestation of neoliberalism by French poststruc-
turalist and postmodernist scholars must be read as an explicit aspect of
political debate, not as the province of disaffected academics and anti-
globalization activists who in the United States are excluded from formal
processes. Prasad's careful historical account shows that France's neoliber-
alism did not arrive whole hog as it did in the United States and in Britain
but rather came in pieces that forced its proponents to engage with the
viable political alternatives of moderate politicians and (nostalgic) radicals
such as Pierre Bourdieu, to pick only one of the most visible "old guard"
who engaged in speeches and editorial writing "against the market." How-
ever problematic the marketization of France and the European Union
has been, debate continues. Moreover, it specifically continues to include
socialist policy, a factor that contrasts with the United States where politi-
cians need only say a word in order to stop, for example, the health care
reform debate in its tracks.
Perhaps I should not have brought up the subject of neoliberalism,
but the contributors to this volume refer to it on occasion, and the vol-
ume's first two readers asked for more about it. Its use by the authors
of the essays has not been to point to tight connections between specific
clinical modalities and neoliberal policy. Instead, directly or indirectly
they question whether the apparent obviousness of neoliberal policy's ill
effects results from the "naturalization" of the idea that neoliberalism has
taken over the planet. The essays suggest places and practices in which
neoliberalism is not only incomplete but perhaps already dead. It is not
possible to argue against the proposition that neoliberalism is everywhere
and in everything: this would require producing forms of data that are
neoliberalism's kissing cousin. The cozy appearance of "evidence-based
medicine" (a domain now fought over by progressives who hope to coun-
ter the Cochrane Review hierarchy of research types by developing vali-
dated scales for social phenomenon like the experience of racism, or for
women the experience of violence against oneself)5 against the value of
ars clinique? has shown on our very own turf how impossible it is to think
about the actuality of health and medicine under the current discursive

xii - CINDY RATION

regime. Producing evidence, I now fear, preempts ars rationale in favor of
duking it out in a reified marketplace of ideas, where the winner is the truth
effect most disembodied from an author. (Evidence-based everything.)

Why Medicine?

Medicine is a rich arena in which to contrast discourse and practice, or

rather the discourse on practice and the practice of practice. The vast
space of market medicine (which sells proliferating pharmaceuticals as
easily as multiplying medical subspecialities) helps to raise the question of
whether postmodern medicine is primarily a change in scale and volume
or whether it is the semiautonomy of marketed medicine—in particular,
the ability to sell directly to patients—that has leveled the walls erected
by the gatekeepers to care: professional associations, social reformers,
financial analysts. The corollary of the new market is the activist con-
sumer who sometimes operates voluntaristically as a lone purchaser, and
at other times, collaborating with other sufferers, works through social
movements to grapple with the frightening agora of an open medical
market. While contesting the very category of "patient" (usually waiting,
waiting, waiting for health) by inventing new subjectivities embodying
emergent and existing diseases, these consumers transform the shabby
act of buying care into the more noble act of demanding the right to care.
But "pure" health social movements have morphed into something else,
something that dampens at least my enthusiasm for the health activism
that I so long pursued and still support. Countering the language of con-
sumer with the language of rights is performed by the people who partake
in clinics, including patient groups such as persons with AIDS; activist
doctors and nurses; feminists; representatives of groups that historically
have been the recipients of inferior care; fans of new technologies and
styles of clinics such as online consultation and support groups; and
architects of patient-centered care solutions to contest the dominance
of experts in health decision making. But the problem with rights-driven
activism in a cybernetic age was almost immediately clear; not only do
persons bear rights but so also do trees and animals and, apparently, cor-
porate "entities." Pharmaceutical companies morphed into agents with
the right to promote their products widely to subjects who had a right
to information and commodities tailored to their needs. Private clinics
claim the right to offer enhanced services to clients who are able to pay

INTRODUCTION - xiii
within otherwise public systems; the government's attempt to distribute
the scarce resource of care infringed upon the right of the well-off to buy
more health care than they believed the public system would offer them.
If we bracket "neoliberalism" then we should also set aside another
term loosely linked with Foucault (though by no means exclusively) that
in concept exhausted medicalization. Thomas Osborne (1992) rightly sug-
gested nearly twenty years ago that readings of Foucault's The Birth of
the Clinic had fallen flat because already they were being read through
(or after mastering) Foucault's later works. In Osborne's account the scru-
tiny of The Birth of the Clinic relative to other texts has produced a quite
lively and politically useful body of scholarship that underscores the
relationship between medicine and surveillance as well as medicine and
self-regulation. Further, in broad terms it undergirds the work on "medi-
calization" read as the unwarranted transformation of a broad range of
bodily, psychic, and social experiences into problems of medicine or
of medical definition. Whether or not providers have a "cure" for these
"medicalized" states they still offer diagnoses, which are in principle a
statement of cause and of cure (once science finds it). The more suspect
arenas of "medicalization" maintain only a transient grip on their patho-
logical object: sexual desires migrate into medicine to be wrestled back
by gay activists, only to be returned to medicine by "sex addicts"; fatness
leaves the domain of morality for the halls of the surgeon (liposuction or
highly risky gastric bypass) to then be set free by fat liberationists, only
to be returned to medicine by endocrinologists who cede some of the
bodies (those whose disorder is will) to the morality plays of reality tele-
vision. Like the premature closure that may be effected by the concept of
"neoliberal" (at least in the domain of "health"), the dissatisfaction with
the idea of medicalization exists even among those who have most amply
used Foucault's insights and method to describe, assess, and offer new
ideas about how to think about and "do" health. Nikolas Rose has exten-
sively deconstructed the very concept that enabled his early work. In a
condensed version of his argument (published in the Lancet, the spawn-
ing ground of medical condensation) he argues that

medicine itself needs to be decomposed. The technologies of the oper-

ating theatre are not those of general practice, or epidemiology, or pub-
lic health medicine, or health promotion. Medicine has no essence, be it
epistemológica! (there is no single medical model), political (the power of
medicine cannot be reduced to social control or the management of social

xiv • CINDY RATION

 problems), or patriarchal (medicine and medics do not merely seek con-
trol over women and their bodies). Medicine is not a single entity: clinical
medicine is only one component among many ways in which individual
and group life have been problematised from the point of view of health.
And medical knowledge, medical experts, and medical practices play very
different parts in different locales and practices. (2007, 700)

Neither Osborne nor Rose blame Foucault for leaving insufficient warn-
ing signals about reducing the argument of The Birth of the Clinic, and it
would be unfair to blame Rose or any of the other critical health scholars
in this tradition for reading The Birth of the Clinic as if it already con-
tained (or needed to be supplemented by) the later concepts and clarifi-
cations (particularly on the question of power). In fact, I join them in the
gnawing feeling that a return to that text in its own right might give us a
better way to understand the components at play in what is very like a
postmodern clinic, or a postclinical medicine. This requires not only an
extension of Foucauldian historical work on clinics but also a consider-
ation of what other forms of research align with Foucault but provide
"positive" evidence of the emerging postmodern clinic.

The Clinic in History

One of neoliberalism's tricks is to double itself by being at once natural

and historical, thus allowing its critics to detail its rise as if this action
could produce its end. But Foucault's form of history is based on the idea
that when the present seems strange it might mean that the present has
already passed, and that something else—something as yet unclear—
is our actual present. Foucault steadfastly cautioned against imaging
the "end" of an era by projecting a future from which one could see the
present as a closed past.
Foucault used the strangeness of the past, the certainty of its under-
standing of its world, to suggest the contingency of or at the least lack of
transparent referentiality among words and things in our present. While
it is exhilarating to see one's own truths as contingent, this understand-
ing of history tells us little about what to do "in the future" or even how
to conduct research in the present. The question of futurity is a hard one
for nonpostmodernists—modernism in its various forms, from liberal-
ism and Marxism to the "framers" literalism and neoliberalism, all relied
on the promise that diagnosis and critique of the present would lead

INTRODUCTION - xv
directly to enlightened praxis. Postmodernists are constitutionally local-
ists; if they have political practices (as did Foucault and virtually all of the
maligned postmodernists of the generation of '68—and not, as Jiirgen
Habermas contends, conservative politics) then they are concerned with
mobilizing the unheard from rather than liberating those already identi-
fied as oppressed, and they rely on a hope that creating space for engage-
ment (as opposed to engaging in dialogue) might lessen the harms that
diffused networked power leaves in its circuits. The idea that a specific
critique won't tell us exactly what to do next is not too troublesome for
postmodernists, who are willing to take a chance in hopes of sustaining
an ethic instead of awaiting a morality in which they are guaranteed to be
"on the right side." Without dismissing the human weight of the question
of a relationship between critical research and politics, the question of
how to "do research" in the present is for postmodernists the more vexing
problem.
In The Birth of the Clinic, Foucault conducts an exhaustive analysis
of shifts in the interrelationship between death, illness, clinicians, and
the spaces in which they work. He argues that this case, though clearly
exemplary, is but one of many that we might examine as part of a history
of ideas. The complex of figures in the swirl of, on one hand, the patient/
clinic/doctor and, on the other hand, the space-time of subjectivity and
knowledge, helps us identify the emergence of the human of human-
ism. This subject/object, the "empirico-transcendental doublet" whose
appearance announces the knowledge formation that underwrites the
double-sided coin of enlightenment, is at once a science of nature and
a system of democratic governance of man. We are more likely to know
Foucault's argument from The Order of Things (1970 [1966] ), but it is actu-
ally in The Birth of the Clinic that he first has this insight about moder-
nity, and in this first iteration the idea is at once more striking and less
clear than in the subsequent analysis of the sciences of biology, econom-
ics, and linguistics.
The Birth of the Clinic opens up two lines of inquiry: the first is extended
through The Order of Things and The Archeology of Knowledge (1972
[1969]), and the second sits fallow for two decades until after Foucault
breaks from the proposed multivolume history of sexuality to instead write
about the care of the self. The first line of thought concerns the very recent
emergence of what we think of as scientific thought, a system that estab-
lishes both positivistic science and the human subject as, respectively,

xvi • CINDY RATION

the means of knowledge and its locus in the modern world. But The Birth
of the Clinic also opens up (and in some sense cannot yet cope with) the
questions of technologies of the self. We see this dual project in the vol-
ume's introduction, when Foucault announces his intent: "The clinic [of
the nineteenth century] is both a new "carving up" of things and the prin-
ciple of their verbalization in a form which we have been accustomed to
recognizing as the language of a 'positive science' " (xviii). This interest is
articulated in his identification of the shift from one medical stylistic to
the next, namely
the minute but decisive change whereby the question: "What is the mat-
ter with you?," with which the eighteenth-century dialogue between doctor
and patient began (a dialogue possessing its own grammar and style), was
replaced by that other question: "Where does it hurt?," in which we recog-
nize the operation of the clinic and the principle of its entire discourse
The clinic—constantly praised for its empiricism, the modesty of its atten-
tion, and the care with which it silently lets things surface to the observing
gaze without disturbing them with discourse—owes its real importance to
the fact that it is a reorganization in depth, not only of medical discourse,
but of the very possibility of discourse about disease. The restraint of clini-
cal discourse (its rejection of theory, its abandonment of systems, its lack of
a philosophy; all so proudly proclaimed by doctors) reflects the non-verbal
conditions on the basis of which it can speak: the common structure that
carves up and articulates what is seen and what is said, (xix)

The problematic of Foucault is not, as some argue, that his empiri-

cal work is on texts long dead rather than on people vitally among us—
that is, that he is a historian rather than an anthropologist. Rather, what
we must grapple with is his carefully documented argument that what
counts as empiricism in the first instance is tied to the apparent realism
of death and its forestalling, disease and its amelioration. That is, before
Foucault treats the research-science disciplines of biology, economics,
and linguistics (as he does in The Order of Things), he launches his argu-
ment about the emergence of modernity in the messy, deeply experien-
tial space installed by and as "the clinic." Fifteen years before Foucault
describes the panopticon and its extension as the carcéral society, he
elaborates "the clinic" and its extension as a relationship between science
and people, between medical practitioners and patients, and between all
of these elements and the state.

INTRODUCTION - xvii
Here and Now

Two of the essays in this volume take up the Foucault of The Birth of
the Clinic by presenting historical accounts (one of which addresses the
text itself). The remainder of the essays combine ethnographic fieldwork,
interviews, and textual analysis to identify the practices that today might
make up "the clinic" as a place where bodies are worked on, subjectivities
are reformed into identities, diagnoses are made practical, and practices
are enhanced or warped by discourses of market and cost algorithms. In
these analytico-descriptive works especially, it is not hard to see traces
of "medicalization" and "neoliberalism." But there is so much more that
eludes or exceeds the market and that works against the supposed draw-
ing of daily life into regimes of the medical. The works in this volume do
not add up to a prescription of what should be done, and they do not
speak in one voice about the relative possibilities of agency for the par-
ties to the clinic. Rather, they propose new approaches for identifying the
"first murmurings of a discourse" that is constitutive of the clinic of the
present and of the future.

Notes

1 In 1978, the World Health Organization hosted a summit at Alma Ata and pro-
duced a consensus paper called "Health for All by the Year 2000," which became
the touchstone for national health plans. The plans themselves then became bench-
marks used to monitor progress toward a bold and broad new emphasis on well-
being for the peoples of the world. The AIDS epidemic occurred in the context
of the early conviction that the world was united or divided by disease, and the
language of the Alma Ata proclamation was widely appropriated by progressive
health planners and activists around the world.
2 As Foucault stated in his inaugural lecture at the Collège de France: "It is thus that
critical and genealogical descriptions are to alternate, support and complete each
other. The critical side of the analysis deals with the systems enveloping discourse;
attempting to mark out and distinguish the principles of ordering, exclusion and
rarity in discourse. We might, to play with our words, say it practices a kind of
studied casualness. The genealogical side of discourse, by way of contrast, deals
with series of effective formation of discourse; it attempts to grasp it in its power
of affirmation, by which I do not mean a power opposed to that of negation, but
the power of constituting domains of objects, in relation to which one can affirm
or deny true or false propositions. Let us call these domains of objects positivist
and, to play on words yet again, let us say that, if the critical style is one of studied
casualness, then the genealogical mood is one of felicitous positivism" (1971, 234).

xviii • CINDY RATION

3 Among the survivors of the French leftist intellectual revolution of 1968 Bourdieu
and Baudrillard remained active and vocal about neoliberalism until their respec-
tive deaths. Bourdieu made his presence known in speeches at labor rallies and
in op-ed pieces assembled "against the market," while Baudrillard was more re-
served and completely devoid of any nostalgia for the form of authenticity that
might once have been believed to underpin solidarity. Despite the gulf in intel-
lectual positions occupied by the men during the course of the second half of the
twentieth century, both believed that neoliberalism's most devious effect was to
self-naturalize (Bourdieu) and to effect an "operational whitewash" (Baudrillard)
of any of the downsides ("negativities") of capitalism off the leash.
4 The first English-language readings of this concept are drawn from Rosi Braid-
otti's English translation in 1979 of the (almost instantaneous) Italian translation
of Foucault's lectures in 1978 at the Collège de France. Braidotti's translation was
adjusted by Colin Gordon for his The Foucault Effect in 1991, and the original lec-
ture was eventually retranslated from the French by Graham Burchell and pub-
lished as " 1 February 1978" in Security, Territory, Population: Lectures at the Collège
de France, 1977-78 (2009), a collection that gives a richer sense of what the con-
cept means in the broader context of Foucault's evolving work on racism, power,
and the state. In retrospect, the work developed from the slim glimpse of "govern -
mentality" vigorously applied the term to the Anglo-British and antipodean con-
text, where ideas of responsibilization that have been so influential on work on
"health." In other contexts, this results in the conviction that neoliberalism is more
successful than it actually is.
5 The Cochrane Review is the gold standard for analyzing health research. The mas-
sive project rates and ranks the quality of research (of evidence) according to type of
research, sample size, statistical approach, etc. Although the qualitative researchers
have toiled long and hard to establish standards for Cochrane to use in the assess-
ment of qualitative research, the gold standard for research remains the random-
ized clinical trial, despite the numerous reports on the degree of cheating done
by bodies in the trials. Researchers are expected to take notice of these literature
reviews, and clinicians are encouraged to turn to them when making decisions
about whether medicines have been proven effective.
Regarding the experience of racism, I am thinking of Nancy Krieger's now
widely used, though not uncontroversial, "perceived racism scale." While the aim
of quantifying and correlating experiences of racism with other demographic factors
promises to explain something about health disparities among racialized groups,
it risks undercutting the effort to attain social justice for African Americans. Rac-
ism is wrong regardless of whether it results in demonstrable health effects.
Similarly, there is something deeply troubling about the felt need to develop
scales to quantify forms of pain experienced by women as done by the fifty indi-
vidually validated scales presented in the Centers for Disease Control's Measuring
Intimate Partner Violence and Perpetration: A Compendium of Assessment Tools
(2006). The rejoinder to this would be "but neoliberal policy required us to justify
our programs and funds by producing such data." (Not a very good exit strategy.)

INTRODUCTION - xix
 6 Part of what makes The Birth of the Clinic a vital text is the story of what hap-
pens to the "art of medicine" as the practices of persons of complex talents, pos-
sessed of historically contingent systems for understanding disease/death/life,
become The Clinic. Paradoxically, the elaboration of twentieth-century medicine—
the clinic that Foucault historicizes—reduces the role of the clinician. The cur-
rent "evidence-based medicine" movement (which, since medicine is the critical
paradigm for many relationships of expertise, has spawned evidence-based move-
ments outside medicine) is the apotheosis of this severing of the doctor from his
or her practice.

References

Baudrillard, Jean. 1987 [1977]. Forget Foucault. New York: Semiotexte.

Brown, Wendy. 2006. "American nightmare: Neoliberalism, neoconservativism, and de-
democratization." Political Theory M (6): 690-714.
Foucault, Michel. 1970 [1966]. The order of 'things: An archaeology of 'the human sciences.
New York: Vintage.
. 1971 [1970]. "The discourse on language." Social Science Information 10 (April):
7-30.
. 1972 [1969]. The archaeology of knowledge. New York: Pantheon.
. 1973 [1963]. The birth of the clinic: An archeology of medical perception. New
York: Vintage.
. 1980. "Questions on geography." In Power/knowledge: Selected interviews and
other writings, 1972-1977, ed. and trans. Colin Gordon. New York: Pantheon Books.
. 2009. Security, territory, population: Lectures at the Collège de France, 1977-1978.
London: Picador.
Osborne, Thomas. 1992. "Medicine and epistemology: Michel Foucault's archeology of
clinical reason." History of'theHuman Sciences 5 (2): 63-93.
Prasad, Monica. 2005. "Why is France so French? Culture, institutions, and neoliberal-
ism, 1974-1981." American Journal of Sociology 111 (2): 357-407.
Rose, Nikolas. 2007. "Beyond medicalization." Lancet 369:700-1.

xx - CINDY RATION
 2_ C L I N I C OR S P A ?
Focioi Surgery in the Context of A/DS-Reioted Facial Wasting

JOHN LIESCH AND CINDY PATTON

GFO4: What I did was get Gore-Tex implants, which are very small strands of
Gore-Tex that are inserted into a channel in the cheeks. So there's four inci-
sions—two on top and two on bottom—and this Gore-Tex gets inserted in
and kind of gets spread out. And then around that is injected what's called
microdroplets of silicone. In theory what's supposed to happen is your nat-
ural collagen attaches to these little microdroplets and it kind of fills in. And
that's exactly what happened.
GFOI: Don't you think it looks natural?

If the eyes are the window to the soul, then the face is a more equivocal
tissue that sometimes hides and sometimes reveals across its expanse
of naturalness. Except for the notoriously beautiful (the celebrities and
fashion models who profit from the face), most of us simply want to
appear natural and maybe a little bit singular through the range of our
good and bad moods, wrinkles and smiles, and character-conveying lop-
sidedness. But for men who are long-term survivors of HIV especially
those whose lives were saved by particular antiretroviral drugs during the
early to mid-1990s, the individual face has taken on a collective shape:
the thinning, even gaunt face of HIV lipoatrophy.
Facial lipoatrophy is one aspect of what is variously called HIV-associated
adipose redistribution syndrome (HARS) or lipodystrophy syndrome, which
are specific components of the more encompassing diagnosis of HIV
metabolic disorder. The various aspects of what is now called HIV meta-
bolic disorder were first recognized by AIDS physicians and the affected
persons who were their patients in the late 1990s, especially among the
first generation of individuals who after 1996 had availed themselves of
the promising new anti-HIV combination therapies called highly active

- 1
antiretroviral treatment (HAART or, colloquially, the "AIDS cocktail").
Like the early moments of the AIDS epidemic, when clinicians began
to circulate information about the unexpected deaths among their gay
patients, lipodystrophy and an apparent increase in heart attacks formed
a conundrum for clinicians writing letters to the editors of medical jour-
nals like the Lancet. Researchers—especially clinician-researchers—
quickly moved to investigate the prevalence, associated factors, and hence
potential causes of these unexpected side effects of what were hoped to be
problem-free, lifesaving medicines.
The denning criteria include visible physical changes such as wasting
at the periphery and fat massing subcutaneously in the neck and viscer-
ally in the torso, and clinical measures such as cholesterol, triglycérides,
and blood sugar values that place an individual within range of being
diagnosed with cardiovascular prodromes and diabetes. In addition, and
controversially, there are dips in testosterone and human growth hor-
mone in some individuals who have HIV metabolic disorder. The par-
ticular pattern of fat loss or redistribution and biochemical changes are
now known to be tied to specific drug combinations, length of time of
infection, aging in general, and the genetically determined composition
of fat-storing cells.
As a surgical procedure, "filling" facial lipoatrophy is still in its infancy.
Further, in most of Canada it is not covered by either provincial health
coverage or the extended plans that many middle-class citizens acquire
as a job benefit. Until recently, most facial surgeries have been designed
to enhance definition by tightening sagging skin across the forehead,
cheeks, and under the jaw (e.g., a "face lift" or "tuck"). For men with facial
lipoatrophy, however, these areas are already far too prominent because
what is lost is the fat that softens the space below the eyes and allows
the cheeks to puff out when smiling, rather than simply pulling the skin
into taut, deep wrinkles. In the interviews that form the basis of this
essay, the men described their conscious decision in their presurgery
years to avoid smiling because their happiness appeared to others as a
grimace. In order to reconstruct the cheek area, surgeons have experi-
mented with a range of compounds, some of which have been used for
the "enhancement" of other areas of the body such as breasts/pectoral
muscles, calves, and buttocks. Given the potentially large new market for
what those with facial lipoatrophy need, the pharmaceutical producers
of the various "filling" substances have rapidly moved their products into

2 - J O H N L I E S C H AND C I N D Y R A T I O N
trials.1 In addition, they have undertaken a remarketing of these products
as somber means of reconstructing damaged faces that is good for more
than merely attaining good looks through cosmetic enhancement.
In this essay, we examine the comments made by seven men with
facial lipoatrophy who spoke to us about their experience in the hands
of the doctors who performed a variety of different types of procedures
designed to "nil in" facial voids. We interviewed ten men, three of whom
had not sought to repair their face. This endeavor, which we called the
"Good Face" project, was conducted in the context of a larger project on
gay men aging with HIV. The interviews were done by John Liesch, a mem-
ber of our community-based research staff who himself has pronounced
facial lipoatrophy, and we employed a snowball sampling strategy to iden-
tify men with frank facial lipoatrophy who might willing be interviewed,
including those who had rejected surgery.
While there is an emerging body of qualitative research on lipodys-
trophy in the medical and psychological literature, this work focuses on
the psychological consequences of bodily change. Studies recognize the
physical discomforts and loss of energy that accompany fat redistribu-
tion and its hidden metabolic changes. But their research interest is in
identifying which aspect is most responsible for psychological changes,
that is, do mental or physical changes "cause" the depression observed
in some lipodystrophic persons? While our interview subjects also talked
about the losses they experienced as their appearance incrementally
changed, we underscore that this loss is not only a matter of regaining
self-esteem but also propels men into a relationship with an unfamiliar
medical speciality that is historically and culturally tied to both gender
normativity and to national identity. Gains in self-esteem as a result of
the "procedure" are, as we will suggest here, ambivalently tied to counter-
balancing transpersonal semiotics that perhaps take back in at the level
of the sociocultural what is offered at the level of the personal. We con-
sider how the private but professional space of the clinic—in Michel Fou-
cault's sense of both a place and a set of practices—forms a space of inti-
macy in which men become implicated in practices of body sensation and
body agency that simultaneously medicalized and masculinized the face.
We want to focus on what the men who have undergone surgery have
to say about their experience, but first we want to make a few remarks
about how our work here aligns with that of other Foucauldians, who
think primarily in terms of biopower and responsibilizing practices and

C L I N I C OR S P A ? - 3
have moved away from Foucault's earliest concerns with the clinic. These
other lines of work are enormously useful in helping us think about the
place of medicine—its discourses and its institutional status—and have
enabled neoliberal approaches to care and to control. And yet to a great
extent they lose sight of the practices that occur within this vast domain
we now call "health." The work here challenges these other uses of Fou-
cault by considering how the intimacy and brutality of surgical practice
allow the "docile bodies" who choose to undergo it to actually evade some
of the larger and contradictory identities and practices swept together
in the context of "living with AIDS." By focusing in some sense very nar-
rowly on the details of the layout of the clinics, the diagnostic process,
and the actual surgery (in its several forms) from the point of view of
the patient, we reveal the tensions within a particular medical practice—
cosmetic surgery—that many view as the zenith of neoliberal ideas of
sellable beauty. The physical clinic veers close to the edge of being some-
thing else (a spa perhaps), and the doctors' views of their work suggest
an uncertainty about the place of this form of doctoring within the larger
professional realm. Rather than undo Foucault, our interview material
about this ambivalent space of intimate medical encounter is very much
what Foucault asked us to look for: murmurings of what can and can-
not be said, with special attention to utterances that seem illogical to us
in our "present." As we have shifted away from the emphasis on the dis-
ciplining and power-networking functions of the "clinic," we may, from
this other Foucauldian ambition, quite possibly have landed in one of
the many locations in which the modern clinic is either incompletely
accomplished, not-accomplishable, or disassembled beyond recognition.
We hope that our surgical subjects suggest some of the reasons why the
"clinic"—postmodern, or postneoliberal—requires us to look as closely
at clinical practices as we have at clinical discourses.
As we discuss below, reconstructive surgery and cosmetic surgery are
two codings of essentially the same practice, namely that of surgically
intervening into the shape of the body. Gay men with facial lipoatrophy
are caught up in a dual paradox: discourses of beauty (excess) versus recon-
struction (wholeness) are linked in the event of this surgery, itself uncer-
tainly suspended between a private act of self-remaking and a public act
of reestablishing the presentation of proper (non-HIV positive? nongay?)
masculinity. Going through a medical procedure provides an equivo-
cal route out of the duality of beauty and medicine, thus paradoxically
reestablishing masculinity through a feminized practice. The place and

4 - J O H N L I E S C H AND C I N D Y R A T I O N
experience—life in the clinic—opens out to form not only spaces of resis-
tance to gender norms but also practices of acquiescence to the inevita-
bility that the body will require medical intervention.

Alternative Techne for Reconstructing Masculinity

Elsewhere (Patton and Liesch 2009) we have shown the predicament

in which gay men with facial lipoatrophy find themselves, cast as they
are in a sea of equivocation about the causes of their individual case of
lipodystrophy the extent to which others recognized their face as asso-
ciated with AIDS, the relative value of beauty for women versus men,
and the utility of good looks for gay men versus straight men. We see
this uncertainty reflected in the contradictory explanations offered to us
by one of the men. This interviewee agreed with most of the others that
facial lipoatrophy is an iatrogenic condition, and that because the dis-
morphism is caused by HIV medication "the government should pay" to
fix the damage (GFOi).2 But he also believed that his visage might bother
him less were it not for the prevailing standards of beauty. Linking his
patient rights rhetoric with the recognition of the social form of beauty
standards, he went on to state that individuals have a "right to feel good
about themselves," which then led him to argue that access to coverage
for what he generally understood to be "cosmetic surgery" should poten-
tially extend to other people and other procedures. Indeed, he cheerfully
reported, he was so pleased with the increased social freedom that his
new face afforded him that, at sixty years of age, he was now considering
a "tuck" to fix a facial sag he believed to be unrelated to his HIV.
This question about whether it is acceptable to want to look better is
implicitly gendered in the very practice of the surgery that accomplishes
the change. Although the men in our study rarely spoke of their face as
a part of their masculinity, they nevertheless drew upon the rhetoric of
masculinity that is implicit in the practice of surgically intervening on
people's bodies. Indeed, there are two branches of such interventions:
reconstructive surgery and cosmetic surgery. Reconstructive surgery was
gendered male after World War I, when the surgical subdiscipline not
only improved its techniques but was given a moral and even nationalis-
tic patina when exercised on the bodies of men who returned from war
with severe battle wounds. Understood as serious business practiced on
deserving men, reconstructive surgery was intended to return soldiers
to their former state of "normal looks." In contrast, "cosmetic" surgery

C L I N I C OR S P A ? - 5
seems to have developed in relationship to cultural demands for women
to achieve certain beauty norms. While there was much trading of tech-
nique between reconstructive and cosmetic surgeons, the latter's job was
not to return women to a former state of normalcy but to help them
exceed the perceived limitations of being ordinary, aged, or even ugly.
Men also increasingly availed themselves of cosmetic surgery in order
to stay competitive in professions that required maintaining a particu-
lar public face (for example, marketing executives), but in doing so they
were perceived to be neurotic or gay. That is, they were not employing
surgery to return war-damaged bodies to a state of normalcy, but instead,
like women, they were taking the short route to achieving beauty stan-
dards (Davis 1991).
The majority of men we approached about being interviewed were
generally inclined to get their faces fixed if they could. Of the three we
interviewed who had not undergone surgery, only two were adamant
about refusing the treatment. The third was on the verge of beginning
the process, which usually starts with an initial consultation in which
the face is "graded" according to the extent of fat loss. But what do these
refusals and explorations actually mean? Few men can either afford the
procedures or have the connections or perseverance to get accepted into a
research study, so in reality the desire remains abstract. Plenty of people
consider making changes to their appearance, but relatively few carry out
these "makeovers" because they prefer—or simply lapse into—a com-
fortable discomfort with who they already are (or rather appear to be).
One man who had declined to have surgery criticized others for being
ashamed of their distinctive faces, which he argued were tribal markers
of survival. But his position was not a contestation of vanity, as he admit-
ted that if he found his teeth to be displeasing then he would immedi-
ately have them repaired. A man who had been "fixed," meanwhile, was
so pleased with his return to facial normalcy that he was beginning to
think about getting something done for the "tummy thing." His acknowl-
edgment that, at present, there is no surgical intervention for "crix belly"
led him to ruminate about his alternatives. He told us that he didn't exer-
cise or "eat properly," and he bemoaned the irony that when he put on
weight it went to his belly instead of his face. In essence, he came back
around to a discourse of laziness; his body prevented him from solving
his own problem by refusing to put his fat where he wanted it. A different
man who had not undergone surgery was very active in yoga and other
self-care strategies, and he believed that he was "fighting aging more than

6 • J O H N L I E S C H AND C I N D Y R A T I O N
medication." Another had longed since he was a child to have his promi-
nent ears reduced but had equivocated when his partner offered to help
pay for surgery. In the end, he entered a facial-filling study and was able
to have his face fixed for free, although he was among those who had
entered studies who said they would not have paid to have the work done.

A Pain of the Face

All of this talk about beauty suggests that men only seek surgery because
of the way they look in the mirror or to others. But there is more to lipo-
atrophy than what appears on the surface of the face. We now move out
of the abstract space of the social imaginary, of the semiotics of facial
lipoatrophy and place this face in the cosmetic surgery clinic—a space
of medical intimacy and social politics. These subjects of surgery are not
simply filling out a visage marked by their ailment but hoping also to
undo a damage that is very painful.

GFOS: I was talking to a colleague who had not had the procedure done and
he—he suffers from a tremendous amount of facial wasting He was talk-
ing about one guy who looks as though his face has been shrunk-wrapped
with that hermetically sealed plastic-vacuum-packed look. And when he
said that... I almost had a visceral reaction because I remember what that
was like for me and I remembered how much it hurt—it physically hurt my
face—in the shower in the morning when I would wash my face So it's
not just a psychological and emotional consequence impact but there is
physical pain associated with loss of facial fat.

Because the face inextricably links self/consciousness to public/pres-

entation, these men cannot separate their private physical pain, the
shared pain in mutual recognition, and the pain of recognizing the pain
of the other. For those who are the subjects of facial wasting, and therefore
subjects or potential subjects of surgery, this pain merges into a single,
vague ache. This whirl of types of pain haphazardly and sometimes pro-
grammatically leads men to the office of the surgeon, not for a heroic act
of reconstruction but for something they view as another "procedure,"
a banality in a life filled with trips to the clinic. This man's description is
characteristic of this fact:

GFO2: It was just another doctor's appointment—I mean, they're a very reg-
ular thing and it was just another one—it was nothing special.

C L I N I C OR S P A ? - 7
A second man was barely able to remember his initial appointment,
although he must have been as shocked by the size of the implants as we
were caught by surprise by his blasé recontextualization of the event in
which he tucks the whole consultation into a day of being dropped off at
and then retrieved from another appointment:

GFO8: It was very fast. [There was the] consultation, and he showed me the
little silicon sort of like spoons that they would put in. And he held up three
different sizes—I took the largest—and I remember going in that day in the
morning, like at 11-ish or 10-ish and getting picked up by my partner at 3.

These casual descriptions of the banality of the clinic belie the real-
ity of the procedure and suggest that for men whose lives require going
to the doctor a lot, the whole experience is "normal." In the larger context
of whole communities of medicalized people, "normal" means routinely
placing one's body in the hands of doctors whose activities necessar-
ily require of the patient the fortitude to withstand painful and intru-
sive procedures. There is a kind of weariness underneath the details of
these trips, an active acquiescence to the passivity of "being patient" and
attending the clinic as a chore.

GFO2:1 was there for almost two hours. First a cream to deaden the nerves
in the skin, which is the same kind that's used for any laser procedure. Then
like dental nerve blocks in the mouth—about at the upper lip corners and
the bottom to completely freeze the facial muscles. And then a series of
little needles across the face where the procedure was going to happen to
deaden it even further. Then the large-gauge needles to actually apply the
product. They were sixteen-gauge needles and it was not comfortable—
even with all the anaesthetic you could feel it happening and as it was pro-
gressing it became progressively more uncomfortable, but not enough to
say "stop." Because I had seen the results on [a friend] it made it even easier
to accept it, it's going to be uncomfortable. But you know, sometimes no
pain, no gain.

The culturally constructed and masculinist ethos of "no pain, no gain"

is only the most available socio-psychological explanation for the will-
ingness of these men to undergo surgery on that most intimate and most
public of spaces—the face. The other possibility is that the clinic itself,
both the physical space and the practices—the medical gaze as well

8 - J O H N L I E S C H AND C I N D Y R A T I O N
as the medical touch (Foucault 1973) —that comprise it, transforms the
personal experience of a highly social face into a more proximate and
tactile tropic of intimacy between doctor and patient.

Clinic or Spa?

The idea that facial reconstruction is the proper right of a wounded man
provided a logic through which the men in our study were able to nego-
tiate the cultural accusations of vanity for trying to remove the signs of
AIDS that might in turn cause them the harm of discrimination. But the
attempts by the men to constitute their facial surgery as a kind of recon-
struction (e.g., the serious repair of a physical disorder and not simply a
frivolous cosmetic cover-up) are made more difficult by the physical lay-
out of the clinic. At the same time, that layout seemed to make their expe-
rience of having their face objectified and in most cases painfully worked
over more palatable ("There was a little bit of bruising" [croa] ; "I couldn't
believe it—it was so swollen" [GFOS]; "There was a light bit of redness"
[GF06]; "I ended up with black eyes" [GFO?]). Perhaps this is why it was
sometimes easier to forego the image of the battlefield-like surgical suite
in favor of something considerably more like a spa, albeit a feminization
of the activity they were about to undergo. As one interviewee recalled
when asked about the clinic:
GFOS: Beautiful offices! And I did see the signed letter of Katharine Hep-
burn. Oh it's a beautiful old office—gorgeous furnishings and nice music
and lovely leather furniture and gorgeous staff, lust absolutely flawless skin
and complexions, everybody there looks great!

Not only does the space offer a relieving counterimage to the mascu-
linist surgical suite, it also places the form of medical practice at some
distance from the usual image of the cold-mannered, scalpel-wielding
surgeon. Poised between the serious practice of reconstructing damaged
bodies and the Botox spa culture of popular media, facial filling entails a
very personal kind of doctoring. The interviewee who visited the attractive
office continued his account, weaving and bobbing between a description
of surgery that compares with a battlefield scene of "excruciating" pain
where "each individual sting was all right, but when you had multiple
stings..." to the banalizing gesture of contextualizing the day as but one
among many in the life of a person living for a very long time with HIV.

C L I N I C OR S P A ? - 9
 GFOS: [The doctor's assistant] held my hand and stroked my thumb—it was
very comforting—and so the first needle went in and it stung—but you
know we're so used to being poked. What's another little poke?

Almost all of the men describe this kind of vertiginous date with sur-
gery that is divided between personal attention reminiscent of a spa and
objectivizing clinical practices that invoke the surgical suite. Revealing the
gallows humor that long-term patients must adopt if they are to remain
at the center of their own care, one man described his procedure (which
entailed the injection of relatively large quantities of gels under his skin)
by undercutting his preferred interpretation of the event (a facial mas-
sage) with his recognition of the real nature of the surgical activity:
GFOI: He gives you quite a facial massage [laughter], really a heavy facial
massage, because he's moving [the filler] around underneath the skin and
smoothing it out.

Pride in the Product: The Art of Diagnosis and Diagnosis of Art

In an interview set filled more with contradictions than with conclusive

evidence of shared experience, the most striking descriptions come when
the men tell us about how they were chosen by their doctors either for the
studies or for the limited number of low-cost slots in physicians' regular
practices. We must read the men's descriptions against the sensational
television stories about unnecessary cosmetic surgery given to people
who to all the world look "normal" or even "beautiful." Both our inter-
view subjects and the surgical discipline upon which they rely have had
to struggle to defend the seriousness of reconstruction. Because the evo-
lution of filling compounds and techniques has resulted in a new appli-
cation for people living with HIV-related facial lipoatrophy it becomes
possible to join the requirement to test new medical products with the
subjects' desire to have their faces repaired. Constituting at least some of
the surgery as research moves the "face" doctor's activity into the realm of
science. And of course clinical trials must have objective procedures, so a
group of specialists has been hard at work to develop an official diagnos-
tic tool (as opposed to the cosmetic surgeon's reliance on what patients
perceive as their beauty deficits) in the form of a scale that "grades" the
degree of severity of an individual case of facial wasting (Ascher et al.
2006). Most of our subjects had been involved in trials or special access
programs, so we assumed they had all been "graded" or assessed in some

10 • J O H N L I E S C H AND C I N D Y R A T I O N
medical manner. A few did not remember this aspect of the process or did
not register it as an event of diagnosis. But one man is clear that he was
given a diagnosis; indeed, he dances quickly from the pain he endured to
his doctor's happiness at finding such a bad case to treat:

GFoy: It was the most painful thing I've ever been through in my life, just
dreadful, just dreadful. He was glad to take me on because I was a category
three, I think he said, the worst one: three or four.

If the patient has slipped around on the oily surface of diagnosis ("a
category three... the worst one: three or four") the experts do not expect
much more traction with a newly devised tool. Instead of finding the sci-
entific high ground that objective diagnosis would provide, the consulta-
tion on how to define facial lipoatrophy done in 2006 by the Facial Lipo-
atrophy Panel reveals that they have run aground on the same old shoal
where reconstructive surgery and cosmetic surgery converge:

The final consensus of the Facial Lipoatrophy Panel encompasses both

aging and disease states: "Loss of facial fat due to aging, trauma or disease,
manifested by flattening or indentation of normally convex contours." The
proposed grading scale includes five gradations (Grades 1-5; 5 being the
most severe), and the face is assessed according to three criteria: contour,
bony prominence, and visibility of musculature. Categorizing the presenta-
tion of facial lipoatrophy is subjective and qualitative, and will need to be
validated with objective measures. (Ascher et al. 2006,1058)

The very possibility of a grading scheme (albeit one that still needs to be
"validated with objectives measures") pulls facial filling toward medico-
science and away from the spa, but the activities the doctor and patient
engage in as they prepare for surgery undermine this bid for objectivity.
The idea of the masculine surgical suite and feminized spa collude in
providing alternating framing devices that enable the ambivalent (and
ambiguous) patient to a movement toward his "filling." Once on the scene,
the opulent use of photographs suggests that the entire operation maybe
part of a portrait session in which the doctor exercises his or her agency
on the palette of the patient's face.

INTERVIEWER: Did you show him pictures of yourself—like "before"?

GFOS: They take a picture before, and [a friend] said take a lot of pictures of
yourself before you have it done because you'll forget what you looked like.
INTERVIEWER: Didyouhave pictures of yourself frombefore the lipoatrophy?

C L I N I C OR S P A ? - 11
 GFOS: Oh no. He didn't want to see that.
INTERVIEWER: No?
GFOS: He's an artist, and so he just steps back with his Magic Marker and
like your face is a canvas—he makes all these marks and then he goes to
town.

In one leap we go from diagnosis to Platonic ideal, from a careful grad-

ing process entirely in the gaze of the doctor to the intimate relationship
of model to artist. Contra the arguments that suggest that anything and
everything about modern life has been medicalized—a plausible obser-
vation from a "society-eye" point of view—the techne of specific osten-
sibly medical spaces suggests that there is more collaboration between
doctor and patient toward the very private goal of producing something
else inside the rubrics and justifications of medicine. Is this resistance?
Not quite, but rather it is a kind of tactical erosion of the proper dichotomy
between, in this case, medical clinic and rejuvenation spa. Tactics, those
concerted actions that amount nevertheless to a rejection of the spatial-
ized order, as Michel de Certeau puts it, "cannot count on a 'proper' (a
spatial or institutional localization), nor thus on a borderline distinguish-
ing the other as a visible totality.... A tactic insinuates itself into the other's
place, fragmentarily, without taking it over in its entirety, without being
able to keep it at a distance" (1984, xix).
The doctor's photograph demarks this borderless border, it is part
of both the diagnostic process and also the visual narrative of the face's
transformation. The patients themselves rely on these documents to make
real the strange events that have occurred on this face. Indeed, several of
our subjects volunteered to bring us "before and after" photographs of
themselves. Slightly shocked, we immediately declined; indeed, we tried
to put the question of their possession of such images out of our minds
(or rather, out of the interview). In part we were concerned about pro-
tecting our subjects anonymity (it had not even occurred to us to put
a collection of photographs in our ethics review). But also, as research-
ers, we admittedly had some slight revulsion at displacing the here-and-
now of the event of interviewing with a discussion of pictures that would
somehow tell the truth of the matter. Our concerns about anonymity, at
least, were misplaced: we have subsequently seen our subjects (with a
black bar over their eyes) in articles and at conference presentations.
For whom were the photos taken? When do the photos cease to be part
of a diagnostic process and become a kind of carnival in which doctors

12 - J O H N L I E S C H AND C I N D Y R A T I O N
are now magicians? We pressed one subject about the photographs of
himself. He somewhat dismissed the whole issue by acknowledging that
photos were taken but then categorizing them as being on par with
the many other forms of medical information that have been collected
about him:

GFO2: He took a lot of pictures that could have been—there can be all kinds
of things that were in the chart that we didn't really know about.

In all of the discussion of photos, never once were photographs from

the period before the onset of facial atrophy part of the collection. It was
as if the men couldn't remember the face before the fall but rather only
the one after the repair. Or as if the story of their face began at diagnosis
and projected out into a forever-after in which the new face is not meant
to be compared to the original face of a younger man but rather to be
understood as a work of art. It is a reconstruction but a copy without
an original, a face naturally pulled from the patient's bones and the sur-
geon's artistic eye. Paradoxically, this invocation of artistry, at odds with
the quest for objectivity in the diagnosis, is the final hurrah of the dis-
course of reconstruction: to ask for an earlier self or a different one would
cross the line into the cosmetic. There is some tragedy in this final, subtle,
assent to the discourse of stoic masculinity that invoking the reconstruc-
tive rationale for surgery requires. Through the range of alternating posi-
tions—the artist's canvas, the master masseuse's body-object—they are
prevented from fully realizing their desires for a new face: the men must
make do with what the doctor orders. They pass from the bodily pain
caused by their atrophy through pain inflicted by the surgeon, and then
they must think of the results not as the face of their will and desire but as
a prosthesis whose success is pronounced in another's voice. There was a
marked difference in the way the men talked about the freedom their face
gave them in the social world and in the way they described their post-
surgery face in the context of the clinic. They spoke of their social face in
active voice and loving detail, joyful accounts of recovered self-esteem
that are rendered less certain when juxtaposed with their description of
their relationship to their doctor after the surgery.

GFOS: At the six-month point he did measure the thickness of my cheeks

and they were larger than they were earlier, sol think in fact my own cheeks
are growing I had over 12 cc put in. I think he overcompensated a bit,
but it looks fine. He did an exceptionally good job. He is very pleased with

C L I N I C OR S P A ? - 13
 the results and I am very pleased with the results. He said of all the twenty-
odd people in the study, I've by far had one of the best outcomes.

Here the interview subject is unable to follow through in his criticism

of the doctor's work ("I think he overcompensated a bit") and instead
accepts what he got ("but it looks fine"). If he had secretly hoped for a
new radiance in his visage, he seems only to be pleased in a second-hand
manner: he is pleased to have been the source of the doctor's pleasure,
his "best outcome" among "the twenty-odd people in the study."

Conclusion: Intervening in Intervention?

I was diagnosed with HIV in 1994 with 140 T cells. After seven years of
antiretroviral therapy, I started to develop lipodystrophy. My legs got
thinner, my belly got bigger, and my bum became almost "undetectable."
With sunken eyes and sunken cheeks, I felt like I had AIDS written all
over my face. I looked weak, exhausted and sick I was exasperated
by the slowness of the health network to recognize the serious effects
of lipodystrophy on the health, physical integrity and quality of life of
PHAs. I wanted desperately to do something about this, so I joined
LIPO-ACTION! — a direct action group in Montreal that was created by
lipo-laden PHAs and their sympathizers....With 70 active members in
Quebec, we've organized many creative and theatrical demonstrations
at HIV events, where our Upo characters wear masks and balloons as
bellies and humps, hold up placards with smacking slogans and shake our
big noisy pill boxes. Our troop of "HIV mutants" and archetypal characters
represents different facets of the reality of lipodystrophy.
MARTIN MAILLOUX, "LIGHTS, LIPO, ACTION!" 2OO5

In drawing on the direct-action style of ACT UP in the 1980s, the Montreal-

based LIPO-ACTION use the grotesque theatrical to underscore what it
is like to live on both sides of physically apparent signs; they expect their
audience to make a somatic connection to the feeling of being a strange
body at the same time that they recoil at the sight of such unsightly bodies.
This kind of ethical challenge is a shot across the bow of intellectual pol-
itics, a blow beneath the belt. In their list of demands, LIPO-ACTION
wants changes in the medical system from top to bottom. Much like the
early efforts of ACT UP LIPO-ACTION argues for research that empha-
sizes the development of HIV medications that are not accompanied by

14 - J O H N L I E S C H AND C I N D Y R A T I O N
such severe side effects; for greater autonomy for patients who want to
select combination therapies that will avoid the visible effects, even if
their doctors believe the therapies are less effective; and, only finally for
greater access to health plan coverage for the two surgeries necessary to
reduce the effects of the two fat maldistributions that those affected view
as most disfiguring: facial wasting (which requires 'fillers') and buffalo
humps (which require liposuction), the surgeries for which are consid-
ered "elective" because they are conducted for "cosmetic" reasons.
Qualitative research implicitly promises to identify solutions to indi-
vidual predicaments or social problems, and thus it is inescapably at the
nexus of the intimate and the political. We support activist efforts to secure
for people with HIV coverage by health care plans of surgery for the sev-
eral morphological conditions related to HIV metabolic disorders. But
while we endorse the founding impulse of LIPO-ACTION, we also under-
stand that neoliberal politics will choose (a probably capitalist-based)
insurance solution to a fundamentally social problem. The location of
this "face" at the interstices of multiple contemporary discourses about
disability, aging, and social discrimination requires us to weigh carefully
the politics of health coverage with the effects of the further medicaliza-
tion of both the face and the self (i.e., as the locus of "esteem").
We would not like to see the complex argument embedded in the
agitation-propaganda visual effects that demand more of the interlocu-
tors than simply agreeing to the fact that "the government should pay."
Where is the line between a body politics of "HIV" (and other) "mutants"
and a solution that—except for the payment mechanism—is basically in
the hands of pharmaceutical companies and surgeons?
In this essay we have stepped away from the discourses of self-esteem
and depression that characterize most of the research on and public dis-
cussion of facial lipoatrophy. We align ourselves with the challenge posed
by the body politics of LIPO-ACTION, even as we question their strate-
gic use of accessability discourse. We focus instead on the practices and
discourses of the clinic, the intimate space in which the face is remade.
We show how the practice of facial filling is bound up in larger dis-
courses of masculinity, and how the individual patient becomes impli-
cated in intramedical speciality battles over legitimacy. Constantly shifting
between comforting practices (massage) and justifying discourses (recon-
struction), men by turns resist and give into a medico-social world that
gives them a new face. The heroic and the abject intermingle in the clinic:
the doctor's intimate touch rests uneasily beside his implacable gaze, the

C L I N I C OR S P A ? - 15
patient's determination suddenly gives way to acquiescence. As we have
suggested, however happy a man is when he shows his face in the outer
world, the larger process of the facial surgery clinic prevents him from
ever fully embracing this face as his own. In the gambit to be recon-
structed, the man must make meaning of the event through the doctor's
point of view. The clinic is not just a location: a man pays for his new
social self-esteem by forever bearing the clinic within himself.

Notes

1 The men in our study used, often as part of a product study, one or more of the
following compounds: calcium hydroxylapatite (Radiance, Radiesse); hyaluronic
acid (Restylane, Perlane, Hylaform); silicone oil (Silikon 1000, VitreSil 1000); ex-
panded polytetrafluoroethylene (ePTFE) implants (Gore-Tex, Gore S.A.M., Soft-
Form); and polyalkylimide (Bio-Alcamid). These substances are injected or sliced
into the face using a range of surgical techniques, depending on the compound.
2 The code "GFOI" refers to interviewee number one in the "Good Face" project. All
subsequent quotations by interviewees are cited in this manner.

References

Ascher, Benjamin, Sydney Coleman, Tina Alster, Ute Bauer, Cheryl Burgess, Kimberly
Butterwick, Lisa Donofrio, Peter Engelhard, Mitchel P. Goldman, Philippe Katz,
and Danny Vleggaar. 2006. "Full scope of effect of facial lipoatrophy: A framework
of disease understanding." Dermatological Surgery 32:1058-69.
Davis, Kathy. 1991. "Remaking the she-devil: A critical look at feminist approaches to
beauty." HypatiaG (2): 21-43.
de Certeau, Michel. 1984. The practice of everyday life. Berkley and Los Angeles: Univer-
sity of California Press.
Foucault, Michel. 1973. The birth of the clinic: An archeology of medical perception,
trans. A. M. Sheridan Smith. New York: Vintage.
Mailloux, Martin. 2005. "Lights, lipo, action!" The Positive Side 7 (1). Available online at
http://www.positiveside.ca/e/V7Il/Iipo_e.htm.
Patton, Cindy, and John Ilesch. 2009. "In your face." In Cosmetic surgery: A feminist
primer, ed. Cressida Heyes and Meredith Jones. Farnham, U.K.: Ashgate.

16 • J O H N L I E S C H AND C I N D Y P A T T O N
2 IMPLICATIONS OF AN

EPISTEMOLÓGICA!. VISION
Knowing What to Do in Home Health Core

C H R I S T I N E CECI AND MARY ELLEN PURKIS

HOME CARE IN CANADA, as well as in many other jurisdictions, is increas-

ingly conceptualized as a sector of health care operating under mounting
pressure. In Canada, the site of our research, the current stresses on home
care are well documented (e.g., Baranek, Deber, and Williams 2004; Ceci
2006b; Coyte and McKeever 2001; Hollander 2003; Purkis 2001). There has
been a shift, for both fiscal and more individualized reasons, in the pre-
ferred location of care from hospital to home. Though some Canadians
may choose home over institutions for recovery or rehabilitation, and new
technologies make sophisticated treatment at home possible for others,
it is also true that new types of home care clients are being created on
an ad hoc basis by policies and practices that, for example, decrease the
absolute number of institutional beds available, discharge people from
hospital "sicker and quicker," or narrow the eligibility requirements for
home care programs. One effect of these sorts of policies is to transfer the
acuity traditionally associated with institutional settings to home envi-
ronments, and in so doing to institute competition for "scarce" resources
between the newer, more acute, and medically fragile clients and the tra-
ditional clients of home care, namely those who are older, frail, or chroni-
cally ill (Purkis 2001). The base or index case of who is to be considered
an appropriate user of home care resources shifts upward in relation to
medically defined acuity, and the legitimacy of need is reconfigured. Our
concern with tracing the effects of these changing conditions and prac-
tices for the group of citizens who are older, frail, or chronically ill was the
central reason we undertook the fieldwork described in this essay.

17
 Our initial intention with this project—a field study of home care case
management practice in a midsize western Canadian city—was to docu-
ment current conditions and, given the climate of change, instability, and
shifting resources, to identify and trace the effects of the influential dis-
courses and practices reshaping the field. Perhaps because of this inten-
tion, that is, to take a reading of a changing field of practice we were struck
early on in our fieldwork with the ambiguity of the field, rendered, in
part, through a continuing revision of the guidelines, eligibility rules, and
resources for practice that work to "materialize" the conditions of possi-
bility for home care and shape the experiences of both practitioners and
clients. As R. Munro observes, one effect of ambiguity is that "material to
exemplify a shift in agendas is always culturally available and only needs
to be made 'visible'" (1999, 630). In situations where such ambiguity is
present or generated, we begin to see that many agendas, many actions
or directions, are always both possible and supportable. Thus a further
question for our analysis of home care became why and how do we move
in one direction rather than another? In following Z. Bauman who has
observed that "in an orderly (ordered) space, not everythingmay happen"
(2004, 31), we look to the field to try to see what does happen and to dis-
cover, if we can, the thought that exists in what we observe as the orga-
nized ways of doing home care.
In the conduct of our fieldwork we were guided by an ethnomethodo-
logical approach of observing everyday activities and analyzing them in
a way that would help to make visible the background understandings
that constitute the conditions of possibility for these activities (Garfinkel
1967, 36). The site of the research, then, was both home care and the pro-
cesses and practices that organize this site in particular ways. The core of
participants in the research, and our entry point into the field, was com-
posed of seven case managers in a home and community care program
who had responded to an open call for volunteers. All of the participants
were women and nurses, which was typical in this setting, and each had
many years of experience in a range of community-based nursing roles.
The greater part of our data was collected through "shadowing" these
case managers as they carried out their various responsibilities. These
tasks included home visits with new clients, reassessments of longtime
clients, connecting with family both locally and at a distance, and coor-
dinating the work of other involved health workers. Alongside these case
managers, we observed unit meetings, program meetings, and hospital

18 - C H R I S T I N E C E C I AND M A R Y ELLEN P U R K I S
and community rounds. Other data collection activities included inter-
views with managers of various aspects of the home and community
care programs and the analysis of the text-based information that influ-
ences the work, such as forms, memos, procedure manuals, the regional
health plan and so on. Our analysis of the data was ongoing, iterative,
and undertaken in light of current writings in home care as well as criti-
cal health and social and philosophical theory more generally.
The analysis of any data set, including that generated through field-
work, has, as M. Strathern observes, a tendency to open up "fresh gaps in
our understanding" (2004 [1991], xxii). This image is apropos, in fact, as
it was the gaps or disjunctures in the field of home care that we became
increasingly concerned with understanding and explaining. In the field
we had the opportunity, in part because of our link with practitioners,
to observe the distance or disjuncture between discourses about home
care—the way that home care "appears," for instance, in policy docu-
ments—as well as how these discourses are enacted in practices, and how
people, who are the target of practices, actually live their lives. Theorizing
this gap is a central intention of this essay. We are concerned here with
the distance between people's actual forms of life and what is assumed in
the discursive practices of home care and of home care policy.
Michel Foucault's articulation of the agonistic relation between see-
ing and saying (1973) is one way to understand, and account for, the gap
between policy, practice, and people's lives—between what is offered
and what people may actually need. The argument to be elaborated
here is that one problem in home care is mistaking what we are able to
"see," through apparently uncomplicated visualizing practices such as
home visits or assessments, as being what actually exists, as the reality of
people's lives. There is a failure to recognize that seeing in these situations
is shaped beforehand by saying. That is, we do not describe what we see;
rather, what is described is what can then be seen. This is an unacknowl-
edged anteriority to our vision, and to simply overlay this epistemologi-
cal vision—what we see shaped by the socio-material arrangements that
guide us in our practices—on people's lives is problematic. More than this,
proceeding without awareness always holds a potential to do violence to
what does exist. The clinical gaze, the gaze that classifies and orders, "a
gaze that was at the same time knowledge," is also a gaze that governs
(Foucault 1973, 99). What is at stake, then, is how we see, with the thought
that precedes the visible, and the implication of this for people's lives.

I M P L I C A T I O N S O F A N E P 1 S T E M 0 LO G I C A L V I S I O N - 19
 As authors this analysis puts us in an awkward position, as clearly we
are engaged in our own practices of seeing and saying that will fail in the
end to grasp what "is," what actually exists. This means, at the very least,
that our goals must remain modest and specific. In this case, our inten-
tion in this setting is to simply write something that might help us to see
practices of home care, and the situations of people, in a new light.

Between Seeing and Saying

Foucault frequently began his various analyses with a picture, or as J. Rajch-

man describes it, a picture used as a puzzle that calls for analysis, a "phil-
osophical exercise in which seeing has a part" (1991, 69). The Birth of
the Clinic begins in this way—a particularly fitting opening for a text in
which the central problematizations include those of surface and depth,
resemblance and recognition, and the articulation of various visualization
schemes upon that which they articulate—which is, finally, the relation
between seeing and knowing, seeing and doing. The preoccupation with
puzzling out the practices of seeing of a period was, for Foucault, merely
the beginning of "deeper" investigations into the relations between seeing
and saying, and into the nature of the distance and disjuncture between
the visible and the articulable. In tracing the modulations of spaces of
specific relations Divisibility—from the evident transparency of objects
subject to the seventeenth-century gaze to a growing awareness of sur-
faces wherein things began to have "powers of truth that they owe not to
light," a truth of their own—Foucault's investigations were not, or not
merely, empirical exercises about what things looked like (1973, xiv-xv).
Rather, Foucault was concerned with visibilités, with breaking open the
larger conceptions of seeing of a period—not merely what is seen but
what it is possible to see. In Gilles Deleuze's words, such "visibilities are
not forms of objects nor even forms that would show up under light, but
rather forms of luminosity which are created by the light itself and allow
a thing to exist only as a flash, sparkle or shimmer" (1988, 52). Rather
than objects, elements, qualities, or things that appear, Foucault's analy-
ses considered these "forms of luminosity" as the conceptual conditions
of possibility for seeing—not light itself but the specific distributions of
its dispersal that make things visible, both as such and at all.
Foucault's investigations were historical, and though we may try to fol-
low his example, it is not at all clear that present forms of luminosity will

20 • C H R I S T I N E C E C I AND MARY ELLEN P U R K I S

be apparent to us. Though Deleuze reassures us that visibilities are not
hidden (57), it is also the case that we who see are the effect and function
of those very visibilities—and that even as investigators we only have the
place of any observer within a system. In The Birth of the Clinic, however,
Foucault offers the possibility of understanding what it might mean to
see differently, a form and a grammar through which we might open the
self-evidence of our practices of seeing and be, as it were, led to see in a
new light (Rajchman 1991, 70). What we, following Foucault, may seek
to see is how, in a specific location, a space of visibility has been modu-
lated or has become a space where features variously appear, disappear,
and gleam in their self-evidence. This is partly a question of spatializa-
tion, that is, of interrogating the organization of the "space where bod-
ies and eyes meet," but also of considering what Foucault refers to as a
"new alliance forged between words and things" (Foucault 1973, xiii; see
also Rajchman 1991, 70). We may begin to see in a new light, in light of
concepts previously unseen, by looking to practices of "saying," or more
specifically, to the problematizations created on the basis of practices of
seeing and saying (Deleuze 1988, 64). Foucault's example in The Birth
of the Clinic is one of sustained scrutiny of the relations between see-
ing and saying, between the visible and the articulable, through which
the clinic, the encounter between client and practitioner, becomes philo-
sophically "visible" (128). That is, the knowledge generated through the
clinical encounter is not a direct knowledge of things but rather one that
calls into question origins, causes, and principles (4). In light of such
concepts, visualization schemes show up differently and are silhouetted
against what now begins to seem a presumptive vision.
As Foucault traces new arrangements or changing economies Division,
what also becomes "visible" is that these attempts to overlay the world
with forms of intelligibility through which we might "see" do not have
"the world" as their object but instead constitute, as an object of dis-
course, a discursive object (xx). Discourse is not identical to that which
it purports to see and to describe. Though he upholds the irreducibility
of the one to the other, the visible to the articulable and vice versa, Fou-
cault does not claim that our discourse has nothing to do with the "real"
but rather suggests a more ephemeral, less harmonious relation between
the real and the observable than we are perhaps accustomed to thinking.
As Deleuze points out, Foucault questioned such congruence and rarely
remained content with surfaces, for "as long as we stick to things and

I M P L I C A T I O N S O F A N E P 1 S T E M 0 LO G I C A L V I S I O N - 21
words we can believe that we are speaking of what we see, that we see
what we are speaking of, and that the two are linked" (65). That they are
not linked, or rather, that Foucault discovers that the relation of words
and things is, in Deleuze's words, something of a nonrelation, is a key
theme to be examined here, because for Foucault a nonrelation is still a
relation (63).
As Foucault traces the shift from the language of things to a relation-
ship of language to things (xv-xvi) we find ourselves grappling with the
implications of a shift from an intentional and phenomenological vision
to an epistemological one. That is, if we follow Foucault's thinking, there
is a loss of a kind of innocence of seeing, a loss of the Childhood-Gaze,
a potent and pervasive myth but also an impossibility: "The discourse
of the world passes through open eyes, eyes open at every instant as for
the first time" (78). Truth is not to be found in the purity or freedom of
such a gaze—via a direct, unmediated knowledge of things—but rather
is something added from the outside: truth "offers itself to knowledge by
offering itself to recognition" (135), which presents as a sort of anterior-
ity of vision, a seeing and knowing at once. Instead of a relation of cor-
respondence between words and things, we are led by Foucault to see in
this relation an essential agonism, a struggle in which neither is reducible
to the other, but rather one in which the "radical primacy" of the sayable,
of the statement, must be acknowledged (Deleuze 1988, 49). What it is
possible to see is not determined by our discourse about it, but neither
does it remain unaffected. As Deleuze describes it, the two forms, the
visible and the articulable, overlap and "spill over into one another, as in
a battle," precisely because there is no relation of isomorphism between
them (66). Thus Foucault's nonrelation is a relation of struggle, and it
is through such struggle that the conditions of possibility of a field of
discourse are constituted. And as Deleuze suggests, to breach the self-
evidence of our seeing we can consider not only "the objects with which
we begin, the qualities we follow and the states of things in which we are
located (a perceptible corpus), but also how we can extract visibilities
from these objects, qualities and things, how do these visibilities shim-
mer and gleam and under what light, and how does this light gather [?]
(63). This, though far less lyrically expressed, is the task of this essay: to
look to a particular field of health care—home care for those who are
older, frail, or chronically ill—and to consider, through a sustained scru-
tiny, what it has become possible to see and to say, and the relationship
between these two possiblities.

22 - C H R I S T I N E C E C I AND MARY ELLEN P U R K I S

A Puzzle That Calls for Analysis

We begin this exploration with a picture, because pictures—as puzzles

that call for analysis, puzzles that have arrived through particular prac-
tices of seeing—are central to the work of many health care practi-
tioners. In fact, as the analysis of The Birth of the Clinic makes clear, this
reality raises the first possibility of a breach in the self-evidence of our
seeing and knowing insofar as we may wish to consider whether, and
to what extent, it would even be possible to "see" clients outside of our
current visualization schemes. This is the reality, and arguably the neces-
sity, of the clinical gaze that orders and classifies. Alongside this possi-
bility is another: that we are each able to look and see quite different
things. While this second possibility introduces uncertainty into partic-
ular visual practice, the first underlines the basic hegemony of vision.
What, we might ask, does it mean to be "seen"?
Home care case managers, the primary participants in the study from
which the examples in the present analysis were drawn, frequently make
use of visually rooted metaphors to describe their work (Ceci 2006a). Given
that one of their key tasks is assessment, it is not uncommon or surprising
to hear practitioners begin their interviews with clients with the reassur-
ance that they are not there to "do" or intervene but rather are just "try-
ing to get a picture of how things are going" or just to "see" how the client
is doing.1 They present to their clients an innocent and guileless sort of
gaze, one open to the client's "reality" and untempered by organizational
strictures. That this is not exactly the case only becomes apparent later
on, when the specific manner in which this gaze is already constituted
and directed is exteriorized in the strategies developed for meeting the
client's ascribed needs. In this section, we want to consider, first, the genesis
of the pictures developed through a case manager's gaze, and second, the
relationship between the development of a picture and knowing what to
do about it.
Foucault suggests that the picture "makes nothing known; at most
it makes possible recognition" (1973, 139). So we will begin with a pic-
ture offered by a case manager. As noted previously, case managers carry
out the assessments that are pivotal to decisions related to the alloca-
tion of resources and services. What they "see," or are able to see, matters
quite a lot for a client's experiences of care. One case manager offered
these words in the course of an interview in which she had been asked to
describe a typical instance of case management practice. What the case

I M P L I C A T I O N S O F A N E P 1 S T E M 0 LO G I C A L V I S I O N - 23
manager sees, she tells us, is a frail, elderly woman with limited social
support experiencing some cognitive decline. This client, she says, "has
concerned me all along":
Basically she sits in the living room, with a little table with a phone on it,
with large numbers on it, and she has a few notes there, by the phone, with
phone numbers. And there [is] also a big note saying, "press number six to
let someone in."

This suggestive picture is one that readily offers itself to recognition

because it is a familiar portrait of old age—a woman, alone, a little be-
fuddled, a little unreliable—and one that leads us to see, and the case
manager to act, in particular ways. Though this woman's apparent wish is
to remain in her home, she is also seen by the case manager as a case for
concern. To the case manager she is a client who "presents well, as very
social" but scores low on the assessment tool, the "mini-mental status
exam" used to measure cognitive status in terms of orientation to person
and place, memory, and basic reasoning ability. This assessment of "cog-
nitive compromise" directs the case manager's actions:
So Helen [not her real name] had medication that needed to be given four
times a day, and her medications, when I met her, were in a blister pack,
and we had the home support workers going into her place twice a day. So
she was assessed at intermediate care level 3,2 and she had about sixty-five
home support hours a month going into her, and at that care level, we can
actually go up to ninety-eight, so I had a bit of room to add extra service,
should we need it.

In the case manager's view, the client seemed to be "managing not too
badly, she had assistance with personal care, and they were helping her
with her breakfast, laying out her lunchtime pills, and coming back in
the evening." But gradually it is noticed that these interventions are not
enough: Helen is not taking her lunchtime pills, and she is occasionally
"a little bit incontinent of urine at night." The case manager adds another
half hour of "service" so that a home support worker can "drop by" around
noon to address the medication concern, and with respect to the night-
time incontinence, she makes a plan "to buy pull-up underpants for her,
and lay them out on the bed with her nightie, with the hopes that she
would realize they were for her to put on." Still, however, conditions dete-
riorated: "There were reports of a change in Helen's condition, increases

24 - C H R I S T I N E C E C I AND M A R Y ELLEN P U R K I S
in urinary incontinence, the bed being flooded in the morning, and just
kind of a general change in her ability with hygiene I was also hear-
ing that she was having trouble letting workers into her building." She
was also presenting as more disoriented "than usual," and at times she
was unable to get in and out of her chair on her own. The case manager
now "sees" that Helen can no longer be left alone, and in a crisis mode
she patches together some "hourly blocks of time" to provide Helen with
almost twenty-four-hour care, or at least supervision. This is a temporary
measure to support Helen until she can be placed, as she now will be
whether she wants it or not, in a long-term care facility.
In the context of this (condensed) recitation of events, we can under-
stand the case manager not only to be seeing but also reflectingback upon
what she has seen in order to justify her work. Her seeing is linked, in the
moment she speaks but also retrospectively, to what she does, though
interestingly what she does (or did) did not seem to alter the essential and
originary situation: namely that Helen was alone most of the time until
quite late in the game. That is, even though the woman's situation was
such that she could not be relied upon to let workers into her building,
she remained more or less alone, supported by workers who visited regu-
larly but infrequently, until much later when events—an unmistakable
deterioration of conditions—pushed the case manager to reconceptual-
ize the client's isolation as a "crisis" and to intervene with the applica-
tion of maximum resources. Because the client's situation was allowed to
become quite desperate, the case manager also finds herself reflecting on
whether she has somehow been remiss in her care, if she perhaps has not
really seen what was going on. This is the first hint of the epistemological
vision: the doing that is not unrelated to the client's "real" life, that over-
lays the life but still somehow fails to actually embrace it.
This account of events is not intended to be critical of the case man-
ager, and perhaps not even of her actions. Indeed, she expressed her own
concerns about the ways her practice was influenced, and limited, by a
particular kind of bureaucratic discourse:

But one of the dilemmas, for me as a case manager, is looking at our poli-
cies and what I'm able to do. Now, a maximum number of hours for home
support in our region is 120 hours. Typically that goes with an extended
care client. When I've seen Helen along the years, she's been intermediate
care level 3 But here's where you have to get creative, and start figuring

I M P L I C A T I O N S OF AN E P I S T E M O L O G I C A L V I S I O N - 25
 out, like, how do you do it? Often the decisions you make dictate how much
paperwork you have to do, which seems sometimes to be awfully stupid. But
I decided I would make her extended care, so she would have her 120 hours.

But an interesting feature of her words, insofar as they reflect practice,

is the apparent ease with which she, as a case manager, can look upon
the mess and complexity of this client's situation and assign her to a care
level—a controlled, and inevitably reductive, cataloguing of elements of
significance that will determine what can be or will be done. It is in this
transformation of client into category that the seeing and saying of our
times is exteriorized, and what is now made visible to us is the logic—if
this, then that—through which the needs of people like Helen will be met
or unmet. In this case, the case manager's seeing is already constrained by
knowing what to do, that is, by the rules that reflect broader societal think-
ing about what people like Helen need rather than by what Helen may
actually need. This ordering practice has and creates a reality of its own,
and it has effects in terms of overlooking the precariousness of Helen's
existence. This is, in Foucauldian terms, an instance of seeing and know-
ing at once that reveals thinking, and the thinking revealed suggests prac-
tices of using categories detached from the consequences for people. As
Deleuze observes: "In the field of knowledge as problem thinking is first of
all seeing and speaking, but thinking is carried out in the space between
the two... creating a flash of light in the midst of words, or unleashing a
cry in the midst Divisible things" (1988,116).
To return to the original picture, and to the woman who sits in the chair
and requires a note to remind her to "press number six" to let someone
in, it may be hard to decide if we would have wished events to unfold dif-
ferently—for ourselves, someone we care for, or especially for Helen. The
case manager has clearly "read the signs" and recognized a sort of down-
hill trajectory. At the same time, as she herself at least partly recognizes,
boundaries exist between the questions she can ask and the things she can
see, that is, the policies she sees and acts within, which have limited the
encounter or perhaps even contributed to its trajectory (Foucault 1973,
135). The case manager works in relation to these policies to develop a
knowledge of this client that is not, Foucault would suggest, a knowledge
of a historic or aesthetic order, not a knowledge of who Helen "really" is or
what her life is really like, but rather is knowledge that (merely) makes her
stand out against an "objective" background against which she becomes
something one can do something with (iv). Thus her "real" world, which

26 • C H R I S T I N E C E C I AND MARY ELLEN P U R K I S

seems a very small and fragile place, remains essentially unknown, invis-
ible, and perhaps unaccounted for in practices that operate in this essen-
tially a priori way. The case manager is directed by a fairly inflexible form
of intelligibility, a structure of analysis that precedes any actual encoun-
ter, and that while shaping this particular encounter with Helen, may not
be registering or responsive to what is real in the client's life.
But an argument could be made that perhaps this is as it should be,
that there are too many risks, of both action and interpretation, in what
may be done and what may be thought, if one were to show oneself or
be shown to power, that to be "truly" seen by a case manager as an agent
of a larger organization (that is itself a representation of social author-
ity) is not necessarily desirable. Except that even in this rather abbrevi-
ated account of events, it seems clear that there has been suffering here,
and perhaps what must be decided is whether this is tolerable or not.
And then, of course, there is the challenge to articulate and respond to
the intolerable. As Deleuze says of Foucault: "He saw things, and like all
people who know how to see something and see it deeply, he found what
he saw to be intolerable. For him to think meant to react to the intol-
erable, to something intolerable that he had seen. And the intolerable
was never the visible, it was something more" (quoted in Rajchman 1991,
73-74). So this question of tolerability has to do not with what we see
but with the something more—with how we see, with the thought that
precedes the visible, the essential a priori, the conditions of possibility
through which ideas about people and their needs are formulated.

The Primacy of Saying

The care levels described above that are used in Helen's case are visuali-
zation schemes through which people's lives are seen and their needs
articulated, and thus they allow a frame of positive knowledge to be placed
over and, importantly, made prior to, these lives and needs. In Foucault's
terms, this is the difference between an experience and the changing
grid through which experience is organized, made analyzable, and then
located within a "whole system of orientation" that shapes the approach
to the field (1973, 64). Again, what is to be highlighted here is the sig-
nificance of recognizing that the object of such a discourse is not "real,"
but rather is in a sense discursively self-referential and concerned with a
"reality" that has its primary existence in language: "Discourse was still to
have the task of speaking that which is, but it was no longer to be anything

I M P L I C A T I O N S O F A N E P 1 S T E M 0 LO G I C A L V I S I O N - 27
more than what it said" (Foucault 1970, 43). Giorgio Agamben (1993, 9) is
helpful in shedding light on this matter. Although care levels and client
categories are real, particularly in terms of their effects and their power to
produce classes of people and knowable worlds, they still have their pri-
mary existence in language. Yet the paradox of such classes is that though
they define only the place of linguistic being, not human being, human
being will be constituted through these practices and languages of clas-
sification. Thus, the concern for Agamben, and also, arguably, for Fou-
cault in his conceptualization of the agonism between words and things,
is not an essential incompatibility between person and category, which
is itself constructed through language, but rather the manner in which
we move from one to the other and back again—that is, questions of
the manner and ethos of exposition. Our risk as beings who are "in" lan-
guage, who have an essentially linguistic being, is the possibility of los-
ing a proper relationship between words and things, words and people:
"The word—that is, the nonlatency and the revelation of something—
might become separate from what it reveals and might end up acquiring
an autonomous consistency" (Agamben 2000, 82). Foucault, of course,
suggests exactly this. However, a key consideration remains the way we
treat the reality of the word, and with practice that grants language such
autonomy, and reality, even though it essentially reveals nothing except
itself (83). However, if we take into account the primacy of the statement,
a primacy that does not determine the visible but is, nonetheless, that
from which determination issues, we know that language will shape what
we can see—and that the "seeable" will always resist (Deleuze 1988, 67).
In the context of Helen's situation described above, there is a case
manager and other care support workers who are interacting with a per-
son, Helen, but who are also thoroughly, and perhaps first of all, engaged
with the institutionally supported discursive structures that give shape
and meaning to their actions. Their work, for very practical purposes, re-
quires the deployment of concepts through which Helen's precarious ex-
istence can be understood and managed, but which at the same time risk
overlooking the actual nature of this existence. The care workers rely on
theories grounded in the significance of resemblance, in what people like
Helen need and what can be done with them. These theories constitute
such persons as, and within, an imperfect scheme of possible, observ-
able, classifiable objects and experiences—all of which came before any
knowledge of Helen's life and situation was possible, and is, in fact, the
constrained basis upon which we seem to be able to have any knowledge

28 - C H R I S T I N E C E C I AND M A R Y ELLEN P U R K I S
of her at all (Rajchman 1991, 75). The prevailing thought seems to be that
if one can discern certain key elements such as cognitive status, social re-
lations, or mobility, then one can manage the complexity that arises from
the combination of these elements (Foucault 1973, 144). So the tension
here is not that care levels may not accurately reflect a person's life and
needs, something that hardly seems possible, but rather that the system
of assigning care levels has greater significance than the more ineffable
realities of the persons that such a system seeks to grasp. And it is this
authority accorded to the forms, policies, and practices that currently de-
fines the field of sayability in home care and that enables the sayable to
then define or delimit a space Divisibility. And it is against this presump-
tion that the real struggles (Deleuze 1988, 47).
To begin to see this is again a matter of exteriorizing, of articulating
how people like Helen become visible. Essentially, the care levels to which
people are assigned, through the predominant language of the organi-
zation, have something like an autonomous existence that is seemingly
manageable quite apart from people and their needs. This is the differ-
ence between being Helen, living alone and experiencing some difficulty
managing day-to-day existence, and being an intermediate care level 3
client eligible for up to ninety-eight hours of home support each month.
In her assessed form as a level 3 client, Helen's existence is vulnerable to
a high level of abstraction and can be made to figure into any number
of apparently benign calculations that may begin with a cataloguing of
her entitlements and yet end with a consideration of the number of such
clients on a caseload or in the system, a percentage of a global budget
spent on home support, the number of home support workers needed
to meet the collective needs of such clients, and so on. Less benignly, if
Helen's experience is shaped through these spaces of constructed visibil-
ity, changing the grid that orders this experience will change the experi-
ence (Rajchman 1991, 65). As Helen is categorized, her actual existence
becomes an externally manipulable element, and she is seen to be know-
able quite apart from the details of her life. This form of knowledge has
disciplining effects: "To look in order to know... is not this a tacit form of
violence?" (Foucault 1973, 102).
A set of events that will serve to illustrate this point began several
months before the fieldwork for our research began, though the effects of
these events persisted throughout our time in the field. The basic problem,
and one that is characteristic of many health care settings, was that man-
agement was confronted with apparently intractable fiscal constraints.

I M P L I C A T I O N S O F A N E P 1 S T E M 0 LO G I C A L V I S I O N - 29
In our setting, the managers attempted to address what were configured
as budget shortfalls by instituting service reductions across the board to
all clients classified as personal care and intermediate care level 1 cate-
gories—that is persons designated as having "lower level care needs." As
one manager explained, they had been directed by higher levels of gov-
ernment to allocate available resources to those with the greatest need,
with this need read primarily as medical need. Even those who ques-
tioned this approach to practice, and who sought to make a case for the
equivalent necessity of those services defined as "supportive," found it dif-
ficult to sustain objections in the face of the obviously pressing needs of
sicker, medically fragile home care clients (Ceci 2006b). Of interest here,
however, is how management, in instituting service cuts across the board,
utilized similarity or kinship through processes of categorization. Folded
back into sameness, resemblance is permitted to have a greater real-
ity and momentum than the difference and detail that challenge it. So,
though justified by budget constraints, the logic of the action lies in this
precedence given to resemblance, in a sameness achieved linguistically,
as well as in the managers' capacity to remain "in" language.
Insisting on sameness in this way, however, may require a narrowly
focused gaze, one that might need to work quite hard at keeping the orga-
nizational, linguistic world of care levels separate from a parallel world
of actuality filled with people's lives and needs. Interestingly, the attempt
to manage the budget by manipulating the meaning of categories, spe-
cifically through a changing grid of eligibility and entitlement, only post-
poned the time and location where the "real" needed to be acknowledged,
and importantly, where the "something more" that enables us to grasp the
tolerability or intolerability of our practices was felt. The latter seemed
to occur partly because it was difficult for workers closer to clients to
sustain the distinction constructed by treating categories as equivalent
to the "real." For example, a weekly bath is a relatively small line item,
something that must have seemed not truly necessary to those managing
a large and complex budget. But the bath is also part of a complicated life
in which such a visit is understood as absolutely necessary. As one man-
ager explained it, for many case managers

it was difficult having to go out and talk to their clients, some of whom were
ninety years old, and say, "You can't have a bath every week." I mean it breaks
down into simple people things I'll give you a for instance. A weekly bath
for a ninety-year-old is so much more than a weekly bath. It's a pair of eyes

30 • C H R I S T I N E C E C I AND MARY ELLEN P U R K I S

 in there noticing things week to week that may be changing. For a client,
it's a surveillance mission basically. It's a visitor, it's a social outlet, it's a lot
of things [Maybe it wouldn't prevent a fall] but maybe there would have
been somebody who would have seen week to week that [the client] was
getting weaker.

Instead of seeing the logic of the organizational action, frontline work-

ers were confronted with the essential arbitrariness and motility of the cate-
gories they employ and construct in their day-to-day practice encounters
(Ceci 2006b, 65). They saw that although the rules that govern the nature of
their practices had changed, the people they encountered and their needs
did not. What seemed at a management level to be an efficient and rather
straightforward way to manage a budget became an ongoing source of
complication and distress. As well as turning our gaze to the "something
more" that might allow us to assess the tolerability of our practices, the
manager's words quoted above push us out of the a priori expectations of
categories to (re) consider what care levels might once have been about.
They also help us see the distinction between these grids of intelligibil-
ity and those who might be figured into them. That is, our articulable
schemes for ordering reality and actual existence are not identical, and
though this may seem obvious, clearly it is not—or perhaps it is just too
easily forgotten. However, when theoretical rationales for practice brush
up against how people are actually trying to live their lives, particularly in
moments when the system undergoes a "shift," we glimpse what actually
organizes our practices.

A Break in Self-Evidence

In what way has our seeing in home care become problematic? In Agam-
ben's terms (2000,82), our seeing could be said to have become problem-
atic because we have lost a proper relation between words and things. If
home care derives its existence from its institution in language, and if,
as Foucault argues, the articulable is prior to the visible, then how home
care appears in language, and how we move from words to things and
back again, is significant. This is where Agamben moves forward with
Foucault's analysis by suggesting that exposition, the constitution of the
world through language, is the preeminent location of political struggle
(93). To speak is not just to say words that are laid on the surface of what
already is, but also to contribute to the production of what comes to

I M P L I C A T I O N S O F A N E P 1 S T E M 0 LO G I C A L V I S I O N - 31
exist, and, importantly, to invest oneself in the direction of certain effects.
Home care is such a field of political effects shaped and conditioned by
discourses, those sets of institutionally and materially supported rules
and resources, rationales, and practices that have effects in setting the
conditions of possibility for knowledge and action.
In our articulations of home care, and importantly, in our assess-
ments of people and their needs, we are never merely cataloguing what is
"there." Our seeing is a "more complex matter than inferring from percep-
tion" (Rajchman 1991, 81). The fact that our perception is ordered is not
new. But what has remained unseen, or at least has not been sufficiently
engaged with, is the deep conceptual organization that gathers these see-
ings together and becomes the basis for our current practices (Rajchman
1991,71). This is the "somethingmore" discussed above, the conditions of
possibility through which ideas about people and their needs are formu-
lated, the seeing and knowing at once, the epistemological vision. What is
it that struggles to become our "visible"?
We do not want to place too much pressure on any single incident that
occurred during the fieldwork, but there was one exchange between case
managers and their program managers that has resonance here. Follow-
ing Munro's suggestion (1999, 624) that focusing on selected "moments"
in fieldwork can open up a site, we offer the following exchange as an
example of the vocabulary currently "in use" to explain and understand
practice. We observed several of the regular monthly meetings between
case managers and their managers where, among other organizational
tasks, they discussed changes in programs and policies. In the example
described here, talk had turned to the difficulties in achieving a "fair"
process for the allocation of a relatively noncritical service, day program
use.3 One of the program managers described her experience of being
"barraged" with requests for use of this service. She explained that to man-
age this "scarce resource," access beyond that specified by an already exist-
ing guideline was to be approved by her since not only were there differ-
ences among case managers in perceiving the need for this service but
also there was "too much humanness in the ways requests were being
made." She stated that she was being unduly influenced by the appeals
by case managers on behalf of their clients, and she described herself
as authorizing access to the program, or not, depending on how strenu-
ously a case manager pushed for her client. She was, therefore, not sure
that "equitable judgments were being made." A case manager at the
meeting challenged this perspective, prompting the following exchange:

32 - C H R I S T I N E C E C I AND MARY ELLEN P U R K I S

 PROGRAM MANAGER 1: If people are getting in [having requests for the ser-
vice approved] because they have a strong advocate, what about people
who don't.
CASE MANAGER 1: That's why we should all advocate, and push for our
clients It's the only resource I have.
PROGRAM MANAGER 2: That's why we need a more equitable process.
CASE MANAGER 1: Our mandate is client-centered care So I'm going to
push for what's best for my clients.
CASE MANAGER 2: But we have to be fair in how they access the system.
PROGRAM MANAGER 1: The policy is that more than twice per week they need
to come through me... [Case manager 1 (quietly): So it's covered ] What
I'm saying is that these incidents are increasing so we need some other
system.

This exchange raises a number of issues. Perhaps most obviously, dis-

cussion about this service suggests that either current resources or cur-
rent guidelines are insufficient to meet the needs of at least some clients.
But a difficulty even here is that clearly not all case managers perceive
either advocacy or their clients' needs in the same way. And for clients
whose case managers are advocating for greater access, it is also not clear
that the manager's intervention will result in a more equitable distribu-
tion of the resource, because surely some clients and families do bene-
fit more than others from respite, depending on their characteristics or
on other resources they have available. Is it more fair or less so to have
these sorts of details taken into consideration in decision making? Is for-
mal equity, an equal number of visits, sufficient, or is it merely all that
the case managers and manager can hope for? Though these questions
are unspoken, the worry that particular need cannot be attended to in
a guideline that merely defines the parameters of access is part of what
underlies the exchange—that and the opposing concern that attending
to such particular need might very well hijack attempts at equity.
A larger and perhaps more instructive point, however, is the refer-
ence to needing to eliminate or at least minimize humanness in deci-
sion making. A striking feature of the program manager's complaint is
the way in which "humanizing" the work, attending to complexity and
particularity on either the client or case manager's end, seems to cre-
ate all these problems. This is a situation that reflects the organization's
difficulty in dealing with variability, which is an important limitation of
home care. Interestingly though, the variability is seen as issuing from

I M P L I C A T I O N S O F A N E P 1 S T E M 0 LO G I C A L V I S I O N - 33
clients, located in their diverse situations and needs, and from the dif-
fering benefit they might receive should their case managers advocate
on their behalf. What is less visible here is a significant organizational
effect of variability stemming from the frequent modifications, rearrange-
ments, and revisions of home care policies and practices, the changes
to and "tweakings" of service provision that often seem unconnected to
people or the assistance they may be seeking (Baranek, Deber, and Wil-
liams 2004; Ceci 2006a, 2006b; Duncan and Reutter 2006). The latter vari-
ability has at least two obvious effects. First is the detachment it seems
to require from clients and workers as particular people with particu-
lar needs, which is seen in the desire to minimize the "humanness" and
individuality of practice. Second is how it seems to require that the field
of home care be treated as "made" not of people and needs but of the
guidelines, standards, and rules used to configure and shape the bound-
aries of both people and needs. These guidelines, standards, and rules
become the substantive focus of discourse (what guideline can solve this
mismatch between needs and resources?), and it is through them that
any uneasiness with the complications of humanness, however articu-
lated, will be managed. The deployment of guidelines, as one way to treat
the complexity of home care practice and of people's lives, will at the very
least keep practice moving and take out of play (again, at least temporar-
ily) the less predictable problem of people. In these terms, it is an excess
of humanness rather than constrained resources that makes the sys-
tem unworkable. Here again, we glimpse how such practice may (have)
become intolerable.
While the reliance on guidelines and rules and the associated suspicion
of humanness is not "wrong" in any unequivocal sense, it should also be
recognized as a political strategy in Agamben's sense of the word, a means
through which a world is constituted and ordered, and more prosaically,
a means through which an organization sets and manages priorities.
Both manager and case manager, as "contestants" in a political struggle
to determine which exposition of home care practice will be accepted as
"true," deploy specific discourses to bolster contestable positions on how
best to proceed in a situation they would probably both agree is defined
by scarcity and variability. Their exchange sets different approaches to
practice—the case manager's morally resonant claim to patient-centered
care versus the manager's call for a different form of accountable prac-
tice—against one another, with both making claims about the right course
of action. However, though they present somewhat differing economies of

34 - C H R I S T I N E C E C I AND MARY ELLEN P U R K I S

vision, differing arrangements of priorities and objects, they also suggest
by their agreement about the scarcity that defines their context that their
visual practices are more alike than they might suppose. In any case, the
program manager, fortified by her (insider) knowledge about what can be
expected from the organization, is concerned with achieving an instru-
mental fit between identified needs and available resources as well as with
a formal, measurable sort of equity achieved through treating all clients
the same. In distancing herself from the unworkable humanness of prac-
tice she sets up "the rules" as a quasi-scientific way to allocate resources in
an orderly, objective, and therefore fair manner. She does not want to be,
and does not think she should be, swayed by the particulars of the indi-
vidual case.
The case manager, meanwhile, argues for the salience of the individ-
ual case. "Knowing" her clients is, after all, her particular strength; it is
what she brings to the organization, and seemingly, what the organiza-
tion has employed her to do. Suggesting that resources should be allo-
cated according to rules has implications both for how she should know
her clients, in terms of prefigured needs, and for how she herself is posi-
tioned in the organization. This is a discourse it makes sense to resist,
and resist she does by drawing on professional discourses of advocacy
to demand that she be allowed to sustain a certain amount of personal
responsibility for her clients' welfare. It is not her responsibility to ensure
the smooth functioning of the organization but rather to look out for the
best interests of her clients. Her question, valid and unanswered, is how
can her manager make fair decisions about the allocation of a resource
if she, the case manager, is not allowed to make her case? And what will
such decisions be based on if not the merits of these individual cases?
As a way to treat the complexity of practices for managing and meet-
ing people's diverse needs, the imposition of guidelines prevents these
workers and their manager from getting bogged down in details and, as
noted above, keeps practice moving. This is no small thing. However, the
anteriority of the process of the imposition of power, for that is what this
application of the guideline is, may have unintended consequences. Per-
haps most significantly, this approach to the problems of practice masks
the possibility that more than one solution to any given difficulty may
be possible, including those that might come to light through the case
manager's more "human" processes of advocacy and discussion. If we
consider the program manager's discourse as strategic, as contributing
to the constitution of a particular kind of home care "world," then it is a

I M P L I C A T I O N S O F A N E P 1 S T E M 0 LO G I C A L V I S I O N - 35
world of constrained possibilities and of layers of guidelines that make
it increasingly difficult to conceive of alternatives to what is. It is a world
organized from the inside.
In this discussion of the appropriate measure of the humanness of
home care practice we see a measure of, or at least a means to articulate,
what may have become intolerable in how we think and act in this field
of care. An alternate way to describe such a breach is as the fractures
between expositions of home care (in organizational policies and phi-
losophy and in social articulations concerning the care of frail or elderly
persons) and its practices, suggesting that home care has one kind of
existence in language and quite another in people's lives. Organizational
practices that rely on achieving only a formal sort of equity, that con-
flate people with categories, and that try to eliminate the inevitable but
troublesome "humanness" of practice highlight this gap when set against
a practice context characterized by resources and services constrained
in both type and amount (Purkis 2001). The fractures suggest that, in
our current context, home care and its practices have been tailored to
fit social, political, and moral claims about what people need and how
they should live, rather than organized to be responsive to people's actual
forms of life.

Notes

1 All undocumented quotes are from field notes and interviews by Christine Ceci
in 2004.
2 Based on case manager assessments, clients are categorized and assigned a care
level (personal care [PC], intermediate care [1C 1-3], extended care [EC]). Care levels
are linked with assessed needs and come with preauthorized maximum amounts
and types of service to meet those needs.
3 The day program functions most often as respite for family caregivers. It is a place
for the clients to spend a few hours outside the home, socializing and the like in a
supervised and supported setting.

References

Agamben, G. 1993. The coming community. Trans. M. Hardt. Minneapolis: University of

Minnesota Press.
. 2000. Means without end: Notes on politics. Trans. V Binetti and C. Casarina.
Minneapolis: University of Minnesota Press.
Baranek, P., R. Deber, and A. R Williams. 2004. Almost home: Reforming home and com-
munity care in Ontario. Toronto: University of Toronto Press.

36 • C H R I S T I N E C E C I AND M A R Y ELLEN P U R K I S
Bauman, Z. 2004. Wasted lives: Modernity and its outcasts. Cambridge, U.K.: Polity.
Ceci, C. 2006a. " 'What she says she needs doesn't make a lot of sense': Seeing and know-
ing in case management practice." Nursing Philosophy 7 (2): 90-99.
. 2006b. "Impoverishment of practice: Effects of economic discourses in home
care case management." Canadian Journal of Nursing Leadership 19 (1): 73-85.
Coyte, P., and R McKeever. 2001. "Home care in Canada: Passing the buck." Canadian
Journal of Nursing Research 33 (2): 11-25.
Deleuze, G. 1988. Foucault. Trans. S. Hand. Minneapolis: University of Minnesota Press.
Duncan, S., and L. Reutter. 2006. "A critical policy analysis of an emerging agenda for
home care in one Canadian province." Health and Social Care in the Community
14 (3): 242-253.
Foucault, M. 1970. Theorderof things: An archaeology of the human sciences. New York:
Random House.
. 1973. The birth of the clinic: An archaeology of medical perception. Trans. A M.
Sheridan Smith. New York: Routledge.
Garfinkel, H. 1967. Studies in ethnomethodology. Englewood Cliffs, N.J.: Prentice-Hall.
Hollander, M. 2003. Unfinished business: The case for chronic home care services, a policy
paper. Victoria, B.C.: Hollander Analytical Services.
Munro, R. 1999. "The cultural performance of control." Organizational Studies 20 (4):
619-40.
Purkis, M. E. 2001. "Managing home nursing care: Visibility, accountability and exclu-
sion." Nursing Inquiry 8 (3): 141-50.
Rajchman J. 1991. Philosophical events: Essays of the '80s. New York: Columbia Univer-
sity Press.
Strathern, M. 2004 [1991]. Partial connections. New York: Altamira Press.

I M P L I C A T I O N S O F A N E P 1 S T E M 0 LO G I C A L V I S I O N - 37
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3 WHERE IS COMMUNITY HEALTH?

Racism, the Clinic, and the Biopolitical State

JENNA LOYD

In all too many instances [the drivingforce behind the health movement]
emanates from the technical-professional ethnocentrism of health
personnel, truly anxious to put their technical skills to work in human
and community service, who seem to think that health care is medical
care and that the appropriate strategy is to start a storefront clinic or
to go door to door doing tests for anemia and handing out iron pills. Does
anyone seriously believe that in most oppressed minority-group urban
or rural communities these are the community's own real priorities—
that there is more drivingforce behind such activities than behind the
need to get the cops off one's back, the landlord out of hiding, the welfare
department out of despotism, the lead paint off the walls, and the rats
off the floors; to acquire a decent shot at a decent job, real schools
instead of prisons, enough food, clothing, and space; and to bring an end
to all the forms (not just the hospital forms) of institutionalized racism?
Does anyone seriously think these are not health issues?
H. JACK GEIGER, "HIDDEN PROFESSIONAL ROLES"

COMMUNITY HEALTH CENTERS have attracted global attention owing to

the possibilities they offer for achieving "health for all," a vision enshrined
in the Declaration of Alma-Ata adopted in 1978.1 Community health cen-
ters in the United States predate the declaration, having been established
in the late 1960s as part of President Lyndon Johnson's War on Poverty.
American interest in this approach to care has waxed and waned, but
not in politically predictable cycles. President George W. Bush champi-
oned community health centers as a mark of his "compassionate conser-
vatism," and he invested heavily in them so as to shift some of the more
than forty-seven million uninsured people away from seeking primary

• 39
care in hospital emergency rooms. "Health" and "community" are notori-
ously fluid concepts. Whereas "community" suggests togetherness, a sense
of belonging, and a shared identity (Williams 1976, 75-76), "health" is
increasingly understood as a universal good but also is ambiguously
applied to everything from the wellness of body and mind and societal
well-being to a pristine quality of environment and a strong economy.
By virtue of the fluidity of the notions of "health" and "community," link-
ing the two concepts is politically attractive across the ideological spec-
trum, even while such slights of hand are contested by social scientists
and health practitioners who actually try to operationalize "community-
based" research and practice ( Jewkes and Murcott 1996; Schlesinger 1997).
In this essay, I examine the establishment of two community health
centers—the Delta Health Center in rural Mound Bayou, Mississippi, and
the Watts Health Center in South Los Angeles, California—as part of the
War on Poverty during the 1960s. As R. Hollister, B. Kramer, and S. Bellin
note, "It is no accident that federally-funded health centers are concen-
trated in areas where the civil rights movement was strong" (1974, 17).
Meanings of community were particularly contentious in the midst of
the Black freedom movement of the 1960s, but the key role of this move-
ment relative to community health care has been widely overlooked. I
bring Michel Foucault's writings on the clinic and biopower into tension
with the Chicago school-based definition of community upon which the
War on Poverty was established to explore the tense, interwoven connec-
tions between "community" as a regulative, aggregating power; the pro-
ductivity of "community" as a material and imaginative locus for collec-
tive demands that exceed biopolitical normalization; and struggles over
racism in the United States. While practices under the banner of commu-
nity health can entrench biopower, they can also serve to subvert state
biopolitical practices.
The valence of community health hinges on specific articulations of
geographically based and group-based understandings of "community."
Community health advocates often distinguish between health centers
that are in rather than of a community, a distinction that geographers
gloss as abstract space and making place (Connor and Mullan 1982; Toll-
man 1991, 637; Strelnick 1999). This is no trivial semantic game. A health
center based in a community might be judged successful by state plan-
ners if it increases access to health care for residents of a bounded geo-
graphic area. But this conflation of community with population and local
space obscures the reality that "access" also depends on whether the services

40 • JENNA LOYD
fulfill the cultural, economic, and linguistic needs of the people intended
to use them.
On the more radical end of the spectrum, community-oriented pri-
mary care (COPC) practitioners argue that community health is not only
the sum of individuals in a geographic space but also the capacity of a
group to create community. The role of the clinic should be to help mobi-
lize people to create a place-based community through the collabora-
tive identification of needs. Such efforts evaluate success not in terms
of increasing access or even in providing culturally competent care but
rather in enabling people to effect change in their own individual and
collective lives. Importantly, this includes the capacity to challenge the
power relations that shape the environmental and social conditions that
affect their life chances.
The tension between health as therapeutic intervention and as a ve-
hicle for social change is not a matter of putting politics into or keeping
it out of health care. Indeed, Foucault provides a prehistory of current
debates in his The Birth of the Clinic (1973) in which he shows how the
development of the medical gaze in eighteenth-century clinical practice
worked to localize disease and death within the body, and simultane-
ously helped to instantiate the modern individual. He expands on this
theme in The History of Sexuality (1978) where he suggests that the clini-
cal gaze is one node in the individuating-aggregating dialectic of disci-
plinary "anatomo-politics of the human body" and regulatory "biopolitics
of the population." Together they constitute an emergent form of bio-
power, which partly displace the power of the sovereign and his "right to
take life or fer live" (Foucault 1978, 134, 136). "In the ordering of human
existence [medicine] assumes a normative posture, which authorizes it
not only to distribute advice as to healthy life, but also to dictate the stan-
dards for physical and moral relations of the individual and of the society
in which he lives" (Foucault 1973, 34).
While the norm of healthy living is central to biopower, healthy living
for all has not been "normalized" or universalized. Rather, death remains
an effect of biopower: "It is no longer a matter of bringing death into play
in the field of sovereignty, but of distributing the living in the domain
of value and utility. Such a power has to qualify, measure, appraise, and
hierarchize, rather than display itself in its murderous splendor; it does
not have to draw the line that separates the enemy from the sovereign
from his obedient subjects; it effects distributions around a norm" (Fou-
cault 1978, 144). In The History of Sexuality Foucault but hints at the role

W H E R E IS C O M M U N I T Y H E A L T H ? - 41
of racism for reconciling the paradoxical production of death within a
system of power devoted to life. Unlike arbitrary deployments of sover-
eign power, death in the context of biopower is not random; rather, rac-
ist discourses radically inscribe state biopolitical practices as a "means
of introducing... a fundamental division between those who must live
and those who must die"—a hierarchy built into an apparently democ-
ratizing form of normalization (quoted in Stoler 1995, 84) ,2 Through bio-
power, the normalization and disciplining of individuated bodies rather
than the universalization of human needs becomes the means of pro-
ducing a "healthy" social body.
What is the role of the clinic in differentially making life? R. Dubos (1987
[1959]) and T. McKeown (1979) demonstrated long ago that nutrition and
salubrious living environments are much more important to improved
population health than clinical care per se. Building on this work, and par-
ticularly since the publication of the Black Report in the United Kingdom
in the early 1980s, there has been a flurry of research seeking to explain the
"pathways" whereby social inequities become embodied and expressed
as health inequities on a population level.3 However, instead of shift-
ing attention away from the clinical individual, the focus on the social
determinants of health—heavily dependent on conventional statistical
methods—treats social processes as so many aggregations of individual
behaviors and lifestyles. This is evident in the so-called new public health
(Petersen and Lupton 1996) in which neoliberal discourses of individ-
ual responsibility are valorized and "health" is insistently commodified
(Porter 1999, 231-313). As part of this regime, what R. Castel (1991) calls
the "epidemiological clinic," the clinical gaze remains an omnipresent
feature of life, but the normalization of individuals focuses on aggrega-
tions of "target populations" or "risk groups" whose collective behaviors
or social relations merit therapeutic intervention (such as through activi-
ties that increase stocks of "social capital"). R. Crawford argues that this
"healthist" ideology, in which personal health is a central preoccupation,
"fosters a continued depoliticization and therefore undermining of the
social effort to improve health and well-being" (1980, 368).
While the "epidemiological clinic" may focus the gaze on, and thereby
create, at-risk communities, epidemiological knowledge can be put to
work in other ways. If risk—"group-differentiated vulnerabilities to pre-
mature death" (Gilmore 2002, 261)—is understood as the violent result of
social hierarchies, then the logical solution from a social medicine stand-
point is to undo the hierarchies.4 That is, community health need not be

42 - JENNA LOYD
understood exclusively as a normalizing intervention but also as a "politi-
cal object" that can be "taken at face value and turned back against the sys-
tem that was bent on controlling it" (Foucault 1978,144-45). Community
health can be a biopolitical institution that naturalizes individual health
status and produces depoliticized therapeutic solutions, but it can also be
employed as a means of producing the possibilities for (healthy) living that
epidemiological distributions themselves demonstrate are possible. "Com-
munity" comes to mark discursively and practically the struggle over this
biopolitical division.
The radical potential of community health is in exposing the contra-
dictory reality of biopower and organizing in such a way that collective
well-being is possible. Existing biopolitical forms of health and health
promotion promise to ameliorate suffering and meet short-term needs,
but they do not do so on a long-term basis. Instead, community health
can show how the state's inability to meet current needs is part and par-
cel of the biopolitical—that is, racialized—organization of scarcity that
extends beyond the state to the structure of the economy. Community
health can demand the biopolitical promise of meeting human needs
and put it to work by creating collective means for living well, hence link-
ing the long-term changes necessary for meeting short-term needs.

Community, Civil Rights, and the War on Poverty

Within the context of efforts by the United States during the cold war to
advance itself as the beacon of freedom, the civil rights movement illu-
minated the white supremacist nature of the state in which social pro-
grams were delimited by class, race, and gender (Mink 1995). Following
the passage of the Civil Rights Act in 1964, which forbade the use of fed-
eral funds for segregated institutions, Medicare moneys provided the
means to undo racial divides in access to health care (Quadagno 1994;
Smith 1999). The War on Poverty was created in the midst of this politi-
cal crisis whereby President Johnson struggled to pacify the civil rights
movement and white voters alike. Centering on the Economic Oppor-
tunity Act (1964), the War on Poverty was an ambitious—but ultimately
sparsely funded and short-lived—part of Johnson's Great Society pro-
grams, which primarily benefited the middle class (Jackson 1993).
In the face of civil rights challenges to exclusions from the national
community, competing discourses of "community" were at the heart of
struggles over the War on Poverty. The biopolitical discourse of community

W H E R E IS C O M M U N I T Y H E A L T H ? - 43
embedded in Chicago school sociology—in which conflict naturally gave
way to assimilation as groups found their functional urban niches—pro-
vided the rationale for pursuing community-based change (Helmes-
Hayes 1987; Venkatesh 2001). In the 1950s and 1960s, urban practitioners
developed two main avenues to intervene in pathological community
disorganization. The first sought to increase the capacity of disorga-
nized communities to assimilate individuals into society, an approach
that "took the notion of community reorganization in a more therapeu-
tic than political direction" (O'Connor 2001, 126). Welded to the concept
of disorganized communities was the idea that such communities fea-
tured a distinctive "culture of poverty," a characterization developed by the
anthropologist Oscar Lewis and popularized, ironically enough, by the
socialist Michael Harrington. In his The Other America (1962) Harrington
sought to explain why "pockets of poverty" still existed in the midst of
postwar American prosperity and global hegemony. The culture of pov-
erty theory explained that poor people were excluded from society—not
integrated in a subordinated position—and that cultural "traits" such as
underemployment, resignation, dependency, and the matrifocal family
were "transmitted" from generation to generation, thereby creating a vicious
cycle of poverty (O'Connor 2001, 117-18).
In contrast, the second trajectory of community-based change subor-
dinated the idea of community disorganization to that of structural bar-
riers to change. This approach is often associated with Saul Alinsky who
emphasized community organizing and empowerment in order to con-
front the forces outside of the community responsible for creating poverty.
While Harrington's book provided the rationale for the War on Poverty, the
Alinsky-style approach formed the motive force for community action,
which was decried by elected officials and the burgeoning New Right as a
form of state-funded class and race war. This is ironic considering that the
War on Poverty's emphasis on community action was enabled by a natural-
ized understanding of poverty. Because the assimilation (normalization)
framework of community could not theorize racism, it could not confront
racial antagonism. As "the concepts of social 'disorganization' and cultural
deprivation became increasingly racialized" (O'Connor 2001,135), the bio-
political discourse of community served to shore up and obscure the
biopolitical "naturalness" of poverty as a racial attribute. While the idea
of race as a biological category fell away, the naturalization of racial
groups through the norm of cultural pathologization has been reworked
through the clinical discourses of risky behavior, lifestyle, and renewed

44 - JENNA LOYD
claims of Black people's natural propensity to violence (cf. Greenberg and
Schneider 1994).
For their part, the white Left along with Black activists roundly criti-
cized the War on Poverty for serving to co-opt movement activists, for iso-
lating "the black poor as clients in government service bureaucracies," and
for funneling "African-American activists into arenas of bureaucratic prob-
lem solving where interrelated neighborhood issues were fragmented"
(Gregory 1998, 99; also see Piven and Cloward 1993 [1971]; Jackson 1993).
In its broadest outlines, I concur with this assessment. However, the early
history of the neighborhood health centers provides a more promising
example of state accountability in the vein of community-determined,
state-funded programs. Beyond the question of accountability, these cen-
ters temporarily became sites of struggle in the project of dismantling the
biopolitical state, which reines, into separate professions and bureauc-
racies, life as a collective liberatory project.
Liberal reformers in Office of Economic Opportunity's Office of Health
Affairs envisioned community action for health as a means to mend the
health gap between rich and poor, white and Black. That is, they claimed
the right to, and possibility of, health for all—a project they explicitly
understood outside of the frame of existing health programs. As the new
neighborhood health center programs were first developed in Watts and
in Mound Bayou, the specific meanings of "health" promotion were wide
ranging and were concerned first with community organizing to iden-
tify "immediate, real needs, not abstractions" (Geiger 2005). Importantly,
establishing clinical programs was secondary to developing community
leadership, but this played out in locally specific ways, depending on the
strengths and strategies of the local civil rights movement.

Radicalizing Health Professionals

The Medical Committee for Human Rights (MCHR) was formed in 1964
by an interracial group of health professionals from the U.S. North and
South. This event came one year after some of the committee's founding
members picketed the American Medical Association's (AMA) national
convention with the demand that it expel segregated local medical soci-
eties (Kotelchuck and Levy 1975; Smith 1999, 116-17). This was part of
much longer Black-led efforts to politicize Black exclusion from govern-
ment services and protest the degradation to which Black people were
subject when utilizing government and private medical care. Over one

W H E R E IS C O M M U N I T Y H E A L T H ? - 45
hundred doctors, nurses, and other health workers answered the move-
ment's call for a "medical presence" at that year's Freedom Summer orga-
nizing drive in the South (Wells 1964; Dittmer 1994). The disappearance
and suspected murders in June of James Chaney, Andrew Goodman, and
Michael Schwerner added urgency to the call and underscored the vio-
lence that activists and residents could expect.
Voter registration, freedom schools, and community centers were estab-
lished as organizing projects, an idea that health professionals also sought
to implement. At the Mileston, Mississippi, community center, MCHR
helped form a health association and establish a clinic with the area resi-
dents.5 Three nurses who worked on the project describe as follows how
the center was planned as well as its political intent:
The members of the Holmes County Health Association not only helped
build, paint, and equip the community center and the clinic set up in it,
they also took part in reaching the decision that the clinic would serve the
community best if it functioned as a diagnostic screening clinic
The day the clinic opened people came from all over the county to see it
and to hear about the services it would offer. We were careful to explain that
it was not a treatment center and to outline just what services it would pro-
vide. It was important not to deprive these people of their motivation to press
state and federal agencies for improved health programs. And that could hap-
pen if they had their own health facility. (Of course if people turned up on
examination day in need of emergency care, we did give it.) (Cunningham,
Sanders, andWeatherly 1967, 802; emphasis added)

While the project was not yet a fully developed "community health center,"
the crux and motivating force—community organizing to meet immedi-
ate needs and develop institutions for the future—was unmistakable. Yet
this passage also illustrates the tension within MCHR, and the movement
generally, over whether energy should be directed toward pushing the
government to enforce its laws and desegregate existing institutions or
toward developing autonomous, Black-led institutions that would serve
current needs and provide the means for continued empowerment and
social change (Kotelchuck and Levy 1975).
Robert Smith, a Mississippi-born Black medical doctor, was a founder
of MCHR and coordinated its activities in Mississippi that summer (Cun-
ningham, Sanders, andWeatherly 1967). He had also worked at the Mile-
ston clinic, and he called a meeting in December 1964 to discuss how

46 • JENNA LOYD
MCHR might continue its work. In an oral history interview in 2000,
Smith recalled how the group talked about creating a new kind of health
institution:
[Such a place] didn't exist, and there was no model in the country. Or, Jack
Geiger talked about, he had South African experiences, and he talked about
the fact of a health center thing from South Africa. But, of course, I didn't
know anything about South Africa. I knew what Mississippi needed, and
from that meeting, we came up with the idea of trying to put together a
comprehensive package which we had no idea how it would be funded or
who would sponsor it, or what have you. But out of that grew the concept of
neighborhood health centers, of comprehensive health centers, that grew
out, really, of the Mileston... experience.

In Mileston, the South African roots of community-oriented primary care

found another expression. Jack Geiger, a longtime civil rights activist and
medical doctor, had trained in Polela with Sidney Kark, who is lauded as
the father of the practice (Tollman J99 J; Kark and Kark J999).

Bartering Dignity for Health: Political Opening at the Office of

Economic Opportunity

Meanwhile, the physician Joseph English along with Lizbeth Bamberger

(Schorr) were in charge of developing health programs for the Office of
Economic Opportunity (OEO).6 In a leading health policy journal, they
explained that the imperative for an innovative health care program be-
came clear when Community Action Program planners concluded that
job training and early education programs were ineffective when people
were living with debilitating, untreated health problems (Schorr and
English 1968). What is more, "medical services provided through the pre-
vailing arrangements were not proving to be as useful as they might in
bringing individuals out of poverty" (Bamberger 1966, 1142).
In contrast to the prevailing "biomédical individualism" (Krieger
1994, 890) that characterized cold war-era epidemiology, public health,
and medical practice (Porter 2006, 1669), OEO's program was a demedi-
calization project. Schorr and English discovered that there was a hand-
ful of "maverick" doctors in the country on whom they could count to
create the program they had in mind (Couto 1991, 267-85). Few doc-
tors could imagine, much less fully embrace, such a "profound—even

W H E R E IS C O M M U N I T Y H E A L T H ? - 47
revolutionary" change in the way they worked (Geiger 1974 [1969], 133).
Geiger, for one, reveled in the possibilities of community involvement:
"So much for apathy! So much for the professional's belief that he has
unilateral control of the system" (1967, 64).
Federal centralization enabled the Office of Health Affairs to create novel
health programs that would engage community members and profession-
als in true collaboration, and to support projects in places that would not
otherwise fund such initiatives, namely in the southern states but also
in Los Angeles.7 As Geiger later explained: "In the South, where almost
all OEO projects were correctly perceived as potential or actual vehicles
for black autonomy, resistance to health centers by local and state govern-
ments and by professional societies was bitter and prolonged" (1984, 20).
Such relative autonomy, in turn, would allow community groups to pres-
sure the local state to be accountable to the entire citizenry (Piven and
Cloward 1993 [1971], 268-76).

Mound Bayou, Mississippi

At the height of the civil rights mobilization, the Office of Health Affairs
asked Geiger and Count Gibson, a fellow member of MCHR and chair of
preventive medicine at Tufts University, for a proposal for what would
become the first two community health centers: Columbia Point in Bos-
ton and an undetermined "Southern rural location." Geiger imported
his experience in South Africa to the United States where it was infused
with political organizing for rights and collective empowerment, thereby
lending an antiracist valence to "maximum feasible participation." As
Geiger recalls: "Why couldn't community health centers be used as a
route to social, economic, and political change—addressing the deepest
causes of disease? And shouldn't we have a new model for primary care
that would draw on the resources of the people themselves, making them
active rather than passive participants?" (Geiger 1996, 16). Identifying a
location in the South for a rural clinic required deft political maneuver-
ing around the white power structure (Geiger 2005). John W. Hatch, an
African American Freedom Summer activist who hailed from the South
and was working in Boston as a social worker, joined Geiger in scouting a
location. They ultimately decided on Mound Bayou, Mississippi, a small
town in the Mississippi Delta (Couto 1991, 269).8
For two years, Hatch worked with local residents in the five-hundred-
square-mile area to organize ten local health associations, while Geiger

48 - JENNA LOYD
and a team conducted a health survey (Geiger 1993,1999 [1993] ). In a tele-
phone interview with me in 2005, Geiger emphasized that "John Hatch
and I had a deal. He wouldn't give any penicillin shots, and I wouldn't do
any community organizing." In continuing to discuss Hatch's pivotal role
in the development of the health center, he stated:
He is one of the great community organizers What John did is what
almost nobody else in the community health center movement and analo-
gous OEO projects did, which was real community organization rather than
instant community organization. Instant community organization in every
community is [as follows]: a whole bunch of people will come forward and
say, in effect, "Looking for the community? Here I am." And they are usu-
ally part of whatever is the existing local power structure, and they are usu-
ally not representative, and they are certainly not likely to be, in fact, poor
people themselves. John's goal and orientation was the slow process of orga-
nizing the poor themselves.

Geiger also described how different "health" issues were identified as part
of this slow process of "real" community organizing:
In one town, people had to go three miles to haul water and drink. The
alternative was to drink out of the drainage ditch. In that community, the
main push was for drinkable water. In another community, care of children
was the main need. In another one it was care of the elderly....
But almost everywhere it wasn't health services that were most impor-
tant to the community. People said, "Health services are fine, and what you
talk about sounds good, and we're happy to share in it, but for the love of
God can you spare some food?"
There were two or three other priorities that came ahead of health as we
ordinarily define it. These were food, jobs, housing, and then maybe educa-
tion. Health was fourth or fifth on the list. It happens to be a good point of
entry for the other things. (Geiger 1974 [1969], 139-40)

The programs they created included "early child care, nutritional and
social programs for the isolated rural elderly, a bus transportation sys-
tem, legal services, and housing rehabilitation" (Geiger 1996, 17). In this
place, community health was a vehicle to materialize "a plenitude of the
possible," as Foucault called the struggle for life itself (1978, 144-45).9
The health associations became the basis for the North Bolivar
County Health Council, which was chartered as a community develop-
ment corporation. The associations built community centers that were

W H E R E IS C O M M U N I T Y H E A L T H ? - 49
rented out to the health center during the day to pay the mortgage while
being used at night for civil rights and voter registration meetings (Gei-
ger 1984, 26). They also bought land to form a farm cooperative, which
Geiger believes was the first to be established by landless people in the
United States. In 1968, they planted and harvested over one million
pounds of vegetables, "more than the annual amount hitherto grown in
the entire Delta for its own consumption" (Hall 1969, 77). Of all these
achievements, Geiger considers education as the most important (Gei-
ger 2005).10 This "has turned out to be a self-sustaining process" and now
multiple generations of health professionals can be traced to the health
center (Geiger 2005).

"Ten Dollars Sick": A "Revolutionary" Health Center in Watts, California

At the time of the Watts uprising in 1965, the War on Poverty Program
in Los Angeles was mired in political wrangling so intractable that no
programs were off the ground (Bauman 1998). The McCone Commis-
sion investigation into the revolt ignored this stalemate, but it did iden-
tify poor health and the need for medical care as contributing factors.
Indeed, the overall mortality rate in Watts was 22.3 percent higher than
in the rest of the city, while the infant mortality rate was three times the
county average (Viseltear, Kisch, and Roemer 1967,8-11; Tranquada 1968,
29). The nearest public outpatient clinic and hospital were located north-
east of downtown at Los Angeles County Hospital, some fourteen miles
away. By car the trip took forty minutes, but by bus it was a grueling two
hours (Tranquada 1968, 29). "Ten dollars sick," the cost of a cab ride,
became the measure of being sick enough to justify the trip up to "Big
County" (Frankel 1969, 14).
Watts Health Center became the first in the nation to run itself auton-
omously from its medical school sponsor, the University of Southern Cal-
ifornia Medical School.11 Before the Watts uprising, the school had been
approached by the OEO to establish a community clinic (Tranquada 1968,
2004). The University of Southern California (USC) is a private university
located just south of downtown Los Angeles, and it was (and often still
is) regarded as a white institution isolated from the concerns of the sur-
rounding community. Thus, it was not in a favorable position before or
after the uprising to establish an ostensibly community-led health center.
Indeed, from the beginning there was widespread skepticism in Watts of

50 • JENNA LOYD
USC's intention for the clinic and resistance to patients being used for
"experiment and study" (Davis andTranquada 1969, 108).12
The dean of USC's medical school, Roger Egeberg, enlisted Robert E.
Tranquada from the Department of Medicine to work on the project with
Elsie Giorgi (an ironic turn considering that weeks earlier Tranquada
had been deployed in Watts as commander of the National Guard's 40th
Armored Medical Battalion). Giorgi was director of clinics for Cedars-Sinai
Medical Center and was already involved with the Head Start program in
Watts. Tranquada and Giorgi, both white, asked Jim Bates, a young Afri-
can American man who had grown up in Watts and was a USC graduate,
to be the community organizer and establish a Community Health Coun-
cil. The council included nineteen community representatives, all resi-
dents of Watts and users of the center's services. From the start the board
was comprised of both African Americans and Latina/os. Giorgi asked
some of the mothers she knew from Head Start to serve on the council,
and she explained that she "wanted a committee to help [her] decide the
best way to set this up for the people." They responded that they were
not the "power structure" in Watts, but Giorgi insisted by stating: "I don't
like power structures because people who like power usually abuse it to
keep it" (quoted in Pullen and Wibecan 1997,24). Several of these women
from Head Start became founding members of the board, and a group of
mothers and elderly women formed the core leadership of the council.
The centrality of women in the Watts Health Center parallels that of the
Delta Health Center (Nelson 2005).
Like other Watts institutions established at the time (Bauman 2007),
commitment to social change and self-determination formed the bed-
rock of the health center. In a personal interview with me in 2004, Clyde
Oden, who joined the center in 1969 with a degree in optometry and a doc-
torate in public health from University of California, Berkeley, explained:

They [the board] wanted to say what was most important and have resources
allocated in that way. They wanted to identify, and did identify, the things
that were most important and say, "This is what we want to do," rather than
saying "This is what you're telling us to do.".. .And so the board felt that
it understood what the community needed, and so they wanted to advo-
cate for those things and see that they happened. Whether or not there was
precedent for them or not was not the issue. The issue was: "These are our
needs; let's respond to those, or let's make certain that we can attempt to

W H E R E IS C O M M U N I T Y H E A L T H ? - 51
 respond to them." And so that was very much in the ethos, very much in the
air, was self-determination.

Establishing community control of the center was an immediate goal of

the board, which Freita Shaw Johnson recalled as "a fight all the way up
the line" (Pullen and Wibecan 1997, 36; also see Davis and Tranquada
1969). The speed with which they established their independence, in Jan-
uary 1970, speaks to their rejection of the racialized structure of medical
practice, which they aimed to implement through community control.
As part of their demand for respectful and accessible health services,
the community board also sought equal footing with the health staff. As
Oden explained to me:

The community was in the driver's seat. It really wasn't medically led, even
though those of us who were "trained professionals" were in leadership
roles. We were responding to the impulses coming from the community. So
they may not articulate it clearly, but we would hear enough to know, "Ah, I
think this is you're trying to say," or "This is what you'd like to have us do,"
and then we'd go do it. I learned, for example, that everything I'd learned
at Berkeley I threw out in about two weeks. It just wasn't going to work, the
public health issues, all the perspectives, all that I was taught there, they
had not even contemplated what community health was all about and so
there was nothing I could really use there. I had to learn—and I was taught
so much from these community activists, these women in particular—in
terms of issues about health, and that's where I really got my grounding.

This process resulted in a number of innovative programs. In 1969, the

center established the House of Uhuru (Swahili for "freedom") in order
to deal with the emergent heroin problem, which in Oden's appraisal was
"the clearest example of self-determination." House of Uhuru was the
first drug rehabilitation program funded by the OEO and one of the first
community-based residential programs in the country (Hambrick 2005).
The center also owned a fleet of vans for transportation, provided child
care, ran nutrition and school-based programs, and operated an emer-
gency room before nearby King Hospital opened in 1972.
Finally, much like the Delta Health Center, the Watts Health Center
served as a key site for African American health education and practice
(Hambrick 2005). As Oden recalled in his interview with me, the "few
full-time doctors we had were committed soldiers, in the sense that they
were social change activists." In 2005 in an interview with me, Harold

52 - JENNA LOYD
Hambrick, who began working at the center in 1968, described the people
who were attracted to work there: "It was like a cluster of young folk who
were excited about having this opportunity to go into the community
and make a difference, and particularly in the area of health care, and
particularly in the area of primary health care."

Whose Community Health?

By 1967, even as the interdependence of civil and economic issues for Black
freedom was becoming more evident, the legislative avenues for reform
were narrowing (Hamilton and Hamilton 1997). Opposition by whites to
socioeconomic transformation mounted as white Americans increasingly
felt that the War on Poverty pandered to African Americans as a "special
interest" group while neglecting the poor, white "forgotten American"
(Hamilton and Hamilton 1997; Quadagno 1994).
In the context of white opposition and blocked avenues for reform,
Black nationalist or Black Power politics became increasingly salient. As
M. Marable writes, "From its origins, Black Power was not a coherent ide-
ology" (1991,99). Rather, from the Black Panther Party to Black capitalism,
many currents of political thought and action were developed to respond
to shared experiences of oppression, violence, and relative powerlessness.
While there was a stronger analysis of the structural dimensions of rac-
ism, as well as debate over the role of white people in the movement and
social institutions, Black Power overall suffered the same internal class
problems as did the civil rights movement (Marable 1991, 108). In the
struggle over who could speak for or represent "the" African American
community, internal class politics were sometimes obscured by claims
of unproblematic national unity, while others insisted that Black freedom
must necessarily mean meeting the needs of the poor or interracial class
struggle. Grappling over the control of state programs was one arena of
this struggle. Was community control oppositional to the (biopolitical)
state or merely an opportunity for the Black middle-class management
of an otherwise unchanged racial relationship? (cf. Allen 2007 [1969]).
Watts and Mound Bayou each featured class conflicts between com-
munity health councils and African American doctors. These conflicts at
once undermined and reproduced the "naturalness" of racial commonal-
ity embedded in the social theory of the Chicago school. Before the cen-
ters were established, Black doctors were often the only source of medical
care for Black patients, but their services were insufficient and often were

W H E R E IS C O M M U N I T Y H E A L T H ? - 53
prohibitively expensive. Like the AMA, many Black doctors claimed that
the free health care provided by the centers would threaten the economic
viability of their practices; they also criticized the "carpetbagging" role of
white doctors. In Watts, the local Black medical society charged the com-
munity health council with serving the interests of USC and not paying
prevailing salaries, but it became clear to the council that the pecuniary
interests of this group overrode their concern for the residents of Watts
(Tranquada 2004; Pullen and Wibecan 1997, 28). As Hambrick and Oden
told me later, few of the doctors who worked at the center came from the
area, and those who did were dedicated "change agents."
In Mound Bayou, class conflict between poor and middle-class African
Americans was at the center of a debate in 1971 over the role of health pro-
fessionals in social change that unfolded on the pages of the progressive
journal Social Policy (Geiger 1971a, 1971b; Levy 1971a, 1971b). Unexpect-
edly, considering the political moment, the issue of class was obscured
by polarized interpretations of social change, which pitted reform against
revolution, integration against Black nationalism, liberals against radi-
cals. The exchange between Howard Levy, a physician and activist,13 and
Jack Geiger began after Geiger argued that some of the activities of radi-
cal health professionals at the time, such as free clinics and the provision
of medical documentation to help young men avoid the draft, threatened
the "movement toward radical reform that many of us are engaged in"
and could "in fact end up as reactionary regression" (1971b, 24). Geiger
empathized with the "fierceness of [the] dilemma" posed by attending
to social change and individual needs, and he offered his experience at
Mound Bayou as a model for radical professional praxis (1971b, 31). For
Geiger, the Delta Health Center was radical because community mem-
bers had set its priorities and because the center had "organized and
transferred power to the rural Black poor—against the deepest wishes of
the local Black elite" (1971b, 28).
While Geiger positioned himself as a "radical reformer" seeking to
address the roots of the contemporary social crisis in "poverty, slums,
racism, the military-industrial complex, the war, and the failing social
and human services" (Geiger 1971b, 24), Levy countered that Geiger was
merely a disarming "academically based, corporate, medical liberal" (Levy
1971a, 50). To Levy, the neighborhood health centers manifested a colo-
nial relationship in which powerful medical schools backed by the federal
government actually controlled the programs. Geiger rejoined that Levy
had maligned "the struggle of 16,000 rural, poverty-stricken Blacks to gain

54 - JENNA LOYD
control over their own programs, lives and destinies against the opposi-
tion of both the white power structure and of a small, pseudomilitant,
Black, middle-class elite" (Geiger 1971a, 61).14
The veracity of the charges and counterclaims is less important than
what this debate can tell us about competing meanings of community
health. Part of the struggle to define the role of health professionals in
transforming white institutions hinged on the power to define commu-
nity and to what ends "community" would be mobilized. Certainly Levy
and Geiger understood that the notion of a monolithic Black community
is an illusory presumption. Nevertheless, sharpened white intransigence
fueled the urgency of a united Black Power front, which in this instance
shored up assimilationist racism by papering over class differences. In
assessing whose project for community health was more liberatory and
hence who should be backed, the question should have been whether
Black health is diagnosed individually or through the legacy of slavery.
Would control by the local Black middle class lead to structural transfor-
mation? Would the presumption of group identity be able to confront the
ongoing dynamics of dispossession lived by the area's landless people?
Levy downplayed class and ideological conflicts within the Black com-
munity and acceded to the idea implicit in some strands of Black nation-
alism that there was once a moment of authentic unity that had been
distorted by neocolonial divide-and-conquer tactics. The ironies abound
here. Taken in a conservative direction, this idea dovetails with the Chi-
cago school social ecology, which obscured racism through the paradigm of
natural and politically neutral assimilation. Next, interpreting the power
relations between the U.S. North and South as a neocolonial proxy for
white-Black relations paralleled southern white resistance against fed-
eral intrusion. Levy's claim that only local Black folks could be account-
able in the freedom struggle obscured the autonomy that the civil rights
movement had built by generating interregional and international soli-
darity. This solidarity forced federal intervention, albeit limited, into race
relations in the South. Ultimately, the posture of community as "local,"
and not as a capacity to create change locally in concert with change
in extralocal places, reiterated the white supremacist mantra of state's
rights.
In many ways, the apparent centrality to the debate of class conflicts
within this southern Black community was a foil that concealed points of
commonality. Rhetorical differences aside, Geiger and Levy agreed that
community controlled health programs were crucial innovations (radical

W H E R E IS C O M M U N I T Y H E A L T H ? - 55
reforms) and that the health care system as a whole had not (yet) been
fundamentally changed by them. The point of contention centered on
Levy's unwillingness to recognize that the community-led health inter-
ventions at the Delta Health Center might actually be more radical than
the free clinics he lauded simply because the former were government
funded and thereby politically suspect. But surely there is a distinction
to be maintained between the possibility that these centers held and the
limits they ran up against.15 The questions up for debate should have
been how centers could be the beginnings of a systemic transformation
of American medicine and health promotion, and what might be the role
played by mass political mobilization—questions that assume renewed
vitality in light of the aims of the Obama administration for health care
reform.

What Happened to the Centers and the Possibilities They Offered?

By the time of the Geiger-Levy debate, the War on Poverty was politi-
cally dead. Though the health centers were very well regarded, the John-
son and Richard M. Nixon administrations systematically hamstrung and
dismantled them. In 1969, the AMA succeeded in forcing the OEO to
change its policy of providing services to all of the residents in their
area to instead permit them only to treat poor patients (Strelnick 1980).
The potential political meanings of community and community health
were thereby restricted to a class-homogenous one, which simultaneously
obscured racism and enabled the continued hegemony of assimilation-
ist explanations of racialized poverty. What is more, as J. May writes, in
the push to professionalize and regularize the program, many "former civil
rights activists were replaced by professional administrators and business
managers," and "as a result, the initial measures taken to guarantee the
accountability of the sponsoring institutions disappeared" (1980, 8).
In his first term, Nixon placed Donald Rumsfeld (with Dick Cheney
as his aide) in charge of the OEO.16 They planned a policy program that
would simultaneously distance them from the Democrats' War on Poverty,
which Nixon had successfully racialized in his politicking, and allow them
to dismantle "the political power of the interest-laden New Deal bureau-
cracy" (O'Connor 2001, 223). Nixon added "New Federalism," a policy that
claimed to decentralize federal funding and democratize decision making,
to the quiver of his southern strategy for his reelection campaign. While
New Federalism had superficial resonances with "community control," it

56 • JENNA LOYD
actually siphoned money away from the inner cities and poorer commu-
nities to wealthier cities and suburbs (Piven and Cloward 1979 [1977], 354).
By separating organically connected issues—such as housing from health
care—and limiting conflicts to a "community orientation," Ira Katznelson
argues that New Federalism worked to "take the radical impulse away from
the politics of race" and renew the Chicago school's treatment of race as
"ethnicity in the traditional community bounded sense" (1981; quoted in
Gregory 1998, 99).
The official demise of the ORO came in 1973, and its remaining pro-
grams were parceled out to other agencies. Once the neighborhood health
centers were transferred to the Department of Health, Education, and
Welfare (HEW) they were obliged to maximize revenue from patients and
improve efficiency. These new regulations "placed centers in direct com-
petition with one another" for funding, which severely tested, and out-
right condemned, the existence of many programs (Hessler and Beavert
1982, 251). Funding for the centers remained tenuous as national health
insurance, the funding mechanism that had seemed inevitable between
1965 and 1972, never materialized. Medicare did not recognize the cen-
ters until 1973, and by 1977 only twenty-two state Medicaid programs
would reimburse them (Sardell 1980).
Perhaps most importantly, professionalization and fiscal austerity forced
the centers into a medical mold in which broad education and commu-
nity health initiatives—not to mention political organizing projects—
became increasingly difficult to maintain. By the mid-1970s, the Delta
Health Center's environmental health, outreach, and other "supplemen-
tary" programs had been cut, and its services had been reduced to tradi-
tional medical service provision and health education (Geiger 1999 [1993],
13). The Watts Health Center, on the other hand, was better able to con-
tinue providing comprehensive services, ironically by forming a prepaid
health plan (health maintenance organization).17 The center maintained
its transportation services, school clinic, and day care center until Presi-
dent Ronald Reagan's budget cuts in 1980 (Oden 2004).
There are two key reasons why, in the end, health centers like Watts
and Mound Bayou could not contain the simultaneous necessity of meet-
ing everyday health needs and addressing fundamental social change.
The first reason is that demands for broad-scale social change that would
promote health equity became narrowed to technical matters as a result
of counterrevolutionary strategies against the grassroots movements of
the 1960s, including opposition from organized medicine. Second, as

W H E R E IS C O M M U N I T Y H E A L T H ? - 57
social movements were demobilized—partly through state repression—
the connections that bound social change to health care within the space
of the health center were also severed, especially for doctors who could
again claim their role as biomédical rather than as part of a broader
framework of social medicine. The positive example of what could be
done by the poor was dangerous because it undermined the old canard
of community disorganization at the root of racist explanations of Black
poverty (Payne 1995, 338; Oden 2004).

Community Health: Efficiency or Change?

Led by conservatives no less than liberals, the assault on the transfor-

mative potential of the health centers drained the radical meaning from
the notion of community health. Nonetheless, both the Watts and Delta
Health Centers continue to operate as crucial safety-net providers in their
respective communities. They have managed to survive—despite the
health care mold into which they have been forced—because of ongo-
ing political organizing and vibrant governing boards, which continue
to require 51 percent consumer representation. For instance, the Watts
Health Center took the lead in organizing the Health Coalition for the
Truly Needy in 1981 to protest federal cutbacks under Reagan (Oden
2004). Further, the National Association of Community Health Centers,
formed in 1970, has been an invaluable network educating and advocat-
ing for the important role and continued funding of these centers (Ham-
brick 2005; see also Hunt 2005; Baxter et al. 2002).
The health centers are lauded for their efficiency; as of 2007, over six-
teen million people receive health care services from nearly thirteen
hundred community health centers across the nation. President Bush
doubled federal investment in the centers, and while President Obama
promised to add another $155 million to the program, this sum is signifi-
cantly less than the quadrupled budget he sought as senator (Sack 2008;
Fox 2009). Even with this marked expansion, community health centers
continue to serve only a portion of the growing uninsured population. In
spite of these severe limitations, researchers have found that community
health centers are responsible for significantly reducing racial and eth-
nic health disparities because of their preventive care, multilingual ser-
vices, and support services. Both the Black/white gap in the death rate
and prenatal care and the Latino/white gap in the tuberculosis rate and
prenatal care have both been significantly reduced in states where the

58 - JENNA LOYD
centers serve higher proportions of low-income residents (Shin, Jones,
and Rosenbaum 2003).
But what of the broader meaning of community health that propelled
Watts and Mound Bayou in their early years? The tremendous energy
of the civil rights era enabled both a critical consciousness of the forces
shaping people's lives and the broad-based desire for "health promotion"
that challenged oppressive social conditions. In the context of a radi-
cal critique of medicine and other social institutions, health care itself
started to be regarded as a Band-Aid or magic-bullet reform. At their
best, community health centers—by seeking immediate and long-term
change at multiple geographic scales, including that of the body, home,
neighborhood, and beyond—work against such normalizing biopolitical
practices that obscure the political forces that create ill health for entire
groups of people. Health professionals were contradictorily placed in
this process of negotiating the shifting and contested division between
ameliorative reform and oppositional modes of healing. The enduring
importance of educating cadres of Black medical doctors can contribute
to ongoing processes of politicization and shore up (Black middle-class)
professionalization.
Community health met its limits when it butted up against struc-
tures of poverty in the form of poor housing and the racial political econ-
omy, health care professionalization, and the reconstruction of the state
infrastructures of white privilege. This does not mean that "community
health" is inherently reformist. Challenging these divides is quite dif-
ferent from community health under the "epidemiological clinic" para-
digm, which shifts but does not undermine biopolitical divides. Health
discourses that reify individual or group attributes—socioeconomic sta-
tus, gender, or race—as the source of harms rather than consequence
of oppressive power relations are biopolitical practices that naturalize
health promotion as a technical rather than political issue. Discipline
to a norm—rather than liberation—becomes the mark of health, and
the impossibility of achieving the norm becomes evidence for maintain-
ing social hierarchies. By contrast, radical community health practice
strives for its own obsolescence by working to create a society in which
all people's needs are met. "Community" becomes a mark of political sol-
idarity and capacity to make and defend change.
The lack of universal health care in the United States is symptom-
atic of the continued biopolitical, racialist nature of the state. But the
struggle for universal health care should not also obscure the structural

W H E R E IS C O M M U N I T Y H E A L T H ? - 59
production of health and health inequities. There are currents of "health"
movements that do not analyze the place of health as that of the autono-
mous individual but rather aim to prevent the production of ill health.
Several movements—environmental justice, women of color-led anti-
violence, and antiwar among them—organize in ways that connect the
need for immediate healing and long-term "prevention." They all con-
front the ways in which the biopolitical state creates or sanctions toxic
and violent living conditions for some groups of people in the name of
security (Foucault 1991), that is, an abstract "social body which needs to
be protected" (Foucault 1980, 55).
Community health can be effective as a life-promoting institution to
the extent that it demonstrates the material connections between struc-
tural violence and the abstract hierarchical distribution of individualized
health status. The fiction of the autonomous individual as the place of
health was undermined by collective antiracist practices in the United
States during the 1960s and beyond that aimed to heal people's bodies
and transform their conditions of living. As Foucault notes, in response
to the knowledge and power of the body produced within the clinic walls
"there inevitably emerge responding claims and affirmations, of one's
own body against power, of health against the economic system, of plea-
sure against the moral norms of sexuality, marriage, decency" (1980, 56).
In the early days of the neighborhood health centers, the clinic became a
base for political change, a place in which, in the words of M. Ramphele,
"private suffering [is] made visible as social suffering, enabling them [indi-
viduals] to stake their historical claims and thereby restore their dignity"
(1997, 114). In this way, the project of community health "without walls"
starts with the social relations and forces that produce health inequities,
not from individualized health factors. Such a strategy illuminates the
prevailing manner in which the notion of health serves as a biopolitical
naturalization of social processes, and deploys it instead as "an entering
wedge for broader change" (Geiger 1971b, 31).

Notes

1 The Declaration of Alma-Ata was an outcome of the World Health Organization-

sponsored International Conference on Primary Health Care, held in Alma-Ata
in the Soviet Union, The declaration proposes community-determined primary
health care as the strategic basis for health for all. The ambitions of the declara-
tion have been leveraged by a wide range of progressive health initiatives, most

60 • JENNA LOYD
 significantly in the People's Charter for Health drafted in 2000 by the international
grassroots group People's Health Movement.
2 Foucault develops the connection between racism and biopower more explicitly
in "Society Must Be Defended" (2003 [1997]), which only recently became available
in English. Stoler (1995), Agamben (1999), Gilroy (2000), and Mbembe (2003) have
elaborated on Foucault's argument to show how biopolitical lines hierarchically
dividing humanity materially work to produce and obscure premature death for
certain groups of people (Gilmore 2002, 261).
3 For a sample of three competing groups of interpretations of the social determi-
nants of health inequities, particularly those centering on the debate over social
cohesion and so-called social capital, see the following references (along with the
other works by these authors): Wilkinson 1996; Kawachi and Kennedy 2006 [2002];
and Muntaner, Lynch, and Smith 2001.
4 Presumably this is why recent social epidemiological literature has been so con-
troversial. For a critique from the Right, see Satel 2000.
5 In the area around Mileston, many of the Black farmers owned their own land,
thereby giving them more freedom relative to sharecroppers and enabling their
political organizing well in advance of that summer (Payne 1995).
6 English was a psychiatrist who had worked with the Peace Corps under Sargent
Shriver, who by this time was in charge of the OEO. Schorr had worked for the
United Auto Workers before joining the national labor federation AFL-CIO to push
for the passage of Medicare. She was also a civil rights activist involved in hospital
desegregation efforts.
7 In an otherwise comprehensive article, Hessler and Beavert (1982) overlook the
racialized political geography of states' rights, and thus the importance of federal
programs for racial equity.
8 Mound Bayou had been established as a Black hamlet in 1887 and had a long his-
tory of self-government and civil rights organizing. The town promised relative
security for its community members and boasted two Black-controlled hospitals
that had been organized by fraternal societies. Robert Moses, of the Student Non-
violent Coordinating Committee, organized there under the tutelage of Amzie
Moore. The physician H. J. G. Wells also worked in Mound Bayou before having to
flee to the North as a result of his civil rights activities. As D. Beito writes, "During
the freedom rides and other protests, the Taborian Hospital extended refuge and
medical aid to Fannie Lou Hamer, Amzie Moore, and their fellow activists. In 1975,
Andrew Young recalled that as 'we marched in those glory days, flanked by police
cordons shielding us from angry crowds, we knew that there was the little hospital
at Mound Bayou that would care for us'" (1999, 31).
9 The early days of the Delta Health Center can be seen in a remarkable documen-
tary film, Out in the Rural: A Health Center in Mississippi (1970), produced by Judy
Schader Rogers and shot by medical students and film students in fall 1969 and
winter 1970. This twenty-two minute film can be seen at the Web site for the Social
Medicine Portal, http://www.socialmedicine.org (accessed May 2010).

W H E R E IS C O M M U N I T Y H E A L T H ? - 61
10 Its in-service training program claimed responsibility for residents earning seven
medical degrees and five Ph.D.s, and educating more than twenty registered nurses
and social workers (Geiger 1993, 1996).
11 The Los Angeles Times dubbed USC's proposal a "revolutionary neighborhood fam-
ily health service center" (Jones 1966). Much of the following section is based on a
longer discussion of the Watts Health Center in Loyd 2005, which more fully details
the conflicts over the establishment of the center.
12 "But to look in order to know, to show in order to teach, is not this a tacit form of
violence, all the more abusive for its silence, upon a sick body that demands to be
comforted, not displayed? Can pain be a spectacle? Not only can it be, but it must
be" (Foucault 1973, 84).
13 Howard Levy had become a cause célèbre in the antiwar movement and the New
Left when he was court-martialed and imprisoned in 1967 for refusing to provide
medical training for Special Forces troops being deployed in Vietnam.
14 And indeed, the year after their argument appeared in Social Policy, the middle-
class elite associated with the Taborian Hospital took control of the Delta Health
Center, thereby supplanting the health associations of and by the Black poor,
which greatly disappointed Geiger. Taborian operated the center for the next ten
years until the health associations regained control (Geiger 1996, 2005).
15 Free clinics have been subject to widespread criticism since their inception for
providing services that the state should provide without simultaneously forcefully
pushing for fundamental change (Hoffman 1989; Loyd 2005). Thus, their work as
part of the "shadow state" (Wolch 1989) or "nonprofit industrial complex" (Incite!
2007) can certainly reproduce the existing biopolitical basis of the state and state-
sanctioned medicine.
16 Howard Phillips, the founder ofYoung Americans for Freedom (YAF), was appointed
to head OEO in place of Rumsfeld. Phillips had worked at the OEO since 1970 and
"had become convinced that the agency was nothing but a wasteful funding con-
duit for what he called 'radical' leftist recipients. Under Phillips' direction, Nixon
appointed several YAF and ACU [American Conservative Union] activists for the
purpose of eliminating numerous OEO programs" (Diamond 1995, 116).
17 Often modeled on prepaid group practices such as Kaiser Permanente, until the
early 1970s HMOs had been associated with liberal health reformers. Nixon ad-
vanced the idea as one of his major health care reforms, but the big difference was
that his legislation would allow profit making, unlike that of the liberal advocates
for universal health care. Under Reagan, California was the first state to attempt
to control Medicaid costs with HMOs (known as PHPs), and its experiment was
widely regarded as a boondoggle that benefited cronies but did not provide bet-
ter services or cost savings. Watts Health Center's application to form a PHP faced
substantial delays, unlike the contracts granted to shady interests (Loyd 2005).
Particularly since the 1990s, HMOs have faced tremendous public discontent be-
cause many people feel they place cost-cutting and bureaucracy ahead of health
services, including the preventive ones that were supposed to "maintain" health.

62 - JENNA LOYD
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4 R E P E T I T I O N AND RUPTURE

The Gender of Agency in Methodone Maintenance Treatment

SUZANNE FRASER

M E T H A D O N E M A I N T E N A N C E T R E A T M E N T (MMT) Was first introduced

into Australia in 1970. In the mid-1980s the program saw significant expan-
sion as a range of factors focused fresh attention on illicit drug use in Aus-
tralia (McArthur 1999). The disease concept of addiction, especially of
addiction to (or regular consumption of) opiates, had played a key role in
illicit drug use discourse in Australia since at least the late decades of the
nineteenth century. In many ways, MMT (or, more broadly, opioid phar-
macotherapy treatment) represents one of the most intensively medical-
ized responses to this medical way of looking at regular drug consump-
tion. Historically, disease concepts of addiction, and the medicalized
responses to these concepts, have developed alongside what Michel Fou-
cault termed "the birth of the clinic" in that they too emerged during the
period in which the production of scientific knowledge shifted to a highly
positivistic form, and science simultaneously came to be harnessed to
issues of governmentality and the production of the self. In this essay I
examine MMT clinical practice by exploring some of the ways in which
power and the production of governable subjects operate in this context.
In the process I take an explicit step that Foucault does not in his work:
that is, I look into the gendered nature of these operations. I do this via
the themes of agency and repetition, which characterize discourses both
of addiction and of femininity, and which arise repeatedly in the empiri-
cal material that forms the basis of this research.
Addictionis commonly understood to be a problem of compulsion: the
compulsion to repeat an activity that brings harm to the self, to others, and
to society as a whole. Methadone maintenance treatment is concerned
with satisfying this compulsion, again through repetition—namely that

• 69
of dosing. Indeed, interviews with MMT clients and service providers
emphasize heavily the theme of repetition in treatment. There are several
respects in which addiction is associated with femininity within Western
society (Keire 1998), and the compulsion positioned at the heart of addic-
tion and treatment, along with the repetition that signifies and material-
izes it, are prime sites of this gendering. This association with the femi-
nine is partly responsible for the stigmatization of addiction, indeed, for
the construction of addiction as a meaningful problem in the first place.
Conversely, the specifics of addiction and of treatment for addiction also
construct gender in particular ways. A key aim of this essay is to examine
these dynamics in detail as a means of developing new insights into the
clinic—in particular into the place of gender in the addiction treatment
clinic's operations—and thus in the experiences of those who are drawn
(or at times obliged) to participate in it. In addressing this aim I explore
how MMT operates differently for men and for women, how the values
and practices associated with it rely upon and produce certain forms of
femininity and masculinity, and how notions of femininity and mascu-
linity shape how MMT is understood.
To get at these dynamics I focus on the issue of agency, one that is
prominent in accounts of treatment and that is directly related to the
question of compulsion and repetition. I begin with a brief discussion
of the literature on gender and MMT in which I highlight some of the
concrete ways in which gender and MMT intra-act in the research find-
ings reported.11 then follow this with a discussion of the theoretical con-
cerns of the essay in which I draw on the work of Simone de Beauvoir
to illustrate the gendering of repetition. Having established the ways in
which repetition is gendered in the feminine in Western liberal discourse,
including in some feminist discourse, I then go on to examine in detail
the interview participants' constructions of gender in their comments
on clinical encounters, heterosexual relationships, and gender violence.
In the final section, I consider repetition from the point of view of Judith
Butler's work on the performativity of gender by posing questions for how
repetition might be thought differently in relation to MMT. Thus, in thi
essay I attend to the gendering of MMT in a double sense: first in terms
of the everyday conditions of treatment and the MMT clinic that affect
men and women differently, and second in terms of some of the gender
implications of the very notion of the "everyday" itself—that is, of rou-
tine and repetition.

70 • SUZANNE FRASER
Background

Methadone maintenance treatment constitutes one arm of a broader

pharmacotherapy-based approach to opioid dependence treatment. By
incorporating methadone, buprenorphine, and naloxone, and the com-
bination of buprenorphine and naloxone, opioid pharmacotherapy treat-
ment is the most common form of treatment for opioid dependence in
Australia. Delivered differently in each state, MMT usually involves regu-
lar (for many, daily) visits to a treatment clinic or pharmacy for dosing.
Clinics are either publicly or privately run and usually incorporate secure
space for staff, areas to accommodate waiting and queuing clients, and
facilities such as toilet cubicles for the collection of urine samples from
clients (see Fraser and valentine 2008 for more detailed information on
the layout of clinics).
In 2005, there were 38,937 people registered in pharmacotherapy pro-
grams across Australia (Australian Institute of Health and Welfare 2006).
The distribution of these between the two main pharmacotherapies,
methadone and buprenorphine, is unknown, and in any case, very much
in flux. However, given that methadone has had a much longer history in
treatment in Australia, and buprenorphine has known limitations (Bar-
nett, Rodgers, and Bloch 2001), it is generally accepted that the majority
of clients overall are taking methadone. Little formally reported national
data exist on methadone use in Australia, but it is thought that around
twice as many men as women are enrolled in methadone programs around
the country.2 Thus, while the number of men and of women in treatment
is not equal, significant numbers of both sexes participate in the program
each year and experience the program in different ways. The contempo-
rary sociological, ethnographic, and cultural studies literature on gen-
der and pharmacotherapy is not extensive, but nevertheless it elucidates
some of these differences. As is the case in other areas of research, a focus
on gender tends to mean a focus on women, as the implicit focus of most
"general" research is on the circumstances and experiences of men. This
is reflected in the scope of the work described below.
Perhaps most relevant to the issues under consideration here is the
book Surviving Heroin: Interviews with Women in Methadone Clinics (2001)
by Jennifer Friedman and Marixsa Alicea. This book examines the social
and political context of women's stories about drug use and treatment
programs in the United States and provides details on the ways in which

R E P E T I T I O N AND R U P T U R E - 71
MMT intersects with femininity to produce treatment experiences spe-
cific to female clients. The authors emphasize women's struggle to nego-
tiate contemporary notions of the "good" woman and "good" mother
in participating in treatment, and they focus on resistance in women's
interpretations of their own journeys through the "heroin social world,"
hitting "rock bottom," and the governing environment of the methadone
clinic. For example, they argue that although their participants "rejected
the status quo through their pursuit of pleasure" (204) via illicit drug tak-
ing, at length this approach proved exhausting and led them to choose
a relatively routine and conventional life on MMT and the compromises
this choice entails.
Like Friedman and Alicea, Cathy Banwell (2003; Banwell and Bammer
2006) explores the agency of women, this time in juggling methadone
maintenance treatment and motherhood. Based on the Australian women
she studied, she describes the ways in which the drug worked to maxi-
mize their efficacy as mothers as well as to minimize any negative effects
of drug use on their children. Although many described MMT as a means
of achieving a more "normal" life, they also noted that in reenacting the
drug taking previously associated with heroin they remained excluded
from designations as normal women or mothers (2003, 31).
Catherine Waldby's report in 1986 on women with children in meth-
adone programs in New South Wales, Australia, describes many of the
same issues noted above, and despite the gap of at least twenty years
since its publication it remains strikingly relevant. Waldby argues that a
reliance upon the medical model of treatment and care tends to nega-
tively impact pregnant female clients (and by implication their children)
by conceptualizing the fetus as the primary medical client and the drug-
using mother as at best an incubator and at worst an obstacle to the
health and well-being of the fetus. As Waldby notes, this can have far-
reaching negative effects: "Wherever the mother's interests and needs
are regarded as antithetical to those of her child and relegated to second
place, her incentive to cooperate with services in the care of her child
is diminished" (83). Waldby argues that treatment services need better
training and resourcing for pregnant clients and women with children.
All of these studies point to important ways in which MMT and the
clinic are thoroughly gendered in that they are implicitly designed around
male clients; for example, they rarely offer services such as childcare or
demonstrate awareness of issues such as the risk of gender-based violence
among clients (see also Broom and Stevens 1990). As demonstrated below,

72 - SUZANNE FRASER
many of these concerns are echoed in the interviews with participants
in our study. The interviews also highlight other gender issues related
to treatment and the treatment environment. As in the literature above,
agency and repetition emerge as abiding themes, and I will focus on these
themes to draw out the central concerns of this essay. In the process, I
build on the existing approaches to women's agency in pharmacotherapy
described above to consider the ways in which MMT and the clinic them-
selves construct particular gendered understandings of agency, and how
these act in turn to materialize treatment in concrete ways.

Approach

As I noted at the beginning of this essay, the disease model of addiction

and medicalized responses to addiction have developed alongside the
broad intellectual forces that Foucault identifies with the birth of the clinic.
These include an increasing emphasis on positivist scientific method,
on the application of disinterested reason to questions about the natu-
ral world and the human body, and on the power of the clinical gaze as
practical knowledge beyond intellectual learning. Foucault explains this
new way of understanding medicine, the doctor, and knowledge about
disease in the following way:
What was fundamentally invisible suddenly offered to the brightness of the
gaze, in a movement of appearance so simple, so immediate that it seems
to be the natural consequence of a more highly developed experience. It is
as if for the first time for thousands of years, doctors, free at last of theories
and chimeras, agreed to approach the object of their experience with the
purity of an unprejudiced gaze. (2003 [1973], 241)

This sense of the clinician's wisdom, based in experience, reason, and

the shrugging off of distracting and misleading theories is of direct rel-
evance for considering the clinical encounter between doctors and MMT
clients. Later, I will examine accounts of this encounter provided both by
clinicians and by clients. First, however, it is worth addressing the ques-
tion of the presence or otherwise of "theories and chimeras" in addiction
treatment. As Foucault implies in the quote above, observation cannot
take place without such intellectual phenomena. In this section, I map
out some of the "theories and chimeras" by which addiction is under-
stood within Western discourse, and, as I demonstrate later, by clinicians
working in addiction medicine. I will begin with definitions of addiction

R E P E T I T I O N AND R U P T U R E - 73
and the place of the idea of repetition in these definitions. I then go on
to discuss the significance of these ideas for gender and the clinic. In
the process, I introduce an issue not explicitly addressed by Foucault
(indeed, one about which Foucault's inattention has been criticized) —
namely, the gendered nature of subjectivity, power, and the clinical gaze
(McNay 1992).
A key element in contemporary definitions of addiction is the notion
of repetition. Consider, for example, a portion of the entry on addiction
in the Oxford English Dictionary (2007): "The, or a, state of being addicted
to a drug... ; a compulsion and need to continue taking a drug as a result
of taking it in the past." Likewise, one of the definitions of addicted is
as follows: "Dependent on the continued taking of a drug as a result of
taking it in the past; having a compulsion to take a drug, the stopping
of which produces withdrawal symptoms." In both of these entries the
emphasis is on compulsion and the continuation of past practice. The
second contains a related element, that of the inability to "stop." Other
sources also refer to compulsion and repetition. The exploration of defi-
nitions of addiction by Savage et al. (2003) demonstrates the ubiquity
of notions of compulsion and repetition. Thus, for example, the current
International Classification of Diseases terminology defines "dependence
syndrome" as involving withdrawal symptoms and tolerance, but it spec-
ifies that these must be accompanied by "compulsive use" to qualify as
"addiction" (quoted in Savage et al. 2003, 660). The fifth edition of the
Diagnostic and Statistical Manual eschews the term "addiction" in favor
of "dependence," yet its definition suggests close alignment to conven-
tional understandings of addiction. Criterion three of "substance depen-
dence," for example, includes the twinned ideas of compulsion and rep-
etition: "substance often taken... over a longer period than intended."
Likewise, U.S. federal and state policies use terms such as "habitual" use
of drugs and use of drugs on a "continuous basis" (quoted in Savage et al.
2003, 660).
This focus on repetition and compulsion as the essence of addiction
also finds expression in critical scholarship. For example, as I have noted
elsewhere (Fraser 2006), David Lenson characterizes addiction in terms
of an altered relationship to time; that is, drug users experience time as
"atomized" instead of as wavelike. This atomization emerges out of the
focus among drug users on the administration of the drug, and the sense
in which the time between these repeated moments of administration is
somehow meaningless or dead time. Lenson argues that

74 - SUZANNE FRASER
 when the next dose comes is as important as what the drug actually does.
This is partly because of the diminution of novelty: what began as a kairos—a
special occasion or privileged moment—through repetition assumes the role
of chronos or horizontal time. What characterises the condition of addiction
is above all else the atomisation of time, the replacement of conventionally
measured seconds, minutes, hours, and days with a different chronometry
based on the tempo of administration. As a result, the drug's reordering of
consciousness loses, over time, the elements of play and pleasure. It becomes
as compulsory as a clock. (1995, 35)

Here the emphasis is also on repetition and compulsion, and on the sense
that repetition precludes agency, creativity, and enjoyment.
What does this oft-imputed connection between repetition and addic-
tion mean for an analysis of gender and agency in MMT? To think this
through, our first question might be what the status is of "repetition" within
Western discourse. R. Middleton provides a survey of this issue in a paper
on repetition in music. He points out that repetition has long been asso-
ciated with the absence of originality and with mass culture and the sta-
tus quo:

From Baudelaire through Nietzsche, Freud and Adorno to Barthes, Derrida

and Deleuze: the sign of critique, the moment of jouissance, is rupture, a
break with the code, a transgression. The terms of debate are set, it would
seem, with repetition at one side, shock at the other. (1996, paragraph 9)

This definition of repetition as operating in a binary relation to the new,

to progress or innovation, is reflected and produced in a range of cate-
gories, in particular that of the "feminine." The alignment emerges in
many ways, for example, through attention to women's consumption of
popular culture (such as through the reading of "unoriginal," "derivative"
romance novels in the nineteenth century, and more recently in the con-
sumption of similarly unoriginal magazines and daytime television), and
through longstanding associations drawn between women and "natu-
ral cycles" such as menstruation and reproduction (see Middleton 1996;
Huyssen 1986). As Middleton explains, cultural products associated with
such marginalized categories as the feminine (he also names others)
have been denigrated as "objects of reproduction, devoid of historical
grandeur," that is, universality or durability.
There are many ways in which repetition figures as feminine in West-
ern thought and is simultaneously judged to be inferior. Indeed, the

R E P E T I T I O N AND R U P T U R E - 75
reference to "reproduction" above is a clue to this idea. Simone de Beau-
voir's canonical work The Second Sex (1984 [1949]) is a particularly vivid
example of the denigration of repetition, although her intention diverges,
of course, from most instantiations of this figuration in that she aims to
benefit the status and circumstances of women. In elaborating her gen-
dered approach to the existentialist themes of immanence and transcen-
dence, and the ways in which these illuminate the standing of women in
the middle of the twentieth century, Beauvoir argues that repetition fig-
ures especially strongly in relation to femininity (via, for example, repro-
duction and housework). In doing so, she both highlights and subscribes
to (though in no simple way) the alignment of repetition, femininity, and
the impaired or absent agency described above. Thus, for example, she
depicts the "housewife" as follows: "Few tasks are more like the torture of
Sisyphus than housework with its endless repetition The housewife
wears herself out marking time: she makes nothing, simply perpetuates
the present" (470). On reproduction she is equally insistent that women
are trapped in repetition: "Her misfortune is to have been biologically
destined for the repetition of Life." Earlier she makes clear what kind of
process reproduction is: "This creation results only in repeating the same
Life in more individuals" (96).
These excerpts are also quoted in Penelope Deutscher's essay on Beau-
voir and repetition (2006). Deutscher challenges the accepted view that
Beauvoir simply dismisses reproduction and housework as inherently value-
less, as mere repetition, and that she is simply echoing masculine values.
In Deutscher's view, Beauvoir's objection is more that women reproduce
activities and roles (themselves at least understood culturally to consti-
tute nothing more than mere repetition) out of habit—repetition—itself
(331). It is this repetition, that of habit and stereotype, that Beauvoir sees
as the main problem with becoming a mother and a housewife (although
it does seem that she argues that the "repetitious" acts women under-
take in these "habitual" roles mean they participate in a double whammy
of repetition). Whether or not Beauvoir's objection to reproduction and
housework and her view of women's activities are accurately character-
ized by Deutscher, there is no doubt that repetition per se figures in her
thesis in thoroughly negative terms. As Deutscher notes, "So, repetition is
depicted as animal, dehumanising, a-temporal, death-like, unrewarding,
unstimulating, boring, uncreative" (335). In The Second Sex then, femi-
ninity possesses an especially potent (if not essential) relationship to the

76 • SUZANNE FRASER
denigrated notion of repetition. Later I will discuss alternative ways of
thinking about repetition, notably as developed by engaging Judith But-
ler's work on iteration with the specific insights offered in the interviews
examined for this essay. For now, the key point is that via these litera-
tures a series of ideas can be linked: addiction, repetition, and feminin-
ity—all of which are associated with an absence or impairment of agency
and all judged inferior to the masculine values of autonomy, creativity,
and activity. In this sense it would appear that MMT, itself associated
with addiction, is likely to figure in culture, and thus to materialize in the
clinic, in terms of repetition, passivity, and femininity.
Indeed, Lenson himself points out that the origin of the word "addic-
tion" relates to the Latin addicere, meaning to say or pronounce, to decree
or bind. In his view, this etymology references drug users' loss of con-
trol over language and consciousness, that is, the notion that they are
"already'spoken for,' bound, and decreed. Instead oí saying, one is said"
(1995, 35). Given the centrality of language to Western liberal formula-
tions of the subject, this has significant implications for understandings
of addiction in liberal societies. Where regular drug use is designated
by a term that implies the inability to generate or enact speech, where,
indeed, the drug user is designated by the ontological state of being
defined rather than by the ontological act of defining (that is, of passivity
rather than activity), addiction comes to be aligned with an ontological
deficit in agency. As Lenson notes, through the representation of regular
drug use as a kind of surrender to (and of) the powers of speech, "the
addict is changed from a subject to an object" (35).3 How does this fig-
uration of addiction as absence of agency contribute to the shape and
processes of treatment? How do the "theories and chimeras" identified
here shape clinicians' practices and treatment as a whole? What implica-
tions for women in treatment might they have? These questions will be
explored via an analysis of the treatment of men's and women's agency in
interview material on methadone programs.

Method

This analysis is based on in-depth, semistructured interviews gathered

between 2004 and 2006 in New South Wales and Victoria for a project funded
by the Australian National Health and Medical Research Council. This proj-
ect, entitled "Comparing the Role of Takeaways in Methadone Maintenance

R E P E T I T I O N AND R U P T U R E - 77
Treatment in New South Wales and Victoria" was based on interviews with
treatment clients, service providers such as doctors, nurses, and pharma-
cists, and policymakers. These participants were recruited via notices and
flyers placed in clinics and pharmacies, as well as with the assistance of
state drug user organizations. Each participant was given an information
sheet and a verbal description of the project and was offered twenty dol-
lars to cover expenses.
A total of eighty-seven interviews were conducted for the study. Topics
covered in the interviews included history on methadone maintenance
treatment, day-to-day experiences of treatment, views on and experi-
ence of off-label use of methadone, and attitudes toward "takeaways"
(those doses not consumed on clinic or pharmacy premises). The inter-
views were tape recorded and transcribed verbatim, then analyzed to
identify themes with the aid of the qualitative data management soft-
ware NVivo. Analysis involved the ongoing development and revision of
codes to capture the themes as the process of analyzing the interviews
proceeded. The two researchers who coded the interviews commenced by
double coding, then when the coding became consistent between them
they reverted to single coding with intermittent checking to ensure that
coding remained consistent. The project was approved by the University
of New South Wales Human Research Ethics Committee and the relevant
state and area health service committees.

Constructing Sisyphus

I have already argued that addiction, repetition, femininity, and lack of

agency are connected in Western discourse. This alignment of concepts
is directly relevant to MMT in that it is understood to be a form of addic-
tion as much as a treatment for it (Fraser and valentine 2008). Further, it
is understood, both in the public domain and in the interview material
referred to in this essay, as intensely repetitive. As I demonstrate in this
section, this conceptualization has significant implications for the per-
ception of clients, both male and female, as lacking agency.
Central to the experience of treatment for clients, it seems, is the sense
that dosing constitutes a daily burden, which is emblematic of the low
status that drug users hold in society. Sydney treatment client Alison, for
instance, has spent several years on the program and currently accesses
four takeaways per week. When asked what the removal of takeaways
would mean to her, she replies:

78 - SUZANNE FRASER
 Well, [you'd have] no choice. Either [daily dosing] or be sick. It would be just
like having to go and get a shot every day, basically. That's exactly what it
would mean to me, just like back to square one.

Alison's remarks indicate the role of repetition in her understanding

of heroin addiction, as well as her sense that MMT has the capacity to
repeat the repetition of heroin addiction. Also clear in her use of expres-
sions such as "no choice" and "having to" is the sense that addiction and
MMT both involve forms of compulsion and a lack of opportunity for
self- determination.
Melbourne treatment client Cameron also sees MMT in terms of rep-
etition: "It's like you don't achieve nothing, you just go up and down with-
out achieving anything. It's like a roller coaster ride. And that's the hard
part." As in Alison's comments, Cameron goes on to present takeaways as
introducing an element of flexibility that is able to disrupt the otherwise
purely repetitious treatment process.
Daily dosing is mandatory in the first two months in treatment in Vic-
toria (whereas it is mandatory for three months in New South Wales),
and it remains common among clients in their first year in both jurisdic-
tions (NSW Health 2006; Drugs and Poisons Regulations Group 2006)
After this time, clients are closely assessed for suitability for access to
takeaways, and many receive only one per week, at least in their first year.
The remarks reported above reflect clients' experiences of this practice
of daily, or near daily, dosing. Ryan (Sydney treatment client), who at the
time of interview was still required to attend every day for dosing, further
clarifies the impact of this dailiness:

Um, it's the liquid handcuffs routine. It's like being on parole or on bail
where you have to report every day. You have to, you know, you're locked
into going to a chemist every day and it does play tricks on you. It does
make you think that you've lost some sort of freedom and you have got a
prison sentence.

In referring to "liquid handcuffs" Ryan makes use of a common analogy

for MMT. His other comments likening daily dosing to other aspects of the
criminal justice system reveal the extent to which the repetition involved
in treatment constitutes a form of constraint on agency ("freedom") for
many.
In these excerpts there is a strong sense in which MMT's mandating of
a period of daily dosing helps shape perceptions of treatment as a whole.

R E P E T I T I O N AND R U P T U R E - 79
They demonstrate the role of takeaways not only in alleviating this daili-
ness a little but also highlight the perception among clients that take-
away allowances are fragile and easily lost, either at the hands of individ-
ual service providers or shifts in policy. This fragility tends to constitute
treatment as always either actually or potentially highly repetitive and
constraining. Service providers are not unaware of this, as the following
remarks indicate:

But you can imagine, two or three years in a program, you'd be getting mighty
sick of fronting up every day. (Beverley, Melbourne nurse)
In time, they all get fed up with the routine as much as we try to make it
quick and not unpleasant for them. (George, Sydney pharmacist)

Some clients explain that the repetition associated with daily dosing is
all the more arduous when it is associated with long-term treatment. In
a few cases, these issues are framed within yet another context of repeti-
tion: intergenerational methadone attendance:

You know, there's guys in their forties and fifties who have been on the
methadone merry-go-round for, you know, twenty-five years. My uncle has
been on it for nearly thirty years, and it's just never ending, yeah. Just awful.
(Sam, regional Victoria client)

This last quote also indicates the extent to which, leaving aside the prac-
tical sense in which MMT constitutes a form of repetition through daily
dosing, it also functions symbolically as mere repetition of heroin addic-
tion itself. Sam laments the fact that some clients do not move on from
treatment. This objection to repetition or continuation per se can be read
as a criticism of MMT as too much like the repetitiveness or continuation
of drug use itself. In this respect, MMT is reminiscent of Beauvoir's cri-
tique of housework and reproduction: it not only adds up to repetition
through individual daily acts but always already comprises repetition
through its perceived recapitulation of the status quo—women reproduc-
ing femininity out of habit; clients reproducing addiction out of habit.

Gender and Agency

Inasmuch as repetition is aligned here with femininity, passivity, and

addiction, MMT must also be so. How do these alignments signify and
play out? As we will see, they help shape clinical relationships, processes

80 • SUZANNE FRASER
and treatment decisions. In short, they play an important role in con-
stituting the clinical encounter, and indeed the clinical gaze so ideal-
ized, according to Foucault, as disinterested and beyond the strictures
of "theory." Yet, as I noted at the outset, the alignments do not operate in
the same ways for male and female clients. After all, it is more than likely
that the feminization of women and men in treatment will operate dif-
ferently and produce different effects. As Beauvoir allows, there are some
men, such as working-class male factory employees, for whom repetition
(or for our purposes, "repetition" and all that certain understandings o
it entail) is also constraining of agency. This does not mean that this pro-
cess is identical in effects to those experienced by women.
Many of the ways in which gender figures in treatment are implicit
in the design of the clinic and processes of treatment. Elsewhere (Fraser
2006) I have described the lack of attention to client security at clinics
and other dosing points. This too affects men and women differently in
that clinics operate under a look-after-yourself ethos common to main-
stream constructions of masculinity that serves neither male nor female
clients well. Some constructions of gender, however, are more explicit,
emerging as they do in the comments that healthcare professionals make
about their work with clients.
Aaron (Melbourne prescriber) serves as my first example here. He talks
about the clinical encounter at length, describing some of his female
clients as follows:

AARON: I'm terrible with manipulative young females. In that I, you know, I
tend to sort of think, you know, I'm not good for them. If I get someone who
is real, you know, borderline personality disorder female, I just sort of see
red immediately. I think, "I'm not, I won't be good for you." So, you know,
I'm better off to say to them, "Look, this is not going to work with us."
INTERVIEWER: Yeah. And would you forward them on to someone else?
AARON: Yeah sometimes I will, or [... ] I'll tell them what my problem is,
you know. I'll say, "Look, sometimes people who carry on the way you've
just carried on annoy the crap out of me, and I can't deal with that, so, you
know, if you're going to carry on like this when you see me, I'm going to say
to you 'Move on.' " And they go, "Oh." Sometimes it's actually worked, you
know, they've pulled their fingers out [... ] and then we're okay. But I know
that about me, that I'm not therapeutic necessarily for some of them. And I
don't think it's in their interest for me to carry on like that either, so I've got
to sort of say "Well I'm not good for them, so get out of it."

R E P E T I T I O N AND R U P T U R E - 81
 INTERVIEWER: [...] Yeah, so [can] I get a bit of an idea of what sort of situa-
tions you're talking about?
AARON: Just where, you know, some of them have got all the jargon of every-
thing and then you sort of get... the story just comes out all down pat.
They constantly dig at you. Um, you can't sort of get a word in edgeways.
They'll be smiling at you while they're saying things like, you know, what
their mother has done and hasn't done to them, and everybody else has
done, and I'm thinking this is inappropriate rubbish. And I find that it just,
you know, it starts to annoy me, and I'm thinking "You're the problem, not
everybody else."

There is much that could be said about Aaron's remarks. They follow state-
ments about the importance of maintaining realism about what clients
can achieve and the likelihood that clients will create problems for them-
selves and others. Of particular relevance to this essay is the way in which
gender is explicitly addressed, and expectations of femininity, in partic-
ular around agency, are elaborated. In, for example, speaking so much
that Aaron cannot "get a word in edgeways," and in commandeering
the very psy "jargon" that Aaron himself employs ("borderline personal-
ity disorder"), the "manipulative young female" client transgresses tradi-
tional ideals of femininity as quiet, retiring, and subject to, rather than
sovereign of, expert discourse. At the same time, in voicing difficult his-
tories and in requiring of Aaron that he engage emotionally with them,
these clients also enact familiar notions of feminine excess. As such, it
seems that they are both too feminine and not feminine enough, and this
ambiguous feminine agency is enacted through various forms of repeti-
tion, from the "down pat" story and the constant "digging" to the restat-
ing of "jargon."
Aaron's approach to feminine agency has practical implications. As he
makes clear, where young women present in this way, they are sometimes
declined treatment and referred on to another prescriber. The implica-
tions of this last sequence of events for clients—that is, of identifying
a prescriber, meeting with the prescriber, providing the prescriber with
details about past history, then being referred on in the terms described
above—are not explored in the interview (nor are they necessarily known
to Aaron), but it is clear that they would be significant and very likely
negative. In describing these circumstances Aaron acknowledges his pro-
fessional and personal limits. It would, therefore, be inaccurate to sug-
gest that he locates the "problem" solely in the clients. Yet, given that

82 - SUZANNE FRASER
methadone prescribers are not always easy to find, ethical questions per-
sist about Aaron's willingness to wash his hands of clients he finds too
challenging.
These issues are especially important in that Aaron appears to relish
his work with other (male) clients whose behavior might be considered
equally or more challenging, if rather different. In the exchange that fol-
lows he describes his experiences with these clients and with another
(male) prescriber. In the process he references traditional constructions
of masculine agency as both informed—and properly controlled—by the
threat of violence:

AARON: But, you know [...]! think there are some doctors who practice in
a way that they would be totally done over. I mean, I had one bloke come
to me for a bit of mentoring one morning, and because I knew he'd been
being stood over in his practice [... ] I'd arranged to get my worst clients
there that day, told them what it was about, and [... ] the first one comes
and says, "Oh, Jesus doc, I couldn't get a fucking park." And this guy has
gone red already. I thought, "We're in for a good day here." [... ] And I then
gave him to my colleague for the second half of the day, and I said, "What
do you think?" And [the colleague] just shook his head and said, "Shouldn't
be doing it."
INTERVIEWER: And what is it that you think is a required attribute to do—
AARON: Do it?
INTERVIEWER: Yeah, successfully.
AARON: Oh, I think you've got to be a low-class prick like me. [both laugh] I
think you've got to be able to function on all levels. I've never had a prob-
lem, I'm not intimidated by it, um, I'm fifty-nine years old now, and most
people sort of deal with me as a nearly sixty-year-old. You know, I [give
as] good as I get, pretty much. I think you've got to be able to do that. You
don't get right down in the gutter with them, but you can go down there if
you need to. [... ] I tell them that, basically, in the words of the vernacular.
I mean, I will say to some of them that I think might be a problem [... ]
"Don't muck me around," I say, "because I can fuck you over a lot harder
than you can do it to me, so just remember that." And they sort of go, "Ooh,
gee." [... ] And after that they're right. Most of my clients I get on really well
with, and they'd do anything for me.
INTERVIEWER: Yeah, yep.
AARON: Um, the odd one will give you trouble, and occasionally you have
to remind them, [... ] "I'm the one who calls the shots here, not you, and

R E P E T I T I O N AND R U P T U R E - 83
 remember that because you start carrying on, you're going to be out of here
so quick you won't even know how you got out." [... ] I remember there
was a bit of a carry-on outside my door a month ago, and I sort of flew out
to see what it was, and [a client] was swearing at [a colleague] and carrying
on, and [the colleague] was saying, "Just get the fuck out of here," you know.
This is in the middle of the waiting room. And the bloke is going, "You bas-
tard, you," you know, and I just looked at him and I said, "Hey [... ] this
is our place not yours. You do what you're told here, so get outside. Cool
down, when you're ready I'll come and get you." You know, he looked at me
as though he wasn't going to do it, and I said, "I mean it," and grabbed him
by the scruff of the neck and started dragging him out the door, you see.
And they just do it. I think if I was twenty years, thirty years younger they
might fight back. But they don't, now, particularly if they see that I really
mean what I'm saying.

This account is rich in detail. Most relevant here is the masculine econ-
omy of implied and explicit violence mobilized in Aaron's management
strategy. The contrast between the circumstances under which female
clients are judged too difficult and referred on, and male clients are con-
fronted but ultimately retained in treatment, is striking. What might
account for this contrast? It could be argued that, unlike the behavior of
the "manipulative females" alluded to above, the behavior of the male
client described is essentially in keeping with gender norms in its con-
ventionally masculine resort to aggression and the threat of violence. This
might partially explain Aaron's relative comfort with the client. Equally,
however, it might be argued that the male client is feminized in the account
in that he is reminded who "calls the shots" and depicted as having to
submit to Aaron. This is a complex issue. In keeping with the alignment
of addiction, repetition, passivity, and the feminine described earlier, the
data leave no doubt that contemporary notions of addiction and the
arrangements in place around MMT often act to coproduce both women
and men as passive. Yet this particular case is ambiguous. After all, Aaron
accounts for the client's submission largely by assuming that the client
exercised ethical restraint in declining to respond to Aaron violently (the
ethical consideration being Aaron's age). In other words, Aaron suggests
that the client could well have dominated him physically but chose not
to. In this sense, the client's access to agency is not entirely denied by
Aaron. The comments presented here begin to suggest some of the ways

84 - SUZANNE FRASER
in which gender norms and stereotypes around agency shape treatment.
Women are accorded agency here, but it is represented as pathologi-
cal, particularly in relation to certain forms of repetition. Men are also
accorded agency, but Aaron makes clear he is far more at home with the
tenor and implications of this agency.
A rather different example of how the gendering of agency affects treat-
ment relates to understandings of heterosexual drug-using couples. The
Sydney pharmacist George, for instance, talks about his observation that
some female clients return to illicit drug use after establishing or re-
establishing a sexual relationship with a man. In making this observa-
tion George assumes a dynamic of "influence" between men and women
clients.
Then there were the other ones where girls would be stable. [... ] They'd
meet an old boyfriend, they'd have a one-night stand sort of thing, and bang,
before you knew it—these guys must have massive powers of persuasion or
they're sexually so empowered, you know—they've got this hold over their
women and they seem to make them do what they want. Then, whether
it's a self-esteem thing with the women that these guys came around and
tell them they love them or whatever, the women just seem to fall for it and
bang, you can see them go downhill and then they have to come back up
again [i.e., the methadone dose must be increased].

In one sense this account treats female clients rather favorably in

that their return to (repetition of?) illicit drug use is attributed to the bad
influence of male partners rather than to their own malign agency. Of
course, in doing so it faithfully reflects gender stereotypes of masculine
activity and feminine passivity and impressionability. It is equally pos-
sible that the male partners described here had also been abstaining
from illicit drug use prior to their contact with the female partners, and
that both partners returned to illicit drug use simultaneously. Alterna-
tively, it might be that contact with the male partners offered the female
partners easier access to cash or illicit drugs, and that they acted upon
this opportunity to resume illicit drug use. There are many alternative
interpretations of the pattern described by George, some of which can
be found in our interviews with clients. Melissa (Melbourne client), for
example, describes her own experience of renewing contact with a past
sexual partner in rather different terms by suggesting, as she does, some
of the complexities of the relationship and its impact:

R E P E T I T I O N AND R U P T U R E - 85
 INTERVIEWER: And so, and so you were injecting the bupe [buprenorphine]
for a while?
MELISSA: Yes.
INTERVIEWER: Yep.
MELISSA: I was doing that and then I jumped off, and then started dabbling,
I was starting to use again. My boyfriend got out of jail, and we both started
using again together. Well, then I ended up falling pregnant with [child]. So
then I changed back to the methadone program because I didn't know the
effects of the bupe for my baby, because they didn't know what the effects
were yet.

In this account Melissa reports involvement in illicit activity (the injection

of buprenorphine, the occasional use of heroin) prior to renewing contact
with her partner. It is not clear whether she had "jumped off" methadone
(abandoned the program) before resuming contact with him or whether
she decided to do so as a result of the resumption of their relationship. In
any case, following the resumption of contact they both began consum-
ing heroin regularly until Melissa discovered her pregnancy. At this point
she reevaluated her heroin use and elected to return to pharmacotherapy
treatment, this time to methadone treatment as, unlike buprenorphine,
it is widely recognized as safe for pregnant women and their children.
Melissa's account describes circumstances that, from a pharmacist's
viewpoint such as that of George, might well look like the effects of the
undue influence of a male partner. Yet, as we have seen, Melissa was in-
volved in illicit activity prior to her partner's return (something a phar-
macist would not necessarily know). She resumed regular heroin use in
tandem with her partner, but there is no reason to assume her partner
instigated or drove this. When her pregnancy was discovered, Melissa
made a decision to return to treatment, thereby actively choosing be-
tween methadone and buprenorphine. In sum, Melissa's account indi-
cates both how a gendered "bad influence" theory of agency might seem
to make sense to those witnessing client relationships and how such a
theory, and its implication that women are able only to repeat their past
or the wishes of men, may oversimplify (or even misconstrue) events as
understood by clients. As I demonstrate below, the tendency to accord
agency to male drug users and the passivity or compliance of repetition
to female drug users impacts materially on some aspects of treatment—
for example, in access to takeaway doses where women are known to
have a partner who is taking illicit drugs.

86 • SUZANNE FRASER
 Beverley's approach to the question of the effects of sexual relation-
ships on resumption of drug use among female clients is again different.
BEVEHLEY: You can enable them and empower them, and I think that's a
role I've enjoyed a lot, and I've seen it work, and I think it's good fun, that
part of it. But, of course it's disappointing when you see them slide back-
wards. Usually associated with a partner coming out of jail, but...
INTERVIEWER: Right, right.
BEVEHLEY: Who is the last person they should be hanging around with.
INTERVIEWER: Yeah, right. That must be hard to advise people on.
BEVEHLEY: Well a lot of, ah, women relapse into heroin use for that reason,
to survive those sort of relationships. I mean, there's no rocket science in
that.

In this formulation of the relationship between renewed contact with past

male partners and resumption of illicit drug use, Beverley both downplays
women's agency and assumes it. On the one hand, women are described
as passively repeating the past in "sliding" back into abusive relationships
and "relapsing" into drug use, while on the other hand they are depicted
as actively self-medicating to "survive" these relationships. Like George,
and notably unlike the client Melissa, Beverley presents the male part-
ner as the source of corruption. As I discuss below, the threat and fact
of gender-based violence is referred to by many study participants. My
intention in analyzing the depiction of agency in these accounts is not
to deny the challenges women face in their relationships with men, or
the structural problem of male violence in drug-using social worlds as in
others. Rather, my point is that in this material, agency along with inno-
cence and culpability are often ascribed rather uncritically along gen-
der lines. This ascription tends to exonerate women at the cost of full
acknowledgment of women's agential subjecthood.
The approach to agency indicated here is similar to that of Aaron in
that both suggest some discomfort with women's agency, in particular
with women's agential undertaking of challenging or criminal behavior.
Thus Aaron avoids this agency by refusing to treat "manipulative" women,
and George and Beverley deny it by accounting for women's conduct via
the agency of male partners. All three produce agency as gendered along
traditional lines (although in ascribing women some legitimate agency
as "survivors," Beverley's account is rather more complex than that of
Aaron or George). This construction of gendered agency in the views
and assumptions of service providers is significant both because of the

R E P E T I T I O N AND R U P T U R E - 87
specific events and practices it institutes and reflects (such as Aaron's
referral on of some female clients) and because it contributes to the gen-
der dynamics of MMT more broadly.
The question of agency and gender in MMT is not confined to the
relationship between heterosexual partnerships and illicit drug taking.
It also bears on one of the most commonly evoked gender themes in the
interviews: that of domestic violence. The following comments, made by
the Sydney prescriber and policymaker Barry in describing his experi-
ences of treating clients, indicate some of this crossover:

I don't like the fact that some of my clients do really shonky things. Male
clients of mine who beat their wives up, I think are scum of the earth and
should be battered around the head. Regardless of what experience they've
had [... ]
If I see women who are abused I will very strongly [tell them], "There
are services here that you can go to, you do not have to go back to this, blah
blah blah." And when the psychopathic men talk to me like this, you know,
I will feed back and say, "This is not an acceptable right of behaviour, I don't
care what your wife has said. There is nothing you can possibly tell me that
says she deserved to be smacked." You know, and it's not colluding with
crap like that [... ]
I remember being in an A&E [Accident and Emergency] department once,
four o'clock in the morning, some eighteen-year-old girl came in, black and
blue, bruised ribs, and she was saying, "There's my Johnny, he really loves
me, he's really sorry for what he did." And Johnny turned up at about half
past four, and wants his girlfriend, and I just had to go and get the nurse to
go and see him, because I wanted to smack him.

As with some of the extracts quoted above, this response is dense and
extremely vivid. Barry indicates a high degree of clarity on the ethical sta-
tus of male violence against women—that is, that it is never justified. This
is laudable, and he might indeed be effective in dealing with these issues
insofar as he reports making concerted efforts to inform women of their
options where domestic violence is involved. In the context of this paper,
however, it is also important to consider how agency is constructed in his
description. Perhaps most striking in the account, beyond its generally
heightened language (though perhaps appropriate for the topic), is the use
of figures of speech that themselves reference violence. In this respect,
Barry compares rather closely with Aaron in that both take for granted an
economy (however symbolic) of violence between men. His account also

88 - SUZANNE FRASER
tends to emphasize his own agency in dealing with domestic violence
rather than that of the women he encounters; the women are depicted
(namelessly) only in terms of being informed and enjoined by him to act
to change their circumstances. Similarly, his portrait of the teenage girl
focuses on her acceptance of her partner's violence—her willingness to
return to the relationship. As above, Barry's remarks tend to reproduce
gender along traditional lines, with women seen as passively willing to
return to (repeat) the circumstances of their abuse, even as the remarks
also indicate a valuable awareness of gender-based violence.
Beverley, too, makes graphic reference to domestic violence among
the female clients she works with:
I think people who are significantly unwell with addiction almost always
have a coexisting mental health problem. [... ] And the other thing of
course that's overlooked time and time again [... ] is the significance of any
acquired brain injury that these people have, due to this chronic relapsing
remitting condition of addiction. Most of my work has been with women
[who] have significant histories of domestic violence where their heads have
been pounded up against walls, on floors, kicked. They've overdosed several
times, they've been exposed to doing some pretty horrendous things to get
their needs met and their partners' needs met, in terms of supplying the
goods. So they've got a lot of trauma. That's not even going anywhere near
any childhood sexual abuse, physical abuse and neglect, abandonment,
blah, blah, blah. Giving up their children, all that stuff, which is significant
for women, as you would appreciate. And [...]! get a bit passionate about
that. And I really do see way past the addiction stuff to all the other stuff. I
work with the people I work with in a very holistic way.

This discussion also positions women in at best an oblique relation to

agency by drawing together a range of factors in which lines of causa-
tion are ultimately ambiguous. Beverley begins by stating her convic-
tion that many of the women clients she deals with suffer from acquired
brain injury caused by "chronic relapsing remitting" heroin addiction. Yet
her comments that follow suggest that domestic violence is the cause.
She then lists a number of other life events and circumstances associ-
ated with addiction, again leaving causal lines unclear. It seems that Bev-
erley's focus is on the female client as a whole and the constellation of
issues she might face. Yet it is the repetition of drug use—women's rep-
etitious return to drug use—that is at the heart of their problems. In this
framework, female clients are presented largely as the target of abuse

R E P E T I T I O N AND R U P T U R E - 89
and disadvantage, rather than as agents. For example, in Beverly's com-
ment, "They've been exposed to doing some pretty horrendous things to
get their needs met and their partners' needs met," the agency of female
clients is muffled by the initial passive construction, "been exposed
to." The use of the term "needs" further mitigates agency by suggesting
compulsion or necessity. Located between these semantic bookends, of
course, is the observation that women actively carry out difficult tasks
for their own reasons and to support their partners. There is no doubt
that women face significant structural disadvantage in Western culture
and elsewhere, and that sexual assault and domestic violence enact and
reinforce women's disadvantage. Yet recognition of the structural should
not necessarily preclude recognition of agency. Indeed, as many femi-
nists have argued (see Fraser 2003, 76-77), without a theory of women's
agency, change in women's status is literally inconceivable.
This tendency to view women as objects of male agency rather than
agents in their own right has significant material implications for women's
experience of treatment. Notably, it can diminish their access to highly
valued takeaway doses. Where, for example, female clients are known to
be associating with male illicit drug users, service providers sometimes
withhold takeaways on the basis that they might be passed on to other
users. As Anya (Melbourne prescriber) explains:
Yes, I'm usually probably a bit more—stricter for women who have got a
partner who's an active heroin user, and I would just say "no," even if she'd
been compliant with the program and she'd been good, she'd been all right.

Elliot (Victoria policymaker) presents a similar approach to evaluating

the appropriateness of takeaway access:
We often meet the mothers during pregnancy, and are involved even before
[... ] the child is born, so we know that there are high-risk circumstances in
the home environment. Um, we might have knowledge that, that the father
or the spouse [... ] is abusive and also may steal methadone, and she might
divulge that in a confidential meeting, but she doesn't want to take action.
All those sorts of things.

Elliot makes clear here that the presence of a drug-using male partner,
especially one who might illicitly access methadone supplied in take-
away doses, can lead to the denial of takeaways to female clients. It is
notable that none of the interviews we conducted referred to recipro-
cal circumstances in which a male client's domestic arrangements with

90 • SUZANNE FRASER
a female drug user were inquired into or used to evaluate his access to
takeaways.
Clients too make reference to domestic violence in the interviews. As
with Melissa's account of the dynamics between heterosexual couples,
the understandings of power and agency at work in them do not always
correspond with those of the service providers. For example, Linda (Syd-
ney client) describes her past involvement in a violent relationship and
the impact of this on her dose levels.
INTERVIEWER: So you're still on the same dose as what you started on?
LINDA: Yeah, yeah. I've like, they say to me, "We better put you up, we better
put you up." I don't want to go up.
INTERVIEWER: Why do they want to put you up?
LINDA: Ahh, because I've had a lot of stress. I was in a relationship for thir-
teen years and he bashed me, you know, and I was pissed all the time and
I [... ] went to see my doctor last week, the week before, and I said "You
know, I'd like to come down a bit." He said, "Not with the baby, because
you're stressing at the moment, you're only going to stress even more if we
start bringing you down," and they said "How about we wait till the baby's
four or five years old before we start to bring you down." And I said, "Well,
meanwhile, what happens?"

In this excerpt Linda makes reference to her involvement in an abusive rela-

tionship and to a coexisting drinking problem without directly according
causal agency for the drinking to the abuse or the abuser. Agency is most
clearly evoked in the suggestion she makes to her doctor that her dose be
reduced. Linda's account suggests that the doctor responds to her agency
by resisting it: not only should Linda's dose remain the same while she is
experiencing the stress of pregnancy and of the conclusion of her abusive
relationship (or of the residue of this relationship), she should abandon
her intention of reducing for at least four more years. Linda's final ques-
tion reveals her frustrated agency: "Meanwhile, what happens?"
There are many other instances of the gendering of agency as outlined
above that, for want of space, I cannot elaborate on here. Most impor-
tantly for this essay, Linda's anecdote, along with the others analyzed
above, points to one of the central questions in this essay: How does the
gendering of agency and repetition in methadone treatment material-
ize clinical experience in particular ways? So far we have seen that this
gendering can potentially affect which clients are seen by which service
providers, and how readily some clients are retained in a program while

R E P E T I T I O N AND R U P T U R E - 91
others are referred elsewhere. We have also seen that particular under-
standings of gender issues such as pregnancy and domestic violence can
sometimes dominate service providers' responses to women's agency. In
all these respects, then, gendered notions of agency and repetition shape
treatment. We have noted, for example, the presumption that female cli-
ents are dominated by their partners at the same time as they are under-
stood to be properly subject to the power of the service providers them-
selves. Indeed, in some cases there is the sense of a power struggle taking
place between service providers and male partners through the bodies
and subjectivities of female clients. The same cannot be said of male
clients. There is no doubt that, as suggested earlier, male clients too are
in some ways "feminized" in MMT. Thus, as we saw in Aaron's account
male clients are frequently reminded that the clinic is not their domain,
that "rules" have been established by others, and that they must simply
follow them. Yet, as also noted above, unlike female clients, male clients
are not described in terms of the degree of surveillance around their part-
ners. They appear to be conceptualized less relationally more autono-
mously, and as less subject to or responsible for their partners. In this
respect, female and male clients are positioned differently in terms of
power, and this shapes the MMT clinic, its activities, and clients' experi-
ences of treatment in profound ways.

Repetition as Change

To this point my aim in this essay has been to demonstrate that a con-
stellation of related concepts (of "theories and chimeras")—addiction,
repetition, femininity and (lack of) agency—operates to materialize the
clinic and treatment practice in different ways for male and female cli-
ents. I have looked at the tendency within Western thought to accrue to
repetition negative associations, and for this negative judgment to both
reflect and enact other judgments, such as those around perceived femi-
nine attributes and the question of addiction itself. As Deutscher (2006)
notes in relation to Beauvoir's unstintingly negative take on repetition,
however, there are also ways in which repetition can be reconceived along
more positive lines. Deutscher turns to the work of Judith Butler, which is
itself partly inspired by Beauvoir's assertion that one is not born a woman
but rather "becomes" one. Butler famously conceived gender as perfor-
mative, as materialized through the repetition of particular gendered
acts. As she explains: "All signification takes place within the orbit of the

92 - SUZANNE FRASER
compulsion to repeat; "agency," then, is to be located within the possi-
bility of a variation on that repetition" (1999 [1990], 185). Indeed, one
of the strengths of Butler's approach is that its focus on repetition and
citation allows for both the reproduction of norms of gender and for the
introduction of change and resistance. As Deutscher puts it, "Beauvoir
sees sameness as sameness and repetition as repetition rather than [like
Butler] difference in sameness and repetition" (336). She notes that it is
the centrality of repetition to the maintenance of social norms that ren-
ders them vulnerable. In each reenactment lies the possibility of change
or difference. In Deutscher's view, Butler's work raises a central question:
"Is repetition ever just repetition?" Given that negative valuations of rep-
etition as emblematic of passivity and a lack of progress strongly inform
broader social estimations of MMT and of those who undertake it, there
is some merit in extending this question to the repetition perceived to
be at the heart of treatment. Indeed, in the interviews that inform this
essay there are many instances of repetition in treatment as generating
change as much as sameness. Some clients, for example, recount the
departures from routine that also emerge from daily dosing. As Darren
(Sydney client) notes:
It's like I've got a special little place I put the bottles down there when I take
them home, you know, so they're safe and everything. [... ] And after you've
been, like a couple of months I've been on it, the weekends now, some-
times, um, was it last Sunday or the Sunday before? I woke up at 11 o'clock
Sunday night and realised I had just forgotten to take my dose for the day.

Graham (regional Victoria client) tells a similar story:

I'll sometimes wake up the next morning all sore and that, and I can't get
out of bed. And [my partner] will say, "Well did you have your 'done last
night?" I say, "I don't know, did I? Is the bottle empty? I mean, go and have a
look." She'll go, "No, there's still two full bottles," so I didn't take it yesterday.
Completely forgot, gone to sleep, you know what I mean [laughs] and then
woke up sore the next morning.

Here, change enters subtly, unbidden, and only belatedly noted. Where
once Darren and Graham had anticipated their doses with some inten-
sity of feeling, the routine of treatment (in this case incorporating take-
aways as well as onsite dosing) now means they are liable to forget to take
their methadone at all, until, that is, physical symptoms remind them.
With repetition comes rupture.

R E P E T I T I O N AND R U P T U R E - 93
 Of course, there are other ways in which change is introduced through
repetition in treatment, and these can be conceived as far more inten-
tional than those described above. Diversion, the off-label use of metha-
done such as selling it to others, sharing it, injecting it, or splitting the
dose into two, does happen in MMT (Ward, Mattick, and Hall 1998,82-83).
By deliberately resisting the rules and regulations of treatment, such acts
introduce significant change into the routines of dosing. Not all agency,
not all refusals of repetition as sameness, are valued, of course. The agency
associated with these (sometimes illegal) acts is generally cast in the neg-
ative, or even as another form of compulsion in some cases.

Conclusion

In concluding this exploration of the gendering of the MMT clinical gaze

and the clinical practice associated with it, two questions remain. First,
given the material presented above, is there a sense in which MMT can or
should be reconceived along lines that emphasize the role of repetition
in change, and in so doing potentially raise the status of treatment from
that of mere passive maintenance? Elsewhere (Fraser and valentine 2008)
I have argued that public understandings of MMT might be improved if it
were identified less with ideas of replacement and inauthenticity. Similar
shifts around treatment as repetition might be beneficial. It is important
to note, however, that the negative associations operating around MMT
are tightly interconnected and as such are unlikely to change easily, par-
ticularly given that medicine and the clinical gaze are as bound up in
these perceptions of MMT treatment and male and female clients as are
others. Also, questions remain here around the denigration of sameness
in the first place. Is denying the sameness of treatment, insisting that
change too is possible, nothing more than an acceptance of the terms
of the debate, of the liberal values of progress and activity that inform
MMT's marginalization? There is no doubt that the conditions of treat-
ment and the operations of the clinic need to improve before clients are
likely to find treatment more bearable, but this is a practical issue rather
than a matter of the inherent value of change.
Given that my focus in this essay is on gender, my second remaining
question follows from this last dilemma: Are current estimations of repeti-
tion especially damaging to perceptions of women's agency in treatment,
and if so, can this be confronted? The interview material presented above
demonstrates clearly the ways in which women's agency is constituted

94 - SUZANNE FRASER
differently in the MMT clinic from that of men. Women are understood
as doubly subjected, both to service providers and to male clients, and
the latter subjection is taken as grounds for treating women differently,
indeed, often disadvantageously. While all clients are to some extent
"feminized" by treatment, it seems that women are doubly so. Again, the
notions of repetition and passivity are central here, and again, it might
be that shifts in the meaning of repetition are called for, both in terms
of how repetition is conceived, and also in terms of the need to question
the alignment between MMT and repetition in the first place. From this
point of view, the repetition of MMT relates to all those involved in it as
clients, service providers, researchers, and policymakers. How is treat-
ment—our understandings of it and its materialization in clinical prac-
tice—repeated by those involved? This question applies equally to treat-
ment in its immediate contexts, such as in clinics and pharmacies, and
its broader contexts, such as in policy, medical literature and research
analyzing drug use. As I have suggested, it is repetition that opens up the
possibility of change: these many instances of repetition are also poten-
tial sites of rupture.

Notes

The research conducted for this essay was funded by the National Health and Medi-
cal Council of Australia. Special thanks go to chief investigators Susan Kippax, Alex
Wodak, and Carla Treloar; to the associate investigator kylie valentine and the ad-
ditional interviewers Nadine Krejci and Anna Olsen; to the organizations that
helped recruit study participants; and most especially, to all those who generously
agreed to be interviewed.
1 The term "intra-act," which was coined by Karen Barad, aims to capture the sense in
which concepts, objects, and other phenomena are always already co-constituted.
A detailed discussion of the term, and its relevance to this area of research, can be
found in Fraser and valentine 2008.
2 This estimate was supplied in a personal communication by Dr. Alex Wodak of
St. Vincent's Hospital, New South Wales.
3 See Fraser and valentine 2008 for a detailed discussion of the implications of
Lenson's observation.

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ButlerJ. 1999 [1990]. Gender trouble: Feminism and the subversion of identity. New York:
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Deutscher, R 2006. "Repetition facility: Beauvoir on women's time." Australian Feminist
Studies2l (51): 327-42.
Drugs and Poisons Regulations Group. 2006. Policy for maintenance pharmacotherapy
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Friedman, J., and M. Alicea. 2001. Surviving heroin: Interviews with women in metha-
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5 FREEDOM OR SOCKS
Market Promises versus Supportive Care in

Diabetes Treatment

A N N E M A R I E MOL

AUTONOMOUS CHOICE is a widely celebrated ideal. This is hardly strange:

who likes to be ordered around by others? Nobody does. But even so, in
this essay I set out to question whether "choice" is always as wonderful
as it seems to be. I do not seek to question choice in general but rather
the generalization of choice. Other ideals suffer from this. In health care
particularly, the ideal of "good care" gets squeezed. "Autonomous choice"
and "good care" may sometimes complement each other, but often they
do not. The different ways of thinking and acting linked up with each of
these ideals tend to clash. As a result, practices designed to foster patient
choice erode earlier practices established to ensure good care. People who
are directly involved in health care, whether as patients or professionals,
have sad stories to tell about this. Where do things go wrong? This is a
large question that has many aspects.1 In this essay I will concentrate on
only one of these, namely how "having a disease" and "being a patient"
differ between the market and the clinic. Thus, the version of "choice"
I am concerned with here is the one pertinent to the neoliberally orga-
nized market. The version of "care" that I contrast it with is an ideal type
distilled from what I learned when observing an outpatient clinic in a
Dutch hospital and while interviewing professionals and patients about
care practices.
From Michel Foucault's The Birth of the Clinic we learned that in the
early nineteenth century the medical gaze shifted from the surface of the
body and the stories told by patients in the consulting room to the hidden
anatomical déviances beneath the skin that would only become directly
visible after death. Thus, Foucault argued, the object of medicine became

• 99
a silent physical structure and the capacity to talk sensibly about dis-
ease shifted from the patient to the doctor. Put like this, Foucault's work
may be used to argue in favor of patient choice: if the clinic has silenced
patients it is about time that they speak up again. Foucault would have
dreaded the liberal version of this, which says that rather than being
"known from the outside" people should "choose for themselves." There
is also, however, another way to build on the Foucauldian heritage. This
is to say that whatever may have been the case in the early nineteenth
century, presently the clinic is definitely not founded on pathological
anatomy. It is a far more complex and layered knowledge space. A great
variety of ways of knowing and acting come together in present-day hos-
pitals.2 This begs the question what, these days, the object of the clinic
is. The response to this is that there are many objects, and one of them is
"daily life with a disease." In relating to daily life with a disease the central
clinical activity, whether of nurses or doctors, is not knowing, let alone
curing, but caring. But what is "caring"?
In order to get a handle on this, I will not compare moments of choice
with moments of care but rather, in good Foucauldian manner, unravel
the logics (discourses, modes of ordering) in which such moments may
arise.3 The version of the logic of choice that I will tackle is that of the mar-
ket,4 where patients are referred to as "customers" who buy their health
care in exchange for money. In this situation, patients are not obliged to
be grateful because they do not receive a gift; instead, they should get
"value for money." The logic of choice suggests that if only supply were to
follow demand then care would be guided by patients. At present, health
care is to a serious extent indeed organized along market lines, albeit less
so in the Netherlands than in most other countries. Let me be clear: I will
not have anything to say here about what this amounts to in practice.
Neither will I go into questions of how best to organize or finance health
care, or what kinds of state regulation might be appropriate. My focus in
this essay is not institutional. It is clinical. This, then, is my question: Is it
clinically speaking a good idea to address people with a disease as cus-
tomers eager to buy a product?
In order to tackle this question I will use an image. I came across this
image in Diabc, a Dutch monthly magazine for people with diabetes. It
was an advertisement, not part of the editorial contents, but it immedi-
ately caught my eye. The company that placed the advertisement kindly
gave me permission to use it for critical analysis, for which I am grateful.
(But even so, in reproducing the image I cut off the company's contact

100 • A N N E M A R I E MOL
information.) The image is a beautiful one of attractive young people,
walking in the mountains. The blood sugar monitor that hangs above
them, larger than life, is beautiful as well. The blue EuroFlash is perfect
in shape and in perfect shape (the Dutch phrase perfect in vorm, printed
below the picture, implies both these things simultaneously). The person
who has just used the monitor is in perfect shape as well, for the device
shows a result of 5.6 (mmol/1).5 Experts (and the readers of Diabc, for
whom this ad is intended, are indeed experts) know that this is an excel-
lent blood sugar level. All in all, the positive associations evoked should,
as advertisements go, provide LifeScan with a lot of customers. The com-
pany wants to sell the EuroFlash less for the direct profits that this device
might yield than for what may be gained from the test strips. Each time
a user measures her blood sugar levels, she needs a test strip. Such test
strips cost approximately one euro each and are device specific; that is,
EuroFlash test strips can only be used in the EuroFlash. A lot of money is
involved in this market.6 However, I am not concerned with money here,
and I am concerned even less with the advantages and disadvantages of
this particular blood sugar monitor compared to others. Instead, I want
to use this magazine image as an example of what may happen when
patients are being addressed as customers.
The EuroFlash advertisement exemplifies the logic of choice. Its point
of contrast is formed by snapshot stories from the consulting rooms of
an outpatient clinic in the Netherlands. In the late 1990s and early 2000s
I made extensive ethnographic observations in those settings, but I will
not faithfully report here everything that I observed there. My sampling
techniques are far from neutral; instead, I have distilled from those prac-
tices illuminating counterpoints. I seek to articulate a way of working that
sharply contrasts with what the advertisement shows and stands for. This
is way of working makes far more clinical sense because it has to do with
handling daily life with a disease. It is infused by a logic of care.

Product or Process

Advertisements do not force anything upon potential customers but

instead offer a choice. Here it is, the EuroFlash, do you want it? The sug-
gestion is that as a customer you are not silenced and made passive but
allowed to actively speak up. You choose. Markets are places where sup-
ply attunes to demand and where, accordingly, customers can exercise
discretion and call the shots.7 This, however, can be difficult. Indeed, in

F R E E D O M OR S O C K S • 101
 LiFEScnn

EuroffaïA
p e r f e c t i n v o r m
criticisms of marketization this is a common theme: as patient-customers
we are left alone. There you are, at home on your couch, with your Diabc.
The magazine is packed with ads for blood sugar monitors that all speak
of wonders. Which one to choose? In the consulting room, the diabetes
nurse would help you. She knows that young people prefer devices that are
easy to carry around and look attractive, while designer devices do not suit
older people because the parts are too small for them to handle. A diabetes
nurse attends to the amount of time that passes between the moment a
test strip is inserted into the device and the moment the results appear on
the display. Any advantage or disadvantage of the device she fails to notice,
some patient or other will tell her about. Professionals collect patient expe-
riences and pass them on from one person to the next.
Is this the difference between the logic of choice and the logic of care:
that on the market customers can actively make choices but have to do
so on their own, while care provides patients, who have no say in the
matter, with an instrument tailored to their needs? No, the answer is more
complex than this. For in the consulting room, nurses talk with their
patients. "What is important to you?" they ask, with several measuring
devices laid out on the table, "What do you want?" At the same time,
patient-customers are not necessarily on their own. They can get orga-
nized. Just like other consumers, patients can have their products tested
or share their experiences. They can collectively acquire detailed knowl-
edge of all products in their market niche. No need for professional go-
betweens: Web sites and patient magazines may assemble all the informa-
tion needed. It is one of the creative innovations that the market brought
along: as organized consumers, patients help each other choose.
However, making a choice in favor of a particular blood sugar moni-
tor is not enough. As a patient you have to learn how to use your new
machine. In the consulting room I observed the diabetes nurse teach-
ing: "Look Mrs. Jansen, you must prick with this thing, this needle. Hold
it like this. Yes, just so. And now prick here, on the side of your finger-
tip, never on the top, but on the side. Right, there. Would you like to try
now for yourself, or shall I do it for you first, so you can feel it? It doesn't
hurt, don't worry." And so on. How to catch the drop of blood squeezed
out on the test strip; how to place the test strip in the device; how to
record the results in the notebook; how to respond to those results. When
advertisements present a blood sugar monitor as an independent product,
this learning process remains hidden. This does not particularly trouble
potential EuroFlash customers who read Diabc: their diabetes nurse

F R E E D O M OR S O C K S • 103
explained to them how to use a monitor a long time ago. But there is
something troubling even so in presenting a blood sugar monitor as a
separate sellable product that is disentangled from the care process in
which it is embedded. So what is that?
One might say that the EuroFlash ad tries to sell a device without men-
tioning the support necessary for using it. But thatis not a problem inher-
ent to the market but rather is a historical coincidence following from the
way health care is currently organized. LifeScan presents the EuroFlash
as a separate product to its potential customers because it finds itself in
a position where it can put "things" in a market with much more ease
than "services" (which, so far, are provided for through other channels).
However, services can obviously be sold as well. Indeed, not only are ser-
vices lucrative products in their own right but many goods sell a lot bet-
ter if they come with the necessary service. It is quite likely that, had the
profession not existed already, LifeScan and its competitors would have
invented the diabetes nurse. As things stand, these companies willingly
subsidize courses and other meetings for diabetes nurses, and in this way
they strengthen the service on which their products depend.
If the work of diabetes nurses is undervalued this is not due to the
market. All sorts of things can be traded in markets: devices, skills train-
ing, and even kindness and attention. Customers appreciate kindness and
attention. So my point is not that the market leads to cold and distanced
relations. Instead, it does something very different: it draws a limit. The
market requires that some product (device, plus skills training, plus kind-
ness and attention) is delineated. A lot may be included in the product,
but what is included and what is not has to be specified. How else to assure
that value is given for money? In the logic of care this is different because
care is a process. And unlike a product, a process does not have clear
boundaries. It is open ended. This is not a matter of size; it does not mean
that a care process is larger or more encompassing than the devices and
activities that it contains. Instead, it is a matter of time. Rather than a
(small or large) product that changes hands, care depends on various
hands working together (over time) toward a result. Care is not a trans-
action in which something is exchanged (a product against a price) but
rather an interaction in which the action goes back and forth (for as long
as it takes).
If you have diabetes your body cannot regulate its blood sugar level by
itself. Its internal feedback system fails. If you have type 1 diabetes (like
the patients who appear in this text) your body does not produce the

104 - A N N E M A R I E MOL
necessary insulin when its blood sugars rise. The care process seeks to
help the body in stabilizing its blood sugar levels by acting from the out-
side. Exactly how "a stable blood sugar level" is achieved is of secondary
importance. Tasks can shift. Most patients inject their own insulin and,
in varying degrees, measure their own blood sugar levels. However, when
someone is first diagnosed with the disease, the nurses in the hospital
inject their insulin for them, and technologists from the lab measure their
blood sugar levels. Only gradually do patients take over for themselves.
Or a machine does, for it is also possible to get an insulin pump installed
that slowly releases insulin throughout the day. Tasks can be shared in all
kinds of ways. Thus, children with diabetes learn how to inject their own
insulin, but their meals tend to be prepared by adults, just like the meals
of most other children. And so on. The care process involves a team (of
professionals, machines, medication, bodies, patients, and relevant oth-
ers), and tasks maybe divided between the members of that team in ever-
changing ways.
The reasons for dividing up tasks in one way or another vary as well.
That people with diabetes learn to inject their own insulin makes sense
because it needs to be done several times a day. ("I cannot follow you
around all day long," explains the nurse to the new patient. "And at some
point you will want to leave the hospital, won't you?") That people with
diabetes measure their own blood sugar levels, however, has a different
rationale. It is more recent, too. During the period when it was only pos-
sible to measure blood sugar levels with large, cumbersome machines,
patients would go to the laboratory once in a while, often no more than
once every three months, just before their regular checkup. The techni-
cian would take a blood sample and get it measured, and the physician
would adjust the daily dose or doses of insulin if necessary. A patient
might also, in exceptional cases, go to the lab several times a day. Only if
that patient were "badly regulated" would he or she be admitted to the
hospital for meticulous monitoring. Measuring one's own blood sugar levels
regularly, then, is not necessary for immediate survival. Instead, it serves
another purpose: it makes it possible to fine-tune the amount of insulin
to be injected in a comparatively nonintrusive way. If patients measure
their own blood sugar levels, they can do so a lot more often than labora-
tory technicians used to do. Thus, physicians are better able to adjust the
doses they prescribe, and, if need be, patients themselves can also decide
to inject a bit more or less depending on the current state of their bodies.
With such fine-tuned dosing, care gets better.

F R E E D O M OR S O C K S • 105
 This means that care can improve even while professionals supply
less "product" and patients do more themselves. With blood sugar regula-
tion, this has happened. While technicians started to do less and patients
did more, blood sugar levels got better stabilized. The implication is not
that good care equals neglect. What matters in the logic of care is the
result of the care. Who takes on which task follows from this. Care may
be distributed in many ways, but it must lead to improvement. To com-
plicate things, however, it is not always clear what should be counted as
"improvement." Traditionally, health was the ultimate goal of health care.
Such goals as stable blood sugar levels were supposed to serve health. Now
such clarity is lost. In chronic diseases, where health is beyond reach, the
ideal of the "good life" has replaced it. But what counts as a "good life"
is not obvious. While one might want to aim for a long and happy life,
"long" and "happy" often have to be juggled. Despite these complexities,
so much is clear: unstable blood sugar levels are bad. Thus, it is good care
to try to figure out how to make blood sugar levels vary less. But trying
does not guarantee success. This is incorporated in the logic of care. If
someone's blood sugar levels remain unstable even though their entire
care team does its best, this, albeit sad, is simply how it goes. Diseased
bodies are unpredictable. It is this very unpredictability that implies that
a well-delineated product can neverbe good care. Instead you try, adjust,
and try again. In dealing with a disease that is chronic, care is an open-
ended process as well. It only ends on the day you die.
If I doubt the logic of choice, then, it is not because the market aban-
dons people: consumers can help each other with their choices. Neither
do I claim that the market has no space for attention and kindness: it is
quite possible to include attention and kindness in a product. Service
may be commodified as well. However, and this is my point, in one way
or another a market requires that the product changing hands in a trans-
action be clearly defined. It has a beginning and an end.8 In the logic of
care, by contrast, care is an interactive, open-ended process that is end-
lessly redefined depending on the intermediate results. This difference
is irreducible. One of its implications is that a care process may improve
while less product is supplied. What counts are the results. More com-
plicated still is the situation that even though care is result oriented, it
is not necessarily bad when "health" and the "good life" remain out of
reach. Some diseases can never be cured, some problems keep on shift-
ing. Even if good care strives after good results, the quality of care cannot

106 • A N N E M A R I E MOL
be deduced from its results. Instead, what characterizes good care is a
calm, persistent, but forgiving effort to improve the situation of a patient.
Or to keep it from deteriorating.

Target Group or Team Member

When I write to Johnson & Johnson, the holding company of LifeScan, to

ask permission to use their advertisement, I not only receive the required
permission but a visitor as well. A friendly young woman from the mar-
keting department, involved in her work and concerned about her cus-
tomers, is eager to learn from my criticism. But what exactly is my point?
Why am I uncomfortable with this ad? Unable to express this clearly, I tell
the story of an elderly couple we interviewed. The husband has diabetes
and they no longer go on holiday because it requires too much effort. As
they go out for a day, the tour bus gets back to the hotel at 8 p.m., but the
husband is used to having his dinner at 5:30, so how to handle that? The
next day things won't settle either as the evening meal is now at 7 p.m.
Evening coffee comes with cake: Should he eat this or skip it? It is all too
complicated. Holiday comes with so many disruptions of daily routines
that it brings more problems than pleasure. Advertisements like yours,
I tell my guest from LifeScan, stand in stark contrast with such stories.
They suggest that insofar as the EuroFlash is concerned, everything is
possible, even if you have diabetes. They suggest that you should be able
to walk in the mountains. If you cannot walk in the mountains then the
monitor is not to blame: it is in perfect shape. Instead, you are the one
who fails.
The marketing manager listens attentively. Well, yes, she says, but the
people in your story belong to a different target group. Look, and she
pulls out another ad, we have something different to offer to them. The
picture shows a simpler monitor held in the outstretched hand of a man
in a striped polo shirt, who does not seem too ambitious. A strange lens
has been used for the photo: the finger ready to be pricked has been mag-
nified. In this ad, pricking for blood is made to appear a straightforward
practical task with no promises (of mountain walks or other wonders)
attached. The simpler monitor is presented as an obedient tool. A mar-
ket, or so my guest explains, consists of different target groups. Some
people may be unable to go on holiday, and of course we do not ask them
to. For them we make simple devices. Others, however, want freedom.

F R E E D O M OR S O C K S • 107
They want to go abroad, visit cities, enjoy holidays, have novel experi-
ences, and indeed, walk in the mountains. These may be better-educated
people, but not necessarily so. They should understand the intricacies of
the disease but also, crucially, be willing to make an effort. People like you
and me, she says, form a separate target group. For them we have devel-
oped the EuroFlash and the advertisement with the walkers.
As a part of putting a product on the market, its target group should
always clearly be identified. My visitor presents me with a carefully designed
sheet that shows four relevant target groups for blood sugar monitors:
those who know a lot and want a lot; those who know a lot but want little;
those who know little but still want a lot; and finally those who know little
and want little. In the course of my research, I will come across a number
of more or less similar fourfold divisions. For example, at the conference
Customers in Careland, a speaker from the Rabobank, a Dutch banking
group, states that the bank categorizes potential customers as follows:
those looking for independence, those looking for harmony, those looking
for certainty, and those looking for control.9 From behind the podium,
the speaker points with his finger to the audience and adds: "You in the
health care world, you should also separate out your customers into target
groups." He thinks it is about time that self-satisfied health care profes-
sionals understood that different groups of people want different things
from them.
But should "we in the health care world" really begin to divide people
into target groups? This does not fit with the logic of care. The marketing
manager of Johnson & Johnson helped me to articulate why not when
she said that "people like you and me" are the target group for the moun-
tain walk advertisement. An expression like that comes with the expec-
tation that "people like you and me," clever and able, have no problems
organizing mountain walks, even though for "other people" it might be
difficult. But it is not so easy. Incidentally, on the day we spoke I hap-
pened to be grateful that she had come to visit me. Though I was not in
bed with a fever, I was not well at all and I had not been so for months. I
was just about clearheaded enough to talk with her, but would not have
been able to travel to her office. Going for a walk in the mountains, no
matter how attractive, was even further beyond my abilities. Against her
expectations, I did not belong to her category of "you and me."10 Care
professionals would not expect me to. Rather than being based on a soci-
ological marker or two, their categorizations depend on clinical data. As
a part of gathering these data, they ask questions. "How are you?" a care

108 - A N N E M A R I E MOL
professional might have asked me. "What? You are unable to travel, even
for an hour or two? That must be hard on you." Care is not for some group
rather than another. Everyone can come to a consulting room and com-
plain (to an appropriate degree, that is). Even people "like you and me."
However, more important still than the recognition that everyone may
need help at some point or other is the fact that, basically, care profes-
sionals do not give up on anyone. Salespeople do. If a group has no inter-
est in their products, they stop being a "target" group. People who "know
nothing and want nothing" are not going to buy a blood sugar monitor,
no matter how hard you try to make them do so. Thus, endlessly trying
makes no sense in market terms. Worse, it is a bad investment. The logic
of care by contrast does not start from what people want but from what
they need. Thus, caring professionals should not let go of their patients
easily. As one physician explained to me as we sat waiting together in
the consulting room: "We expect nothing much from the next patient. I
no longer push him, nor does Maria (the diabetes nurse). It is of no use.
Somehow he can't take proper care of himself. But fortunately he keeps
turning up for visits, so we keep things going." Once the patient in ques-
tion arrives, he is received with a typical professional mixture of friendli-
ness and severity. The doctor listens to his stories and answers his ques-
tions. ("What should I do if I have a tiny temperature? Should I stay home
or go to work?" the patient asks. "Don't take your temperature," replies
the doctor.) I do not want to romanticize what happens in consulting
rooms, and "keeping things going" is not ideal. But it is care. Even in
moments that leave a lot to be desired, care does not write people off as
bad investments.
In the market variant of the logic of choice, customers are divided
into target groups. This makes it possible to adjust products and adver-
tisements to different buyers. Those who want freedom are graciously
served; those who find life difficult get something simpler; and those who
resist are left in peace. In the logic of care it is different. The point is not
that health care practices abstain from categorizing people. Categories
like "type 1 diabetes" and "type 2 diabetes" are very important and a
lot depends on them: the organization of outpatient clinics; assembling
groups of patients together for courses and supportive patient groups;
arranging payments; conducting scientific research. Diagnostic catego-
ries, however, are not based on what people are likely to want but on what
they are likely to need. In the clinic, moreover, in the day-to-day practice
of care, these categories fall apart. Care practices are concerned with the

F R E E D O M OR S O C K S • 109
specific problems of specific individuals in specific circumstances. The
art of care is to figure out how various actors (professionals, medication,
machines, the person with a disease, relevant others) might best collab-
orate to stabilize a person's blood sugar level or improve her daily life.
What to do and how to share the doing? In the logic of care, patients are
not a target group but crucial members of the care team.11

Dreams or Support

Maybe some people are not able to go on holiday, the marketing man-
ager of Johnson & Johnson says, but others want the freedom to do so. In
saying this, she not only distinguishes between groups of people but also
suggests that "what people want" is a given. It is the demand to which pro-
ducers and sellers should target their supply. This is the language of neo-
classical economics, in which customers are people who make rational
choices and stick to them. At the same time, however, my guest is respon-
sible for marketing Johnson & Johnson's blood sugar monitors. So she went
to an advertising agency and ordered two ads: one for the simple moni-
tor her company produces and another for the EuroFlash. The first had to
evoke ease, efficiency, and simplicity; the second was meant to appeal to
"people who want freedom." What might seduce them into thinking that
the EuroFlash will bring such freedom? Advertising agencies are not at all
inclined to understand "demand" as something that is given, and neither
is "what people want" a rational phenomenon for them. They try to create
demand, and they do so not with arguments that might appeal to people's
rationality but through seduction.
Three young people walking in the mountains: it looks just great. The
EuroFlash capitalizes on the desire of potential customers to be able to go
out and walk. This walking has little to do with putting one foot in front
of the other; getting into a rhythm; sweating; or even escaping from daily
obligations.12 What is at stake instead is the ability to walk. The ability to
go wherever you might want to go, despite having diabetes. The ability,
too, to be energetic, even if diabetes comes with a precarious energy bal-
ance. Thus this ad (as it was meant to do) appeals to the desires of "people
who want freedom." But it nourishes these desires at the same time. Look
at the photo again. It shows people walking in the mountains, but what
is represented is not so much walking as it is freedom. The freedom to
escape from the pressures of modern life into the otherness of nature.
The freedom to go where the birds go and to forget about diabetes. It is

110 • A N N E M A R I E MOL
a common advertising strategy: an attractive situation that can be cap-
tured in an image representing something else, a higher good, an ideal
beyond it. Meanwhile this situation itself is stripped of its specificity. No
wonder this ad caught my eye: I love walking. I am highly suspicious of
the suggestion that freedom (out of reach at that) is more important than
walking.
The logic of care does not similarly exploit desires. Granted, if walking
happens to be mentioned in a consulting room, it is again unlikely that
this is to celebrate walking "for its own sake." This may happen, the nurse
or doctor may be a walker herself, or she may be kind enough to empa-
thize with her patient's fascinations.13 But the clinically relevant character-
istic of walking is that it is a good way of getting exercise: it increases one's
overall fitness, stimulates blood circulation, and has a low risk of acci-
dents related to it. For these reasons, a diabetes nurse is likely to encour-
age walking. Yes, she may well say, walking, very good. And then she will
talk about socks. Or, more likely, first she warns you to carry enough food
with you on a walk, because when you exercise your muscles burn up
sugar and this might make your blood sugar level drop. Beware, don't just
refrain from injecting insulin. After all, your cells will need to be able to
absorb enough sugar to burn and they need insulin for that. Then come
the socks. Diabetes tends to slow the healing of small wounds on one's
feet. This is awkward, and even more so if you like to walk. So you should
protect your feet, says the nurse. The point about good shoes and socks
is not that they are attractive (however attractive they may be). The point
is that they are necessary. The difference in register is striking. In the con-
sulting room walking does not call up a dream but rather calls for practi-
calities. It is not associated with freedom but with socks.
Conversations in the consulting rooms of the diabetes outpatient clinic
tend to turn around topics like socks. They are concerned with endless
practical details of daily life that are mysteriously absent from the Euro-
Flash advertisement. For while this enticing image presents us with a
promise of freedom, it hides everything that users of blood sugar moni-
tors actually need to do in order to be able to walk in the mountains. Plea-
sure is depicted, but effort—let alone pain—is not. But machines do not
work on their own. They depend on the work of others. Miniature blood
sugar monitors depend on the activities of patients. Stop walking, sit down
somewhere, clean your fingers. (Where did that tissue go?) Prick your fin-
ger, catch the drop of blood, put the test strip into the machine. Wait, read
the number. Respond to it. And measuring your blood sugar levels is not

F R E E D O M OR S O C K S • 111
enough. In order to walk in the mountains, you need to do a lot more. Keep
your insulin cool. Always take enough food with you; eat on time. Not too
much. Rest when you are tired, even if the others would have wanted to
walk on. Carefully manage your relations with these others. "Shouldn't you
eat something now?" your friends will ask. You may want to scream: "Let
me be." But if your blood sugar levels drop too low, one of them will have
to inject you with glucagon in order to get you out of your coma.
Pricking blood, measuring it, and otherwise dealing with your own
unpredictable blood sugar levels is not fun, it is sensible. In health care,
nobody will suggest otherwise. As professionals encourage patients to take
care of themselves, they appeal to their minds, not their desires. They
explain that taking good care of yourself may be difficult, but it is also
likely to postpone the nasty complications of diabetes. Statistics show
that people with badly regulated blood sugar levels tend to suffer more
and sooner from blindness, clogged arteries, and the loss of sensation in
their fingers and toes. Such threatening prospects make it advisable to try
and control your blood sugar levels. Care is not attractive. Let me under-
line this: even good care is not attractive. This is the case if only because
as a patient you cannot let go and just buy it, as if it were a product to pas-
sively consume. Instead you have to actively engage in care—painfully,
enduringly, as a prominent member of the care team. That is demanding.
And yet you may try, because suffering from complications is likely to be
a lot nastier.
Chronic diseases make life even more difficult than it already is. The
logic of care is attuned to that difficulty and concludes from it that patients
deserve support (advice, encouragement, consolation). However, offer-
ing support is not the same thing as doing what patients want. It does
not necessarily mean going along with them. While the market fuels the
desires it mobilizes (such as the desire for freedom), care seeks modera-
tion. Balance is the magic word. Not only should blood sugar levels be
balanced, but everything else as well. "You don't really want to die early,
do you? Or to go blind?" says a doctor confronting a woman who is taking
good care of her children, her husband, her job, and her ideals, but not of
her own blood sugar levels. He wants her to realize that taking better care
of herself is important. But when people try very, very hard to take care of
themselves, professionals aren't enthused. As one of the doctors tells me:
"The worst people are those who think they can stay below 10 (mmol/1)
all the time. Help, doctor, I once had a blood sugar level of 11, they say to
me. Yes, of course you have a blood sugar level of 11 once in while. What

112 - A N N E M A R I E MOL
do you think?" Doctors do not go along with people who get obsessive
but rather incite them to let go: "Come on, these things happen, they
always do." Fighting against the unpredictability that is inherent to life
with a disease leads only to more misery. It is not a sensible thing to do.
So in care practices it is our minds that are called upon, not our desires.
But this does not lead to rationalism. Like our desires, our minds are far
from rational. Instead, they are full of gaps, contradictions, and obses-
sions. Caring professionals therefore seek to cultivate our minds in much
the same way that farmers cultivate their land. They convey insights, ask
probing questions, or try to reassure. And in doing so, they seek to not just
reflect back what we thought already. Rather, in the hope of making us
more balanced they give counterbalance. They do not feed the illusion of
control. Take good care of yourself, but expect unpleasant surprises. The
market has no repertoire for dealing with unpleasant surprises. A market,
after all, depends on marketing, on seductive advertisements that show
everything a EuroFlash monitor might help you to achieve. Look! Imag-
ine yourself walking in the mountains! Thanks to our wonderful blood
sugar monitor! That walking in the mountains might also fail is never
mentioned. And if ever it does, the EuroFlash cannot be blamed: it is in
perfect shape. Maybe you are the one who fails? No, that is never men-
tioned either. But on the market such fears are evoked, not contradicted.
In good care practices the fear of failure is explicitly addressed. A caring
professional reminds you that, no matter what statistics may promise,
everything—from diseases to mountains, machines, friends, and blood
sugar levels—is erratic. The world is unpredictable. So do your best, but
if that turns out not to be good enough, let go. Don't take the world on
your shoulders.

Hoping for Health or Living with Disease

The advertisement for the EuroFlash mobilizes the desire to be free in

order to sell blood sugar monitors to "people who want freedom." Other
desires are also played with. The desire to walk, to be young, to have
friends. And the desire to be healthy. Look at the advertisement again:
it does not show test strips; there is no blood; there is nothing messy,
nothing that speaks of disease. The well-designed blood sugar monitor
looks like any "normal" tool, a walking stick for instance, that likewise
helps you to walk in the mountains. Walking itself also evokes associa-
tions with "healthy." And with a blood sugar level of 5.6 (mmol/1), the

F R E E D O M OR S O C K S • 113
walker who has just used the EuroFlash is in perfect shape. Who, by the
way, is the user of the EuroFlash? It is impossible to tell. The image shows
three equally vital and energetic walkers.14 So even if it is never explicitly
stated that the EuroFlash will bring health, health is visible in this image.
As the absent present, it is represented in various ways.15
Many people with diabetes do not feel ill, and neither should they be
reduced to their disease: there is more to life than one's diagnoses. How-
ever, as it is, type 1 diabetes is a chronic disease that cannot be cured and
does not go away. This means that appealing to the desire for health in
an advertisement for a blood sugar monitor is a remarkable way of play-
ing with desires. It might well be more enticing than the worrying tone
of health care counseling. This is likely to be a serious part of the mar-
ket's appeal: consumption is all about pleasure. While care professionals
lecture sternly about the miseries of long-term complications, on the
market these are never mentioned. Instead, customers are seduced into
dreaming of wonderful things: walking, freedom, health! In this way, one
may keep on selling goods to customers who happen to have diabetes (as
long as they also happen to have money). There are, after all, no limits to
the desire for health among people with a chronic disease.16
Good care promises less, but it is more attentive to pain. It strives for
improvement while simultaneously respecting the erratic character of dis-
ease. Let us revisit the scene in which the diabetes nurse explains to Mrs.
Jansen how to prick for blood. This scene is typical of the way that care
tries to tame but not deny disease. "You should hold it like this, yes, very
good. And then you prick here, on the side of your fingertip, never on the
top, but on the side. There it is." Mrs. Jansen learns how to measure her
own blood sugar levels so as to avoid, or at least postpone, the compli-
cations of diabetes. One of these complications is blindness. Measuring
blood sugar levels is meant to prevent blindness. But from day one, Mrs.
Jansen learns not to prick on the top of her fingertip, but on its side. The
reason for this is that people who do go blind despite their best efforts
will need the top of their fingertips in order to feel the world around
them. Thus at the very moment when one learns how to prick, there is
hope of health as well as acceptance of disease. You learn how to prick so
that you may stay as healthy as possible. But you respect the fact that the
reality of disease is erratic by practically anticipating that complications,
blindness included, may yet occur.
In the logic of care, promising something too good to be true is a pro-
fessional sin. Tempting, perhaps, but wrong. "It is difficult," confesses a

114 - A N N E M A R I E MOL
physician in an interview. "You have to ask people to do something that
is incredibly difficult to do: to watch over themselves the whole time, to
continuously do their very best. This is for later, you add, because now,
in the present, they often do not benefit from their efforts. Then they
see someone in the waiting room whose right leg has been amputated.
That is scary. Very much so. So they ask me: 'Doctor, if I try really hard,
is this not going happen to me?' But I cannot promise anything. I just
cannot, you never know. It may well happen to them." Sensible patients
have to take care of themselves continuously; and yet diseases are erratic.
Good doctors do not make false promises. There is only one certainty:
in the end, you die. The moment will be different for each one of us, but
that it will come is certain. If interventions will no longer seriously help
you, your doctor will say: I am sorry, but there is nothing more I can do
for you. And however great your desire for health, from that moment
onward you will still be offered support and sympathy but heroic actions
are abandoned.17 Good care sets limits to its own activism. This is a cru-
cial, irreducible difference from the market. On a market almost anything
may be traded, but nothing limits futile transactions. Did you ever hear a
seller say: "There is nothing I can do for you"? No is hard to sell.

Actors Who Let Go

The logic of choice refers to people seeking help as "consumers" instead

of using the old term "patients," which etymologically is related to "pas-
sive." It addresses us as "customers in careland." Please, buy the prod-
ucts that you find attractive—insulin, machines, attention. You choose.
Within the logic of care, by contrast, people who seek help are called
"patients" for good reasons: they suffer. Patients have a disease that they
never choose to have: diseases happen. But this does not imply that the
logic of care makes patients passive. Instead, patients are involved in a lot
of work. This work is first and foremost practical: it is a matter of eating
and drinking, injecting, washing, and measuring; working, learning, and
walking. All this activity is rarely solitary and mostly interactive. Activity
moves between doctors, nurses, machines, drugs, needles, patients, and
the rest of the world. And it is called for again and again. Until death do
us part.
When it calls patients "customers," the logic of choice opens up splen-
did panoramic views. From the top of the mountain you see no suffering.
The language of the market contains only positive terms. Products for sale

F R E E D O M OR S O C K S • 115
are attractive. They are, tellingly and nonneutrally called "a good." The
logic of care, by contrast, starts out from something negative: you would
prefer not to have diabetes. And if you do, you will never be healthy again.
But the fact that health is out of reach does not mean that you should give
up on life and be miserable. The active patient that the logic of care tries
to make of us is a flexible, resilient actor who, by caring, strives after as
much health as her disease allows. What the results of the joint activities
of a care team turn out to be is uncertain. Diseases are unpredictable.
The art of care, therefore, is to act without seeking to control. To persist
while letting go. That is care: wherever you are, if you need to, you sit
down, prick the side of your fingertip, squeeze out some blood, put the
test strip into the blood sugar monitor, and wait for the results to appear
on the screen.

Notes
1 For other aspects of this, see Mol 2008. This essay is a slightly adapted version of
a chapter from that book. While working on the book chapter I had grants from
ZON/Mw, the Netherlands Organisation for Health Research and Development,
and NWO, the Netherlands Organisation for Scientific Research, especially its pro-
gram Ethics, Research and Policy, and I am grateful for their help. I would also like
to thank the patients, nurses, and physicians who allowed me to interview them
and to observe consultations. Thanks as well to Jeannette Pols, Dick Willems, Rita
Struhkamp, John Law, Miriam Kohinor, Hans Harbers, David Healy, Bernard Kruit-
hof, Nienke Uniken Venema, Mieke Aerts, Amâde M'charek, Tsjalling Swierstra,
Peter van Lieshout, Ingunn Moser, Tiago Moreira, and Nick Bingham for their own
work on "good care" and/or for their comments on earlier versions of my work.
2 This is the argument that I put forward in Mol 2002, where I showed that the kind
of knowledge that pathology may provide is often not just absent from but also
irrelevant to the diagnostic and treatment practices of daily hospital care. Even the
vascular surgeons whom I studied presented their operations on patients with se-
vere atherosclerosis of their leg arteries not so much as interventions in bodies as
interventions in daily life. Their hope was not to prolong people's lives, as well as to
allow them to walk to the corner of the street without too much pain. This, then, is
a clinical (rather than a laboratory or a pathological anatomy) way of shaping the
object of care.
3 I combine philosophical and ethnographic methods. As an ethnographer-at-home,
I sat in on consultations in a diabetes outpatient clinic in a university hospital
located in a medium-sized town in the Netherlands; I interviewed professionals
as well as patients; I was helped by Claar Parlevliet and Efanne Bok who also
conducted such interviews; and I analyzed a variety of scientific as well as pop-
ular literatures about (life with) diabetes and its treatment. Then, helped by my

116 • A N N E M A R I E MOL
 philosophical training and by reading a lot, I distilled, like a chemist who distils
pure substances from a mixture, the logics of choice and the logic of care out of my
materials. That my fieldwork was done in the Netherlands and that diabetes care
is the case being studied are facts that obviously both inform the specific variant of
the logic of care that is articulated here. I do not claim to present a universally valid
or valuable "model," and neither do I seek to set rules. Instead, this text presents
you, its reader, with a question: How might you translate and transform its logics
to the sites and situations in which you happen to be situated?
4 Of course markets also come in different shapes and sizes. The market I refer to
here is the one that is both articulated and coshaped by neoclassical economic
theory. For a sociology of the market that does not take neoclassical economy to
describe its object but rather to inform it, see Gallon 1998. The introduction of
market language, meanwhile, is not the only form of "economization" possible.
There are several others, such as the ideal of working efficiently, which has slightly
different connotations. See Ashmore, Mulkay, and Pinch 1989.
5 In my field, mmol/1 was the commonly used unit of measurement for the con-
centration of blood sugar and this is the custom I follow in this essay. Elsewhere
mg/dL is in use. If you have trouble making a quick calculation from one unit of
measurement to the other, then imagine what happens if a person with diabetes
travels from a country with one tradition to one with the other. And not only blood
sugar levels but also units of insulin are also expressed in different ways between
different countries.
6 Obviously though, money is a crucial topic. It is quite an intervention to bracket it
off. How it might be drawn in, without reductively claiming that everything comes
down to the desire to make money, is a challenging task. For an interesting attempt
to do so, and to analyze how people working in the pharmaceutical industry deal
with money as well as morality, see Martin 2006.
7 As customers, our position in capitalism seems to be far better than it is as workers.
For workers do not own the means of production they work with, but customers
can choose and thus believe that they are in charge. This feeds into the profound
shift in Western countries where worker identities have made place for customer
identities. See Lury 1996.
8 That products that change hands on markets have a beginning and an end and
may be isolated from their surroundings is not a natural capacity of the objects in-
volved. It is something they gradually acquired, it is how they got shaped. Studies
that go back to earlier phases of capitalism manage to bring the effort and the
changes involved to light. See, for example, the essays in Appadurai 1986. In light
of this work, it would be naive to say that it is impossible to turn health care into
a market. So that is not my argument. But, and this is what I do argue, a lot is lost
along the way. This begs the question whether it might also be possible to (still,
again) think of interesting alternatives for existing markets for (other) "goods," But
this is beyond the scope of the present study.
9 This conference was organized by the very organization that provided financial
support for the present project. I was invited to explain in one of the parallel

F R E E D O M OR S O C K S • 117
 workshops why patients might not benefit from being called "customers in care-
land." It felt like spoiling the party, but at least some people present were pleased
that I put into words the unease they felt as well.
10 Some of those who read earlier versions of this text urged me to take out this per-
sonal reference. Why would my being ill be relevant? Or why would I make myself
so vulnerable as to tell about it? But we are vulnerable, all of us, and this is not a
bad occasion to underline as much. And in a study like this, the state of health
of its author is likely to be relevant to "method." Even if the link is not linear, my
illness as well as my love of walking both inform this text. About situating one's
knowledge, see Haraway 1991. And about some intersections of "auto" and "eth-
nography" in academic life, see Menely and Young 2005.
11 The ways in which, in the course of the second half of the twentieth century, pa-
tients were gradually turned into members of the care team has raised the suspi-
cion of sociologists of medicine who take this as a way to silence possible patient
resistance to medical power. For two different but equally compelling studies of
the subject that is subjected while it is created, see Armstrong 2002; and Arney and
Bergen 1984. Here, however, I seek to differentiate two versions of this subject: a
choosing one and a caring one.
12 "Walking itself" is obviously not a natural, ahistorical category but rather a recent,
and culturally highly specific, invention (see Solnit 2006). And even something like
"love of walking" does not come "naturally" to a person but instead has to be grad-
ually acquired, just like other things that involve "taste" (see Hennion 2001).
13 In this text I do not say a lot about the empathy, support, and generosity relevant
to care. This is not because I hold these factors to be of secondary importance but
rather because they get attention elsewhere. See, for example, Frank 2004. Clini-
cal ways of working and the way care deals with technology, knowledge, and dis-
ease in nonrationalist ways are in the forefront of my analysis because they are
understudied. For a more extensive analysis of the relations between biomédical
technology and diseased bodies, see Mol 2002. For the impossible position of pro-
fessionals who are being squeezed between the requirements of evidence-based
practice and those liberal ethics, see Pols 2006.
14 How could one see it? First, diabetes is not visible in a simple and straightforward
way. And second, although this image, or so my informant told me, may well target
the Dutch market, it came from a North American agency that specializes in mak-
ing and selling photographs for advertising. It is highly unlikely that the agency
asks models to reveal their diagnoses, so they may have all kinds of diseases or
none at all. Potential buyers of a blood sugar monitor, then, are seduced into buy-
ing a product by vital and healthy models. This is quite like the way seventeen-
year-old girls are used to show that, "thanks to our wonderful product," one may
hold onto smooth skin. For this, and more generally for learning to "read" adver-
tisements, see Coward 1996,
15 See Law 2002 for this term and for an analysis of various forms of absence/pres-
ence. Law shows how a lot of what is involved in shaping a technology is not nec-
essarily immediately visible in the here and now. As an example he traces the

118 - A N N E M A R I E MOL
 design of a war aircraft and the way such factors as the distance of the pilots to
their base camps and whether pilots are prone to get sick if movements are too
violent are "present" in the design even if only in indirect ways.
16 This alone makes it absurd to think that organizing health care as a market might
make things cheaper than alternative organizational forms, especially those that
are able to organize care in such a way that "needs" are being addressed while limits
to what can be done are respected. Along with the market, a "regime of hope" is
rapidly expanding in health care; and it is being fed by research practices that, par-
tially embedded in industry and private funds, promise return on investment both
financially as well as in terms of "health gain." See Moreira and Palladino 2005.
17 This also comes with patient narratives in which living with a disease is not told
as a heroic endeavor where the disease-enemy is to be harshly fought and con-
quered so as to not slide into fatalism. See Diedrich 2005 for an interesting analysis
of alternative possibilities; and for one of the narratives that she reflects upon, see
Stacey 1997.

References

Appadurai, A. 1986. The social life of things: Commodities in cultural perspective. Cam-
bridge: Cambridge University Press.
Armstrong, D. 2002. A new history of identity: A sociology of medical knowledge. Basing-
stoke, U.K.: Palgrave.
Arney, W., and B. Bergen. 1984. Medicine and the management of the living: Taming the
last great beast. Chicago: University of Chicago Press.
Ashmore, M., M. Mulkay, andT. Pinch. 1989. Health and efficiency: A sociology of health
economics. Milton Keynes, U.K.: Open University Press.
Callón, M. éd. 1998. The laws of the market. London: Blackwell.
Coward, R. 1996. Female desire: Women's sexuality today. London: Paladin.
Diedrich, L. 2005. "A bioethics of failure: Anti-heroic cancer narratives." In Ethics of the
body: Postconventional challenges, ed. M. Shildrick and R. Mykitiuk. Cambridge,
Mass.: MIT Press.
Foucault, M. 1973. The birth of the clinic: An archaeology of medical perception. Lon-
don: Tavistock.
Frank, A. 2004. The renewal of generosity: Illness, medicine, and how to live. Chicago:
University of Chicago Press.
Haraway, D. 1991. Simians, cyborgs and women: The reinvention of nature. London: Free
Association Books.
Hennion, A. 2001. "Music lovers: Taste as performance." Theory, Culture and Society 18
(5): 1-22.
Law, J, 2002, Aircraft stories: Decentering the objectin technoscience. Durham, N.C.: Duke
University Press.
Lury, C. 1996. Consumer culture. London: Routledge.
Martin, E. 2006. "Pharmaceutical virtue." Medicine, Culture and Society 30 (2): 157-74.

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Meneley, A., and D. Young, eds. 2005. Auto-ethnographies: The anthropology of academic
practices. Peterborough, Ontario: Broadview Press.
Mol, A. 2002. The body multiple: Ontology in medical practice. Durham, N.C.: Duke Uni-
versity Press.
. 2006. "Proving or improving: On health care research as a form of self-reflection."
Qualitative Health Research 16 (3): 405-14.
. 2008. The logic of care: Health and the logic of Patient Choice. London: Routledge.
Moreira, T., and R Palladino. 2005. "Between truth and hope on Parkinson's disease,
neurotransplantation and the production of the self." History of the Human Sci-
ences 18 (3): 55-82.
Pols, J. 2006. "Accounting and washing." Science, Technology and Human Values 31 (4):
409-30.
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6 CLINIC WITHOUT THE CLINIC

CINDY PATTON

THE STREETS ARE ON FIRE with hyperactive men and women who
openly challenge traffic laws by willfully crossing against the light and in
the middle of the block. Their combination of anger and ecstasy fright-
ens me; I have never felt the level of defiance that seems to grip these
neighborhood residents. But my initial anxiety that I might become the
object of this agitation dissipates. No one is interested in me, except per-
haps when they want to get a little bit of a rise out of someone who obvi-
ously doesn't know how to act on Welfare Wednesday. Everyone is above
panhandling today; they have checks to cash and plans for how to spend
their money.
I learned about the spirit of the anticipation of check day on my ear-
lier visits to patients in this beleaguered neighborhood—the plans to buy
a new stereo component or to pay back money borrowed from a friend.
I also saw what became of these normativizing desires when check day
actually arrived; the good intentions to repay the financial kindness of
others most often took a back seat to assuming the mantle of consumer.
But even this ethical compromise engenders further practical assaults
on the temporary quest to be "normal" through money. The high price
tags on goods within the formal economy quickly wear down residents'
resolve to prove their place as consumers, and they yield to the direct
and indirect savings that result from acquiring both temporary and dura-
ble pleasures in the informal economy. The most-together residents will
spend part of their check on new clothes or CDs or other small treasures,
but few will undergo the scrutiny that going to the mall adjacent to the
neighborhood entails. Instead, they will shop at the local army/navy store
and pawn shops, or join their more desperate brothers and sisters at the
informal markets that crop up on the street. This economy appears and

- 121
disappears before our eyes. Commerce sloshes over and around us as we
stumble into drug sales, scan the crowds of street-market buyers and sell-
ers for our patients, and steer clear of the anxious storekeepers alert to
the shifty customers looking for the "five-finger discount" that promises
to extend their shopping spree beyond the value of their meager welfare
check.
Newspapers and research reports often describe this kind of neigh-
borhood as "chaotic," and so it appears to an outsider. Health planners
and even the myriad service providers who have worked in this neighbor-
hood for years extrapolate from place to person and refer to the inhabi-
tants themselves as "chaotic" (Patton et al. 2005a). But this label seems
less true each time I walk in the path of two nurses who work out of a
home care program, a unit of the local health authority, that serves this
tiny, dilapidated, but amazingly resilient neighborhood. It is not chaotic,
I came to see, but purposeful: even in the most visually arresting scenes,
when residents are twitching and lurching into the street, they are headed
to places that I am not yet able to perceive as destinations. I have come
to understand that health planners in particular think of residents here
as "chaotic" not so much because of the way they live their lives—which,
in any event, outsiders know very little about—but because of the messy
trace they leave in the medical record system as "patients" who ping-
pong their way into and away from the service agencies created over the
last fifty years.1
We, too, ping-pong through the neighborhood, stopping by one place
because they have a reliably clean bathroom, another place because a client
we are looking for often has lunch there, and yet another place because it
still manages the methadone for a client who has otherwise been trans-
ferred to the nurses. Some days I feel that "services" are splattered across
the neighborhood, with program requirements (or "threshold for ser-
vices") so low or so vague that what is on offer at one bleeds into what is
on offer at the next. This lack of clarity about who does what bothers the
health authority, which perceives a massive "duplication of services." But
most residents see this swirl of overlapping offers of care as a complex
and inescapable system of surveillance.
Our job today is to "deliver health care" in the form of home care nurs-
ing for people with terminal illnesses, primarily HIV and cancer or both.
The nurses, acknowledging why I am here, note wryly, "You aren't going
to see much today, no one is going to be at home." The nurses are accul-
turated to the daily and weekly rhythms of the neighborhood. They know

122 - CINDY PATTON

that for check day—indeed, for this entire week—their patients will not
be found at the index location that the nurses' employer envisions.
The health authority management system is less than a decade old in
our province,2 but it has enthusiastically embraced the national mandate
to move health care from "hospital to home." Although the home care
nurses provided virtually the same care in the same general geographical
boundaries for two decades before the invention of this new administra-
tive structure, from the health authority's point of view the revitalized
job of this set of nurses is to respond to the nationally mandated deter-
ritorialization of services away from the hospital.3 The nurses deliver a
range of medical services from wound care to medication monitoring
to patient-family education designed (by yet other planners) to prepare
those released from intensive hospital care to undertake (along with the
"family" they are presumed to have) quasi-medical self-care at home.
The new home care mandate instantiates a "new practice" with no appar-
ent recognition of any similarities between the new "home care" and the
daily practices of care in which the nurses engaged before their work was
absorbed under the aegis of a health authority. Implicitly, regardless of
whatever they did "before" they are now understood to be transforming
the home into a clinical space. But what happens when the patients, as
on this day, are not at "home"? Or when "home" is not a fixed, private, or
enduring space to begin with? How does this new health activity inter-
sect with a "home" that is already a site of intensive surveillance by land-
lords, police, "bad boyfriends," and petty criminals? How can the vague
range of services and attitudes toward care (for what is the desire to help
oneself medically but a practice of the self potentially at odds with other
facets of presentation of self in fluctuating contexts?) be accomplished
by nurses who operate in spaces that are almost completely devoid of
the practical and affective components that the middle classes think of
as "home"?
In this essay I narrate the "clinic" as a vacillating space and time in
the recognition and management of disease in contexts seemingly hos-
tile to the practice of medicine at all. Though, as I will demonstrate, care
activities morph into each other, are suddenly suspended, or incremen-
tally appear, my examples focus on two of the four care activities that the
health authority defines as the nurses' scope of practice: wound care and
patient education. I leave the third and fourth areas—palliative care and
medication management—for a more extensive treatment in a future
analysis. It is important to note here that Canada has universal health

C L I N I C W I T H O U T THE C L I N I C • 123
care, and that all of these tasks correspond to categories of nursing care
that are covered under the provincial health care payment plan, that is,
each of these activities has a billing code and a definition. But while these
services are provided at no cost to patients, the particular elements of
care that the governing health body defines are distinct practices, but
actuarial categories used further up the food chain of health system
management to determine costs—and allocation of the presumptively
scarce resource—of care. The distinct care practices defined by the health
authority are compared to a representation (a "chart," which itself is a
pale rendering of what actually happens) of the nurses' practice in spe-
cific cases to ensure that they are providing neither too much nor too
little care (figured as an amount of time, and sometimes as a list of mate-
rials, such as bandages or protective booties, types of antibiotic cream,
and home support adjuncts such as walkers and portable toilets) for a
particular type of patient. Within this framework, a patient equals a dis-
ease—a "diabetes patient," a "cancer patient," an "HIV patient"—and each
disease is in turn articulated to a set of care components that are ranked
by the level of specialization required to provide the care and by the time
to be expended on it.
The increased use of home care is believed to decrease costs by having
"lower-level" (hence, cheaper) allied health personnel deliver the mini-
mal activities that will enable patients to become self-supporting. The
home care mandate dovetails uneasily with a second emergent out-of -
hospital mandate, namely that of establishing special venues or "regular
home" capabilities for "palliative care" (care designed not for recovery
from disease but for easing an individual's last days with a recognized
illness).4 The thin line between home care and palliative care for the des-
perately ill HIV or cancer patient complicates the nurses' management
of their caseload. Cost algorithms limit the number of visits available for
home care patients presumed to eventually be able to function on their
own, whereas death serves as the time limit for palliative patients, who
are presumed to die imminently. Like the neoliberal approach to home
care, palliative care sentimentalizes the family and the patient by imag-
ining the patient/dying person to be enfolded in the comfort of their
own home, surrounded by sad but brave family members who can make
decisions about highly personal but nonmedical care such as changing
diapers and feeding systems as well as medical decisions such as pain
management enacted through legal channels via prescriptions. Like home
care, which asserts that care in the home is less alienating than care in

124 - CINDY RATION

the hospital, palliative care is understood not only to be more humane
for individuals but also a more cost effective way than a hospital bed to
manage the very last days of life.
In the context of impoverished neighborhoods, the harsh reality is
that palliative care may be the first real care received by individuals who
have led their medical lives beneath the radar. After decades of watching
people "die with their boots on," the nurses are not concerned with end
of life care and cost containment but rather "dying with dignity"—in this
case defined as not dying totally alone or in a back alley. From the nurses'
point of view, having a patient declared "palliative" enables them to prac-
tice more flexibly. And however much the health authority may scruti-
nize their requests for signs that a patient isn't really so bad, for a class of
people whose alienation from society is precisely their chronic ill health,
their throw-away status, one is hard pressed to say where the living starts
to end and the dying starts to begin.
The nurses have long argued (and actuaries and systems analysts now
agree)5 that patients do not equal diseases and diseases like AIDS and
cancer do not immediately spell "death." Individuals may have more than
one disease, and they may have compounding circumstances that are
either quasi diseases ("addiction," "mental health issues") or nondiseases
(at present) like poverty, unemployment, or homelessness. Multidiagnosis
patients affected by the recently designated and much discussed "social
determinants of health" not only complicate our understanding of etiol-
ogy and treatment of specific diseases but also result in a fundamental
ethical and practice crisis in the very act of "giving care," beginning with
the glaring disjuncture between the rhythm of the neighborhood and the
structure of the physical clinics that have cropped up in the neighbor-
hood over the last decade.

Neighborhood Time, Clinic Time, and the Constitution of Spaces for Care

The nurses and I weave toward the main clinic (the actual clinic, a rela-
tively new facility in the neighborhood), which is staffed with doctors
and nurses who never leave the building.6 The home care nurses are very
small women, even smaller than I am, and they walk very fast. Their size,
speed, and trademark blue backpacks are their "signature." They look and
move totally differently from the "street nurses" who are employed by
the public health department to do outreach, education, and triage "on
the street." The street nurses are much taller and tougher looking, they

C L I N I C W I T H O U T THE C L I N I C • 125
carry satchels and stand around on corners much like the drug dealers
who look nonchalant but open for business. The division of labor in the
neighborhood is clear, or rather, the venue of labor is clear: street nurses
on streets, doctors and their nurses in the clinic, and the home care
nurses—well, they dash from home to home, or what passes for home,
for the people on their overwhelmingly large caseload.
A few weeks on the job in the neighborhood revealed to me one of the
first conflicts between medicine as offered and care as needed, as well as
the underlying dynamic of and accentuated need for both homes and care
in poor neighborhoods. The most obvious conflict is that between the reg-
imented schedules of middle-class life, which underwrite the modalities
of the typical physical clinic, and the nonregimented temporalities of the
neighborhood. Physical clinics typically operate by appointment, and al-
though drop-ins are always "welcome," those who come unannounced
are rarely treated with hospitality. Thus, while formally available, care out-
side the home is rarely "caring," even if it leaves the tattered privacy of the
patients' place of habitation intact. Furthermore, the quality of relation-
ship between the physical clinic and the patient is entirely different from
the relationships in home care, and it reflects the sense of disposability
that people in this neighborhood have described in interviews. For exam-
ple, a forty-four-year-old woman heavily involved in the drug subculture
complained that her doctor mainly only dealt with her "addiction," but
even then she was unmotivated to change doctors: "It's mostly metha-
done—all my other health needs seem to get ignored there and I know
that I should be switching to another doctor but I just don't seem to do
that, I don't know why."7
In contrast to most middle-class residents of Canada, who under-
stand themselves to have an assigned doctor, residents of this neighbor-
hood feel little attachment to their primary care physicians. Middle-class
people have a certain feeling toward their doctor, however much they
may dislike going to visit him or her. Indeed, even if they rarely see their
assigned doctor they know they can fairly easily access primary care
when they need it. There is, then, a sense of continuity and even intimacy
in even the least activated doctor-patient relationship among members
of the middle class. But while many residents (up to 50 percent) claim to
have a primary care physician, and many see these doctors quite often,
they do not exhibit any sense of comfort from the arrangement. When
asked whether they go to their doctor, many give accounts of waiting
undue amounts of time before undergoing the rigors of clinic time.

126 • CINDY RATION

 Organizing patients' time to correspond to clinic time is one of the
major tasks of the home care nurses, and they have various strategies for
keeping track of patients' medical appointments: they make notations in
the patients' records, place notes on the wall calendars that a minority
of patients have in their homes, and rely on more-responsible partners
and friends to remind the patient when they are supposed to appear. But
specialist appointments are frequently booked ahead for weeks or even
months (and thus many "check cycles" into the future), and even if the
assessment or operation initially was greatly desired by the patient, their
interest in "getting care" almost always wanes with the passage of time,
and they instead employ their own pain management strategies, which
unfortunately, often involve street drugs.8
Getting patients to their appointments entails another set of strate-
gies; the nurses arrive at patients' homes early on appointment day and
make certain that the patient is out of bed and dressed in time to take a
taxi or to be accompanied by one of the many advocacy groups whose
volunteers escort patients to medical and social service appointments.
But it is never clear until appointment day how, exactly, a patient will
get to their appointment; on these days, the nurses press through their
visits with unusual attention to the amount of time elapsing as they do
their best to rendezvous with the particular patient neither too early nor
too late. On one occasion, the nurses roused a patient, helped her get
dressed, and escorted her to the designated taxi stop so that she would
arrive well in advance of her appointment. Before the taxi arrived, how-
ever, the patient apparently realized that she had "plenty of time" and
proceeded to get involved in illicit activities, thereby missing her taxi and
her appointment. On another occasion, the nurses arrived at a seem-
ingly ideal time only to discover that the patient had gotten up unusually
early and had already left to make their own round of morning activities,
again, missing their appointment. Rarely did patients seem to have either
a strong sense of impending appointments, or any feeling of duty to cali-
brate their own time to match clinic time.
As I became enmeshed in this vortex of made and missed appoint-
ments, and as I saw the nurses' daily attempts to explain the differing
advice given to patients by the various clinicians they did manage to see, I
realized that these temporal and affective lags between neighborhood time
and clinic time are made even more complex as more specialists come
into the picture. Medicine itself (and each subdiscipline differently) has
its own sense of timing for when "prevention" has failed and "diagnosis"

C L I N I C W I T H O U T THE C L I N I C • 127
occurs, when "treatment" is required and for how long, and when "treat-
ment" has failed and what happens "next." But the temporal flow of poor
neighborhoods, tied to the cycle of government payments, does not easily
interconnect either with clinics' schedules or with medicine's understand-
ing of the timing of care. When we made our rounds on check week, I was
frequently admonished by clinicians and advocates that I shouldn't expect
to see any real work, that is, I wouldn't be able to observe them caring for
or interacting with residents. "Check week" was presented to me as a kind
of time out of time—carnivalesque, even—but almost no one tried (any-
more) to make neighborhood time work in favor of the timing of health.
Instead, medicine and its purveyors seemed to acquiesce to the idea that
they must push their patients toward health during the intervening weeks
and hope they didn't lose all of their ground during check week. They sim-
ply gave in to the neighborhood time, and some actually used check week
as an opportunity to catch up on the clinic's unseen activities of record
keeping, desk organizing, and supply ordering.
Indeed, it is hard to imagine how to correlate these different times, not
just because residents are less interested in receiving care during check
week, but because their sense of self varies through the phases of neigh-
borhood time. The opulent presentation of self through commercial par-
ticipation, enabled by the switch on check day from the informal econ-
omy to the formal, lasts about a week. After the initial blush of wealth,
money becomes scarce and is primarily in the hands of the most ruthless
residents, who parcel it out in exchange for the forms of loyalty associ-
ated with abject dependency. Over the next two weeks the level of vio-
lence and interpersonal crime will increase in parallel with the despera-
tion level of the uniformly beleaguered residents. Time becomes space,
as people who have partied a little too hard and behaved badly when they
had a cash cushion find themselves evicted from their crummy single-
room apartments. Others, who avoided conflict by sleeping outdoors
when they were too wasted to go home, return after a few days to find
their belongings in the alleyway, pitched out by the (ex) boyfriend or girl-
friend who has exercised an undocumented preemption of their space.
Of these variously displaced people, those with friends or relatives and
any semblance of credibility may engage in a round of "couch surfing"
that results in too many people in one apartment and no one in others.
I have not seen any accounting of the number of people who lose or
change domicile in tandem with the temporality of welfare payments,
and it is difficult to sort out whether one group of people is constantly

128 - CINDY RATION

marginally housed while another group maintains more or less continu-
ous occupation, and whether any particular form of social embedded-
ness or personal trait separates these groups (Patton et al. 2005b). How-
ever it is that personal biographies and structural dynamics interweave
in the neighborhood, a substantial minority of individuals do not have
anything close to a "home" that could be the locale of their home care
when their time of need arrives. Instead, when patients become very sick
and need home care—often upon release from hospital (that is, they got
there very late in their disease process, often after a round of housing
changes that depleted their last health reserves)—they are usually at that
point without a home in any middle-class sense and are "placed" in the
best location that release planners and advocates can identify. Thus, their
poor health pins them down to a place and time where their nurses may
intercept them.
Working in single-room apartments (often called single-room occu-
pancy spaces, or SROs) and shelters is quite different from what is involved
in the "home care" that conventional home care imagines. Unlike the
suburban home, which presumes privacy as well as security from polic-
ing forces, the nurses must negotiate their care practice in highly sur-
veilled spaces. It is not uncommon for people to come outside of their
rooms to receive treatment, medication drop-offs, or simply check in
with the nurses. This is related to residents' experience of being hassled
by police, coping with the variable rules about visitors, and having their
rooms scrutinized by housing personnel who require varying levels of
cleanliness and orderliness if renters are to retain their housing. They
may have drugs and paraphernalia lying about, and in some cases they
are actively dealing drugs from their room. Women in the sex trade may
have customers in their room, or they may simply have evidence of their
work around. People living in social housing may be violating regulations
by having live-in partners, and patients in SROs may be violating rules
that require payment of nightly fees for extra "guests." It is very common
for people in the relatively luxurious social housing units to engage in
informal rental arrangements with relatives or acquaintances. Those who
"rent" a couch in this way act far more entitled to the space than mere
visitors, since, from their point of view, they have a quasi-contractual
relationship to the principal renter of the single room or social housing
unit. Thus, nurses must be nonjudgmental and must convince patients
that they will not expose these activities to police, building managers, or
others who are seen by the patients as keeping them under surveillance.

C L I N I C W I T H O U T THE C L I N I C • 129
 Health planners rarely look at the intransigent monthly cycle in the
life of impoverished neighborhoods. Their "health indicators" look at the
long-term morbidity and mortality of the ailments that cost the system
the most money (those that require long hospital stays in particular), since
hard-nosed actuaries believe that they are at least allowing some sem-
blance of care for those who have spent their life destroying their health.
Rarely do such indicators measure fluctuation in illness and disability
as these are experienced in poor neighborhoods. One solution might be
to incorporate a question into surveys to indicate where in the welfare
cycle the data were gathered (certainly not during check week, when "no
one is home"), but even this acknowledgment of the contingency of that
particular slice of time cannot help us isolate the effects of the rhythm of
economic, social, and habitational changes and their synergistic effect
on personal attitudes, practices, and presentation of self in a micro-
culture in which possessing, using, and trading health-eroding goods like
drugs, alcohol, and cigarettes are means of gaining social status. In par-
ticular, most research has been unsuccessful in parsing out the effects of
couch surfing, which counts as "homelessness" but may well be a time of
greater intimacy, caretaking (especially eating), and rest than periods of
high-energy activities undertaken in one's own—eviction-prone—room.
But it is precisely these contingent and compounding situations and
interrelationships that care providers, like the nurses in my study, nego-
tiate as they try to materialize the clinic as a small part of the total context
in which health is generated and sustained.

Wound Care: Making Do

This complex relationship between the nurses, their patients, and the
spaces in which nursing practice is supposed to occur results in consid-
erable "making do." In one case, for example, a patient refused to admit
the nurses to her room in an SRO. The nurses were obliged, then, to cre-
ate "clinical time" in a hallway. We had gone there to perform a bandage
change on the woman, who had been severely burned when she passed
out in her bathroom and lay for some time unconscious against the radi-
ator. At this point the dressings needed to be changed daily. But after sev-
eral days of changing the dressings in the woman's small apartment, she
would not allow us in. When we arrived, the nurses knocked and a man
answered from inside. The nurses announced who they were, and the

130 • CINDY RATION

man relayed this information to the woman. The woman replied from the
other end of the apartment, saying, "Tell them to come back later." But
when the man understood that we were there to change her dressings,
he went back to have a discussion with the patient, who then reported
through the door that she would come out into the hallway. The patient
was quite high and unable to stand easily, and we asked if we might go get
her a chair. She propped herself up in the corner and said, "No, just do it."
The dressing change took about five minutes, during which time other
residents came up the stairs and looked our way. I had noticed that when
residents see the nurses enter a building, they sometimes approach and
ask, "Is someone sick? Is someone hurt?" or request that the nurses check
up on a particular person. But this time, they just moved on. Certainly,
some recognized the nurses, and there were medical supplies in easy
sight, but the scene was quite different from, say, the times when we have
come across paramedics trying to revive someone who has overdosed.
Instead of gawking at our patient, people simply glanced and moved on.
The air of efficiency and privacy that our encounter in this quite public
place exuded had transformed this dirty end of a hallway into a "clinical
space," or what the nurses have, in more formal moments, called a "clinic
in a corner" (Giles 2001; Griffiths 1996).
Their notion of a clinic in a corner comes from having established
several "clinics" in shelters. Two shelters allow the nurses to share actual
rooms where materials can be stored. In a third space they have access
to, there is no separate room. Still, the "clinic" happens temporally when
the nurses arrive and are given a list of people who want to see them. But
a clinic in a corner can happen almost anywhere. Some days during my
study, it seemed that half of the people we met on the street wanted a
Band-aid, or wanted the nurses to look at a wound or hear a complaint.
The nurses then often move the person, transformed into a patient, into
a less busy part of the street and apply a small dressing, but as often they
attenuate the clinical encounter by telling the person to meet them later
at whichever of the shelter "clinics" they are going to be. I have been quite
amazed that individuals almost invariably appear at these "appoint-
ments"—much more often, it seems, than when they make the appoint-
ments, scheduled far in advance, with their specialists. On one hand,
this makes sense because the individual already has a plan for their day,
and they can immediately make adjustments in order to arrive at this
appointment an hour or two later. On the other hand, it has seemed to

C L I N I C W I T H O U T THE C L I N I C • 131
me that their momentary transformation into a patient when they seek
advice on the street inheres, and they carry this sense of proximate medi-
cal care with them more readily for this short duration.
The vacillation between patient and person, and the corollary vacilla-
tion between care provider and person, are a routine (and for me, exhaust-
ing) part of the day. The shift would sometimes occur at warp speed, such
as on the second day that we treated a patient I will call Hal. Hal was a well-
known and, I gathered, well-loved drug dealer who had managed his HIV
very successfully for years until he discovered a rapidly progressing bone
cancer in his skull that was quickly destroying his inner ear and brain tis-
sue. This was very disconcerting to him since he felt—rightly—that he
had a giant hole in his head and that he was losing his mind. Although I
had seen bodies riddled with larger and deeper holes, this one was more
visually alarming because it could not be hidden with clothing. We wanted
desperately, as did he, to change the dressing on his head, which involved
removing and then repacking a hole about the size of an orange.
Hal was extremely mobile and independent almost to his very last
day of life, and we had trouble finding him for several days after he
was released from the hospital, when he landed (perhaps courtesy of an
aggressive placement advocate) in a fairly nice SRO hotel, albeit with only
a small trash bag with his remaining belongings.9 On the day we finally
found him, his home care worker, a tall young man assigned to difficult
male clients, was helping Hal clean his place and organize his clothes to
be washed. In other cases the worker, whom I'll call Barrel, has waited
with us while a patient is treated, but on this day we felt we did not need
his help, and we knew that he had other patients to see. Hal, disgusted
by his hole and both wanting and not wanting it cared for, said, "Just wait
a minute while I smoke some rock." Recognizing the discomfort of the
situation, he took pains to medicalize his drug use—in fact, to help cre-
ate the space of clinic. "I have to smoke my rock first. That's my medica-
tion and I can't deal with this until I do." We then stepped the eight feet
across the room to the couch and began laying out the dressings, thereby
reprivatizing his half of the room by more explicitly constituting the
couch as the space of the clinic. Hal smoked one rock while we pretended
not to notice as the tell-tale acrid smoke wafted by, and then he came
across the room to be treated. But before the nurses could make much
progress, he leapt up again and crossed over to the "domestic" space we
had all worked to construct. He couldn't find his rock and proceeded to
dismantle his bedding and small collection of belongings. We became

132 - CINDY RATION

caught up in the frenzy of his obsessive behavior and moved into the
"domestic space" ourselves, now as persons recognizing that special feel-
ing of having lost something that was only just there. Hal began accus-
ing his care worker of stealing his rock, asking us, "Does Barrel smoke
rock? I bet he smokes rock." We now took on the role of Barrel's friend
and defended him as we were brought deeper into the frenzy of finding
the missing drug. Mixed feelings and motives ran high. We were afraid
we would never be able to treat Hal's wound. We were afraid of being
accused of stealing his drugs. It did no good to move toward the clinic/
couch because we could not get Hal to "come to the clinic." He shuttled
us back and forth between domestic and clinical space, at once asking us
to help him find his drugs and ordering us to get away from his belong-
ings. Finally, he allowed the nurses to change his dressing and we left,
anxious that we would not be allowed in his room again.
We called Barrel to warn him about what he would find when he
returned to Hal's room, and Barrel called us a few hours later to say that
the drugs had been in the pants Hal had put in the washing machine. By
some miracle of plastics technology, the rock survived the wash. For the
next few days, Hal had his dressing changed at the clinic where he picked
up his methadone. It was nearly a week before Hal allowed the nurses to
come to his room, and then care proceeded as if nothing had happened
at all. Although this case is an extreme of black comedy, the scene of con-
struction and deconstruction of clinic is the daily stuff of home care prac-
tice for nurses working in impoverished neighborhoods.

Patient Education: Who Needs to Know What?

A central analytic concern of our overall research project was to inter-

relate the forms of "connectedness" among residents with their relation-
ships to the various sources of health care. As I suggested above, one
of the central premises of the hospital-to-home movement, often flying
under progressive-sounding terms like "patient-centered" care, assumes
that when the patient leaves the hospital they will arrive home to a fabric
of concerned others, usually presumed to be blood relatives, who along
with the patient can be educated to be self-sufficient, responsibilized
care supporters. I rarely use the term "responsibilized," which is a con-
cept aligned with the excellent work of scholars working in the Foucaul-
dian tradition (especially as usefully extended by Nikolas Rose [1999])
that understands the current state of "governmentality" as one in which

C L I N I C W I T H O U T THE C L I N I C • 133
individuals take on self-management and self-policing functions once
enacted by the state. I use the term here, however, because it accurately
describes the repatriated patient envisioned by current home care rheto-
ric, governing practices, and billing standards. Patients who are in the
hospital, barring an accident that is no fault of their own (though, as
Kristen Tytler [2008] and others have shown, the logic of insurance that
assigns degrees of responsibility for acts suggests that even accidents are
partially one's own fault), have evidently already failed to self-govern (or
else why would they be in the hospital?). The home care process, then, is
not a return to a prior state of self-governance but rather is a reeducation
process, an attempt to take a person who has, almost by virtue of being a
patient at all, failed in their ethic and practices of care. In its most explicit
formulations, patient education is a none-too-subtle occasion for bring-
ing the patient toward middle-class norms.
The patients I observed were, and had long been, far from the proper
citizens imagined by home care. But the nurses I observed have worked
in the neighborhood for so long they have ceased to see this difference.
Thus, as they adapt the mandates established by the current health
authority to make them function in the real lives of their patients, they
do very little of the reeducation that is the implicit goal of much of the
conventional patient education that accompanies home care. Instead
of "teaching" patients how to take their medicine or change their drug
patches, the nurses try to discover how patients have undertaken these
activities in the past. Aware of the high level of suspicion of people in the
neighborhood generally, they take pains to ask patients what help they
need rather than assuming that the individual needs a particular set of
information. Patients' learning in relation to accommodating medica-
tion schedules or understanding the importance of not missing doses
always seemed to occur incrementally, or even, it seemed to me, inciden-
tally. Unlike the newer nurses in the neighborhood, the long-term nurses
actually developed their practice style years before the implementation
of the current health authority scheme and before the neighborhood was
declared a health emergency, thereby allowing for deviation in some clini-
cal practices. Thus, the nurses work within a model that is much closer
to an empowerment model of care than the neoliberal "self-sufficiency"
model that has the practical effect of limiting the number of visits an indi-
vidual patient is meant to receive. Indeed, as longtime participants in the
"care" of this neighborhood, the nurses are highly attuned to the complex

134 - CINDY RATION

interconnections that individuals might maintain despite appearing to be
totally socially isolated—by middle-class and home care standards, that
is. Instead of conceptualizing their patients as a particular type, with a
specific trajectory of illness and referral for care, the nurses recognize that
the mosaic of services in the Downtown Eastside (DTES) offers many dif-
ferent entry points to, in particular, HIV services, and that the dense inter-
connections that outsiders view as pathological relationships of mutual
use and abuse might at any moment bring them a new patient who needs
information and referral to other services (see Giles 2006).
During my field study, I saw that it was often on the most exhausting
days of the nurses' work that the most revealing interactions took place.
On one very long day, after seeing the fifteenth of the twenty patients
who would fill the day's roster, we stopped in at a shelter and entered the
small room that the nurses were permitted to maintain there. This was
a Friday, the day when the doctor makes her rounds through the neigh-
borhood, and by common agreement it was the nurses' practice to ren-
dezvous at the shelter and use the occasion to make a sweep of known
and yet-to-be-known patients. One of the people on our list that day,
"Dave," came to see the doctor because he was ready to start HIV anti-
retroviral treatment. His very request signaled to us that he was already
fairly knowledgeable about HIV. He told a typically long and inconsis-
tent story, the gist of which was that he had experienced unexplained
weight loss a few years ago and then was shocked to discover he had
HIV. He treated us to a story of his downward spiral and run-ins with the
law that had resulted in a persistent bench warrant. We realized that he
was trying indirectly to explain why he had not been receiving care, but
why he should now be considered a good candidate for medication. He
described his legal troubles as completely disabling: "I had a cloud over
me, you see, I couldn't do anything." But this problem was resolved, and
he had acquired a housing subsidy and a place at one of the nicer social
housing units. In the story, he recounted living somewhere else, a slip in
his neat narration of himself as on the way back to normal. We asked why
he had decided to come back to our city, to which he responded: "The
HIV community and amenities and help available." He specifically men-
tioned his case worker at the local AIDS society, and exclaimed: "Those
girls really follow through!" He was very upbeat and looking forward to
having his own place: "It's nice to have your own bathroom, and be able
to sit at a kitchen table then go sit on a couch. It is those little things."

C L I N I C W I T H O U T THE C L I N I C • 135
 Dave's performance was quite clever, and it was obvious that while
he was supposed to be receiving AIDS education, all he really wanted
was a prescription for his medications. He clearly recognized the stereo-
typical case that he was supposed to embody—that of the down-and-out
man who had "hit bottom," put his life back together, and was now ready
to undertake the strictures (including appropriately maintaining a quite
nice apartment) that would move him upward on the path to health and
propriety. Although it cost him nothing, he made a mistake in his story-
telling by showing too much familiarity with the local agencies; indeed,
he had clearly been a client there and spoke of his caseworkers as if they
were old friends.
In sharp contrast to Dave, who clearly had deep knowledge of the
complex of services available to him, was another patient we saw at the
ad-hoc shelter clinic, who was also already connected to a range of ser-
vices, though this fact passed nearly unspoken because of her presen-
tation as the victim of a beating. We saw this patient on an equally busy
and complicated day, and we might easily have skipped over her because
there didn't seem to be anything wrong with her—indeed, from the health
authority point of view, she was not an appropriate patient because she
was young, fully able bodied, and had no illness that required "home
care." But as we were leaving the shelter, the day manager asked the
nurses to see a young woman who couldn't have been over twenty and
they agreed. She did not live in the neighborhood but had arrived at the
shelter overnight and was expected to stay for a few days. She had injured
her ankle and, because she was not completely mobile, she was accorded
"bed rest" privileges; that is, she was allowed to spend the day in a "night
use only" room because she was injured. In assessing her ankle, which
seemed barely injured, it became clear that she had been in an alterca-
tion with her boyfriend and that he had stomped on her ankle. In the
course of discussing where she might go for an X-ray, the nurses asked
if she had a regular doctor. She gave a name and then said very casu-
ally, "That's who monitors my HIV meds." Although no one reacted, I dis-
cussed this moment with the nurses later, and they admitted they were
shocked: after all of their years dealing with every kind of patient in this
neighborhood, they too had been unprepared for an otherwise robust-
looking teenager whose HIV was sufficiently advanced that she had been
placed on antiretroviral drugs. They had also been blown away by the
casualness with which she had offered the information. Apparently for

136 • CINDY RATION

this young woman, HIV was a relatively common condition that was not
worthy of undue fuss or hiding.
This woman received her HIV care via a doctor who monitored her
HIV medications. But, unlike Dave, who perceived a unique community
populated by persons with AIDS, HIV care, and support workers, she nor-
malized HIV in her world of bad boyfriends and periodic homelessness.
Both individuals were knowledgeable about their medical conditions and
were connected to HIV care, but through very different routes. The causes
of their homelessness were also quite different. In Dave's case, a life of
problems and an abrasive personality (and, likely, a psychiatric diagno-
sis) had left him in life circumstances in which his HIV providers were
the warmest relationships in his life. The pleasant young woman found
the shelter her best option after a violent run-in with her boyfriend—an
interlude before going to friends or family or returning to him again. In
neither case was traditional "patient education" appropriate, and indeed,
in their own ways each patient asserted their knowledge of their own care
needs. For these patients, and for others who aren't able to fully under-
stand what is happening to them, the model of a patient returning from
hospital to home with the helpful nurse explaining their new situation is
clearly ludicrous.

Conclusion

In these examples I have tried to show that "clinic" is as much a disposi-

tion and a relationship as a particular place and time. In all likelihood,
the reality of physical clinics helps underwrite the nurses' practice, if only
through its stasis, inflexibility, and surveillance capabilities (versus the
nurses' adaptability, mobility, and capacity to provide care without "see-
ing" what is happening around them). But in the care of the poor, at least
in this case, it is clear that timing is everything; that relationships of care
have very little intrinsic durability; that trust must be built and rebuilt—
or built in groups that are different from the middle-class care model.
When the Canadian government decided to try to address many differ-
ent health system problems through increased utilization of home care,
they created both an expanded mandate and a false expectation for the
many urban nurses who were already practicing care among the poor. At
its worst, this has resulted in thrusting new agents of the state into the
lives (but less often spaces, since they have very few) of people with little

C L I N I C W I T H O U T THE C L I N I C • 137
capacity to reverse or redirect policy. But at its best, the very impossibil-
ity of localizing care in denned spaces, the very impossibility of "home
care for homeless people," leaves this form of care in a kind of Wild West
condition practiced by highly experienced and adaptable outlaw nurses
whose care exceeds the systems' ability to police it precisely because its
temporality is "quicker on its feet" than the health authority's algorithms
and billing categories. While this leaves the nurses vulnerable to criticism
and results in no increased staffing, the care that they can provide opens
up new possibilities for understanding the transient "clinic" as a space
of resistance to the otherwise unresponsive (to patients and nurses) new
health systems.

Notes
I am extremely grateful for the patience, kindness, and huge depth of knowledge of
the main two nurses that I followed, Susan Giles and Evanna Brennan. They have
documented their work at the Web site www.multidx.com.
1 I should say something about what I am studying. In British Columbia from 2004
to 2007 I headed a research team examining the fit and lack thereof between ser-
vices offered by various groups and agencies and the needs expressed by people
living in a neighborhood heavily affected by poverty, unstable housing, and, in the
last decade, HIV and hepatitis C. The project I worked on was titled Homecare
for Homeless People with HIV, and it was supported by the Social Sciences and
Humanities Research Council of Canada (grant no. 855-2003-0003) and the Cana-
dian Foundation for AIDS Research (grant no. 016009) and approved through the
ethics board of Simon Fraser University and the health authority in which I con-
ducted the work. The tasks of the project included a study of the history of service
placement in the neighborhood, including archival research and interviews with
longtime providers and advocates; interviews of friendship networks; reanalysis
of survey data generated in another study conducted by one of the coinvestiga-
tors; art-based community investigations of housing and health care issues, and
issues of consent to care; and my own ethnographic work with the actual home
care nurses. I entered the field from the point of view of these nurses, and from
the outset I understood my work to be a clinic ethnography. I had conducted two
previous clinic ethnographies—one a multisite team study of a set of methadone
clinics; one a single-ethnographer study in a specialized HIV clinic—and I was
interested in how such an approach would play out in this new setting.
There were important differences from the more formal clinical settings in
which I had previously worked. By definition, home care nursing takes place in a
home; hence, this field of nursing is about managing the domestic and the medi-
cal. As I will note here, and have described at length elsewhere (Patton and Loshny

138 - CINDY PATTON

 2009), the complication for the nurses in this context is their very unique and
interesting negotiation of "home" among people who do not have homes by the
conventional definitions of the "home care" model. The line between the "space-
time" of "clinic" and its "other" is blurred from two directions: in the constitution
of "clinical time" in the home spaces of the homeless, and in the constitution of
"domestic space" in the bleak places that are designated as "clinics" in shelters.
2 According to the informational Web site of the British Columbia health authorities,
there are five health authorities that "govern, plan and coordinate services region-
ally within sixteen health service delivery areas and participate with... one Pro-
vincial Health Services Authority, which coordinates and/or provides provincial
programs and specialized services, such as cardiac care and transplants The
structure, introduced in December 2001, modernized a complicated, confusing
and expensive health care system by merging the previous 52 health authorities
into a streamlined governance and management model" (Ministry of Heath Ser-
vices 2009).
3 There are several kinds of nurses working in the neighborhood, and the residents
make little distinction between their functions but rather recognize only the indi-
viduals, whom they sometimes like and other times dislike. I studied the home
care nurses who work in an adult care unit of the regional health authority. The
other neighborhood nurses are from much newer programs instituted in the
wake of the area's declared HIV public health crisis in the late 1990s, and they
include street nurses who work under the public health department (distinct from
the health authority); clinic nurses stationed permanently at the two new clinics
established by the health authority; nurses at the longer-standing clinic for native
people, which has extensive day programs and frequently houses homeless people
for a night; nurses attached to a shelter society; and several "methadone" nurses
who are attached to the above facilities but function separately out of their own
office within the facility.
It is important to recognize that home care nurses—both the functions of and
many of the actual individuals—predate the health authority. To some extent the
veterans do what they always have done, even when it does not fit entirely with the
health authority's more recent but official mandate. When this results in enhanced
attention to the patients, the nurses' activities are invisible to the health authority.
But when doing what they always did results in overtime, or additional mileage,
or acting outside their new scope of practice, the health authority's regulatory and
actuarial structure kicks in, and the nurses come under scrutiny. I did not observe
the nurses prior to the implementation of the health authority. However, based on
my observations, I believe that while the nurses have refined their care practices
as the health needs of the neighborhood have evolved, they are providing essen-
tially the same care with the same logic as they did before the health authority was
implemented. In my opinion, it is as much the disciplining result of the recon-
ceptualization of their work, which has been accompanied by a structural inabil-
ity to calculate costs and results to reach the obvious conclusion that more staff

C L I N I C W I T H O U T THE C L I N I C • 139
 members are needed, as it is the changing needs (especially for HIV hepatitis C,
and drug addiction in general) of patients that places heightened pressure on the
nurses providing home care in this neighborhood.
4 By definition, one is only palliative after one has received "acute" or "chronic" care
that has failed to "save" the patient's life. In practice, people who are mainly "dying
of old age" may also come under the aegis of "palliative care," but that is mainly
because of the alarming rise in chronic illness in Western populations related to
declining cardiovascular health and independent of increases in longevity rates.
Our studied refusal to aggressively pursue all manner of preventative medicine has
abandoned all but a modest few to emergent and chronic illness that will plague
them from their middle years to the much later death that our advances in pallia-
tion have enabled.
5 The emergence of the diagnostic and actuarial category of "complex patient,"
described as an entirely new type of patient, represents both the admission by
the health system that there is not a simple equation between patient and disease
and the reinstantiation of precisely that equation, but with a far more complex
calculus.
6 One of the benefits of working in community nursing, as the home care nurses
now prefer to call their subdiscipline, is that the nurses are at some remove from
doctors. There are quite a few older nurses in this unit, and over lunch, when I
ask them how they came to work there, they tell me stories about their stifling
years of work as ward nurses. Crypto-feminists all, they begrudgingly appreciate
the fact that their main prescribing physician is a woman, and she makes house
calls on Mondays and Fridays. These doctor-nurse days were particularly interest-
ing opportunities for me to observe the subtle attitudes, styles, and speech pat-
terns that define "clinical practice" as doctorly or nursely. On several of the occa-
sions when we were all on the road together, patients, some of whom have known
me for a while, ask me: "Are you a doctor or a nurse?" A small triumph for women's
rights is that it is now imaginable that a woman might be a doctor. It is also a small
tribute to sexism, since it is likely that my general practice of watching others work
has signaled me as "not a nurse."
7 All undocumented quotes are from my field notes and interviews conducted dur-
ing the course of the research as outlined in note 1.
8 It is very common for patients to spontaneously argue that their drug use is their
self-managed form of medication. As I show in a later passage, one patient claimed
that he had to smoke crack before having a bandage changed because that was
his form of medication and anxiety reduction. As anthropologists and sociologists
who investigate drug cultures almost uniformly argue, "illegal drugs" are almost
always viewed by users as being closer to Pharmaceuticals than the law imagines.
9 People who live their lives bouncing between living settings have an extremely dif-
ficult time hanging onto their belongings, A few have specific people (sometimes
a family member) who agree to keep their most prized things when they go to jail
or are kicked out of their housing. But the most peripatetic individuals just go

140 • CINDY RATION

 through endless cycles of replacing clothing and personal items time and again;
their structured inability to hold onto "belongings" is doubled by their overwhelm-
ing lack of "belonging."

References

Giles, S., and E. Brennan. 2001. " 'Home' nursing of HIV-positive clients in the urban
core." Canadian Nurse 97 (1): 33.
. 2006. "Action-based care in Vancouver's DTES." Multidx, http://www.multidx
.com/multidx_frame.htm (accessed June 2008).
Griffiths, H. 1996. "Nursing in the urban core." NursingBC(November-December): 14-16.
Ministry of Health Services, n.d. "British Columbia's health authorities." http://www
.health.gov.bc.ca/socsec/about.html (accessed June 2008).
Patton, C., and Helen Loshny. 2008. "Negotiating 'home' and 'care' amongst the HIV+
homeless: An ethnographic case study of homecare nursing habitus shaped by and
through competing philosophies of care." Canadian Journal of Nursing Research
40 (2): 172-88.
Patton, C., D. Culhane, I. Goldstone, O. Hankivsky, S. Kamal, M. Petty, J. Sommers, and
M. Tyndall. 2005a. "Chaotic lives or hidden networks? An analysis of care seeking
strategies in four groups of marginally-housed persons at risk of contracting HIV"
Poster presentation 102, Fourteenth Annual Canadian Conference on HIV/AIDS
Research, Vancouver, May 12-15.
Patton, C., D. Culhane, I. Goldstone, and M. Tyndall. 2005b. "Patterns of housing and
service access among actively injecting drug users." Poster presentation 103, Four-
teenth Annual Canadian Conference on HIV/AIDS Research, Vancouver, May 12-15.
Rose, Nikolas. 1999. Powers of freedom: Reframing political thought. Cambridge: Cam-
bridge University Press.
Tytler, Kristen. 2008. "Insuring intimacy: Reconfiguring the subject of risk." Ph.D. diss.,
University of Melbourne.

C L I N I C W I T H O U T THE C L I N I C • 141
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7 PRACTICES OF DOCTORING

Enacting Medical Experience

LISA D I E D R I C H

IN A CHAPTER IN The Birth of the C/z'nz'ctitled"The Old Age of the Clinic,"

Michel Foucault argues that the history that medicine likes to tell of itself
has at its center an unchanging idea of the clinic. "Medicine has tended,"
Foucault writes, "since the eighteenth century, to recount its own history
as if the patient's bedside had always been a place of constant, stable
experience, in contrast to theories and systems, which had been in per-
petual change and masked beneath their speculation the purity of clinical
evidence" (1973, 54). Like all of Foucault's work, The Birth of the Clinic
attempts to challenge this age-old and seemingly fixed idea by inves-
tigating the clinic as a multiple and complex object that emerges at a
particular moment in history and gets enacted in and through various
practices. For Foucault that moment of emergence is between the years
1769 and 1825 (x)} By exploring the moment that the idea of the clinic first
emerged, Foucault demonstrates how one particular historical "truth" of
the clinic comes into being and covers over multiple other "truths" of the
clinic. Foucault argues that this ideal account of clinical medicine must
be historicized in order that it may "be understood in relation to the...
establishment of clinical institutions and methods," which then present
this ideal account "as the restitution of an eternal truth in a continuous
historical development in which events alone have been of a negative
order: oblivion, illusion, concealment. In fact, this way of rewriting his-
tory itself evaded a much truer but much more complex history" (57).
Foucault returns to the historical moment of the birth of the clinic in
order to rewrite medicine's own historical rewriting by presenting a more
complicated and less eternally true history of clinical experience. Like
all of Foucault's work, The Birth of the Clinic is as much a history about
how we tell history in a particular present as it is a history of a particular

- 143
object. For Foucault, the form of thought matters as much as the con-
text of that thought. While Foucault's archeological methods help him to
glimpse and describe the domain of clinical experience and "the structure
of its rationality," he is also aware that it is only "because a new experi-
ence of disease is coming into being," thereby making possible "a histori-
cal and critical understanding of the old experience" (xv). The particular
historical moment in which he writes—the early 1960s—provides him
with a changing discursive framework that he is able to utilize in diagnos-
ing the conditions of possibility that resulted in the birth of the clinic two
centuries earlier. We can explore a particular medical experience and its
"types of discourse" only if that experience and those discourses are not
still our own (xviii). Foucault's The Birth of the Clinic becomes, then, not
simply a diagnosis of the condition of the old age of the clinic but also
participates in the enactment of a new age of the clinic. In this sense, The
Birth of the Clinic is a history of the present of a shifting medical expe-
rience in the 1960s. In this essay, I want to explore that present, which
is now our past, by reading The Birth of the Clinic along with another
book of the time that I think also describes an older age of the clinic and,
at the same time, begins to enact a new age. That other exploration of
a changing conception of medical experience is John Berger and Jean
Mohr's A Fortunate Man: The Story of a Country Doctor, which was first
published in the United Kingdom in 1967.
Berger and Mohr's text is a remarkable historical document that com-
bines reportage, memoir, social and psychoanalytic theories, and photo-
graphic images to present the story of an individual, John Sassall, the
fortunate man and country doctor of the title, and a community of "for-
esters" in rural England.2 Although I have no evidence that Foucault was
familiar with A Fortunate Man, or the extensive critical and literary work
of John Berger, the more prominent of its two authors, I think it is fair
to say that this is the kind of work that would have interested Foucault
as an exemplary text of a particular historical moment. It is in this spirit
that I look back at Berger and Mohr's text. I have written elsewhere about
what I call the multiple practices of witnessing (Diedrich 2007a; 2007b;
2008), and here I want to think in terms of doctoring itself as a practice
of witnessing that gets demonstrated in and through words and images
in Berger and Mohr's account.3 In considering witnessing as a practice,
I want to move away from a focus solely or mainly on the subjectivity of
the witness. My concern is less with who sees what than with how see-
ing happens in practice, and with how subject positions are constituted

144 - LISA D I E D R I C H
through particular modes of seeing. This also shifts the question from one
concerned first and foremost with discerning the accuracy or authentic-
ity of the account of a particular witness to one concerned with the con-
stitutive effects of witnessing. What do we bring into being through our
practices of witnessing? In taking up medical perception and experience
as a practice of witnessing, I am self-consciously extending the concept
beyond a specifically psychoanalytic understanding of the term, which
tends to fixate on individual encounters between doctors and patients
within the privatized space of the psychoanalytic clinic. Instead, to use
terminology that echoes Foucault's work, especially his work in the 1960s,
I want to consider the conditions of possibility that constitute a particu-
lar experience of seeing, in this case the particular experience of a doctor
seeing illness in rural England in the 1960s.
While it is certainly true that A Fortunate Man might be read as a
humanist text that presents Sassall as an ideal model of a compassion-
ate doctor (and, as I will discuss below, one who reads and is changed by
his intellectual encounter with Freud),41 think such a reading misses the
formal, theoretical, and methodological complexity of Berger and Mohr's
text. And although it may strike some as odd to read The Birth of the
Clinic with and against A Fortunate Man, in reading these texts together
I am attempting to follow Foucault's own method of historical analysis
by juxtaposing—"present[ing] side by side," as he says in The Order of
Things (1970 [1967])—various practices, figures, and "forms of finitude"
(1973,198) of the old and new ages of the clinic. Foucault is known to have
dissuaded scholars from writing about him, but he did encourage schol-
ars across various disciplines to make use of, and transform, his meth-
odological "gadgets" in order to explore domains beyond, in time and
space, the ones to which he had already applied his methods (1980, 65).5
By reading The Birth of the Clinic and A Fortunate Man as historically
situated texts, and in relation to each other, I hope to show the ways in
which they each attempt to enact a method for analyzing a kind of expe-
rience, in this case medical experience, in a particular time and place.
I also want to read the texts together as a means to consider, more
generally, the function of literature and the literary criticism in Foucault's
work. To put it plainly, Foucault frequently turns to literature to pro-
vide exemplary texts of particular kinds of thought, and this is espe-
cially true of his work of the early 1960s. As Pierre Macherey has noted,
in one of the few works to discuss Foucault and literature, "Foucault does
more than reflect on literature. He works with literature; he is preoccupied

P R A C T I C E S OF D O C T O R I N G - 145
with making theoretical use of it rather than elaborating a theory of litera-
ture" (1995, 211) ,6 Macherey doesn't find it simply happenstance that Fou-
cault should have published his one book-length work on literature (on
the early-twentieth-century French writer Raymond Roussel's somewhat
obscure modernist fiction) the same year as he published The Birth of the
Clinic. Taking up the figure of Roussel, the figure of writer and madman,
the figure of writer as madman, allows Foucault to consider the relation-
ship between language, experience, illness, and death, which is also the
complex relationship at the center of The Birth of the Clinic.
One might even argue that this complex relationship is the object of
all of Foucault's early work, especially, of course, Madness and Civiliza-
tion, the text that had made an intellectual splash in France two years
before the publication of The Birth of Clinic. The volume Madness and
Civilization would have a significant political impact later in the decade
in relation to the emergent antipsychiatry movement in both France and
Britain.71 want to suggest here that we take up The Birth of the Clinic in
a similar way, as anticipating and participating in the task of transforma-
tion, by offering an antimedicine, which is not opposed to medicine per
se but suggests the possibility of some other historical truths of medi-
cine. Macherey describes Foucault's reading of Roussel's literary method
as "exemplary because, thanks to his rigorous work on the forms of lan-
guage, it results in a questioning of the order of things. We can speak here
of an ontological question. What is a thing?" (218). By manipulating lan-
guage, by dissecting it, Roussel reveals its hidden disease, what Macherey
calls the "sickness of language" (211). Macherey explains that Foucault
reads Roussel's work with and in language as demonstrating "that things
themselves are sick, or in other words not quite as we see them" (219).
How might this revelation from the domain of literature on the being
of language help us investigate the domain of medicine? Or, put more
simply, why this detour into literature and Foucault's work with litera-
ture? I make this detour because I want to suggest here that A Fortu-
nate Man is a work of literature that is exemplary in its work on forms
of language—including visual forms of language—that also results in a
questioning of the order of things. I want to make theoretical use of A
Fortunate Man in an attempt to discern the beginning of a shift in the
ordering of medical experience in the 1960s. In A Fortunate Man, Berger,
Mohr, and indeed Sassall together enact both an old medical experience
and the possibility of a new one. I will organize my discussion of their
enactments of doctoring in a shifting medical order of things around four

146 • LISA D I E D R I C H
general domains—space, time, theory, and politics—which are also the
main coordinates of Foucault's method demonstrated in The Birth of the
Clinic. What are the spaces of the clinic, and what are the temporalities
of doctoring? How do various theories inform or transform medical prac-
tices? How is politics brought into or excluded from medical experience?

Becoming Clinical

In The Birth of the Clinic, Foucault sought to explore how medicine became
clinical. If we consult the Oxford English Dictionary for its definition of
"clinical," we discover that Foucault's archeological account of clinical
medicine is backed up by the history of the word itself. The first use of
the word in English is from 1780, for the newly elected "Clinical Profes-
sor to the Radcliffe Infirmary at Oxford," and its earliest meaning is given
as follows: "Of or pertaining to the sick-bed, specifically to that of indoor
hospital patients: used in connexion with the practical instruction given
to medical students at the sick-beds in hospitals." In the nineteenth cen-
tury, the word would also take on an ecclesiastical meaning by referring
to baptisms administered at the bed of someone ill or dying. By the time
Foucault is writing The Birth of the Clinic, and Berger, Mohr, and Sassall
are enacting A Fortunate Man, the word has acquired a new meaning:
"Coldly detached and dispassionate, like a medical report or examina-
tion; diagnostic or therapeutic, like a medical investigation or treatment;
treating a subject-matter as if it were a case of disease, especially with
close attention to detail; serving as part of a case-study." Coldly detached
and dispassionate refers here to clinical spaces, discourses, and prac-
tices, and these might be said to be the culmination of the shift in medi-
cal experience that Foucault describes in The Birth of the Clinic, a shift
other commentators have described as from bedside medicine to hospi-
tal medicine to laboratory medicine.8 Looking back to the 1960s, we can
now see this moment in which Foucault writes as creating the conditions
of possibility for a movement away from this rarefied clinical mode and
toward a practice of doctoring that once more takes the patient as subject
of her experience of illness rather than simply or only as the object of dis-
ease. This movement away from a rarified clinical mode requires another
look back, and this is demonstrated explicitly in Foucault's work, if less
explicitly in Berger and Mohr's work. The look back is not motivated by
a desire to restore an older medical experience but rather by a desire to
inspire a different future of the clinic from the one that appears to be an

P R A C T I C E S OF D O C T O R I N G - 147
inevitable culmination of a history always already conceived of as pro-
gressive. These histories of the clinical present of the 1960s anticipate
changes in medical experience of the 1970s. And I want to argue that we
can read Foucault's text as continuous with those intellectual, social, and
political movements that would seek to transform medicine in the late
1960s. A brief genealogy of some of the transformations taking place at
this time would have to include the rethinking and restructuring of gen-
eral practice in the British context, the related emergence of family prac-
tice as a new field of specialization in medicine in the American context,9
the emergence and institutionalization of bioethics and medical humani-
ties, the community health and mental health movements, and the women's
health movement. Although the rhetoric and practices of specialization
and scientization would continue to dominate medical experience, a
counterrhetoric and counterpractices of generalization and narrativiza-
tion would emerge at this same time. Or, as David Armstrong has argued
(following Jewson), in the 1960s the "sick man" reemerged in medicine,
and I argue that both The Birth of the Clinic and A Fortunate Man demon-
strate and, indeed, help to enact this reemergence.10

Spaces of the Clinic

The Birth of the Clinic begins with the following words: "This is a book
about space, about language, and about death; it is about the art of see-
ing, the gaze" (ix). After this statement, Foucault presents his readers with
two descriptive images. The first is an image of a body and its treatments,
which is meant to shock us as we read it in the twentieth and twenty-
first centuries. The image is taken from Pomme's mid-eighteenth-century
account of treating and curing "a hysteric by making her take 'baths, ten
or twelve hours a day, for ten whole months' " (ix).11 The hydrotherapeu-
tic treatment for hysteria that Pomme describes results in "membranous
tissues" peeling away "like pieces of parchment" and causing"some slight
discomfort" to the hysteric (ix). As presented by Pomme, the treatment
apparently works as a result of the sloughing phenomenon caused by
the hysteric's lengthy immersion. She is cured because her disease liter-
ally sloughs away from her internal organs, thereby restoring them and
her to health.
Foucault's second image is from fewer than one hundred years later
and is of an anatomical lesion on the brain of a patient with "chronic men-
ingitis," a term Foucault places in quotation marks to signal the crucial

148 - LISA D I E D R I C H
observation that all diagnoses are historical events. A particular diagnosis
like "chronic meningitis" does not simply identify a thing that is chronic
meningitis; the disease is constituted in the act of diagnosis. Diagnosis
might be thought of, therefore, as a kind of performative, in J. L. Austin's
sense of the term. According to the historical account that Foucault dis-
cusses, meningitis causes "false membranes" to form in the brain, and
these membranes are described in detail and in a tone that sounds mea-
sured to our ears, especially in contrast to the hysterical-sounding descrip-
tion of the hysteric's peeling internal organs. We are told, for example, that
"this matter often displays different shades in different parts of the same
membrane" (x), which seems to be an unembellished and matter-of-fact
assessment to us even now. Foucault anticipates that his readers will
apprehend the two images as being in sharp contrast to each other:
Between Pomme, who carried the old myths of nervous pathology to their
ultimate form, and Bayle, who described the encephalic lesions of general
paralysis for an era from which we have not yet emerged, the difference is
both tiny and total. For us, it is total because each of Bayle's words, with
its qualitative precision, directs our gaze into a world of constant visibility,
while Pomme, lacking any perceptual base, speaks to us in the language
of fantasy. But by what fundamental experience can we establish such an
obvious difference below the level of our certainties, in that region from
which they emerge? How can we be sure that an eighteenth-century doctor
did not see what he saw, but that it needed several decades before the fan-
tastic figures were dissipated to reveal, in the space vacated, the shapes of
things as they really are? (x)

For Foucault, our ability to perceive the shapes of things as they really
are is hindered by a historicist certainty that we perceive better now than
we did then. Foucault challenges this historicist attitude by juxtaposing
two historical images in order to demonstrate two different arts of seeing.
He suggests that we can perceive the artifice—fantasy even—that struc-
tures the first art of seeing because we no longer perceive in this manner,
whereas the fantasy or artifice behind the later image is harder, if not
impossible, for us to discern.
Medical perception is always shaped by discourse, by the words we
use to describe what we see medically. Foucault delineates the emer-
gence of the clinic as a particular mode of discourse governed by exem-
plary exchanges between doctors and patients. The new structure that
emerges at the beginning of the nineteenth century, of which the clinic

P R A C T I C E S OF D O C T O R I N G - 149
is a sign, "is indicated—but not, of course, exhausted," Foucault argues,
"by the minute but decisive change whereby the question: 'What is the
matter with you?'... was replaced by that other question: 'Where does
it hurt?,' in which we recognize the operation of the clinic and the prin-
ciple of its entire discourse" (xviii). In this new discourse of the clinic, the
experience that matters is not the experience of the patient, who must
remain silent,12 but the experience of the doctor, who is alone capable
of perceiving and speaking the truth of disease. The change in question
reflects a change in authority (from patient as authority on the subjective
experience of illness to doctor as authority on the objective experience of
disease), and it also signals a change in the spatialization and temporal -
ization of disease. "What is the matter with you?" is a question that asks
for a response that situates the body of the person who is ill in a larger
world and a longer history, while "Where does it hurt?" is a question that
already assumes that the answer can and must be localized in the body
that the doctor examines here and now. The first question moves from
the individual patient and her particular embodied experience out into
the world and back into history, while the other moves in from world to
body to tissue to diseased lesion. The clinic is a space where the internal
spaces of the body can be made visible through the doctor's supposedly
objective practices of examination and his interrogation of the patient.
The emergent instantiation of the clinic that Foucault delineates is as a
space in which the body is isolated from history and the outside world in
order that disease may be objectified, made visible to and by the doctor.
The clinic is the space of that isolation.
A Fortunate Man is also a book about space, language, and death, and
it too uses images to demonstrate a particular medical experience and
its art of seeing. Like The Birth of the Clinic, A Fortunate Man brings
together writing, philosophy, and doctoring in order to problematize the
relationship between words, images, and practices in a particular his-
torical moment. The book opens with two of Mohr's black-and-white
photographs, both of which cover two pages. The first image is of a nar-
row road, bordered on either side by hedgerows, that curves its way
through an idyllic-looking English countryside. The landscape is dense
with trees, except for a field that enters the picture's frame on the right.
There are at least three built structures, two in the background, which
appear to be houses, and one in the foreground, which may be a barn.
A tree branch jutting from the foreground into the upper half of the left
side of the photograph both obscures our view of the scene and directs

150 • LISA D I E D R I C H
our gaze toward the right side of the photograph, in particular toward a
small, white car making its way along the country lane. The significance
of the car in the scene will become clear once we begin reading Berger's
written narrative. On first glimpse of this photograph, before we are pro-
vided with a narrative that will contextualize, at least in hindsight, the
image for us, we might read the car as a sign of movement through space,
and as indicating that this particular place, though perhaps idyllic, is not
isolated from but connected to a larger world.
Turning the page, we are presented with another image, this time of
a man either going in or out of a partially opened door. He appears to
pause at the threshold, looking slightly downward, and is perhaps speak-
ing to someone who is not visible to the viewer, suggesting that what is
absent from view will still be significant to this story. It appears that we
are looking from within a hallway or entryway to a door that leads further
into a house. Our gaze is directed by the angles of the walls of the hall-
way and by the light that slips out from behind the door and shines on
the face of the man. We can see that he is carrying a leather bag, which
we gather is a medical bag from our knowledge of the book's subject mat-
ter. This is the title page and the names of the book's authors, John Berger
and Jean Mohr, are above the door, and the title is written across the door
and below the man's head. The book's cover is a cropped version of this
image, further framing the doctor at the door with a border of words—
the authors' names at the top and bottom and the book's title on either
side, written from top to bottom on the left and from bottom to top on
the right. Words serve literally as a frame for the image of the country
doctor on the book's cover. From the cover image, we sense we will have
a glimpse into the country doctor's experience, but we are also made to
see him as a liminal figure who moves between certain spaces and who
embodies a hinge moment in history, a moment marked by a shift from
one type of doctoring to another.
I describe both of these images in detail because they are meant to
tell us something about the spaces of medical experience that the book
investigates. Berger's written narrative begins in the midst of two more
photographs that also cover two pages. His words help us to read the
photographs, but not in a conventionally illustrative way; that is, they
are not simply captions that serve to explain the photographs. Berger and
Mohr have placed the opening words of the book in the top right-hand
corner of another idyllic scene, this time of a river running through a
rural landscape. A small wooden rowboat with two men, one fishing and

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the other rowing, sits on the river, with fields and then shadowy hills ris-
ing in the background. Berger's text begins as follows: "Landscapes can
be deceptive. Sometimes a landscape seems to be less a setting for the life
of its inhabitants than a curtain behind which their struggles, achieve-
ments and accidents take place" (13). This photograph appears to have
been taken at dawn; a mist hangs over the river valley, somewhat shroud-
ing the dark mountains in the background and creating a ghostly light
and painterly effect.
The next image is similarly ghostly and painterly, though this time the
scene appears to be at dusk. A heavy darkness descends from the top
and rises from the bottom of the photograph, squeezing a band of light
between black clouds and mountains. A dozen or so houses glow in the
darkness of the mountains, but are otherwise dwarfed and obscured by
the landscape of which they are a part. In white typescript across the dark
and somewhat foreboding landscape, Berger and Mohr have placed the
words: "For those who, with the inhabitants, are behind the curtain, land-
marks are no longer only geographic but also biographical and personal"
(15). Berger and Mohr's archeology of medical perception will attempt
to look behind the curtain to discern the geographic, those larger envi-
ronments that frame experience, and the biographical, those personal
stories that are embedded in those larger environments. But, like Fou-
cault, they will also try to bring the curtain itself into view to expose those
structures that determine what and how we see.13
After the opening sentences about landscapes as curtains and land-
marks as biographical and personal, Berger's narrative opens with the
story of an accident in the forest: "One of them shouted a warning, but it
was too late. The leaves brushed him down almost delicately. The small
branches encaged him. And then the tree and the whole hill crushed him
together" (17). In Berger's account, the man is literally crushed by the
landscape, which we have up to this moment come to perceive as simply
beautiful, or in my already overused term, "idyllic." The doctor is called
to the scene of the accident, and we are told that, "as he drove through
the lanes he kept his thumb on the horn the whole time, partly to warn
oncoming traffic, partly so that the man under the tree might hear it and
know that the doctor was coming" (17). The story Berger tells makes us
look back at the photograph of the car on the lane, and see it too as part
of the record of a doctor on the way to the scene of an accident. Com-
bined with the photograph of the doctor on the threshold, these are the
opening images of John Sassall, and both images are importantly of him

152 - LISA D I E D R I C H
being called. He is called to the forest to administer to a man crushed by a
tree, and he announces his coming as a means to give comfort to the man
even before he arrives. The horn echoing across the landscape signals the
doctor's coming, and this echo and its offer of comfort is Sassall's first
treatment. Or, in less humanistic terms, Sassall is interpellated as doctor
in the moment he is called and responds to that call. His practice of doc-
toring is incumbent upon his interpellation as doctor by the people of the
forest community.14
In the images and words gathered together to remember this scene,
we are given a glimpse behind the curtain, but we are also made to think
about the construction of the story and to problematize the evidence of
experience.15 Berger demonstrates the constructedness of experience by
telling us that one of the witnesses to the accident "would tell the story
many times, and the first would be tonight in the village. But it was not
yet a story" (17-18). What are the discursive conventions that will trans-
form an event that is "not yet a story" into an event that becomes a story?
Such a question must be asked not only about the accident in the forest
and the story of the accident but also about the doctor's treatments and
the story of those treatments. In its form and content, A Fortunate Man
demonstrates medical experiences as enacted through both treatments
and the story of treatments, and in the space between these two things.
In this respect, A Fortunate Man might be read as anticipating the emer-
gence of a kind of "narrative medicine," not simply by acknowledging the
need for better communication between doctors and patients but also
by attempting to delineate those discursive practices—including the dis-
cursive practices of examination, diagnosis, and treatment—that bring
clinical experience into being.
As the event of the accident in the forest makes clear, the spaces of
Sassall's treatments are not limited by the four walls of his clinic, which
is close to, but separate from, his house. A photograph of the clinic shows
it as part of the rural landscape, and Berger's narrative situates it for us:
the clinic "is on the side of the hill which overlooks the river and the large
wooded valley. From the other side of the valley it is almost too small to
be visible" (43). There are several other photographs of the interior spaces
of Sassall's clinic, including one of the waiting room and another of what
appears to be Sassall himself dispensing pills to one of his patients. The
small window of the dispensary frames the face of one of his patients,
and Sassall is a blur as he consults what looks to be an appointment book.
The small window through which we see the patient is itself framed by

P R A C T I C E S OF D O C T O R I N G - 153
neat rows of medical charts, suggesting that each patient's experience of
illness is framed by, and in the particular knowledge recorded in, those
charts and case histories, reminding us again that medical perception is
shaped by discourse. There are other photographs of Sassall in his clinic:
in some he is examining his patients, in others performing minor surgery,
but such images of the practices of surgery and examination are not at
all predominant in the text. Instead, they are interspersed among photo-
graphs of landscapes, of community gatherings (in which Sassall is often
included as a participant), and of many more portraits of the people of
this rural community. There are no captions to tell us exactly what we are
seeing; both Mohr's photographs and Berger's narrative must be read and
interpreted. Sassall and his medical practice are integrated into the fabric
of the community, and his practices of doctoring are extended beyond
the four walls of his clinic. In order to give us a fuller image of Sassall as
doctor, Berger and Mohr present him in relation to the people and envi-
ronment of the community in which he works. The text demonstrates
the possibility—necessity even—of doctoring as extending out from the
doctor at the patient's bedside to the doctor in and of the community.
There is something both old and new about these images; they conjure a
hallowed figure of the rural general practitioner and a futuritial figure of
the specialist in family medicine.

Temporalities of Doctoring

If the spaces of the clinic are extended in A Fortunate Man, so too are
the temporalities of doctoring. David Armstrong, in his essay "Space and
Time in British General Practice" (1985), provides a genealogical account
of the shift in the spatial and temporal organization of the experiences of
British general practitioners (GPs) from the interwar years to the 1960s.
Armstrong's rendering of this shift in spatial organization shows a move-
ment from domestic to public spaces, from clinics in the GP's own home
to clinics, like Sassall's, "constructed as a separate annexe of the GP's own
home" to the "specifically designed or built separate surgery premises,"
that is, the health centers or "group practice premises" that are established
beginning in the 1960s (208). One of the explanations for this shift in the
spatialization of the clinic is that these newly designed clinic spaces were
considered more efficient than the earlier ones, as a result of increas-
ing specialization as well as the increasing concentration in one place of
various outpatient health care services and procedures (Armstrong 1985,

154 - LISA D I E D R I C H
213). This is also the moment when doctors become less likely to make
house calls, and this change in the spatialization of the event of illness is
rationalized in terms of the necessity of saving the doctor's time, which
begins to be understood as limited and thus in need of being constantly
and closely monitored.
Armstrong connects the new spaces of the clinic with an emergent
"time orientation" of medicine in the 1960s. But he also suggests that this
"reconstruction of space and time within British general practice" was not
enacted in the same way everywhere in Britain. He argues that the "per-
ception of time pressures and constraints were mainly found in urban
practices," and that the "different time perceptions of some remote, rural,
single-handed GPs might also represent the vestiges of an older regime of
general practice" (214). These vestiges of an older regime of general prac-
tice, with time oriented not toward efficiency in any simple sense, are
revealed in A Fortunate Man. Yet, I also want to read these vestiges as
more than just traces of the past. They also reverberate into the future,
and will be heard in later conceptions of medical experience.16 When we
encounter A Fortunate Man today, we will miss the force of those echoes
from the past into the present of the 1960s and beyond if we simply take
it as evidence of abygone form of medical experience.17 A Fortunate Man
is evidence of a past medical experience, but it also calls for a new tem-
porality of doctoring, from one based on efficiency and emergency to
one based on what I have elsewhere called "health and the emergency
of the long term" (Diedrich 2008).18 This new temporality of doctoring
requires that we reconceive the relationship between health and illness.
Rather than treating health and illness as essentially dichotomous condi-
tions and mutually exclusive categories, we must consider the frequently
chronic character of illness, as well as the fact that the cellular changes
that may eventually lead to illness often take place long before we have
any symptoms or other signs of illness. In many cases, the time of disease
is extended well beyond a clear-cut and acute temporality, and if we are
to understand the complexity of disease then a new temporality of doc-
toring seems called for.
Sassall himself describes discovering a new temporality of doctoring
as he is forced by his own experience to think about illness and its treat-
ments in the long term. He explains to Berger that when he first started
his practice in the forest community, initially assisting another older doc-
tor, he "had no patience with anything except emergencies or serious ill-
ness." As Berger writes of Sassall:

P R A C T I C E S OF D O C T O R I N G - 155
 When a man continued to complain but had no dangerous symptoms, he
reminded himself of the endurance of the Greek peasants and the needs
of those in "very real distress," and so recommended more exercise and,
if possible, a cold bath before breakfast. He dealt only with crises in which
he was the central character: or, to put it another way, in which the patient
was simplified by the degree of his physical dependence on the doctor. He
was also simplified to himself, because the chosen pace of his life made it
impossible and unnecessary for him to examine his own motives (55).

In his mid-thirties, Sassall's approach to doctoring begins to change, and

his own transformation comes about when he begins to see his patients
as complex individuals whose lives are constantly in flux and impossible
to simplify. His new interest in the long-term situations of his patients
required that he develop different practices of doctoring. He realizes
that, although "emergencies always present themselves as faits accom-
plis" (55), if we trace back far enough we will likely discover a moment
before the emergency became inevitable. As he lived among the same
people over a longer and longer period of time, Sassall "began to notice
how people developed. A girl whom three years before he had treated for
measles got married and came to him for her first confinement. A man
who had never been ill shot his brains out" (55). The long-term view of
health and illness necessarily deheroicizes his interventions; rather than
coming to the rescue from outside the community, he is of it. This allows
him to anticipate problems better, to be in a position to try to understand
why, for example, a man who has never been ill might shoot his brains
out. The key is not the discovery of some final, complete understanding
of the meaning of such an act but rather a new disposition, which takes
the time to comprehend even as one realizes one will fail to know with
certainty why someone has done something so drastic or desperate or...
what? Questions always remain.
One story in particular helps Sassall explain the shift in his time orien-
tation and practices of doctoring. He is called to the cottage of a couple
of old-age pensioners who had lived in the forest for thirty years, and
when he examines the wife he discovers something completely unex-
pected: "'She' was a man The trouble was severe piles. Neither he
nor the husband nor she referred to the sexual organs which should not
have been there. They were ignored. Or, rather, he was forced to accept
them, as they had done according to their own reasoning which he would
never know" (56). In this moment, doctoring becomes something more

156 • LISA D I E D R I C H
than simply the examination of a patient and the diagnosis of a condi-
tion. Here, doctoring is characterized not by the certainty of knowing a
diagnosis or the heroism of offering a treatment; rather, it is based on
an awareness "of the possibility of his patients changing," and that, as a
result, his knowledge of them and their bodies will always be only partial.
Berger explains that Sassall's patients, "as they became more used to him,
sometimes made confessions for which there was no medical reference
so far as he had learnt. He began to take a different view of the meaning
of the term crisis" (56). In order to be better able to handle a crisis in the
present, his knowledge of his patients must extend beyond the spaces of
the clinic and the immediate moment of examination. He must see his
patients not in isolation but in relation: to their own past, to their family
history, to their changing community, and to the future, but also in rela-
tion to all that is unknowable. The art of seeing that Sassall must cultivate
is a bifocal one; it must be able to focus both inward with a magnifying
lens on his patients' bodies and outward with a wide-angle lens on his
patients in the world and in history. With medicine's ever-increasing cul-
tivation of expert knowledges and specialized practices, its mode of per-
ception at the time of the making oî A Fortunate Man is becoming more
and more microscopic. But Sassall is a figure of a doctor who struggles
with, though not entirely in opposition to, this reduction of the practices
of doctoring. It isn't that he doesn't utilize those technologies that help
to better illuminate disease within the patient's body, but rather he rec-
ognizes that these technology-based practices cannot entirely define the
contours of the task of doctoring.

Theories of/and Medical Experience

This bifocal art of seeing that is enacted in and by A Fortunate Man chal-
lenges the dominant idea of the clinic that Foucault diagnoses in The
Birth of the Clinic. Foucault argues that the clinic emerged as a result of
certain exclusions. In "Signs and Cases" and "Seeing and Knowing," two
chapters at the center of his archeology of medical perception, Foucault
investigates what the "conceptual transformation" of clinical medicine
excluded as it emerged: namely, theories, experimentation, and imagina-
tion (97). According to Foucault's rendering of the history of the clinic,
"eighteenth-century doctors had used and abused the notion of'compli-
cation'" (101) because they had not yet mastered the art of the clinical
gaze, which required opening up "to investigation a domain in which each

P R A C T I C E S OF D O C T O R I N G - 157
fact, observed, isolated, then compared with a set of facts, could take its
place in a whole series of events whose convergence or divergence were
in principle measurable" (97). Within the spaces of the clinic, theories,
experiments, and imaginings were seen as obstacles that could insinuate
themselves between the doctor's observing gaze and "the sensible imme-
diate" of disease, which was the object of the clinical gaze (108). The clinic
becomes a neutral domain in which a "pathological fact" can appear "in
its singularity" in order that it may be observed and described in exhaus-
tive detail by the doctor (109). The clinic, then, is a space in which it is pos-
sible to set aside that which is deemed "extrinsic" to medical experience:
theories and systems, anticipatory knowledge, and uncertainty and com-
plexity, all of which require cultivating the practice of imagination (109).
The "great myth" that structures clinical thought and its methods is,
according to Foucault, "a speaking eye," which combines a pure gaze
with pure language, and which is "the servant of things and the master of
truth" (114-15). A concept Division, and the relationship between seeing
and knowing, is also at the center of A Fortunate Man, and, somewhat
eerily, Sassall's eyes figure prominently in Berger and Mohr's account.
Berger recounts a story of Sassall having to perform a procedure on one
of his patients, which disturbed the patient in the intimacy of its violation
of his person. When Sassall inserts a syringe deep into the man's chest,
the man explains to Sassall that it makes him feel not so much pain as
revulsion, because, he says, " 'That's where I live, where you're putting
that needle in.' " To this remark, Sassall replies: " 'I know.... I know what
it feels like. I can't bear anything done near my eyes, I can't bear to be
touched there. I think that's where I live, just under and behind my eyes' "
(47, 50). Berger understands that Sassall's belief that he lives just under
and behind his eyes tells us something about Sassall's identity as a doc-
tor, but I think it also tells us something about becoming through a kind
of desubjectification. Sassall becomes his eyes and his eyes become him
in certain moments of practicing doctoring. Again, I am suggesting that
A Fortunate Man shows something about witnessing, not just in relation
to the subjectivity of the person who witnesses but in terms of what a
kind of seeing brings into being historically.
Later in the text, Sassall's eyes come up again. When Sassall tells a
story about himself, Berger explains, he often makes himself appear
absurd, as a "comic little man." Berger interprets this habit as part of Sas-
sall's method of seeing and knowing; his comic performance provides
him with a position from which "he can then re-approach reality once

158 - LISA D I E D R I C H
more with the entirely un-comic purposes of mastering it, of understand-
ing it further" (84). As Berger continues: "You can see this in the differ-
ence between his two eyes: his right eye knows what to expect—it can
laugh, sympathize, be stern, mock itself, take aim: his left eye scarcely
ever ceases considering the distant evidence and searching" (84). Sas-
sall's bifocal vision allows him to concentrate on both the here and now
and that which is distant in space and time. His seeing combines the abil-
ity to feel in the present, as well as to ask questions of the past and future.
Berger tells us that the only time Sassall's left eye stops "considering the
distant evidence and searching" is when "he is occupied with some rela-
tively minor surgical task." The concentration required for such a task
brings him relief, because "for a moment there is certainty" (84). This
certainty is expressed not through exhaustive description in the sense of
Foucault's speaking eye but rather in and through surgical practices. In
these moments in his clinic, Sassall's is a doing eye. But, those moments
of doing, of relief and certainty, are only one aspect of Sassall's practices
of doctoring, only part of his method of seeing and knowing. Several of
Mohr's photographs make visible Sassall's bifocal vision. Two close-ups
of Sassall's head reveal that one eye appears focused on what is immedi-
ately in front of him, while the other is focused farther afield. One other
photograph captures the moment of concentration on a surgical task,
and perhaps even a sense of the relief and certainty that Sassall feels. In
that photograph, Sassall wears a magnifying lens over one eye and the
other is squeezed shut as he leans closely over the skin of a patient, who
is otherwise out of view. The prosthetic eye both extends his vision and
depersonalizes his doctoring, but this doesn't so much dehumanize him
as it seems to shield that place where Sassall can't bear to be touched.
As Sassall, Berger, and Mohr present them, Sassall's practices of doctor-
ing explicitly incorporate the theoretical. For Sassall, including the theo-
retical in his practices means that he must observe closely and broadly
not just his patients but also himself, as well as each—patient and doc-
tor—as always in relation to others. Berger and Mohr's text extends this
method of observation, not to fix once and for all and with certainty
Sassall's identity as a country doctor but to reveal the uncertainty—the
knowing that he can never know enough—that drives Sassall's curios-
ity. In order to learn more about himself, his patients, and illness, but
also as a recognition of all he will never know, Sassall begins to read. In
particular, Berger tells us, Sassall reads Freud. Berger describes Sassall's
period of reading Freud as a time of self-analysis and isolation, and he

P R A C T I C E S OF D O C T O R I N G - 159
compares this to the period of crisis that "precedes in Siberian and Afri-
can medicine the professional emergence of the shaman or the inyanga"
(60-61). The doctor studies Freud, and this encounter with the theories
and practices of psychoanalysis leads to a transformation of Sassall's
practices of doctoring: from "the life-and-death emergency" to "the inti-
mation that the patient should be treated as a total personality, that ill-
ness is frequently a form of expression rather than a surrender to natural
hazards." As Berger warns, "this is dangerous ground, for it is easy to get
lost among countless intangibles and to forget or neglect all the precise
skills and information which have brought medicine to the point where
there is the time and opportunity to pursue such intimations" (62). When
an idea of the clinic as a space for seeing and knowing unencumbered by
theories, especially social and psychological ones, is seemingly secure in
its dominance, it is at that very moment that complication returns.19 In A
Fortunate Man, but also in The Birth of the Clinic, the simplification and
biological reductionism at the center of clinical experience is problema-
tized, and through this problematization of what is taken for granted as
foundational to a particular clinical experience, the possibility of other
ways of doing the clinic appear.

Politics of/and Medical Experience

Foucault ends The Birth of the Clinic by bringing together and demon-
strating the affinities between medical, philosophical, and lyrical expe-
rience at a particular historical moment. "This form of experience, which
began in the eighteenth century, and from which we have not yet escaped,"
Foucault argues, "is bound up with a return to the forms of finitude, of
which death is no doubt the most menacing, but also the fullest" (198).
In order to examine the "changes in the fundamental structure of expe-
rience" that took place at the end of the eighteenth century and the
beginning of the nineteenth, and which still structure our experience to
a great extent today, Foucault takes as his object the "formation of clini-
cal medicine" (198). In The Birth of the Clinic, he demonstrates "a vertical
investigation of this positivism," and his method uncovers "a whole series
of figures—hidden by it, but also indispensable to its birth—that will
be released later, and, paradoxically, used against it" (199). In the early
1960s, Foucault's vertical investigation releases some of these figures in
history so that they might be used against the established structures of
medical experience in the present of the 1960s and echoing forward to

160 • LISA D I E D R I C H
today. While Foucault's method is vertical, Berger and Mohr's method is
horizontal, but, like Foucault, they also demonstrate the structures that
connect medical, philosophical, and lyrical experience. Berger and Mohr,
however, extend the weblike structure of A Fortunate Man into another
domain, namely that of politics, which is implied in Foucault's text if we
read it as a history of the present, as I have tried to do here, and in rela-
tion to the rest of Foucault's oeuvre. Taken together, Foucault's work can
be read as extending politics into domains not previously perceived as
domains of struggle. Politics is made explicit in A Fortunate Maw because
Berger and Mohr describe the structural violence of poverty and isolation
that constrains the choices of the foresters whom Sassall treats.20 A Fortu-
nate Man, then, connects politics with medical experience, even though,
as Berger asserts, Sassall himself does not or cannot within the particular
historical a priori that structures his medical perception. Sassall again
represents a kind of threshold figure not just with regard to his medical
practices of doctoring but also to his nascent and only partially realized
political practices of doctoring.
Sassall acknowledges a feeling of inadequacy in relation to what he
can and cannot do for his patients. He asks questions—social as much
as medical—about his patients' lives: "Do his patients deserve the lives
they lead, or do they deserve better? Are they what they could be or are
they suffering continual diminution? Do they even have the opportunity
to develop the potentialities which he has observed in them at certain
moments?" (133). He believes that his patients do indeed deserve better,
and he understands that an important aspect of the treatment he can
offer is to recognize them not just for who they are but for who they might
be. Sassall's ability to recognize his patients in this way requires "continu-
ally speculating about, extending and amending his awareness of what
is possible" (142). This speculating, extending, and amending requires,
according to Berger, that Sassall combine three practices: "Theoretical
reading of medicine, science and history;... his own clinical observa-
tion!; and] his imaginative 'proliferation' of himself in 'becoming' one
patient after another" (143). These are Sassall's practices of doctoring,
and they are also practices of witnessing,21 but still Berger admits, "it is
easy to criticize" Sassall for "ignoring politics" and for "practicing alone"
rather than in a group practice or health center. Recognizing his own fail-
ures, Sassall tells Berger: " 'I sometimes wonder... how much of me is the
last of the old traditional country doctor and how much of me is a doc-
tor of the future," and he asks, " 'Can you be both?' " (147). It seems that

P R A C T I C E S OF D O C T O R I N G - 161
Sassall can be both traditional doctor and a doctor of the future only in
and through A Fortunate Man.22 In that text, Berger and Mohr uncover a
complicated figure: the country doctor, who is both the present Sassall of
A Fortunate Man and future Sassalls, both a vestige of the past and a sign
of the future.
By reading A Fortunate Man with The Birth of the Clinic, I want to use
the figure of one Sassall against the other. I do this not in order to say once
and for all what medicine is or should be but instead to propose a geneal-
ogy of medicine that problematizes, and indeed struggles against, a total-
izing discourse of the progressive scientization of medicine. Foucault's
insistence in his preface that The Birth of the Clinic "has not been written
in favour of one kind of medicine as against another kind of medicine,
or against medicine and in favour of an absence of medicine" does not
render the practices of medicine outside of political critique (xix). Rather,
what Foucault wanted The Birth of the Clinic to do in the early 1960s is
still relevant today: to open medicine up to the task of transformation.

Notes

1 Later in the text, Foucault describes the years 1760-1800 as "forty years that wit-
nessed the formation of the clinical method" (126).
2 Throughout this essay, I will refer to both Berger and Mohr as the authors of A For-
tunate Man, though when I discuss a direct quotation from the written text I will
refer to Berger as the author of that text, and when I discuss a photograph I will
refer to Mohr as the photographer. Although there is not a lot of critical work on
A Fortunate Man, some of the little work there is ignores Mohr's contribution to
the text. For example, Griffin 2004 mentions at the outset and in passing Mohr's
contribution, but then only refers to Berger's written account and never once dis-
cusses the photographs and the aesthetic and cultural work they do. This elision
of Mohr's participation in the enactment of the story that A Fortunate Man tells
is strange because Mohr's name is equally prominent on the book's cover as one
of the authors. Berger and Mohr have collaborated on two other works, Another
Way of Telling (1982) and A Seventh Man: Migrant Workers in Europe (1975). For
an essay that does acknowledge Jean Mohr's important contribution to A Fortu-
nate Man, and that reads the photographs and narrative together but nonetheless
focuses on Berger's work more generally, see Hudson 2000. However, even in the
section of his essay headed "The Pictures," Hudson's analysis of the use of photo-
graphs in A Fortunate Man remains rather abstract and only rarely looks very
closely at particular photographs, an approach that seems to fit with Hudson's
primary concern with Marxist history-writing.
3 My choice of the word "doctoring" is inspired by Annemarie Mol's essay "The
Logic of Care" (2006), in which she describes doctoring as a kind of tinkering that

162 - LISA D I E D R I C H
 involves many persons, objects, and technologies. In her formulation, patients
doctor as much as doctors themselves do. See also Mol's work on the logic of care
and "shared doctoring" in her volume The Logic of Care (2008).
4 This is how Fred Griffin reads A Fortunate Man in "The Fortunate Physician: Learn-
ing from Our Patients" (2004).
5 In his biography of Foucault, David Macey describes a conversation that the femi-
nist philosopher Jana Sawicki had with Foucault when she met him at a semi-
nar in Vermont in 1982. As she explains to Macey, she told Foucault that she "had
just finished writing a dissertation on his critique of humanism. Not surprisingly,"
Sawicki continues, "he responded with some embarrassment and much serious-
ness. He suggested that I do not spend energy talking about him and, instead, do
what he was doing, namely, write genealogies" (1993,450). I am motivated by Fou-
cault's methods to incorporate Foucault's own work as part of a genealogy of the
changing experience of medicine in the 1960s.
6 For another text that explicitly takes up Foucault's work with and as literature, see
During 1992. For a collection of some of Foucault's own writings on "language
and the birth of 'literature,' " see part one of Language, Counter-Memory, Practice:
Selected Essays and Interviews (1977a).
7 Foucault himself will take up antipsychiatry in the course summary for his lectures
on psychiatric power at the Collège de France in 1973 and 1974. Foucault explains
that antipsychiatry opposes a certain truth produced within the space of the asy-
lum. "Instead of a withdrawal outside the space of the asylum," Foucault writes,
"antipyschiatry involves its systematic destruction through work inside; and it in-
volves transferring to the patient himself the power to produce his madness and
the truth of his madness, instead of seeking to reduce it to zero" (2006, 344).
8 In a classic text in medical sociology published in 1976, Norman Jewson describes
three "medical cosmologies"—bedside medicine, hospital medicine, and labo-
ratory medicine—and the historical shift between the dominance of one to the
other. Other medical sociologists have since extended Jewson's cosmologies into
the contemporary period by discussing various other cosmologies, including "sur-
veillance medicine" and "e-scaped medicine." See Armstrong 1995 and Nettleton
2004. All of this work on shifts in medical practices and thought, including that of
Foucault, is indebted to the historico-philosophical work of Georges Canguilhem.
In the essay "Epistemology of Medicine: The Limits of Healing," which is included
in the collection A Vital Rationalist (2000), Canguilhem diagnoses the shifts be-
tween several "points of view" or forms of medical perception: the physiological
point of view, the statistical point of view, and the applied or public health point
of view.
9 The family practice movement began in the 1960s, after years of decline in the
arena of general practice in the United States. As Nicholas Pisacano, the first execu-
tive director of the American Board of Family Practice, has written: "The American
Board of Family Practice was born many years before it was officially recognized
in February 1969 as the 20th primary medical specialty" (2007, n.p.). Pisacano and
others have described Family Practice as a "revolutionary movement" that sought

P R A C T I C E S OF D O C T O R I N G - 163
 to overturn the increased specialization of medicine with, paradoxically, a new
specialization in general medicine. For a fascinating account of the early years
of the family practice revolution in the United States, see John McPhee's "Heirs
of General Practice" (1985). McPhee describes the reaction to overspecialization
in the U.S. health care system in the mid-1960s, and he says that this "reaction
became known as the family-practice movement. Its aim was to shift some of the
emphasis in medicine, to give refreshed importance to generalism; and it arose...
at a time when many people had come to distrust the pervasion of technology in
every field from high-energy physics to superfast foods, and to look upon the de-
humanization of medicine (a phrase much in vogue) as just one of a great number
of unfortunate results" (110).
10 Armstrong calls this new style of medical thought "biographical medicine" (1979,
5), and he cites Michael Balint's The Doctor, His Patient and the Illness (1964) asan
important text exemplifying this thought style. A Fortunate Man could also be cat-
egorized as demonstrating biographical medicine by emphasizing the patient's bi-
ography and environment. Interestingly, J. S. Huntley (2001) explains that Balint's
work had a profound influence on Berger's conception oí A Fortunate Man.
11 Later, Foucault will begin Discipline and Punish with another shocking image of a
body and its treatments. This shocking image is of the public execution on March
2, 1757, of Damiens, the regicide, who is described as having "molten lead, boil-
ing oil, burning resin, wax and sulphur" poured on his torn flesh, before his body
is "drawn and quartered by four horses and his limbs and body consumed by fire,
reduced to ashes and his ashes thrown to the winds" (1977b, 3). Interestingly, Fou-
cault quotes from an article in the Gazette d'Amsterdam, in which the regicide is
described as "the patient" (3).
12 This silence is perhaps not literal because the patient does need to answer the
question "Where does it hurt?" But, of course, the patient might remain silent in
response, answering the question by pointing. Foucault's point, however, is that
the question signals an effacement of the patient's experience. The patient is re-
duced in this exchange to a collection of body parts, some of which might hurt.
The quality of the hurt—its feeling for the patient—is less important than its loca-
tion and visibility to the doctor.
13 Berger and Mohr's text might also be read in relation to a British cultural studies
tradition beginning with Raymond Williams that combines a Marxist analysis of
social structures with an investigation into less formal and more practical ele-
ments of consciousness that are often "not yet recognized as social but taken to
be private, idiosyncratic, and even isolating," which are what Williams calls "struc-
tures of feeling" (1977,132). For a Marxist reading of A Fortunate Man, see Hudson
2000. Hudson's reading of Sassall as an intellectual among the peasants has the un-
fortunate effect of heroicizing Sassall and objectifying his patients/the foresters.
Another classic British cultural studies text that resonates with A Fortunate Man
in interesting ways both theoretically and methodologically is Carolyn Steedman's
Landscape for a Good Woman: A Story of Two Lives (1986). One of the anonymous

164 - LISA D I E D R I C H
 readers of an earlier draft of this essay noted that A Fortunate Man might be read
as a nostalgic rendering of a disappearing form of doctoring exemplified in the fig-
ure of the country doctor. I think this is indeed the way the text is often read, and
I appreciate the anonymous reader's astute assessment of the potentially conser-
vative effects of nostalgia. Fred Griffin's essay "The Fortunate Physician: Learning
from Our Patients" (2004) for example, discusses the text as a tool utilized in the
context of the contemporary medical humanities workshop to encourage doctors
to talk about their feelings and explore the ways that contemporary medicine is
dehumanizing for doctors as well as patients. Yet, Berger, Mohr, and even Sassall
himself work against this nostalgic view of the figure of the country doctor by chal-
lenging the simplistic idea of the rural idyll isolated from the time and place of
postmodernity.
1 4 1 gesture here to Althusser's work, partly in order to suggest his theories of subjecti-
fication as a link between Berger and Mohr's Marxist-inflected text and Foucault's
proto-poststructuralist text.
15 See Scott 1992 for her classic problematization of the evidence of experience.
16 I am indebted here and elsewhere to Joan Scott's formulation of the echo as a key
concept for doing feminist history. See Scott 2002 and 2001. For further applica-
tions of Scott's work on feminist reverberations, see Diedrich 2007c and Hesford
and Diedrich 2008.
17 Ann Stoler in her reading of Foucault's lectures on race and biopower provides a
brilliant summary of Foucault's method, which I am attempting to apply to his
own The Birth of the Clinic and A Fortunate Man. Stoler argues that in Foucault's
analysis, "the changing force of racial discourse is not understandable in terms of
clean semantic breaks. Again, what occupies Foucault are the processes of recu-
peration, of the distillation of earlier discursive imprints, remodeled in new forms"
(1995, 68).
18 I take the term "emergency of the long term" from Jérôme Bindé (2000).
19 This is also the moment when psychoanalysis will begin to lose its dominant posi-
tion in psychiatry, and be replaced by a psychiatry that is increasingly scientized
and codified, concerned with accuracy in diagnosis, and reliant on pharmaco-
logical treatments. For a genealogical discussion of this particular moment in the
history of psychiatry, see Jonathan Metzl's Prozac on the Couch: Prescribing Gen-
der in the Era of Wonder Drugs (2003). As his title suggests, Metzl argues that a
psychoanalytic-thought style will still influence this new evidence-based era in
psychiatry. In the same moment that psychoanalysis loses its hegemony in the
domain of psychiatry, it also gains authority in critical theory in particular and
humanities scholarship in general. This is an odd displacement that Freud him-
self might have found fascinating, if also, perhaps, a disturbing reaction formation
against the claim that psychoanalysis is a science.
20 1 take the term "structural violence" from Paul Farmer, who defines this concept
as "historically given (and often economically driven) processes and forces [that]
conspire to constrain individual agency" (1999, 79).

P R A C T I C E S OF D O C T O R I N G - 165
 21 Berger calls Sassall an "objective witness" to his patients' lives, but he thinks a
humbler term is more fitting: "the clerk of their records" (109). In an essay on Berg-
er's work, Robin Lippincott says that "witnessing" is one of Berger's favorite terms
(1991, 134).
22 The real John Sassall would eventually commit suicide. J. S. Huntley, in his fascinat-
ing essay for the literature and medicine section of the Lancet entitled "In Search
of A Fortunate Man," grapples with what he sees as the "apparent paradox" of Sas-
salTs suicide. He concludes that the text itself bears witness to SassalTs place and
life (2001, 549). I mention his death in this concluding footnote to make a slightly
different, if more banal, point, which is that who John Sassall really was, conclu-
sively, is precisely what A Fortunate Man cannot give us. And it seems to me that
the title, as cliché, might be understood ironically as working to discourage such
conclusive readings.

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168 - LISA D I E D R I C H
 CONTRIBUTORS

Christine Ceci is assistant professor in the Faculty of Nursing at the Uni-

versity of Alberta. In the framework of questions of knowledge, power, and
organization, the current site of her research is supportive home care for
those who are older and frail.

Lisa Diedrich is associate professor of women's and gender studies at

Stony Brook University. She is author of Treatments: Language, Politics,
and the Culture of Illness (Minnesota, 2007).

Suzanne Fraser is a senior lecturer in the Centre for Women's Studies and
Gender Research, School of Political and Social Inquiry, Faculty of Arts,
Monash University. She writes in the areas of health, addiction, the body,
and gender, and her most recent book is Substance and Substitution:
Methadone Subjects in Liberal Societies.

John Liesch is a community-based researcher, activist, and volunteer

in gay and HIV/AIDS issues, and he is the data manager at the Health
Research Methods and Training Facility at Simon Fraser University. He
is coauthor (with Cindy Patton) of an essay about facial filling for people
with HIV, "In Your Face," which was published in Cosmetic Surgery: A
Feminist Primer.

Jenna Loyd is a postdoctoral fellow at the Center for Place, Culture, and
Politics at the Graduate Center, The City University of New York. She
is a scholar-activist whose work centers on the political geographies
of violence and health. She has written a book manuscript that traces
health activism in the Black freedom, women's, and antiwar movements

• 169
in Los Angeles during the 1960s and 1970s, and she is coediting Beyond
Walls and Cages, a collection that analyzes the connections between mili-
tarization, mass incarceration, and migration policies.

Annemarie Mol is professor of Anthropology of the Body at the Univer-

sity of Amsterdam. She is author of The Logic of Care and The Body Mul-
tiple, and she coedited Complexities (with John Law) and Differences in
Medicine (with Marc Berg). Combining philosophy and ethnography she
has published widely on technologies, spatialities, and health care, and
she now studies "what it is to eat."

Cindy Patton holds the Canada Research Chair in Community Culture

and Health at Simon Fraser University in British Columbia, where she is
professor of women's studies, sociology, and anthropology. She has writ-
ten numerous books, including Inventing AIDS, Fatal Advice, Globalizing
AIDS (Minnesota, 2002), and Cinematic Identity (Minnesota, 2007). She
directs a qualitative research laboratory focused on community-based
research related to HIV and health in marginal populations.

Mary Ellen Purkis is associate professor of nursing and Dean of the Fac-
ulty of Human and Social Development at the University of Victoria in
British Columbia. She uses ethnographic methods to explore the impact
of professional practice encounters (specifically nursing encounters) on
people seeking assistance with health concerns. Most recently her work
has focused on nursing practice in home settings.

170 • CONTRIBUTORS
 INDEX

abortion, xi clinical practice, vii, xii-xiii, xiv-xv, xxn6,

ACT UP, 14-15 4, 18-19, 23-36, 80-84, 95, 103-4,
addiction, 69-70, 74-77,126 109-10, 111-13, 114-15, 125-28,
advertisement, 101-4, 110-11, 113-14 130-33, 137-38, 139n3, 140n4-6; as a
agency, 3, 93-94 space of intimacy, 3, 4, 9-10, 15-16
aging, 3, 6, 23-36 clinical trials, xixn6
AIDS epidemic: early years, 1-2 Cochrane Review, xii, xixnS
antiglobalization, x, xii community health centers, 39-40, 46-47,
antipsychiatry, 146-47, 163n7,165nl9 58-60, 154-55
cosmetic surgery, 2-3, 4, 5-6
Baudrillard, Jean, ix, xixnS
beauty, 5-6 de Certeau, Michel, 12
Beauvoir, Simone de, 76-77 Deleuze, Gules, 20-22
body: as normal, 6, 8 Delta Health Center, 40, 48-56, 57-58,
Bourdieu, Pierre, xixnS 61n9
Britain, xii, 145-46, 148, 154-55, diagnosis, 10-12,105, 127, 149
164nl3
Brown, Wendy, x-xi economy: informal, 121-22, 128, 130
bureaucratic discourse, 25-26, 28-32, electoral politics, x
45-46, 62nl7, 123-25, 128, 130, endocrinology, xiv
134, 137-38, 139n2-3 ethnomethodology, 18, 116n3, 118nlO
Butler, Judith, 92-94 everyday life, 7-8, 78-80, 105, 107, 115,
127, 130-33
care: acquiescence to, 8, 77, 125,126, evidence-based: decision making, 32, 36;
130,134-35,137-38, 139n3, 140n6, medicine, xii-xiii, xixnS, xxn6,165nl9
144,147-48,151-154; theories of,
vii, 17-18, 23-36, 93-94, 103-7, face: as interface between public and
109-10, 111-13,114-16,118nll, private, 1, 7,13
118nl3 fieldwork, 18-19

• 171
Fortunate Man: The Story of a Country market, ix, xi-xiii, xixnS, 99,103-4,
Doctor, A (Berger), 144, 148, 150, 106, 107-9,110-11,113, 114, 117n4,
162,162n2 117n8, 119nl6
Foucault, Michel, vii, ix-x, xiv-xviii, medical gaze, 8-9, 11-14, 19-23, 99,
xviiin2, xixn4, xxn6, 3, 4, 20-29, 149-50, 157-61
41-42, 61n2, 69, 73, 81, 99-100, medicalization, xiv-xv, 3, 69, 72
143-51, 157-61; concept of arch- medical subspecialties, xiii-xv
aeology, ix, xviiin2, 144; concept medical touch, 8-9
of biopower, vii, xi, 40-42, 59-60, middle class, 2,126, 134, 135,137
61n2; concept of genealogy, xviiin2, modernity, ix, xv-xvii
162; concept of governmentality,
ix, xixn4, 133-34; concept of respon- narrative medicine, 153,160, 164nlO
sibilization; vii, ix, 78-80, 87,111- neoliberalism, ix, xv, xixn3-5, 4, 15,
12,133-34; concept of techneof 99-100, 134
the self, ix
Foucault, Michel, works of: The Osborne, Thomas, xiv
Archaeology of Knowledge, xvi-
xvii; The Birth of the Clinic, x, palliative care, 124-25
xiv-xviii, xxn6, 20-23, 41-42, 73, patient advocacy, xiii, 5,14-15
99-100, 143-51,157-61; Disci- patients, vii, 131-32,135-37
pline and Punish, 164nll; patient self-determination, 119nl7,
History of Sexuality, 41; Mad- 128, 132
ness and Civilization, 146; Pharmaceuticals, xiii, 2, 15, 78-80,
Order of Things, xvi-xvii 117n6, 140n8
France, xi-xii, xixnS, 146 photography, 11-13, 118nl4
postmodernism, xv-xvi
gendered violence, 87-91,136-37 poverty, 44-55, 121-22, 125, 137-38,
gender normativity: masculine, 3, 138-39nl,140-41n9
5,11, 81, 83-85; feminine, 4, power, xixn4, 92
9-10, 11, 69-70, 71-73, 75-77, Prasad, Monica, xi-xii
81-83, 85-92 pregnancy, 86, 90-91

health care reform, xi-xii, 139n2 racism, xixn4, xixnS, 52-56

health coverage, 2,15 reconstructive surgery, 2-3, 5, 13
health for all, ix, xviiinl, 39 repetition: as part of everyday,
HIV 1-16, 135-37, 138nl 74-77, 92-94
home care, 17-18, 23-36, 122-23, 124, rights, xiii, 5
130-33, 134-35 Rose, Nikolas, xiv-xv, 133-34
housing, 128-29, 138-39nl
social capital, 42-43, 128,129
lancet, xiv, 166n22 social determinants of health,
liberalism, ix-xii 61n3-4,125

172 INDEX
state, the, xixn4 War on Poverty (USA), 43-45, 50
subjectivity, xvi-xviii Washington Consensus, ix
suffering, 7-9, 27,112, 115 Watts Health Center, 40, 50-53,
57-58, 62nll
United States, xi-xii World Health Organization, xviiinl

INDEX • 173