Critical Public Health
Volume 29, 2019 - Issue 4: Pseudo Matters in Global and Public Health. Guest Editors: Patricia Kingori and René Gerrets
Introduction
In May 2014, the United States Central Intelligence Agency (CIA) announced that it would halt its ‘fake’ vaccination programmes, which had been exposed by The Guardian newspaper three years earlier. What transpired was that for many years the CIA had been using local health workers as its intelligence agents, instructing them to gain security information while administering vaccines to unsuspecting members of the local population (Lenzer, 2011). Adopted in various locations in the Global South,1 including in Pakistan and Afghanistan, this ‘sham vaccination campaign’ (Rushton & Kett, 2014) provided DNA and other crucial information in the search for Osama Bin Laden (Robbins, 2012).
President Barack Obama halted these CIA programmes after twelve heads of global and public health institutions argued they undermined the legitimate aim of reducing the global burden of disease, while jeopardising the lives of genuine health workers, who were being attacked and killed as suspected spies (Ingram, Kett, & Rushton, 2011). Further investigations also questioned the authenticity of the vaccines administered by the CIA, as some were certified while others were not. Moreover, at times vaccination regimens were initiated but not completed in accordance with protocol.
These revelations, then, call into question facile distinctions between genuine and fake. For example, how is one to differentiate between deliberately ‘fake’ vaccination programmes and the presumably ‘genuine’ activities of global health institutions involving vaccines of uncertain efficacy (Rushton & Kett, 2014)? It is this very ambiguity in the status of the vaccines – or, for that matter, all kinds of global health phenomena – that exemplifies pseudo global health. We conceptualise pseudo global health as the indeterminate, blurry and messy spectrum that exists between binary oppositions such as fake/real or authentic/inauthentic. Central to global health, but also encountered in related domains such as public health (Green & Speed, 2018), such binary classifications can obscure and misrepresent ‘in-between phenomena’, as evinced by the halted CIA vaccination intervention, which manifested complex ‘co-mingling’ of fake and real.
This special issue aims to open up new analytical horizons by problematising such binary oppositions and probing in-between phenomena – the fake-in-the-real, the authentic-in-the-inauthentic, and so forth. Instead of taking dichotomies such as fake/real or authentic/inauthentic as ontologically and epistemologically stable, this collection of articles examines the continua between these poles, to shed light on ambiguous, uncertain and unstable phenomena which we loosely lump together as manifestations of pseudo global health. We argue that this ambiguity, uncertainty and instability bear a closer relation to the everyday lives of many actors engaged with health and, as such, merit scholarly attention.
Here we use global health to provide empirical examples for the conceptual and analytical frame of the pseudo which we consider to be pertinent to other domains including public health. Drawing on ethnographic insights gleaned in diverse locations, the assembled articles explore uncertainty and ambiguity in pseudo global health phenomena. The authors, hailing from disciplines such as anthropology, bioethics, history, law and sociology, seek to deepen critical understanding of global health by examining how its aims and values translate in everyday spaces such as clinics, hospitals, ethics committee meetings and board rooms, as well as in the field (Pfeiffer & Nichter, 2008).
Prior to discussing the articles, we elaborate on the concept of pseudo global health, a notion inspired by Popper’s concept of pseudoscience. This involves examining several significant factors that have shaped the structure and relationships involved in global health, paying special attention to the binaries which operate in its conduct.
Global health and its binaries
The mushrooming of global health2 coincided with a rising demand for procedures, standards and tools to differentiate between its ‘real’ and ‘fake’ versions – to assess, authenticate and certify its products and activities across a vast array of institutions, actors and locations (Adams & Biehl, 2016; Erikson, 2012; Hayden, 2008). The need for assurances and proof can be witnessed in the flourishing audit culture, performance-based evaluations and assurances of standardisation and authenticity – all crucial to maintaining and attracting resources (Lorway, 2017; Rottenburg, Merry, Park, & Mugler, 2015).
Global health draws on, reproduces and entrenches discourses that are laced with binary oppositions such as North/South, rich/poor, male/female or healthy/diseased. This is related to the prominence in global health of European languages, especially English; binary oppositions – paired concepts that are opposite in meaning – pervade these languages, and their associated ‘systems of thought’ (Lévi-Strauss, 1963). The ways binary oppositions interplay and reinforce one another have been studied extensively by linguists (Jakobson, 1957), structural anthropologists (e.g. Lévi-Strauss, 1963) and linguistic anthropologists (e.g. Schieffelin, 2014). Studies investigating the roles and effects of binary oppositions in discursive practices also exist in public health (e.g. Fraser & Treloar, 2006; Petersen & Lupton, 1996), medicine (Lemoine, 2009) and development studies (e.g. Briggs, 2005). However, in global health such research is scarce (see e.g. Biehl, 2016).
Collectively, this scholarship shows that binary pairs can become imbued with emotional, moral or ethical associations. For instance, discursive linking of inauthentic/fake with obstructing or perverting health goals – and by extension, failing to prevent diseases, deaths and suffering – can emphasise the negative associations of this pole. Conversely, tying the pole authentic/real to achieving or aiding global health objectives augments its positive hue.
Considerable resources are channelled towards detecting and exposing health-related activities considered fake or inauthentic, yet far less methodological and theoretical attention is given to their analysis or to exploring their social, political and ethical value. Take for example the roles ascribed to ‘fake’ drugs in anti-microbial resistance, which are alleged to threaten people’s health in the Global South and North (Mackey & Liang, 2011). In global health, discussions of such issues often reflect two widespread interconnected assumptions: 1) that boundaries between ‘real’ and ‘unreal’ or between ‘authentic’ and ‘inauthentic’ are easily ascertained and clearly recognisable, and 2); that global health actors generally value a particular, shared view of authenticity or realness whose pursuit can and should override other concerns. This reasoning may make sense when taking such binaries at face value. However, what if these categories were approached as opposite ends of a spectrum, with multiple possibilities, ambiguity and fluidity between the poles?
This question has inspired the assembled articles, which explore how the entanglement and co-constitution of phenomena that resist categorisation expose facets of pseudo global health.
‘Pseudo’ global health
Many aspects of global health might be conceptualised as ‘pseudo’. While the term is often used as a pejorative prefix, in this collection ‘the pseudo’ is borrowed from and builds on Karl Popper’s (1957) theory of pseudoscience. Popper defines the pseudo as the unresolved space between real and fake science, containing findings and practices yet to be classified as science or non-science. According to Popper, authentic practices sometimes fail and questionable methods occasionally work, sometimes yielding successful theoretical innovations and, at other times, theories that flounder. Extending such approaches to global health creates an opportunity for important insights and makes a valuable contribution to understanding the phenomenon of the pseudo.
There is a paucity of research examining topics related to the pseudo in global health. However, scholarship from other domains can further our understanding of the conditions which enable or obscure ambiguity and ‘fakery’ in global health. The following section discusses literature on the anthropology of fakes to explore the idea of pseudo global health.
The anthropology of fakes and the crisis of authenticity
Anthropological studies of fakes and fakery foreground the everyday and provide fruitful perspectives for examining global health, as well as concepts useful for exploring blurry spaces between binary oppositions. For example, Reeves discusses the term ‘clean fakes’, used by migrants in Russia to distinguish authentic and counterfeit employment and citizenship registration documents bought in railway stations or marketplaces (2013, p. 515). Migrants paying large sums for supposedly ‘clean fake’ registrations regularly discovered that these documents were counterfeits – ‘dirty clean fakes’. Navaro-Yashin, studying documentary practices among Turkish Cypriots seeking citizenship in Britain, distinguishes between ‘make-believe’, ‘legal’ and ‘counterfeit’ documents to differentiate beyond distinctions such as authentic and counterfeit, and legal and illegal (2007). In Bubandt’s work examining propaganda material in eastern Indonesia, ‘truthful fakes’ emerge to capture the dual social reality of claims which seem both factual and fake (2009, p. 561). Crăciun, studying branded goods in Turkey and Romania, introduces the concepts of ‘half-fake’ and ‘entirely fake’ (2012, p. 851).
‘Clean fake’, ‘truthful fake’ and ‘half-fake’ are examples of concepts which scholars have used to open up and analyse the spectrum between binary positions such as authentic/inauthentic. Many such analyses explore the physical, legal and social uncertainty amid the blurred boundaries that shape the lives of the world’s poorest people (Chidester, 2005). These accounts show that fake is often too narrow a category. Hence, Reeves coined the notion ‘fake-realm’ – a ‘social space in which people live, work, love, and struggle to make ends meet, [a] grey space [that] is necessarily “entangled” ’ (2013, p. 511). This grey space in regard to global health is what we explore through the lens of the pseudo. We seek to problematise and examine what widespread, taken-for-granted ‘myopic binarism’ in global health might be obscuring.
Proposing the pseudo as an analytical tool calls for methodological inventiveness and close attention to what can be learnt from areas of ambiguity, uncertainty and compromise. The following section discusses the themes in this special issue, and seeks to illuminate various assumptions about how global health works in practice, and to show how investigating areas where the pseudo is apparent can enrich understandings of global health.
Themes in this special issue
The topics under discussion share three intersecting themes. The first concerns ideas of geography, and in particular, questions about assumed relationships between (jn)authenticity and locality. All the articles question the common assumption that authenticity, credibility and the genuine are predominantly created in or associated with the Global North (e.g. Prasad, 2014). The second theme concerns the role of methods in examining pseudo global health. Taking the fake as a starting point, and designing research on that assumption, has important methodological implications for findings produced, as each article illustrates. The final theme, centring on the dichotomy genuine/fake involves the role of power and how paying attention to areas of ambiguity can disrupt assumptions about who holds power and where it lies.
Geographies of pseudo global health
Global health is simultaneously global and local, and, through claims of universality, everywhere yet not specifically anywhere. Consequently, one theme emerging from this collection of articles is the importance of geography, particularly in terms of where authentic practices are more likely to take place. One tenacious idea holds that institutions, politics and ideologies from the Global South fall short of those from the North; the Global South can at best imitate, mimic or copy those associated with the North (Mavhunga, 2017).
Following this thinking, the Global South is also seen as more prone to fakery, forgery and fabrication than the Global North. An often tacit, ‘almost automatic, disposition to consider everything local as the mere imitation of an original that exists elsewhere’ (Crăciun, 2012, p. 846) often associates ‘the South’ with imitation, repetition, belatedness, the almost. By extension, authenticity and innovation typically happen elsewhere. Pervasive in global health thinking and praxis, such associations have received limited critical attention, raising the following question: how do understandings of geographical situatedness inform perceptions of what is real or fake? What becomes clear is that geography in global health indexes more than location: it is important as a cipher for race, authenticity and power.
Through exploring aspects of the pseudo in global health, the articles demonstrate that tenacious assumptions regarding the geographies of authenticity bolster the political and economic interests of certain powerful actors and institutions. Hence all the contributions take seriously tenets of ‘studying up’, as location and perspective matter (Nader, 1969). When studying up moves beyond binary poles such as up/down or top/bottom to illuminate in-between positions and perspectives, it stimulates ‘common sense questions in reverse’ (Nader, 1969, p. 289). This helps reorient our focus in exploring understudied phenomena. Hence when probing the pseudo, we not only explore whether the categories and practices central to global health are what they seem; we also ask what such questioning can reveal about phenomena operating beyond the binaries of global health.
In this regard, attention to language matters. For instance, discourses about fake medicines persist despite mounting evidence that in certain settings medicines perceived as fake are actually substandard because incorrect storage or handling have reduced their pharmacological efficacy (Johnston & Holt, 2014). This distinction between substandard and fake drugs directs attention away from deceptive or criminal intentions towards mundane issues such as the infrastructures of global health (Redfield, 2016; Star, 1999), misdirection of resources, or management and oversight failures, which can cause certified drugs to change and be perceived as fake. Such examples, found in the articles by Gryseels, Kuijpers, Jacobs, and Peeters Grietens (2019), and Hodges (2019) act as signposts to pseudo global health and areas where greater analytical attention is needed.
The ethnographic investigation of fakery in the contemporary Cambodian health system carried out by Gryseels et al. (2019) traces the ramifications of the inadequate technical support, drug supplies and training that the WHO provided in the early 1990s in efforts to re-establish a viable health system. This uneven investment generated and then, over time, normalised substandard health care facilities, according to the Cambodian doctors interviewed for this research. Furthermore, it illustrates how Northern and global health institutions are implicated in substandard or fake practices in the Global South.
In her article, Hodges (2019) questions a perceived comfort among global health actors with ideas of India as a producer of fake medicines. Such ideas, Hodges (2019) argues, draw on a well-established historical narrative about the presumed geographical distribution of authentic scientific practices versus sites where inauthentic science and fakery prevail. Allman’s work (2019) reveals a similar narrative, according to which academic journals originating in the South are often presumed to be, and are classified as, predatory. The idea that practices and institutions in the South are predatory is explicit in the article by Gryseels et al. (2019), which examines fake health care in Cambodia, and in Douglas-Jones’ (2019) exploration of suspected fake ethics committees (2019). In Hornberger’s (2019) South African ethnography, the spectre of China looms in the background and taps into growing geopolitical concerns and prejudices about China’s general activities in Africa, and the country’s role as a producer of fakes with its eye on vulnerable African populations (Lin, 2011; Pang, 2008).
Hence, invoking particular geographical locations can elicit certain expectations of authenticity or fakery. The extent and tenacity of such views mean that when the association of geographical locations with assumptions of (in)authenticity is examined, the processes underlying the creation of these associations come under scrutiny (De Laet & Mol, 2000). In examining them, many of the authors have employed an ethnographic approach but, as Hodges (2019) and Cloatre (2019) discuss in their articles, long-standing historical lineages – harking back to imperial scientific ideas and projects – can be detected behind the positions that certain countries and institutions occupy on the real–fake spectrum. Investigating these assumptions reveals the pseudo. The expired vitamins procured by the poor in India do not quite live up to the more sensational examples of the fake given in Hodges’ (2019) work and nor does the lack of standardisation of medicinal plants made into tablets by non-clinical practitioners in African contexts discussed in Cloatre’s (2019) work. Nevertheless, in both cases, items deemed to be fake work for those using them and we are led into believing that they are fake because of their association with specific locations.
Importantly, though most contributions are anchored in the Global South, they also trace involvements from the Global North, illustrating how manifestations of the pseudo, such as fluidity and uncertainty, can be observed crossing these spheres and influencing them both. The articles implicate the Global North in co-constructing the pseudo, by exposing intersecting forces, priorities and agendas which structure options and practices. Addressing such complex linkages, as discussed next, requires careful reflection on methodological approaches.
Pseudo-methods and methods for researching the pseudo
Methods play a crucial role in distinguishing between the scientific and the non-scientific. However, as Popper (1957) notes, on certain occasions inaccurate scientific methodologies (non-science) can produce or corroborate facts (science). Popper considered such occurrences examples of pseudoscience – a ‘holding bay’ for observations and ideas until sufficient evidence, derived from the correct methodology, was produced for them to be classified as science or non-science. Following Popper, utilisation of the correct methodology demarcates science from non-science and pseudoscience from science. While this special issue does not focus on the history and philosophy of science, we draw on Popper’s ideas involving uncertainty and in-between phenomena, such as the fake-in-the-real, in the conduct of science, to explore the ambiguous and indeterminate spaces of global health as an empirical example of the pseudo. For global health, the rise of randomised control trial (RCT) methodology constitutes a notable methodological shift in comparison with ‘predecessors’ such as tropical medicine and international health (Bell, 2012). RCTs have become the preeminent method for providing certainty and evidence in global health notwithstanding debates about their shortcomings (Packard, 2016), also in related domains such as public health (e.g. Kaplan, Giesbrecht, Shannon, & McLeod, 2011).
Reflecting this pre-eminence, this special issue examines the RCT method through the lens of the pseudo. Friesen’s (2019) paper in this collection draws attention to limitations of RCTs regarding the ‘placebo-effect’ in both evidence-based medicine and Complementary and Alternative Medicine in public and global health where a ‘efficacy paradox’ exists (2019). Within a RCT, a treatment must be shown to improve clinical outcomes significantly more than the placebo control for the treatment. However, some treatments improve clinical outcomes, but operate primarily through placebo responses, leading effective medicines to be labelled ‘ineffective’ within RCTs. This phenomenon is known as the efficacy paradox and is explored as an example of the pseudo. The other articles by Peeters Grietens, Gryseels, and Verschraegen (2019) and Graham (2019) explicitly question the RCT method, particularly certain epistemological ramifications. The authors draw on the literature on the anthropology of fakes to interrogate widely used dichotomies such as legal/illegal, documented/undocumented, genuine/fake, and regular/irregular. Uncritical ‘binary reductionism’ can flatten analyses, findings and representations of social reality, for example by effacing the multiplicity and hybridity shaping the lived realities of much the world’s population, whose lives are riddled with uncertainty, ambiguity and moral paradoxes. Moreover, this can reproduce and obscure power imbalances, inequalities and inequities, by generating data and facts that divert attention away from the lived experiences of the actors whose afflictions global health seeks to fight.
Examining such issues in global health, through the lens of the pseudo, is another theme in this special issue. In the early 2000s, mounting anxieties about spreading fakery – of branded designer goods, drugs, medicines, art, and so on – precipitated discussions of what has been called a ‘crisis of authenticity’. This inspired anthropological inquiries which conceptually and methodologically opened up explorations of fakery and faking, enabling greater diversity in interpretations and experiences (Crăciun, 2012). For example, Reeves examined how ‘[t]he color of the stamp, the texture of the paper, the quality of laminate covering’ reflected the expertise of the producers of forged registration documents and work permits in Moscow (2013, p. 509). Similarly, for Crăciun’s informants in Turkey and Romania, ‘fakes connote a clever businessman, who feels the market, orientates towards goods that are in high demand, and, thus, consolidates his position and increases his capital’ (2012, p. 852). Likewise, successful ‘419 scams’ – forms of financial fraud – point to forms of expertise involving faking among actors excluded from the world’s stage (Blommaert & Omoniyi, 2006; see also Smith, 2007). While 419 scams often fail, the largest on record led to the near-collapse of Banco Noroeste in Sao Paulo, Brazil, after Nigerian scam perpetrators siphoned US$242 million off from the bank. Blommaert & Omoniyi note that the perpetrators’ possession of sophisticated communication and computer skills was key to the success of the scam (2006, p. 587). This special issue draws on these findings, and approaches fakery as an acquired skill involving and reflecting expertise and workmanship (Fleming & O’Carroll, 2010).
A common position taken by those investigating fakery in global health is that of the anti-establishment rogue who exposes the ‘truth’. Like Hegel’s (1807/1967) marginal and deviant anti-hero, they challenge the status quo; however, they still operate from within a structure which reproduces and seldom questions established knowledge practices. These ‘whistle-blowers’ or ethnographers are regularly praised for exposing malpractice (see Edwards, 2001). Nevertheless, criticism of anti-hero ethnographic approaches is long-standing. For instance, Kenyatta (1938) asserted that those acting as interlocutors and translators, while revealing ‘the truth’ often overlooked complexities and nuances in their work. Additionally, there are many sobering examples of the anti-hero’s attempts to produce exciting and controversial accounts which uncovered the truth, while their research participants had other ideas. A classic example involves the anthropologist Margaret Mead, who thought she had discovered exotic sexual practices yet was actually misled by Samoan informants, who deemed her probing questions about young girls’ sexual practices unacceptable (Freeman, 1999). More recently, scholars such as Fassin (2007) have urged caution over ‘confessional’ narratives that appear to provide personal, authentic insights to ethnographers in contexts where producing such narratives can provide access to scarce resources from global health institutions.
Heeding these warnings means taking care when making claims. Hence, this special issue explicitly foregrounds the importance of the pseudo as a methodological and ethical position, taking ideas and practices of authenticity as its subject of study so as to understand the conditions shaping their production. Crucially, the pseudo’s questioning of binary positions aims for more panoramic views of the different positions and vested interests. At best, explorations from the position of the pseudo can ask questions of phenomena purporting to be ‘real’ or ‘fake’ – adopting what Bloor (1991) describes as an agnostic relationship to either position in the process. This requires considerable amounts of reflection on positions and vantage points and their methodological implications.
For some articles in this special issue, the research initially aimed to uncover the truth about fakes. Often authors were keen to show the extent of fakery and provide empirical support for their view. For example, Allman’s (2019) investigations started from the position that predatory journals were fake, and aimed to contribute to discussions about the implications of this for global health (see e.g. Green & Speed, 2018). Similarly, Kingori and Gerrets (2019) began by examining claims of data fabrication among fieldworkers in East Africa.
Operating on an implicit or explicit assumption that something is inauthentic has important methodological implications, as the articles reveal. For example, in Hornberger’s (2019) work this meant going undercover, as a fake patient, to test out the Quantum Resonance Magnetic Analyzer machine, which she believed was a scam. Douglas-Jones (2019) discusses whether the idea of going undercover or creating a sting operation seems a legitimate approach only from the position of seeing something as fake or disingenuous. Moreover, these assumptions reverberate, and after becoming embedded in methodological choices, they can shape findings and further confirm ideas of the fake, illustrating Hacking’s notion of the ‘looping effect’ (1995). These assumptions also entail important ethical considerations. For Hornberger (2019), going undercover and pretending to be a patient was a methodological approach that raised ethical concerns and that she reflected on in her article.
The complicated entanglements of methods, ethics and subject-matter pertinent to investigations of pseudo global health, raise different types of ethical questions, which run through the contributions. For instance, whom ought ethnographers in/of global health feel obliged to, if anyone? The articles also ask questions about the ways in which data are obtained and how narratives should be presented. Douglas-Jones’ (2019) article raises questions about the process of gaining genuine ethics approval that can be deemed authentic by international standards.
How can any claims to truth can be made by ethnographers examining global health if their findings are obtained by dishonest means? Most authors in this special issue have made modest claims to the truth and have adopted methodological approaches which seek to highlight multiple truths or areas of ambiguity in dominant ideas of the truth. Yet this is not straightforward. For some, highlighting multiple truths is akin to remaining on the fence or giving credence to an idea which, from their position, lacks sufficient merit. For instance, the interests of Douglas-Jones (2019), in her position as an ethnographer on an ethics committee, lie in the use of sting operations which are regularly used to uncover inauthentic ethical review processes.
All the articles in one way or another also address the ethical and methodological implications of researching these ambiguous and, depending on one’s perspective, troubling aspects of global health. Hence, Allman (2019) and Cloatre (2019) present their work in the form of case stories rather than by using the typical case-study approach, which might compromise anonymity, and lead readers to consider findings as case-specific, potentially diminishing the wider, more general relevance and implications they can contain. Using fictional ethnographies or case stories is often undertaken as an ethical way of researching sensitive issues (e.g. Taussig, 1997). Importantly, the case story approach is a pseudo-method, which amalgamates real and fake elements from multiple case studies into a single narrative, to highlight salient features while occluding identifiable attributes. This composite, fictionalised approach, used both by Allman (2019) and Cloatre (2019), gives the author, and the reader, opportunities to identify key contextual features and developments, to help locate boundaries and points of difference between social phenomena. These two articles illustrate the pseudo emerging in relation to two authoritative forms of knowledge: biomedicine and the law.
The power and props of the pseudo
It would be remiss to discuss global health without some reference to power, and how power infuses and shapes all of its relationships, interventions and initiatives (Benatar, 2016). In this literature, generally speaking, descriptions of power – where it resides and who possesses it – tend to map neatly onto where funding comes from and also where the real is assumed to reside. The global health literature offers numerous accounts which give a glimpse into the complexities of attendant power dynamics. Examples such as women presenting falsified urine samples in clinical trials of FEM-PrEP in sub-Saharan Africa (Corneli et al., 2016) or undetected data fabrication among seemingly uneducated fieldworkers in the Global South (Finn & Ranchhod, 2013) are indicative of the ways in which actors from the Global South undermine, subvert or reclaim power by withdrawing from initiatives or tampering with data, the oxygen upon which much of global health depends. Accounts which discuss power mainly in terms of it being possessed by actors in the Global North or those in higher societal strata, run the risk of overlooking the considerable agency of those in the South or in lower social echelons (Kingori & Gerrets, 2016). Similarly, saying that these actors resist power but failing to take into account the strength of the socio-economic and political structures and stratifications they come up against can over-state the effects and long-term impact of such actions (Shukla, Teedon, & Cornish, 2016).
In many of the articles in this special issue, sites where power relations are being reworked are significant because they draw attention to certain aspects of pseudo global health. The pseudo can, at times, open up opportunities for change or advancement. This resonates with Crăciun’s observation that ‘[f]akes are a source of procuring advantages over an economy that excludes some and enriches others’ (2012, p. 860), and Newell’s assertion that deliberate preferences for fake goods by marginalised people can signal both their participation in consumerist societies and their sidestepping or rejection of dominant economic structures (2013). The authors contributing to this special issue have extended these arguments in their work by exploring diverse aspects of pseudo global health where the slippery space between real and fake is reinterpreted and used for contesting and destabilising power.
The lens of pseudo global health can shed unique light on sites where these power dynamics are unstable and being contested. This collection begins with Peeters Grietens et al. (2019) introducing the concept of misdirection. Borrowed from the field of magic, misdirection is a term denoting the art of diverting an audience’s attention away from crucial features in performances by focusing it on something else. Peeters Grietens et al. (2019) mobilise misdirection to explain what they describe as the encouragement of a narrow focus on the standardisation of intervention methodologies and on decontextualised generalisations, in the conduct of malaria elimination programmes in Vietnam. The ability to misdirect attention, to decide where an audience looks, is a manifestation of power. By analysing this misdirection, which fixes the audience’s eyes on bed net and repellent use as evidence in the malaria transmission paradigm while diverting attention away from contextual factors which shape how these interventions unfold, this article demonstrates how power can operate in global health, and how it thereby reinforces particular epistemological premises.
At first glance, scientific endeavours such as global health might appear to be at odds with the concept of magic. Yet analogies between magic and science are common. Moreover, attention to magic and misdirection can expose many performative aspects of pseudo global health: its onstage and backstage features, its audience and its props. Examining these interconnected facets, as Erikson (2019) argues in her commentary, which concludes this special issue, is critical to understanding emergent manifestations of global health centring on health security, health innovation and health finance.
We began this introduction with the CIA vaccination programme, which was unmasked to reveal its true face. This controversy is a good example of misdirection because it diverts attention away from the ambiguities in global health, and shifts the focus to extraneous factors while reinforcing the centrality of binaries such as real/fake. If we take binaries for granted, we can overlook the complexity that they exclude which can challenge agendas, motivations and neatly constructed performances. Hence, we invite readers to explore more deeply what the pseudo as a lens can reveal.
Acknowledgements
Our special thanks go to the contributors of this special issue, to our colleagues who participated in various pseudo global health-oriented workshops, to the peer-reviewers, editorial support from Isabel Tucker and to Vincanne Adams, Judith Green and Bambi Schieffelin for insightful feedback. We also greatly appreciate the contribution of study informants – without you this project would not have been possible.
Disclosure statement
No potential conflict of interest was reported by the authors.
Notes
1. Here we use the terms Global North and Global South for convenience, accepting that they are problematic. Global North generally refers to the 57 countries with so-called ‘high human development’; most, but not all, of these are located in the northern hemisphere. Global South commonly refers to the remaining countries in the world, predominantly located in the southern hemisphere.
2. Defining global health is challenging, and a universally accepted definition is lacking. One more common definition considers global health to be ‘a collection of problems rather than a discipline’ focused on ‘the quest for equity’ in health indices, within and across national boundaries and between rich and poor (Farmer, Kim, Kleinman, & Basilico, 2013).
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Additional information
Funding
For providing financial and organisational support, we thank the Ethox Centre and the Wellcome Centre for Ethics and Humanities (WEH), University of Oxford, the University of Amsterdam, the Institute of Tropical Medicine – Antwerp, the University of Kent – Paris. We further acknowledge financial support from (PK) Wellcome Trust Society and Ethics funding scheme (WT080546MF), a Wellcome Trust Strategic Award (096527), and the Wellcome Trust Investigator Award (grant number 209830/Z/17/Z) ‘Fakes, Fabrications and Falsehoods? Interrogating the social, ethical and political features of pseudo-global health; (RG) the National Science Foundation - Science and Technology Studies Award (0350160), the Max Planck Institute for Social Anthropology, the University of Amsterdam, and the Wellcome Trust Collaborative Award (grant number 212584/B/18/Z) ‘What’s at Stake in the Fake.’