Contributors. Aditya Bharadwaj, Caroline H. Bledsoe, Carole H. Browner, Junjie Chen, Aimee R. Eden, Susan L. Erikson, Didier Fassin, Claudia Lee Williams Fonseca, Ellen Gruenbaum, Matthew Gutmann, Marcia C. Inhorn, Mark B. Padilla, Rayna Rapp, Lisa Ann Richey, Carolyn Sargent, Papa Sow, Cecilia Van Hollen, Linda Whiteford
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About the Author
Carolyn F. Sargent is Professor of Anthropology and Women, Gender, and Sexuality Studies at Washington University in St. Louis. She is the author of Maternity, Medicine, and Power and a co-editor of several books, including Childbirth and Authoritative Knowledge.
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REPRODUCTION, GLOBALIZATION, AND THE STATENew Theoretical and Ethnographic Perspectives
Duke University PressCopyright © 2011 Duke University Press
All right reserved.
Chapter OneSUSAN L. ERIKSON
Global Ethnography Problems of Theory and Method
Ingrid, a raven-haired twenty-nine-year-old medical student almost four months pregnant, strode gracefully into the ultrasound exam room, joining Dr. K and me. Dr. K was the head obstetrician in the ultrasound department, and I had begun my fieldwork in an obstetric hospital in Germany only a few days earlier. Dr. K motioned for Ingrid to sit down in the empty chair on the other side of her desk for the pre-exam chat, and reached to take a blue, passport-sized booklet Ingrid was holding out to her. The booklet was the Mutterpass (literally, the "mother passport") that documented Ingrid's pregnancy and that all women in Germany are required to carry during their pregnancies.
Yes, it was true, Ingrid began slowly, answering Dr. K's question in a voice barely above a whisper. As her Mutterpass documented, she had spina bifida. Just a slight case, though, she added. She had been born with a small hole in the tissue at the base of her spine, and it had been surgically closed soon after her birth. But she was here now because she was concerned about her fetus. Her Frauenarzt (gynecologist or obstetrician in private practice) had recently given her the results from her amniocentesis, and the results for fetal spina bifida were inconclusive. The Frauenarzt had recommended that Ingrid get an ultrasound in Dr. K's hospital department, where the machines produced better images and the doctors had special diagnostic training and experience. As Dr. K described how she would use ultrasound to look for an opening along the fetal spine, Ingrid closed her eyes and folded her tall, thin body forward in the chair, elbows resting on her knees, listening, but sitting very still. When Dr. K was done talking, Ingrid stood up and moved away from the desk like a sleepwalker. She climbed carefully onto the exam table and slowly lay down.
After almost thirty minutes of looking, first with transabdominal and then vaginal ultrasound, Dr. K abruptly gave up. She pulled the gel-covered condom off the vaginal transducer with a snap and told Ingrid she would have to walk around so that "das Kind" would move into a better position for them to see. Ingrid dutifully consented.
Ingrid returned to the waiting room an hour later that morning and waited until after lunch for Dr. K to look again. After about fifteen minutes, Dr. K said it was still too hard to see with enough precision. She had been able to see more of the spine the second time, but the possibility for spina bifida still existed. Come back in a week, Dr. K told Ingrid, and we will look again to be sure. Later Dr. K told me that Ingrid, though she wasn't fat, "had the density of a fat woman." Some women's skin and tissues were just difficult to see through and that made looking for anomalies more difficult. Nothing to attribute the density to in this case; "Ingrid was just hard to see through."
I saw Ingrid three more times. Her boyfriend came with her for the next exam a week later. Sweet and gentle with Ingrid, he asked pointed questions of Dr. K and expressed exasperation at yet a third instance of "not being able to see 100 percent." The next time I saw Ingrid, she had received the same inconclusive news from Dr. K. She agreed to be interviewed that day, but the interview felt flat, and she wasn't particularly engaged or self-revealing.
My last meeting with Ingrid was by chance, and I wouldn't have recognized her if she hadn't greeted me first as I passed her in the hospital foyer. She looked different, transformed, downright bubbly, her dark eyes dancing. Ingrid was well into her fifth month, and her pregnancy was obvious now. She was just coming from an ultrasound exam with Dr. K, who had finally seen the entire spine clearly, top to bottom. It was completely intact. Ingrid's excitement, obvious in her face, was palpable. Then her face changed, becoming serious. Now, she said, she wanted to modify something that she had told me during her interview: when I had asked what she would do if the ultrasound detected a fetal anomaly, she had said something vague, on purpose, she added confessionally. But she wanted me to know that even then she had known: she and her boyfriend had already decided she would have had an abortion if Dr. K had found fetal spina bifida.
Like much of the ethnography in this edited volume, Ingrid's experiences articulate interactions between agency, structure, state, market, biomedicine, disability, politics, and economy. In this chapter, I also situate her lived experience in relation to multiple local, national, and global dimensions. The aims of the chapter are ambitious, and I state them up front as a way to bring the problems of global ethnography into sharper focus: in global ethnography we try to do too much. The sheer number of dimensions we as anthropologists aim to negotiate is daunting. The theories we deploy as explanatory frames are multiple. The methodologies we must engage in to conduct research of both macro and micro forms are staggering in their breadth. How does a discipline embrace the global/macro and the local/ micro theoretically and methodologically and make the results comprehensible in narrative form? How do anthropologists actually produce ethnographic narratives that are truly all-encompassing in the global sense? What is required of a social scientist collecting and analyzing data from so many different types of sources, from pregnant women like Ingrid to obstetricians like Dr. K, hospital directors, government bureaucrats, and vice presidents of multinational med-tech corporations? There are many answers to these questions in this book. In this chapter, I offer one way to try to get at the multiple ambitions of global ethnography, to transcend the micro-macro divide more inclusively and move more productively away from the local-global binary.
At first glance, Ingrid's personal narrative may not seem up to the task of global ethnography. Her narrative follows a fairly common trajectory: Ingrid gets pregnant, begins prenatal care, uses diagnostic technology, and (eventually) receives information about her future child. Compared with the other women I interviewed, the specifics of Ingrid's case are compelling but not exceptional. (Many women reported receiving diagnoses during prenatal visits that made them extremely anxious, and which were not resolved as unauffällig [without pathology] until later exams.) More significantly for the purposes of global ethnography, though, even in this abridged version of Ingrid's story, the signs and symbols of much larger social, political, and economic influences weave throughout. Ingrid's use of ultrasound technology is shaped by her membership in various groups as well as by different types of governmentality. She is at once a pregnant female citizen of contemporary reunified Germany, a former West German, a woman labeled disabled by her society and thus automatically labeled a high-risk pregnant patient, and a smart and well-educated (soon-to-be) member of Germany's upper class. Additionally, Ingrid's use of prenatal diagnosis is shaped by several global or "universalizing" forces obscured at the narrative's surface. Government policies and corporate marketing strategies undergird Ingrid's prenatal care in ways that are invisible to most Germans. Many of the obstetricians I worked with did not seem to understand the full complement of government policies and corporate practices that shape Ingrid's prenatal care and their everyday praxis.
The theoretical and methodological tensions of global ethnography—agency-structure, micro-macro, local-global—are vexing, but they are also rich sources of ethnographic opportunity and complexity. Theoretical debates about how best to link individual experiences to large-scale structural factors have troubled anthropology for almost three decades now, dividing academic departments and the discipline itself. In studies of lived experience, what is the relationship between structure and agency? How do we describe universalizing effects of maternal-care policies at the same time that we embrace Ingrid's personal experiences of pregnancy as, for example, a first-time mother, a woman with spina bifida and labeled disabled, and a future doctor? My research points to the futility of claiming an overarching or irrefutable causality at one end of the structure or agency continuum. Further, it suggests that global ethnography needs to be reconceived in ways that simultaneously attempt to capture the more imposed (i.e., structured) aspects of people's lives while also capturing individual resistance, resiliencies, choices, and complicities.
If we use Ingrid's case as an opportunity to explore the tensions between agency and structure, we see the tension eases when we distinguish between Ingrid's use of prenatal diagnostic technologies and her experience of prenatal diagnostic technologies. Her use of prenatal diagnostic technologies was nested in large-scale infrastructures of medicine, technology, and knowledge practices, as well as the German government policies that guarantee her and every other pregnant woman living in Germany access to prenatal care. Her experience, though, was not determined by these infrastructures or by her membership in various social groups. Her decisiveness about having an abortion if prenatal scans revealed fetal spina bifida, for instance, was not consistent with what other former West German women said they would do with an anomalous diagnosis. Most women I interviewed in the former West Germany said they would not have an abortion. Ingrid's decision was also contrary to the position some German disability rights advocates have taken about postdiagnostic abortion, opposing such abortions on the grounds that they are an insult to individuals who live with disabilities. But while Ingrid's decision was contrary to the majority opinions of several of the groups to which she belonged, it was consistent with what most doctors think: anomalous results will be followed by an abortion. Capturing both Ingrid's individual experience of prenatal technologies as well as the policy structures, medical praxis, and social norms that make her use of technology highly likely in her pregnancy is one way of addressing issues of structure and agency. Aggregating multiple dimensionalities, with an emphasis on aggregating and collecting multiple and methodologically different types of research data, is one way to approach the challenges of global ethnography.
Starting with Ingrid
In my work, I have tried to move away from the binary of local and global that shaped globalization scholarship in anthropology in the 1990s. During the 1990s, when anthropologists contended with academics from other disciplines who insisted on the homogenizing effects of global forms, the local-global schema turned scholarly attention to more nuanced considerations of the heterodox ways in which global macro processes affected people's lived experiences at the local level. It was important to provide research that contested assumptions about globalization and homogenization. The downside of this, though, was that, in too many cases, this turn meant we gave short ethnographic shrift to the global in global ethnography, glad-handing the global in ways we would never tolerate at the local. We use words like flows, circulation, and processes to describe global phenomena but have been slow to design research projects that more fully contend ethnographically with macro forms of governance, institutions, and finance. What could a fuller complement of global ethnography look like?
My research suggests that we treat global ethnography constitutively as an aggregating process. Start with people like Ingrid and move through the various dimensionalities that directly affect their experiences. Move through the contexts of biomedicine, disability, politics, and the economy within which they live. Do research in those places. Follow the people, the thing, the conflict (Marcus 1998), and allow one site to lead to another. Pay attention to only those state and market sites that are actually relevant to lived experience. Using this approach, I met Ingrid and women like her in the hospitals, parents of children with disabilities, the German parliamentarians debating the ethics of prenatal diagnostic technologies in the Reichstag in Berlin, and vice presidents at Siemens Medical Solutions in California and Bavaria, interviewing almost three hundred people. I moved from village-scale (hospital) research sites to national-scale (government bureaucracies) and global-scale (multinational corporation) sites. This approach to ethnographic research is iterative, a kind of snowball sampling of sites rather than populations, rooted in the kind of commitments that brought Michael Burawoy and his students to operationalize "grounded globalizations" (2000a, 2000b).
Methodologically, such an approach has its challenges. It requires the relativity anthropologists have long employed in their research. Relativity is demonstrably more complicated for anthropologists, though, when the informants are bureaucrats, politicians, and corporate types. It also requires the flexibility to think about ethnography itself in more than one way, with multiple sets of design criteria. My research design included a large sample size at the lived-experience dimension (many women have ultrasound during pregnancy), but only a few people at the corporate level (there are only so many vice presidents). In the hospital stage of research, I could go and "take up residence" in conventional anthropological fashion (I lived in the hospital's fourth-floor doctors' quarters), but the governance and corporate stages of research required that I traipse all over the country. My mix-and-match methodological approach sometimes seemed suspect to those I consulted for advice, at some points too positivist, at others too poststructuralist, depending on the person's own orientation.
Theoretically there were challenges as well. Contemporary anthropology offers many theoretical tools to think with, but few are able to merge different types of data sets into one narrative stream. Quantitative results tend toward a particular narrative form; qualitative research toward several others. I found refuge in Collier and Ong's conceptualization of global assemblages—that is, the convergence of scientific practices, material structures, administrative routines, value systems, legal regimes, and more (Collier and Ong 2003, 3). Within this notion of assemblage there is room for the tensions and contradictions I found between the local, national, and global dimensionalities that shaped Ingrid's prenatal care, as well as the different types of data sets I had collected. Assemblage, as Ong and Collier (2005, 12) conceive it, accommodates the heterogeneous, contingent, unstable, partial, and situated elements that constitute prenatal diagnostic technology use in Germany. It makes room for critical perspectives of the state and market features that in conventional analyses tend to mask the interests and ambitions of administrations, corporations, institutions, and individuals. It provides a perspective on the "national and economic priorities, moral and civic values, and technoscientific institutional cultures" (Franklin 2005, 61) that constitute what Lock has called the "local biological" (Lock, in Franklin 2005). For this German case, a fuller complement of the global is not one true thing or one true group of people but rather a messy mix of rules and reactions, histories and habits, technologies and teleologies, that play out in the management of women's pregnancies.
Returning to Ingrid Again ... and Again ... and Again
When I asked Ingrid and other German women why they used ultrasound, most said they wanted to be safe and certain about the health of their fetus. They expected ultrasound to confirm that their child-to-be was healthy and developing normally. Getting a scan at every prenatal exam was just part of being pregnant in Germany, they said (few were aware that this is not the norm elsewhere). Individual experiences of ultrasound and other prenatal diagnostic technologies—like Ingrid's experiences during pregnancy of her own spina bifida as well as the possibility of finding the same condition in her fetus—are at the heart of this ethnographic project. But those narratives in and of themselves are not global ethnography, and they do not tell us much about the global circulation of prenatal diagnostic technologies. When I realized that Germany's high rates of ultrasound were a product of more than individual agency, patient demand, or obstetrician's self-interest, I faced a problem: if I were to turn my attention to the national and global phenomena that created a prenatal environment in Germany in which ultrasound "goes without saying," how would I keep Ingrid and other women from going missing in the ethnography? In a research endeavor that had decidedly federal and corporate components, how would I keep women center stage, as feminist anthropologists of reproduction have advocated (Ginsburg and Rapp 1991, 1995; Browner and Sargent 1996; Davis-Floyd and Sargent 1997; Browner 2000; Rapp 2001) and where my own commitments lie? How would I keep Ingrid central to more-encompassing ethnographic narratives of the social life of government policies and the state-and-market collusions that made Ingrid's use of prenatal ultrasound a taken-for-granted aspect of her prenatal care and create the context for this particular intersection of women and technology use?
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Table of ContentsForeword / Rayna Rapp ix
Introduction. Toward Global Anthropological Studies of Reproduction: Concepts, Methods, Theoretical Approaches / Carole H. Browner and Carolyn F. Sargent 1
Part I. Global Technologies, State Policies, and Local Realities/ Introduction to Part I 19
1. Global Ethnography: Problems of Theory and Method / Susan L. Erickson 23
2. Globalizing, Reproducing, and Civilizing the Rural Subjects: Population Control Policy and Constructions of Rural Identity in China / Junjie Chen 38
3. Planning Men Out of Family Planning: A Case Study from Mexico / Matthew Gutmann 53
4. Antiviral but Pronatal? ARVS and Reproductive Health: The View from a South African Township / Lisa Ann Richey 68
5. Birth in the Age of AIDS: Local Responses to Global Policies and Technologies in South India / Cecilia Van Hollen 83
6. Competing Globalizing Influences on Local Muslim Women's Reproductive Health and Human Rights in Sudan: Women's Rights, International Feminism, and Islamism / Ellen Gruenbaum 96
Part II. Biotechnology, Biocommerce, and Body Commodification/ Introduction to Part II 111
7. Reproductive Viability and the State: Embryonic Stem Cell Research in India / Aditya Bharadwaj 113
8. Globalization and Gametes: Islam, Assisted Reproductive Technologies, and the Middle Eastern State / Marcia C. Inhorn 126
9. Law, Technology, and Gender Relations: Following the Path of DNA Paternity Tests in Brazil / Claudia Fonseca 138
Part III. Consequences of Population Movements for Agency, Structure, and Reproductive Processes/ Introduction to Part III 155
10. From Sex Workers to Tourism Workers: A Structural Approach to Male Sexual Labor in Dominican Tourism Areas / Mark B. Padilla 159
11. Family Reunification Ideals and the Practice of Transnational Reproductive Life among Africans in Europe / Caroline H. Bledsoe and Papa Sow 175
12. Problematizing Polygamy, Managing Maternity: The Intersections of Global, State, and Family Politics in the Lives of West African Migrant Women in France / Carolyn F. Sargent 192
13. Lost in Translation: Lessons from California on the Implementation of State-Mandated Fetal Diagnosis in the Context of Globalization / Carole H. Browner 204
14. Reproductive Rights in No-Woman's-Land: Politics and Humanitarian Assistance / Linda M. Whiteford and Aimee R. Eden 224
Epilogue. The Mystery Child and the Politics of Reproduction: Between National Imaginaries and Transnational Confrontations / Didier Fassin 239