Perspectives

www.thelancet.com Vol 384 November 29, 2014 1921

The art of medicineThe other global SouthOur story begins with a place. We are standing in front of the former United Community Hospital with a visiting French historian of medicine who works on central Africa. We gaze up. Along the fi rst fl oor are massive metal louvres that stretch the length of the building, below rows of boarded and broken windows. The modern fi ve-storey hospital is covered in dull metallic siding. Trash is scattered in the fi elds that have grown wild around the building. A rusty patina made by the nearby rail yard and petroleum refi nery covers everything. It’s warm and the sun is setting. The hospital is solitary, as if out of place and time. “We could be in Kinshasa”, Guillaume Lachenal says. We are in Detroit.

United Community Hospital was the last of several “black-owned and operated” hospitals in Detroit, the fi rst established in 1917, and this one built in 1974 after the merger of several smaller hospitals owned by African Americans. Originally called Southwest Detroit Hospital, it was the product of a segregationist past and, in the 1970s, represented a huge political success just after the city erupted in race riots in 1967, wounds from which were still raw. Despite the magnitude of need for health care in the city, the hospital struggled fi nancially during cycles of economic downturn and competition in an increasingly integrated health-care marketplace. Eventually it went into bankruptcy in 1991, and after a few attempts to revive it the hospital closed in 2006.

Today, the abandoned hospital is not so much a testament to the slow corrosive power of neglect, but a vestige of retreat. At the time of its closure, exodus was speedy—examination rooms still held equipment and its administrative offi ces remained fi lled with personal eff ects and scattered fi les. In one sense, the hospital is not unlike the countless deserted schools and factories in this now bankrupt city. These spaces do not simply create a background to illness and suff ering. They are bound up with representations and experiences of the city as an environment of injuries. Those Detroiters who remain in the city’s neighbourhoods of decaying buildings and homes together suggest that suff ering is easily objectifi ed and depersonalised if represented through the city’s landscape of ruins alone, as it so often is by visiting outsiders and journalists. A closer look at this African American-controlled hospital complicates any simple view of the city as desolate and overtaken. The hospital hints at Detroit’s uneven geography of historical and political contingency beyond the shell of a building and the borders of the city.

How should a city like Detroit—and this abandoned hospital—fi gure into today’s discussions about health in the global South? For researchers living in and near Detroit,

this is a sticky question, one arising especially upon return from other places with more conventional, though no less fraught, relationships to global health discourses about disease and calamity in the South. In both hemispheres, health and survival are profoundly uncertain. In Detroit, poverty and inequality have helped to fuel astonishing rates of infant mortality (15 per 1000 livebirths—albeit in Africa’s poorest countries it is over 100 per 1000 livebirths), low immunisation rates, obesity, high rates of new HIV infections among African American adolescents, and one of the highest rates of child homicide in the USA. When children die at a greater rate than in any other American city of Detroit’s size, to call this situation a public health emergency is not hyperbole.

One concern is how far such comparisons reach. While a focus on indicators such as immunisations, malnutrition, infectious disease, reproductive health, health-care expenditures, and all-cause mortality help to guide resource allocation and coalesce sentiment, they do little to advance an understanding of how epidemiological accounting keeps an American city like Detroit excluded from “global health” agendas. Another concern is about concepts. Illness is but one injury. If entangled with other forms or situations of lack and insult, injury may be hard to quantify but even harder to ignore. There is no question that injuries take a unique, cumulative, physical, and mental toll on those living in any setting of sustained economic and social insecurity. We are suggesting that a focus on specifi c forms of harm and their consequences is a valuable analytic starting point for broadening discussions and practices of global health, beyond ex-colonial worlds in

The vacant United Community Hospital, Detroit, USA

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Perspectives

1922 www.thelancet.com Vol 384 November 29, 2014

the South to precarity throughout the globe. The theorist of colonial medicine par excellence—of the way medical encounters in such hierarchical milieus were skewed toward fearful, harmful incongruities—was Frantz Fanon. The types of harm he described, fl owing through lives and clinics, remain germane to medical care in all kinds of global locations today.

United Community Hospital could almost be a hospital in postcolonial Democratic Republic of Congo in the sense that it emerged from similar architectural and political norms and shared—and still shares––particular modernist characteristics. Yet this visual and material rhyming has the potential to obscure the varied realities of people who live in and near these clinics in ruins, to dissolve specifi city as well. The actual practices by which poor citizens cope with decaying infrastructure, collapse, scarcity, and injury are too often absent from the calculations of health policy, bioethics, and global humanitarianism. Universalising poverty misleads and reduces grain, with the everyday texture of injury perforce not sustained and confronted.

Detroit is always already an uneven landscape where the terms of health and illness and connectedness and futures are negotiated each day, not unlike in Kinshasa or Douala or Ferguson, Missouri, for that matter. Recently, the suspension of water services for thousands of low-income households with unpaid utility bills added Detroit to global conversations about the plight of the poor—so much so that a United Nations panel called the water shutoff s a human rights violation, admonishing city government for attempting to alleviate its fi nancial woes by further burdening residents. Access to clean, aff ordable water is an issue that joins the challenges of providing a sanitary infrastructure for poor, rich, and the middle class in Detroit, Delhi, Lagos, and Johannesburg alike.

To what end, therefore, is it useful to think of Detroit as fi guring into the ideas and practices of the global South and of global health? Knowing how to name—and where to place––Detroit within a global scale highlights the paucity of words for situations that approximate but still remain on the periphery of that strange, post-1989, neoliberal edifi ce: Global Health. If we consider rates of disease, of crime and insecurity, of penury and income inequality, Detroit’s participation in the global South is apparent. Surely the word “health” as much as the misnomer “global” (which, let’s not forget, replaced “Third World”) requires scrutiny. When the physician and philosopher of medicine Georges Canguilhem wrote that health’s “existential meaning has been occulted by the demands of accounting”, he suggested that “health” often could no longer be found in a guise of life, but only in its limit within a fi eld of intervention. Health is not only challenged by illness and harm, but becomes a contest between its experience and the indices, histories, and politics that defi ne and shape it.

Whether or not Detroit belongs to a set of measures that make it part of the global South is an open question––one that should remain so. Indeed, combining the objective and the subjective enables an appreciation of how race, poverty, and history produce social injury, pathology, and political consciousness. Detroiters may understand their predicaments as stemming from an American history of racism, riots, white fl ight, post-industrial ruin, and neoliberal-engineered bankruptcy, but also as very much a part of a global history about race, denigration, poverty, humiliation, and insult.

Maybe every discussion of the global South leads to contests about “the other global South”, or greater and lesser instantiations of global health. When we speak of global health—this world of measurements, ambition, innovation, hierarchies, and sometimes venality—we would do well to remember it is not limited in practice or imaginations to formerly colonised worlds, from Africa to India, from post-Ottoman worlds to Latin America. Wherever extreme poverty, catastrophe, disaster, and war enter, those same zones may encounter and often come to rely on global health knowledge and practices. And yet as with Hurricane Katrina, the confl ict in Syria, or the aftermath of Haiti’s earthquake, the move from emergency to the everyday tends to turn escalating humanitarian attentions fi ckle. Concern fades, alarm quiets. We do not write to suggest that a particular kind of epidemiology—critical and social, one underlining the salience of history––has not already been underway for America’s most compelling metropolis today. Rather, we suggest the merit of pondering a paradox: Detroit and its precarities should count as part of the global South, not only in statistical but also in historical and aff ective terms, since global health, injury, violence, and ambivalence are still wrapped up with each other. Excluding Detroit from such catastrophe logic, from the well-funded humanitarian gestures that so often fuel global health eff orts, only works to reinforce North–South asymmetries, to keep them alive––making Fanon’s words just as potent and relevant today as they were in the colonial situation in which they were written: “[in medicine] there is always an opposition of exclusive worlds, a contradictory interaction of diff erent techniques, a vehement confrontation of values”.

*Todd Meyers, Nancy Rose HuntDepartment of Anthropology, Wayne State University, Detroit, MI 48202, USA (TM); and Department of History and Department of Obstetrics/Gynecology, University of Michigan, Ann Arbor, MI, USA (NRH)eg1421@wayne.edu

Todd Meyers is the author of The Clinic and Elsewhere: Addiction, Adolescents, and the Afterlife of Therapy (University of Washington Press, 2013). Nancy Rose Hunt is the author of A Colonial Lexicon: Of Birth Work, Medicalization, and Mobility in the Congo (Duke University Press, 1999); and A Nervous State: Violence, Remedies, and Reverie in Colonial Congo (Duke University Press, in press).

Further reading

Das V. Affl iction: health, disease, poverty. New York: Fordham

University Press (in press)

Fanon F. The wretched of the earth, translated by

Richard Philcox. New York: Grove Press, 2005

Keshavjee S. Blind spot: how neoliberalism infi ltrated global

health. Berkeley: University of California Press, 2014

Lachenal G. Kin Porn. Somatosphere Jan 21, 2013

http://somatosphere.net/2013/01/kin-porn.html

(accessed Nov 18, 2014)

Schulz AJ, Williams DR, Israel BA, Lempert LB. Racial and spatial

relations as fundamental determinants of health in Detroit.

Milbank Q 2002; 80: 677–707

Sugrue TJ. The origins of the urban crisis: race and inequality

in postwar Detroit. Princeton: Princeton University Press, 2005