Resistencia desde lo cotidiano

Brain death is a prime example of the competing meanings of embodiment

endemic to organ transplantation as a phenomenon. Sharp’s seminal Strange Harvest

(2006) effectively covers these contradictory meanings of organs as promoted throughout the organ transfer process. A large portion of her work is dedicated to demonstrating the strategies of organ procurement organizations (OPOs) to keep donor kin and recipients from communicating with one another, precisely so their contradictory messages do not get mixed. Donor kin are told that their loved one will live on in another person, saving their life. Recipients, on the other hand, are reminded that their new organ is entirely their own to prevent psychological rejection. Donald Joralemon (1995) details the

psychological rejection process, drawing on Mauss to explain how organ recipients, given the “gift of life,” experience the “tyranny of the gift.” Reminded daily by nauseating and debilitating anti-rejection drugs that their transplanted organ is foreign tissue, recipients frequently lapse into life-altering depression over a debt that can never be repaid. The debt is two-fold: not only can they never repay the symbolic gift of the organ, but the financial costs—which can run more than a million dollars without health insurance—will burden most recipients for the rest of their lives (Transplant Living | Financing A Transplant | Costs n.d.). Sharp points out that while public donor memorials can be important catharsis for recipients, donor kin are typically kept away from the events to prevent reinforcing the idea of the Other living within.

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Donation communication campaigns also introduce competing messages. Siminoff and Chillag (1999) scrutinized the narrative themes of donation advertising through ethnographic research, concluding that a reliance upon the “gift of life” narrative may actually lead to increased reluctance to donate because these themes are

inappropriate to the potential donor, who does not typically view the complex donation process as an exchange, while recipients face more psychological rejection as a result of the “tyranny of the gift.” Sque, et al. followed this line of research and found that

although the “gift of life” discourse can actually motivate families to donate a loved one’s organs, when donation is called a “sacrifice” by OPOs, it can evoke gruesome images of harm done to the donor’s body, such as those of ritualistic human sacrifice or the

suffering of Christ upon the crucifix (Sque, Payne, and Macleod Clark 2006). 1.4 RECONCILING DISCIPLINES

Organ donation registration perfectly illustrates the problems of a zero-sum approach to health behavior research, by suggesting the interests of the medical establishment are inherently and diametrically opposed to the interests of the

communities it purports to serve. Some critical anthropology can yield a trap in which it becomes easy to humanize the victim with stories of individual unmet need for organs and generalize the oppressor, as when the medical transplant community and OPOs are lumped together with black market organ brokers, as in Scheper-Hughes (2000; 2004). While anthropology (and health promotion and education alike) has in recent decades given a powerful voice to the disenfranchised and shone a light on those powerful entities that harm, through mere neglect or institutionalized violence, the marginalized and vulnerable, perhaps the decision to position ourselves at the bottom looking up yields its

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own peculiar myopia. This is not a new phenomenon within the field. Laura Nader (1972) writes of the preference of anthropologists to study, as she puts it, “the underdog,”

chastises the field for neglecting to “study up,” or conduct fieldwork and detailed analysis of the power structures responsible for inequality or oppression. In an effort to ferret out the institutions and broad epistemologies (such as the biomedical paradigm) responsible for causing or perpetuating structural inequality, critical medical anthropology has done very little to identify or analyze individuals and groups within the structure that fight for the very same causes championed by anthropologists and grassroots movements. In the case of organ donation, medical professionals, OPOs, and government certainly share some responsibility for the inequities of organ transplantation across the nation and world. Nevertheless, the professionals within these organizations are working to increase the supply of organs for underrepresented populations, not restrict it.

As demonstrated throughout the literature, CIMA represents two themes: the critique of biomedical knowledge production and the effects of political and economic structure on the “three bodies” described by Scheper-Hughes and Lock. These threads are intertwined, and though one may be stressed over the other, both can be seen in every critical-interpretive study. Nevertheless, as seen most clearly in studies of structural violence, “structure” becomes a problematic concept if not properly defined. A critical medical anthropology that recognizes the impact of political-economy is a vital step toward social justice in health, but rarely is a view from below matched with a “view from above.” That is, “structure” becomes a catch-all phrase for all entities more politically or economically powerful than the informant, from the specific—individual

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physicians, government officials, military officers, NGOs—to the vague—the global North, the ethnic majority, and so on.

Surely this dehumanization of political and economic powers is not merely due to preconceived biases or lack of consideration to the faces behind these forces. More likely, it is a question of access. The “critical” aspect of critical anthropology is not one which engenders favorable consideration for the researcher seeking audience with dictators, war criminals, or elite government officials. In some circumstances, the anthropologist may be seen as an investigative journalist without the weight of a cable news network or high circulation paper as channels demanding cooperation—simply put, an annoyance and a liability. As Nader notes, “Telling it like it is may be perceived as muckraking by the subjects of study” (1972:21).

Yet the result of not studying up is that it creates scenarios that presuppose the most sinister of forces locking horns with the marginalized and, by extension, the anthropologist. Using a study of illicit organ transplantation to argue for a “militant anthropology,” Scheper-Hughes writes that she positions herself “…on the ‘other side’ of the transplant equation in order to represent the silent or silenced organ donors, I am attempting to reconstitute living donors as rights-bearing individuals and persons rather than as faceless organs ‘suppliers’, ‘vendors’ or living cadavers and medical material for transplant procedures” (2004:64). On the other side, “the corrective field of bioethics and the profession of transplant medicine have both capitulated to the dominant market ethos… Transplant surgeons sometimes see themselves as ‘above the law’” (2004:61).

The public health institution in America, despite its governmental ties, does not fit so easily into this mold. Public health represents an amorphous collaboration among

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government, healthcare providers, nonprofits, churches, communities, and individuals trying—in the face of scarce financial and human resources—to win the battles against illness and death that humanity has lost since time immemorial. Although American public health’s pedigree owes as much to the tragedies of eugenic movements as it does to social medicine, the shift to health disparities in recent decades—and my own personal experience working for governmental public health—suggest that its goals are not

incongruent with the “militant” anthropology Scheper-Hughes proposes. Without a careful examination of definitions and boundaries of “structure,” I worry that, as a critical anthropologist, I run the risk of tilting at windmills, creating antagonistic relationships between themselves and structural institutions when no such relationships may actually exist.

I offer this characterization not to suggest that American public health is free of prejudice or responsibility for the state of health—particularly among underserved populations—in the United States. I instead use it to provide the context for a parallel thread to the grassroots anthropology of our time. For just as critical medical

anthropology, empathizing the plight of the marginalized, can allow its critical eye to blind it to the humanity that underpins even the most structural of power relations, so too does public health hesitate to critically examine the ideologies underpinning its practices (cf. Bhatia 2003). As Good (1994), Krieger (2000), Pelto and Pelto (1997) and others suggest, public health and medicine have historically relied too heavily upon the health behavior and risk factor models of disease at the expense of critical examination of structural factors, though that paradigm is shifting (cf. Frieden 2010). No anthropologist will argue that a lack of exercise and unhealthy eating are not responsible for obesity and

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heart disease, or that African-Americans have higher rates of stroke than White populations. The question is how much the individual is responsible for or has control over lifestyle “choices,” and how poorly-defined, biological constructions of race mask socioeconomic disparity. While health behavior theories offer conveniently quantifiable models for intervention, they overemphasize individual agency in contexts where, quite frequently, they are structurally constrained. In so doing, these models enable structural inequalities to persist.

My objection to the corpus of organ donation research is this: on one side of the divide, you have an overly-reductionist biomedical approach that paints donors and non- donors with broad strokes of selfless versus selfish, educated versus ignorant, rational versus superstitious. On the other, anthropologists have revealed (or created) an impossibly tangled mess of ethics, history, and meaning, that leaves no room for intervention; if the transplantation system or technology itself is corrupt, any attempt to increase donation registration is itself feeding a system of inequality. Yet both models presuppose that the average American’s donation registration decision is—at its core—a product of forces that are ultimately outside his or her sphere of control, the decision made either by clever campaigns or by entrenched cultural memory. But what if links could be found between culture and behavioral outcomes—in which complicated relationships and schemata are not reduced to a single box labeled “culture” on a logic model, but which could be used to inform (rather than problematize) effective organ donation communication campaigns? Understanding how meaning is created and interpreted within a political-economic context can provide better insight into how

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donation registration behavior occurs. The first step is understanding the concept of intersubjectivity, and how donation communication draws upon it.