Foregrounding possibilities and backgrounding exploitation in transnational medical research projects in Lusaka, Zambia

in Focaal
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  • 1 Independent Scholar Birgitte.bruun@anthro.ku.dk

Abstract

Today medical research funded by resourceful commercial companies and philanthropic organizations increasingly takes place in much less resourceful settings across the globe. Recent academic studies of this trend have observed how global inequalities have shaped the movements of this research, and how human subjects who make their blood and bodies available are at risk of exploitation. In Lusaka, people expressed their fears of being used by transnational medical research projects in various idioms of concern. While such concerns were always latent, people were generally eager to join the projects. Concerns were often backgrounded in favor of pragmatic attention to—and active creation of—possibilities that might stretch well beyond the purpose and time limit of individual research projects. The article illuminates how intimately the ambiguities and possible scenarios of exploitation inherent in transnational medical research projects are intertwined with scenarios of possibility.

Exploitation is a prominent theme in recent critical academic observations of the workings of transnational medical research that recruit study subjects from less privileged se ttings. Kaushik Sunder Rajan, for example, illuminates the inherent structural violence of industry-funded clinical trials in India where the confluence of neoliberal policies and pharmaceutical markets puts a market value on life (biocapital) (2006) and turns laid-off textile mill workers into experimental subjects (2005). Rajan’s interest is to describe and question a new mechanism of the market that absorbs and gains from (biological) life itself. Attention to this mechanism and a critique of the way it creates and maintains inequalities is most prominent in studies of industry-funded transnational medical research for commercial gains (Rajan 2007), but in Africa state- and philanthropy-funded transnational medical research for public health purposes is also often founded on the basis of the same global inequalities that it is meant to alleviate (Crane 2013). Acknowledging Rajan’s observations about the mechanisms of biocapital, but directing my attention toward the ways that these mechanisms unfold in the lives of “experimental subjects,” I trace how extractive transnational medical research operating in less privileged settings may in fact become inseparable from new possibilities for experimental subjects, and I suggest that theories of dispossession address this paradox. More concretely, I show how exploitation and possibility are intimately intertwined for people engaging in transnational medical research in Lusaka.

In Lusaka, during the first decade of the 2000s, the majority of transnational medical research was state donor- and philanthropy-funded research for the betterment of global public health. Still, inequalities between the resourceful transnational organizations that ran the projects and the communities where people were recruited from were clear and tangible for all involved. Such inequalities resonated with wider—and widening—structural asymmetries in the distribution of wealth in Zambia, which is often associated with the implementation of market-oriented and neoliberal policies in Zambia in general, and more specifically with the ups and downs of the value of Zambia’s one primary good on the global market—that is, copper, which is, moreover, controlled by multinational mining houses that take advantage of lacking state regulatory power to avoid channeling profits from the copper mines back into the country (Fraser 2011).

By framing transnational medical research as a parallel case of “body mining,” it is possible to understand transnational medical research projects in Lusaka in terms of poor people being dispossessed of their blood and bodies in both a direct and a structural sense by resourceful organizations who work to make products available in the future for others than the very people who make their bodies available for the development of these products.

It seems curious, then, that people who engaged in the transnational medical research projects as study subjects, peer educators, and recruiters often felt quite privileged to be included and often worked to extend their engagement beyond the time limit of individual projects. It seems even more curious in the context of the widespread critical stance toward such projects that were commonly expressed in Lusaka in different idioms of concern.

This article explores how people in Lusaka who engaged in transnational medical research projects in various capacities expressed concerns of being used by medical research projects and at the same time hoped for continued attachment to the projects. Based on ethnographic fieldwork in Lusaka in 2008–2009,1 the article observes how people who are sufficiently well connected to be included in the projects as study participants or employees tend to “background” concerns of exploitation in favor of attention to various possibilities in the projects, however vague and ambiguous. I have selected three case stories to illuminate how this foregrounding and backgrounding works for women who have different positions in and previous experience with such projects in the context of a deteriorating public health care system, the wider landscape of projects in Lusaka, the lack of wage labor, and moral obligations in relation to others. First, however, I describe the context that has spurred this analysis in the first place: recent developments in transnational medical research in Africa and Zambia.

Transnational medical research in Africa and Zambia

Industry-funded clinical trials initiated by pharmaceutical companies based in Europe and the United States have been outsourced to private companies operating in middle- and low income countries, including Africa, since the mid-1990s. In Africa medical research funded by Europe and the United States is, however, not a new phenomenon. Historians have dealt extensively with colonial medicine and science in Africa (Comaroff 1993; Tilley 2011; Vaughan 1991), but the volume and trends of postcolonial and contemporary medical research for public health purposes mobilized relatively less academic attention until the AIDS epidemic sent prestigious American universities scrambling for Africa in search of hospitals where they could base their international HIV and global health research (Crane 2011). Within a decade this effort has made Africa a key locus of knowledge production in HIV and global health research (Crane 2013).

In Zambia until the late 1990s, medical research was mainly carried out by a few doctors with international connections at the University Teaching Hospital in Lusaka. With the massive international funding for HIV and AIDS in the late 1990s there was a leap in scale and complexity of studies as new collaborators approached the hospital in Lusaka. Quite early on, research was also carried out in the public clinics at district level. Today, a handful of larger transnational research organizations have established themselves firmly in Lusaka, funded by American or British state and philanthropic donors as well as the European Union (EU). Some research organizations have evolved from pure research organizations into providers of health services, such as the distribution of antiretroviral medicines to control HIV, prevention of mother to child transmission of HIV, and screening for tuberculosis and cervical cancer. They have invested heavily in infrastructure, such as laboratories, clinics, fleets of project cars, a whole hospital wing, as well as data management systems and the upgrading of various human resources in the health and hospital sector.

Depending on the setup of the studies, research organizations engage lay people as study subjects, peer educators, outreach workers, recruiters, research assistants, or community advisory board members. During my twelve months of doctoral research I followed thirteen women and two men engaged in these ways. Living close by one of the public health clinics with research activities, I met my most of my main interlocutors weekly and at least fortnightly for informal conversations and went along with them in their daily routines, whether related to research projects or not. I conducted semistructured and structured interviews with them toward the end of the fieldwork period. The three case stories in this article are selected from this material.

Feeling cared for (I)

The first of the case stories concerns a group of young women who engaged as study subjects in a multicountry clinical trial conducted by the Centre for Infectious Disease Research in Zambia (CIDRZ) and funded by American state and philanthropic donors to test microbicides in the form of a vaginal gel to protect against HIV infection. The young women were all in their late teens or early twenties, some of them married with children. Others were mothers, but not necessarily in relationships with the fathers. They all lived in one of the “compounds” of Lusaka.2 The young women had been encouraged to join by one of the young women’s grandmothers, who worked as an outreach worker for the research project. During the recruitment and informed consent process that stretched over several weeks, the young women were informed about the purpose and procedures of the research project that took place in a new building at the district clinic. The young women had regular appointments at the clinic over a period of eighteen months, where they received the next month’s supply of gel, condoms, and free contraceptives. They received a meal and a soda while they waited to be interviewed, examined, and tested for various conditions through blood drawn from their veins. They were entitled to free health care and treatment for the duration of the project, and they received ZMK 20,000 at each monthly visit to the clinic. This amount was about enough to cover a good meal for a household of six to eight people. For purposes of research ethics this cash was very explicitly not listed among the benefits of participating in research, but in practice it was often understood as a kind of payment (cf. Geissler 2012). The young women had learnt to refer to it as transport reimbursement, but like everyone else, they walked to the clinic.

The combination of blood and money in the project was disquieting, however. Sometime after the young women had enrolled in the project, stories about Satanism intensified in connection with the research project. Lukonde explained to me:

The reason why people said that they were Satanists is because when you go to the clinic they will interview you and draw blood for testing, and after that you will be given money for transport and for your time that you have spent there. When you go home, you tell your friends that they drew blood and gave money. People think that the money is in exchange with the blood.

Lukonde’s friend Albetina added:

Some people were saying that they were Satanists because they were drawing three bottles of blood, and so when drawing it felt like sucking. The rumor was sent out in the neighborhood that they were selling the blood. Many people got scared.

Money for blood is a core element both in stories of Satanism and in the procedures of medical research in Lusaka. Stories of Satanism come in many variations, but they share a focus on the clandestine sucking or selling of human blood that will somehow enrich worshippers of Satan and leave the person whose blood has been sucked weakened or even empty. Medical research procedures often entail the drawing of blood in volumes that exceed what is drawn for testing of malaria or HIV that people may already know from previous visits to the clinic. After each scheduled visit to the research clinic study subjects receive a small amount of cash.

Another element is big cars. Tabita had hesitated when she first heard about the research project: “It was my first time hearing about ‘project, project’—I didn’t know much about it. But some people were saying that they are Satanists. They were saying that ‘what do they do with the big ambulance for donating blood?’” This particular project did not employ ambulances, but if study subjects did not appear for their monthly checkups at the clinic they would be visited at home by project staff who came in a project car to take a blood sample. A visit in the compound by a big car might occasion many questions from neighbors and raise suspicions about Satanism, so for this reason the young women never missed an appointment at the research clinic.

Lukonde, Albetina, and their relatives and neighbors readily associated medical research projects with bloodsucking Satanists. This association between medical research and the dangerous and secret sucking or sale of human blood is often noted in sub-Saharan Africa (Geissler and Pool 2006; Stadler and Saethre 2010).

Stories of Satanism, wealth, and medical research

The young women had been quite concerned with stories of Satanism in connection with the project. Their friend, Emelda, had also suspected Satanism and explained: “Okay, when you start with CIDRZ and you want to stop they didn’t allow you to stop … Many people wanted to stop, and I also wanted to stop, because when drawing blood I used to feel dizzy and bad.” For her, as for her friends, stories about Satanism were not abstract hypotheses but translated into uncomfortable physical sensations and deep-seated unease with the drawing of blood in a clinic setting that was both familiar and unfamiliar at the same time. Particularly the event of having one’s blood drawn in the clinic was worrisome. Tabita, Emelda’s friend, explained: “when testing you they [the project nurses] draw about three bottles of blood, and people say that they suck blood, and when you tell your friends that are not in the study that they draw three bottles of blood … they think that they suck your blood.” Tabita’s remark shows how people may distinguish between the drawing of blood as a routine procedure in the clinic and the sucking of blood that is closely associated with Satanism. The extract also shows how easily the same event may slip from one interpretation to a radically different one.

Talk of Satanism seems a fairly recent phenomenon in Zambia, first recorded in the 1990s (Udelhoven 2008), but images of the rich and cosmopolitan Satanists share many features with older stories of banyama (White 1993a) or “vampire men” (White 1995: 236) that spread from Tanganyika to Northern and Southern Rhodesia (today’s Zambia and Zimbabwe) from the 1930s until the mid-1950s together with, and sometimes ahead of, the movements of colonial intervention. As the stories traveled, the vampire men changed names and attributes (which sometimes included cars), but the stories shared and kept a focus on the theft and sucking of blood, a most powerful symbol of life force and strength on the continent. In Northern Rhodesia at the time, according to historian Mwelwa Musambachime (1988), strangers, chiefs, European doctors, fat administrators, prospectors, surveyors, and tourists could be suspected of being banyama, who were said to abduct innocent people to sell their blood to Europeans, who needed African blood for modern medicines. Musambachime and White both related elements of stories about the banyama to experience with colonialism. Following these scholars and Evans-Pritchard’s classic observation (1937: 513), that new situations demand new magic, contemporary stories about Satanism can be interpreted broadly as a new idiom of concern in debates about new conditions.

Conditions for everyday lives have indeed undergone changes in Zambia. When Zambia became independent from British rule in 1964, profits from the rich copper mines that had otherwise been an important source of the wealth of the British Empire since the early twentieth century turned Zambia into one of the most economically promising independent states in Africa in the early 1960s. Only a decade later, Zambia plunged into an extraordinarily steep economic decline—even for Africa—due to a combination of shifts in terms of trade for copper and growing external debts. These changes can be related to shifts in the political economy toward a market-based neoliberalism that began as early as the 1970s in Zambia with “stability measures” encouraged by the multilateral financial institutions, the International Monetary Fund (IMF) and the World Bank (Rakner 2003: 12). These measures shared their logic with the later structural adjustment programs of the 1980s and 1990s, which had such harsh consequences for the general population. The result was not only economic hardship but also loss of a sense of future (Ferguson 1999). Since the early 2000s new wealth has come into the country, mainly following new foreign investments in copper mining. Huge malls, often South-African owned, have appeared, and the tall and crumbling modernist concrete buildings along the main road in Lusaka that were built around independence as birthmarks of the new nation are now being redesigned and renovated by foreign corporations.

People in the compounds rarely feel any impact of this new wealth. On the contrary, they try to cope with recurring price hikes of basic commodities and services (www.jctr.org.zm), and limitations to their attempts to trade (Hansen 2004). They talked about the many new cars jamming roads that had otherwise been leftto turn into dust but that had recently been given new tarmac. Cars are among the most desirable signs of (conspicuous) wealth in Lusaka. They also observed the construction and completion of an enormous new cathedral by a Pentecostal church near the center of Lusaka. Pentecostal churches that are often observed to focus on prosperity have proliferated across sub-Saharan Africa in recent decades, and the figure of Satan is often very prominent in the rhetoric of the churches (Maxwell 1998, 2005; Meyer 2003). At some point stories began circulating in Lusaka that buckets full of human blood were kept behind the altar of the new cathedral to use in rites enriching devil worshippers. Around the same time riots broke out around the church where people smashed the windows of the cathedral and the cars parked around it.

Since Geschiere’s observation that ideas of witchcraft are integral to contemporary politics in Africa (1997), stories about occult phenomena and the ways that they mobilize people have been interpreted as an idiom of resistance to the workings of contemporary forms of accumulation, or as a metacommentary on global forces (Comaroff and Comaroff 1999; see also Taussig 1977).

Rumors about vampire men and Satanists with their many layers of meanings are, however, notoriously difficult to interpret. Interpreting them as a form of resistance or a critique of exploitation risks violating their polysemic nature and their inherent situatedness (cf. White 1993b: 756). They are sometimes retold with a degree of skepticism, and they often appear in very particular social processes where interpersonal relations are strained and where local particularities regarding the meanings of blood and money play into the retelling of the rumours (Fairhead et al. 2006; Geissler 2005). In Lusaka, for example, Satanist stories were often brought up as a legitimate reason for avoiding the HIV test that was an element in most research projects. Besides, stories of Satanism are not only told in relation to medical research projects and churches but may also be invoked in connection with boarding schools and with regular public health projects. A director of district health in Lusaka once observed that any new research or health program would be suspected of being Satanic (Bond and Shanaube 2005).

Whereas stories of Satanism are often about the risk of being used for someone else’s benefit, an important point here is that there was no one-to-one relation between stories of Satanism and medical research projects. Still, the repeated connection between Satanism and medical research projects in Lusaka; the returning motive of blood being taken away to enrich others; and the way project staff, including temporary employees who received a salary from the project, could be accused of Satanism might be seen as an expression of concern with the research projects and whom they would really benefit. Was blood drawn or sucked in the clinic? Whom did the project staff really work for? It was such concerns that formed the background for Lukonde and Albetina’s accounts in the excerpt above and that their friend Emelda viscerally felt when she became dizzy after having her blood drawn in the research clinic. Acknowledging how stories of Satanism invite for many different interpretations they should be seen as an available idiom (Geissler 2005) with rich historical and regional roots that people may apply in connection with transnational medical research to foreground a scenario of being used or exploited for someone else’s advantage.

Feeling cared for (II)

As Lukonde mentioned above, there had been many rumors about Satanism some years earlier. The association of the project with Satanism could have been unsettling, and Albetina’s parents had even told her stop going to the clinic at the time. She had not followed their advice, however, and neither had her friends. In fact, stories of Satanism were not prominent in the young women’s own accounts of their engagement in the project. Instead, the young women talked at length about how they appreciated learning new things in a setting where learning and education were closely associated with images of social mobility. They shared this knowledge with friends, who were not enrolled in the project. Depending on their position in their household they spent the little cash that they received in the project on lotion, clothes, or on food to share, and like many other study participants, they waited for the next project to begin when the study was over. They also talked about the way they had been cared for by the staff in the project.

Project nurses had encouraged them when they first came to the clinic and realized that they would have to be tested for HIV. The HIV test caused intense concern since a positive test result is usually first associated with shame and fear of ridicule, stigma, suffering, and death. I asked Albetina and Emelda what the difference was between getting the HIV test at the clinic and from the research project. Emelda answered: “When I got pregnant I was tested [for HIV] at the clinic and I was scared, but when I went for CIDRZ I was encouraged and welcomed. I felt open to discuss anything, but at the [district] clinic they just test and give you the results.” Albetina added: “At CIDRZ they will counsel you nicely and welcome you, and they will even tell you that you still be our friend even if you are HIV positive. But at the clinic they will just test you and forget about it. They won’t even make follow-up.”

The expansion of transnational medical research in sub-Saharan Africa has happened at a time when state-financed health care services have been in decline for decades in many countries (e.g. Masquelier 2001), for reasons often ascribed to neoliberal policies. The young women saw a contrast between the way they were treated in the study and the way they would have been treated in the district clinic. This contrast was not just a matter of access to free medicines and research projects having more and better resources in terms of staff, medicine, and technologies. It was also a matter of the way their initial fear of the HIV test was handled by the project staff which made the young women feel that the project and the project staff took care of them. It is in this light that their explicit appreciation of follow-up should be understood.

This feeling of being cared for in relations with attentive staff from an obviously resourceful project, combined with their trust in the grandmother who had recruited them, made them able to overcome the concerns that arose during the period when the circulation of stories about Satanism intensified. Even if the project seemed ambiguous and dangerous, the young women’s momentary doubts were backgrounded in the context of its possibilities. This case illuminates how the young women, like many other study subjects, tended to foreground the care or service scenario of the project rather than the scenario that could be talked about in the idiom of Satanism.

Making an uncertain career

Joanna had also very much enjoyed the care that she had received as a study subject. Besides, because of her training as a counselor for HIV testing, she was one of the few study subjects who had also been employed as a peer educator and recruiter in several medical research projects by two different research organizations. Joanna was twenty-eight years old, and she lived in a compound with her two school-aged children and her relatives in a cluster of low huts and houses. She referred to a husband, but I never met him. When Joanna first began working as a recruiter for the CIDRZ project, she mentioned how people had talked about the project logo on the T-shirts that came from the project: “Eee, they have come from the Satanists, see their T-shirt, [with an image of] a man and a woman wearing red things, that symbol is showing that … [whispering] Satanism.” Joanna had then asked people: “A Satanist living in one room? Not having mealie meal?” implying that Satanists could not be as poor as she. Another layer in stories of Satanism and their focus on money and wealth is activated when it is applied to accusations of greed in relations between neighbors and colleagues, who might not be equally well connected to projects that offer possibilities for formal employment.

Formal employment has played a comparatively large and identity-shaping role in urban Zambian livelihoods since mining became a source of income for many men from the 1920s on (Ferguson 1999; Mitchell 1956). During the first years after independence many new and prestigious white-collar jobs were created in state and parastatal institutions, particularly in Lusaka—also for women. Since the economic crisis beginning in the early 1970s and the Structural Adjustment Programs of the 1980s and 1990s, formal employment has become increasingly difficult to come by. Instead, many men and women in urban areas try to make a living from “business,” meaning small-scale trading of various goods (Hansen 2008).

Working for the research organization was certainly a good source of income for Joanna. She had earned about 1.4 million Kwacha per month (about USD 300) in her work as a recruiter for CIDRZ, which was slightly more than that of a trained junior nurse at the time. But it was also more than that. Joanna enjoyed educating study subjects, sitting in meetings with the professional project staff, and being a specialist within the area of medical research projects. Joanna’s accounts of her work were full of the language that comes with development projects (“stigma and discrimination,” “sensitize,” “volunteer,” “the community,” “the field”), but also the more specialized language that comes with medical research specifically (“screening,” “mapping,” “retention,” “informed consent form”). Joanna talked with pride about the way that her “boss,” the community liaison officer in the study, would listen when she talked in meetings. Her work was temporary, however, limited to the duration of the project.

In Zambia, as elsewhere in Africa, international nongovernmental organizations (NGOs) and churches have made “volunteering” a relevant possibility—particularly for women—that many hope might turn into salaried, although usually only temporary, job openings (Prince 2013; Swidler and Watkins 2009). In Lusaka, transnational medical research projects have to a large extent become part of this wider landscape of health and social development projects and programs run by national and international NGOs, churches with international ties, and the Zambian state, which received earmarked international support for such activities (cf. Whyte et al. 2013: 143–144). Getting these temporary jobs depends on knowing the right people as much as on training and skills.

Joanna was acutely aware of the temporary nature of her position, and she made efforts to maintain good relations with project staff, even after the end of the project, in the hope that she would be employed again. She also maintained good relations with colleagues on the project and at the district clinic to stay informed about new possibilities for projects by other research organizations. Not so many people in the compound knew about more than one research proj ect or research organization, but like most of these few people (often volunteers in the district clinics), Joanna was less interested in the particular products on trial and their purpose, and more interested in ways of becoming attached to research projects and organizations. Her work was a matter of economic security as well as identity for her, and in an effort to sustain both, she tended to her relations with staff, colleagues, neighbors, and friends who knew that she was connected with such research organizations.

Joanna laughed at talk of Satanism in connection with medical research. She did not associate the projects with being used or with exploitation but with possibilities for herself and those that she cared for. She was aware that she could be accused of Satanism herself, but she also told me how neighbors and others had now started approaching her to ask when the next project would begin. Joanna herself did not relate much to the research elements of the projects, but appreciating the regular health checks and being attentive to possibilities in the shifting constellations of project infrastructures and organizations, she worked to make a career out of her experience with projects and with medical research projects in particular. Joanna was clearly aware of all the associations that stories of Satanism brought along as a frame for understanding what medical research was about, but she consistently foregrounded and tried to expand the possibilities that came with the projects.

Fulfilling moral obligations

Like Joanna, Precious, who was in her early thirties and married to an unlicensed taxi driver, was experienced in project work. She was very active as a volunteer in the Neighborhood Health Committee at the local district clinic. In addition, she worked in four different donor programs at the clinic aimed at infants and malnourished children, which included the distribution of various foodstuffs and therapeutic foods. She was on good terms with the sister-in-charge at the clinic, who often sent Precious to workshops and seminars to represent the community and to share what she had learned in the workshops and seminars with other volunteers. By patching together more or less regular salaries and allowances, she supported several of her relatives and their education, and many others relied on her for advice and as a connection to health staff at the clinic.

Several years before I met her, Precious had been enrolled in a study run by a foreign researcher based at the University Teaching Hospital. The project recruited from the compound where she lived to test a pill that was intended to prevent diarrhea. Telling me about the events years later, she explained how she was approached by the project research assistants in her home, and how she had first thought that she was being offered free health care. She had agreed to join the project, but she had soon realized that it was a research project. She had asked the researcher many questions, and she had begun dropping the pills that she was supposed to take every day in the latrine because she was not sure about their effects. She left the project after six months—in spite of research assistants’ efforts to persuade her to stay—when she was called to have an endoscopy made at the University Teaching Hospital. She feared the procedure too much.

Through her contacts at the district clinic she had heard about a job as a recruiter of couples for couple counseling by a research organization, just as Joanna had. She had found the job difficult, however, because people accused her of being a Satanist and threw stones at her. She herself had also been concerned about the volume of blood that was drawn in the project, but her concerns had been addressed when she had been invited to visit a laboratory where blood samples were processed. She saw, for example, that all blood samples were burnt after analyses had been carried out on them. Still, she had concerns. She had heard about the CIDRZ study that the young women had been enrolled in, and she became a recruiter for it. But when she was asked to join the project as a study subject herself she refused, as she had her doubts about medical research and foreign researchers operating in Zambia. I learnt about her doubts when one day Precious pulled out some papers from her bulky bag and came over to show them to me. They were a photocopy of a chapter in The body hunters by Sonia Shah, an investigative journalist, with a foreword by John le Carré, published in New York in 2006. The book critically examines examples of Big Pharma’s medical research for the benefit of the industry and rich consumers in the global North at the expense of poor people in the global South. She showed me that the chapter mentioned the same doctor who had once enrolled her in the endoscopy study. Now Precious got agitated:

In the future I will join the CAB [Community Advisory Board], because they don’t stand up for us. They should provoke researchers much more. How can they just come here and use us just because we are poor? … And then they start insulting us! They should not get an advantage of our poverty. They are even contributing to our poverty by giving us 20,000 because that does not make us do anything new. They will say, “Zambians are weak, just give them 20,000 and you’ll get what you want.” I don’t know how Zambians permit them to come and do this work? … They should teach us skills so we can work. They should say, “Let’s try to help them where they are weak.” But most people will join the researchers … here is a researcher offering everything … I don’t want anybody touching my body any more. I am never going to join research again.

Here Precious expressed her concern about transnational medical research in an idiom that drew from a more political vocabulary to point to the same feeling of exploitation that elements in stories of Satanism may tap into. She blamed Zambians with influence for letting foreigners exploit poor Zambians without influence—pointing to both national and international politics and power relations, rather than blood-sucking Satanists. Precious did not question the purpose of transnational medical research, but that it took place in Zambia. Invoking a scenario of global inequalities, she chided the researchers for the little money they gave people. She did not call for access to medicines and other classic benefits from ethical codes of conduct for medical research and neither did she speak of abstract rights. Instead, she wanted the researchers to teach people skills so they could work.

Precious was one of the very few people that I met who expressed her concern by drawing on this kind of critical political discourse about transnational medical research. She only voiced her critical stance this explicitly once, however, and she still recruited for various research projects, because she found it important how study subjects could learn something from being in the projects, and because many people relied on her for the kind of possibilities that projects (of any kind) could offer. Considering her position as a provider for many people, she was obliged to share the possibilities that came out of her many connections to projects at the clinic. She could not not share (and besides, she herself could stay informed about new possibilities in the research organizations, like Joanna).

This case illuminates how the same person moves between scenarios of exploitation and possibility in relation to transnational medical research projects, and it adds the more explicitly political discourse of foreign researchers exploiting poor Zambians to the repertoire of concerns with transnational medical research that can also be expressed in stories of Satanism. Precious’s story illuminates how people who are quite explicitly critical about the inherent inequalities in transnational research projects still foreground the possibilities that come out of the services and infrastructure of the projects to be able to share and care for others for whom she felt responsible.

The pragmatics of foregrounding possibility in unequal relations

Critical studies situate transnational medical research within a frame that highlights how neoliberal market mechanisms facilitate the dispossession of blood and control over bodies when people from less privileged settings make their bodies available as sites for medical experimentation by transnational research organizations.

In Lusaka, many people had been engaged in transnational medical research projects, and they did indeed express concerns about exploitation in various ways, including by telling stories about Satanism. Still, as an available idiom of concern with extraction and the purpose of medical research Satanism was not the only frame for engaging in the projects (cf. Andersson 2002) and it was in fact not very prominent in people’s engagement in the projects. Neither did people who framed their concerns in a more political discourse organize to demand more or different benefits from the research organizations. Instead, people in the compounds of Lusaka were often eager to join the projects. Many explored transnational medical research projects with a sense of possibility more than dread (once they had dealt with their fear of the HIV test).

Common to the three case stories in this article is the way that both study subjects and temporary employees in the projects often backgrounded stories of Satanism and exploitation that were associated with the purpose of the projects. Instead, they paid attention to the possibilities that were variously and closely linked to the health service aspect and the organizational infrastructure of the projects and tried to stretch them beyond the time limit of the individual research projects. In the context of deteriorating public health services, life in a compound, the lack of wage labor, and moral obligations to share, possibilities from the projects included cash and free medicine, a sense of feeling cared for and of learning something, temporary jobs, new connections, and an identity as someone with a job, a position from which possibilities could be shared with relatives, friends, and neighbors in the ongoing moral obligations of everyday relations that included project staff. The relevance and realization of each of these possibilities depended on one’s position in a web of connections and previous experience in projects.

From a perspective that sees transnational medical research as one more instance of exploitation in a long history of dispossession it seems like a paradox that people in Lusaka submit their blood and bodies to the projects and even see attractive possibilities in them. For many people in the compounds, who are occupied with the pragmatics of everyday life and relations, there is no paradox, however, but rather the unceasing concerns that come with exchanges in shifting unequal relations (cf. Ferguson 2013).

Still, examining patterns of dispossession from a critical perspective it is noteworthy how transnational medical research projects—whether industry- or philanthropy-funded—tend to recruit their study participants in relatively less privileged countries. This pattern is repeated within countries, when, as in Lusaka, it is mainly people from the poorer compounds of the city who join the research projects. They are dispossessed of their blood and full control over their bodies when they make themselves available for transnational medical research projects from the results of which (in terms of both new treatments and the profits from selling them) they may never benefit directly (Hayden 2007). From this perspective transnational medical research can be seen as facilitating a neoliberalization of the body, which takes blood and dignity away. Paradoxically, as this article has foregrounded, transnational medical research concurrently opens up possibilities for applying one’s body in new ways that sustain life and dignity. The ethnographic study of this paradox offers necessary nuances to theories of experimental subjects in transnational medical research and to the wider field of critical studies of dispossession.

Acknowledgments

I thank Oscar Salemink and Mattias Borg Rasmussen for their careful reading of my drafts and their immensely patient feedback. Likewise, I thank the reviewers for asking the questions that clarified my argument. All remaining shortcomings and errors are mine.

Notes
1

I received permission from the Ministry of Health and the Lusaka District Health Management Team and ethical clearance from the London School of Hygiene and Tropical Medicine in the United Kingdom and the Tropical Diseases Research Centre Ethics Review Committee in Ndola, Zambia. The study was funded by an Internationalization stipend from the Danish Research Council.

2

A common term throughout the southern African region, a “compound” originally referred to a designated African housing area within a colonial settlement. Today earlier racial divisions have become socio-economic divisions (Hansen 1997), and a compound in Lusaka refers to all “high-density,” low-income areas, which are often unauthorized squatters’ settlements.

References

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  • Musambachime, Mwelwa C. 1988. The impact of rumor: The case of the Banyama (vampire men) scare in Northern Rhodesia, 1930–1964. International Journal of African Historical Studies 21(2): 201215.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Prince, Ruth J. 2013. Precarious projects: Conversions of (biomedical) knowledge in an East African city. Medical Anthropology 33(1): 6883.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Rajan, Kaushik Sunder. 2005. Subjects of speculation: Emergent life sciences and market logics in the United States and India. American Anthropologist 107(1): 1930.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Rajan, Kaushik Sunder. 2006. Biocapital: The constitution of postgenomic life. Durham: Duke University Press.

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    • Crossref
    • Search Google Scholar
    • Export Citation
  • Stadler, Jonathan, and Eirik Saethre. 2010. Rumours about blood and reimbursements in a microbicide gel trial. African Journal of AIDS Research (AJAR) 9(4): 345353.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Swidler, Ann, and Susan Cotts Watkins. 2009. “Teach a man to fish”: The sustainability doctrine and its social consequences. World Development 37: 11821196.

    • Search Google Scholar
    • Export Citation
  • Taussig, Michael. 1977. The genesis of capitalism amongst a South American peasantry: Devil’s labor and the baptism of money. Comparative Studies in Society and History 19(2): 130155.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Tilley, Helen. 2011. Africa as a living laboratory. Empire, development, and the problem of scientific knowledge, 1870–1950. Chicago: University of Chicago Press.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Udelhoven, Bernhard. 2008. Satanism in Zambia: A new tree with old roots. Faith and Encounter Centre Zambia (FENZA).

  • Vaughan, Megan. 1991. Curing their ills: Colonial power and African illness. Cambridge: Polity.

  • White, Luise. 1993a. Cars out of place: Vampires, technology, and labor in East and Central Africa. Representations (43): 2750.

  • White, Luise. 1993b. Vampire priests of Central Africa: African debates about labor and religion in colonial Northern Zambia. Comparative Studies in Society and History 35(4): 746772.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • White, Luise. 1995. Tsetse visions: Narratives of blood and bugs in colonial Northern Rhodesia, 19319. Journal of African History 36(2): 219245.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Whyte, Susan Reynolds, Michael A. Whyte, Lotte Meinert, and Jenipher Twebaze. 2013. Therapeutic clientship: Belonging in Uganda’s mosaic of AIDS projects. In João Biehl and Adriana Petryna, eds., When people come first: Anthropology and social innovation in global health, pp. 140165. Durham: Duke University Press.

    • Crossref
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Contributor Notes

Birgitte Bruun has a PhD in anthropology from The London School of Hygiene and Tropical Medicine, where she was a member of the Anthropologies of African Biosciences Research Group. She has conducted fieldwork in rural Ghana and Malawi and in urban Zambia. Her PhD dissertation “Daily trials: Lay engagement in transnational medical research in Lusaka, Zambia,” explores trajectories of engagement in transnational medical research projects as part of a wider landscape of projects and interventions. E-mail: Birgitte.bruun@anthro.ku.dk

Focaal

Journal of Global and Historical Anthropology

  • Andersson, Jens A. 2002. Sorcery in the era of “Henry IV”: Kinship, mobility, and mortality in Buhera District, Zimbabwe. Journal of the Royal Anthropological Institute 8(3): 425449.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Appelbaum, Paul S., Loren H. Roth, Charles W. Lidz, Paul Benson, and William Winslade. 1987. False hopes and best data: Consent to research and the therapeutic misconception. Hastings Center Report 17(2): 2024.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Bond, Virginia, and Kwame Shanaube. 2005. Making sense of Satanist accusations in Zambia: A modern witchhunt against exploitation and disorder? Paper presented at the conference “Locating the field: The ethnography of medical research in Africa,” Kilifi, Kenya, December 4–.

    • Search Google Scholar
    • Export Citation
  • Comaroff, Jean. 1993. The diseased heart of Africa: Medicine, colonialism, and the black body. In Shirley Lindenbaum and Margaret Lock, eds., Knowledge, power, and practice: The anthropology of medicine and everyday life, pp. 305329. Berkeley: University of California Press.

    • Search Google Scholar
    • Export Citation
  • Comaroff, Jean, and John L. Comaroff. 1999. Occult economies and the violence of abstraction: Notes from the South African postcolony. American Ethnologist 26(2): 279303.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Crane, Johanna. 2011. Scrambling for Africa? Universities and global health. Lancet 377: 13881390.

  • Crane, Johanna Tayloe. 2013. Scrambling for Africa: AIDS, expertise, and the rise of American global health science. Ithaca: Cornell University Press.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Evans-Pritchard, Evans E. 1937. Witchcraft, oracles, and magic among the Azande. Oxford: Clarendon.

  • Fairhead, James, Melissa Leach, and Mary Small. 2006. Where techno-science meets poverty: Medical research and the economy of blood in The Gambia, West Africa. Social Science and Medicine 63(4): 11091120.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Ferguson, James. 1999. Expectations of modernity: Myths and meaning of urban life on the Zambian Copperbelt. Berkeley: University of California Press.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Ferguson, James. 2013. Declarations of dependence: Labour, personhood, and welfare in southern Africa. Journal of the Royal Anthropological Institute 19(2): 223242.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Fraser, Alastair 2011. Boom and bust on the Zambian Copperbelt. In Alastair Fraser and Miles Larmer, eds., Zambia, mining, and neoliberalism: Boom and bust on the globalized Copperbelt, pp. 130. New York: Palgrave Macmillan.

    • Search Google Scholar
    • Export Citation
  • Freston, Paul. 2005. The Universal Church of the Kingdom of God: A Brazilian church finds success in Southern Africa. Journal of Religion in Africa 35: 3365.

    • Search Google Scholar
    • Export Citation
  • Geissler, Paul Wenzel. 2005. “Kachinja are coming!” Encounters around a medical research project in a Kenyan village.” Africa 75(2): 173202.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Geissler, Paul Wenzel. 2012. “We are not paid—they just give us”: Liberalisation and the longing for biopolitical discipline around an African HIV prevention trial. In Paul Wenzel Geissler, Richard Rottenburg and Julia Zenker, eds., Rethinking biomedicine and governance in Africa, pp. 197227. Bielefeld: transcript Verlag.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Geissler, Paul Wenzel, and Robert Pool. 2006. Editorial: Popular concerns about medical research projects in sub-Saharan Africa—a critical voice in debates about medical research ethics. Tropical Medicine and International Health 11(7): 975982.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Geschiere, Peter. 1997. The modernity of witchcraft : Politics and the occult in postcolonial Africa. Charlottesville: University Press of Virginia.

    • Search Google Scholar
    • Export Citation
  • Hansen, Karen Tranberg. 1997. Keeping house in Lusaka. New York: Columbia University Press.

  • Hansen, Karen Tranberg. 2004. Who rules the streets? The politics of vending space in Lusaka. In Karen Tranberg Hansen and Mariken Vaa, eds., Reconsidering informality: Perspectives from urban Africa, pp. 6280. Uppsala: Nordiska Afrikainstitutet.

    • Search Google Scholar
    • Export Citation
  • Hansen, Karen Tranberg. 2008. The informalization of Lusaka’s economy: Regime change, ultra-modern markets, and street vending, 1972–2004. In Jan-Bart Gewald, Marja Hinfelaar, and Giacomo Macola, eds., One Zambia, many histories, pp. 213239. Leiden: Brill.

    • Search Google Scholar
    • Export Citation
  • Hayden, Cori. 2007. Taking as giving: Bioscience, exchange, and the politics of benefit-sharing. Social Studies of Science 37(5): 729758.

  • Masquelier, Adeline. 2001. Behind the dispensary’s prosperous façade: Imagining the state in rural Niger. Public Culture 13(2): 267291.

  • Maxwell, David. 1998. “Delivered from the Spirit of Poverty?” Pentecostalism, prosperity, and modernity in Zimbabwe. Journal of Religion in Africa 28(3): 350373.

    • Search Google Scholar
    • Export Citation
  • Maxwell, David. 2005. The Durawall of faith: Pentecostal spirituality in neo-liberal Zimbabwe. Journal of Religion in Africa 35(1): 432.

  • Meyer, Birgit. 2003. Commodities and the power of prayer: Pentecostalist attitudes towards consumption in contemporary Ghana. In Birgit Meyer and Peter Geschiere, eds., Globalization and identity, pp. 151176. Oxford: Blackwell.

    • Search Google Scholar
    • Export Citation
  • Mitchell, J. Clyde. 1956. The Kalela dance: Aspects of social relationships among urban Africans in Northern Rhodesia. Published on behalf of The Rhodes-Livingstone Institute by Manchester University Press.

    • Search Google Scholar
    • Export Citation
  • Musambachime, Mwelwa C. 1988. The impact of rumor: The case of the Banyama (vampire men) scare in Northern Rhodesia, 1930–1964. International Journal of African Historical Studies 21(2): 201215.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Prince, Ruth J. 2013. Precarious projects: Conversions of (biomedical) knowledge in an East African city. Medical Anthropology 33(1): 6883.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Rajan, Kaushik Sunder. 2005. Subjects of speculation: Emergent life sciences and market logics in the United States and India. American Anthropologist 107(1): 1930.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Rajan, Kaushik Sunder. 2006. Biocapital: The constitution of postgenomic life. Durham: Duke University Press.

  • Rajan, Kaushik Sunder. 2007. Experimental values: Indian clinical trials and surplus health. New Left Review 45: 6788.

  • Rakner, Lise. 2003. Political and economic liberalization in Zambia 1991–2001. Uppsala: Nordiska Afrikainstitutet.

  • Reuters. 2005. Zambia bans Brazilian church in Satanism row. http://wwrn.org/articles/19706/?&place=southern-africa.

  • Reynolds, Joanna, Peter Mangesho, Martha M. Lemnge, Lasse S. Vestergaard, and Clare I. R. Chandler. 2013. “… in the project they really care for us”: Meaning and experiences of participating in a clinical study of first-line treatment for malaria and HIV in Tanzanian adults. Global Public Health 8(6): 670684.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Stadler, Jonathan, and Eirik Saethre. 2010. Rumours about blood and reimbursements in a microbicide gel trial. African Journal of AIDS Research (AJAR) 9(4): 345353.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Swidler, Ann, and Susan Cotts Watkins. 2009. “Teach a man to fish”: The sustainability doctrine and its social consequences. World Development 37: 11821196.

    • Search Google Scholar
    • Export Citation
  • Taussig, Michael. 1977. The genesis of capitalism amongst a South American peasantry: Devil’s labor and the baptism of money. Comparative Studies in Society and History 19(2): 130155.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Tilley, Helen. 2011. Africa as a living laboratory. Empire, development, and the problem of scientific knowledge, 1870–1950. Chicago: University of Chicago Press.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Udelhoven, Bernhard. 2008. Satanism in Zambia: A new tree with old roots. Faith and Encounter Centre Zambia (FENZA).

  • Vaughan, Megan. 1991. Curing their ills: Colonial power and African illness. Cambridge: Polity.

  • White, Luise. 1993a. Cars out of place: Vampires, technology, and labor in East and Central Africa. Representations (43): 2750.

  • White, Luise. 1993b. Vampire priests of Central Africa: African debates about labor and religion in colonial Northern Zambia. Comparative Studies in Society and History 35(4): 746772.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • White, Luise. 1995. Tsetse visions: Narratives of blood and bugs in colonial Northern Rhodesia, 19319. Journal of African History 36(2): 219245.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Whyte, Susan Reynolds, Michael A. Whyte, Lotte Meinert, and Jenipher Twebaze. 2013. Therapeutic clientship: Belonging in Uganda’s mosaic of AIDS projects. In João Biehl and Adriana Petryna, eds., When people come first: Anthropology and social innovation in global health, pp. 140165. Durham: Duke University Press.

    • Crossref
    • Search Google Scholar
    • Export Citation

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