08 Feb Nation, health and citizenship

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

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

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

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

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

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

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

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

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

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

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