Public good, ethics, and everyday life: Beyond the boundaries of bioethics

Daedalus

Volumn 128, Issue 4, 1999, Pages 99-133

  Das, Veena ^a,b  

^a NEW SCHOOL FOR SOCIAL RESEARCH   (United States)

^b UNIVERSITY OF DELHI   (India)

Author keywords

[No Author keywords available]

Indexed keywords

DRUG;

ANTHROPOLOGY; ARTICLE; BIOETHICS; BIOETHICS AND PROFESSIONAL ETHICS; CHILD; COMMUNICABLE DISEASE; CULTURAL ANTHROPOLOGY; DEVELOPING COUNTRY; EVALUATION; FREEDOM; HEALTH CARE AND PUBLIC HEALTH; HEALTH CARE DELIVERY; HEALTH CARE ORGANIZATION; HEALTH CARE PERSONNEL; HUMAN; HUMAN RIGHTS; IATROGENIC DISEASE; IMMUNIZATION; INDIA; INFORMATION PROCESSING; INTERNATIONAL COOPERATION; MORBIDITY; MORTALITY; PERSONAL AUTONOMY; POLICY; PUBLIC HEALTH; RESOURCE ALLOCATION; SOCIAL BEHAVIOR; SOCIAL PSYCHOLOGY; SOCIAL WELFARE; SOCIOECONOMICS; SOCIOLOGY; STATISTICS; TRUST; UNITED NATIONS; UNITED NATIONS CHILDRENS EMERGENCY FUND; WORLD HEALTH ORGANIZATION;

BIOETHICS AND PROFESSIONAL ETHICS; HEALTH CARE AND PUBLIC HEALTH; UNICEF;

ANTHROPOLOGY; BIOETHICS; CHILD; COMMUNICABLE DISEASES; DELIVERY OF HEALTH CARE; DEVELOPING COUNTRIES; EVALUATION STUDIES; FREEDOM; HEALTH CARE RATIONING; HEALTH PERSONNEL; HUMAN RIGHTS; HUMANS; IATROGENIC DISEASE; IMMUNIZATION; INDIA; INTERNATIONAL COOPERATION; INTERNATIONALITY; MORBIDITY; MORTALITY; PERSONAL AUTONOMY; PHARMACEUTICAL PREPARATIONS; PUBLIC HEALTH; PUBLIC POLICY; RECORDS; RESOURCE ALLOCATION; SOCIAL RESPONSIBILITY; SOCIAL VALUES; SOCIAL WELFARE; SOCIOECONOMIC FACTORS; SOCIOLOGY, MEDICAL; STATISTICS; TRUST; UNITED NATIONS; WESTERN WORLD; WORLD HEALTH ORGANIZATION;

EID: 0033186749     PISSN: 00115266     EISSN: 15486192     Source Type: Journal    
DOI: None     Document Type: Article

References (104)

1. Arthur Kleinman, Writing at the Margin: Discourse between Anthropology and Medicine (Berkeley: University of California Press, 1995);
2. Kleinman, "Experience and its Moral Modes: Culture, Human Condition, and Disorder," in The Tanner Lectures on Human Values (Salt Lake City: University of Utah Press, 1999), 357-420;
3. Patricia A. Marshall, "Bioethics in Anthropology: Perspectives on Culture, Medicine and Morality," in Medical Anthropology: Contemporary Theory and Method ed. Carolyn F. Sargent and Thomas M. Johnson (Westport, Conn.: Praeger, 1996);
4. J. M. Muller, "Anthropology, Bioethics and Medicine: A Provocative Trilogy," Medical Anthropological Quarterly 8 (4) (1994): 448-467.
5. T. L. Beauchamp and R. R. Faden, "Informed Consent II: Meaning and Elements for Informed Consent," in Encyclopedia of Bioethics, rev. ed., ed. Warren T. Reich (New York: Macmillan, 1995), vol. 3, 1240.
6. See the series of papers under the general title of "Bioethics for Clinicians" edited by Peter Singer in the Canadian Medical Association Journal (1996 and 1997).
7. See the contribution of Renée C. Fox in this volume.
8. D. Macer, "Bioethics in and from Asia," Journal of Medical Ethics 25 (4) (1999): 293.
9. Renu Addlakha and Jan Seeber, Health Ethics in South East Asia: Vol. III (New Delhi: WHO, 1999).
10. It is not my case that Eastern philosophical systems may not have the resources to reconfigure bioethics in a new way. However, simply providing quotations from authorizing texts, such as the Upanisads (Vandana Shiva, "Bioethics: A Third World Issue," 1997; available on website , downloaded on 14 September 1999)
11. or the Constitution (N. Katuriarchi, R. Lie, and J. Seeber, Heath Ethics in South East Asia: Vol. 1 [Delhi: WHO, 1999]), is not likely to advance matters further.
12. Steven Epstein, Impure Science: Public Action and the Politics of Knowledge (Berkeley: University of California Press, 1996).
13. See David Arnold, Colonizing the Body: State, Medicine, and Epidemic Diseases in Nineteenth-Century India (London: Oxford University Press, 1993);
14. Veena Das and Abhijit Dasgupta, "The Cholera Vaccine: Trajectories in Contemporary Bengal," Economic and Political Weekly: Special Issue on Social Science and Immunization (in press);
15. Mark Harrison, Public Health in British India: Anglo-Indian Preventive Medicine, 1859-1914 (Cambridge: Cambridge University Press, 1994);
16. Kavita Misra, "The Productivity of Crisis: On the Relation between Science and State in Colonial India," Economic and Political Weekly: Special Issue on Social Science and Immunization (in press);
17. Harish Naraindas, "Care, Welfare, and Treason: The Advent of Vaccination in the Nineteenth Century," Contributions to Indian Sociology (32) (1998): 1.
18. Arnold, Colonizing the Body;
19. Richard N. Cooper, "International Cooperation in Public Health as a Prologue to Macroeconomic Cooperation," in Cooper et al., eds., Can Nations Agree? (Washington, D.C.: Brookings Institute, 1989);
20. Harrison, Public Health in British India.
21. CISET (Committee on International Science, Engineering, and Technology), Global Microbial Threats in the 1990s, working group on Emerging and Reemerging Infectious Diseases (Washington, D.C.: National Science and Technology Council, 1995).
22. The literature on reemerging infectious diseases is vast; the emergence of resistant strains of tuberculosis and a new strain of cholera in 1992 have been cause for special concern in India. See Cholera Working Group, "Large Epidemic of Cholera like Disease in Bangladesh caused by Vibrio cholorae 0139 synonym Bengal," Lancet 24 (1993): 387-390;
23. A. Kumar, "Microbial Resistance to Drugs - A Universal Problem in Need of Comprehensive Approach," National Medical Journal of India 10 (5) (1997): 221-224;
24. G. B. Nair et al., "Vibrio cholorae 0139 Bengal: The New Serogroup Causing Cholera," Reviews in Medical Microbiology 7 (1) (1996): 49-51;
25. R. Prabhakar, "Tuberculosis - The Continuing Scourge of India," Indian Journal of Medical Research 103 (1996): 19-25;
26. N. Siddiqui et al., "Molecular Genetic Analysis of Multi-drug Resistance in Indian Isolates of Mycobacterium Tuberculosis," Memorias do Instituto Oswalsdo Cruz 93 (5) (1998): 589-594.
27. Stuart B. Levy, The Antibiotic Paradox: How Miracle Drugs are Destroying the Miracle (New York: Plenum Press, 1992);
28. Stuart B. Levy, J. Burke, and E. Wallace, "Antibiotic Use and Antibiotic Resistance Worldwide," Review of Infectious Diseases (9) (1987).
29. Lincoln C. Chen, Tim G. Evans, and Richard A. Cash, "Health as a Public Global Good," in Global Public Goods: International Cooperation in the 21st Century, ed. Inge Kaul, Isabelle Grunberg, and Marc A. Stern (New York: Oxford University Press, 1999), 284-304.
30. Lincoln C. Chen, Tim G. Evans, and Richard A. Cash, "Health as a Public Global Good," in Global Public Goods: International Cooperation in the 21st Century, 1999, 284-304. Ibid.
31. The question of priority is also influenced by what is technologically and administratively feasible. This being granted, it is often overlooked that feasibility cannot be defined in a vacuum. It is itself a function of the imagination of a particular kind of future. If, for instance, the emphasis is on the eradication of a particular disease from society and nature, then not many diseases can be candidates. If, on the other hand, the concern is with the reduction of case load or the case-fatality ratio of a disease, then the policy implications and technological requirements are quite different.
32. Chen, Evans, and Cash, "Health as a Public Global Good," 292.
33. Kleinman, "Experience and its Moral Modes."
34. See Veena Das, Ranendra K. Das, and Lester Coutinho, eds., Social Science and Immunization, special issue of Economic and Political Weekly (in press). This work was conducted as part of an international project on immunization practices in nine countries and was coordinated by Pieter Streefland and Paul Greenough. My colleague, Ranendra Kumar Das, and I directed the country study on India. Following this study, a group of researchers primarily based in Delhi formed a group under the auspices of the Institute for Socioeconomic Research in Democracy and Development and are engaged in researching the burden of disease and health-seeking behavior in both urban and rural settings in India. We are grateful to the governments of the Netherlands and Denmark for their support of the project on Social Science and Immunization for the India country study.
35. But see Fredrique Appfel-Marglin, "Eradication of Smallpox, the Cult of Sitala, and Ecological Politics," Soumen Anthropology 4 (1986): 160-181,
36. Paul Greenough, "Intimidation, Coercion, and Resistance in the Final Stages of the South Asian Small Pox Eradication Campaign, 1973-1975," Social Science and Medicine 41 (1995): 633-645, for important critiques of this position.
37. Statement issued by Dr. Terrell M. Hill, senior health advisor in UNICEF's division. Statement available on website , downloaded on 14 September 1999.
38. R. H. Handerson, "Immunization: Going the Extra Mile," in The Progress of Nations Report (New York: UNICEF, 1998).
39. Despite claims made by WHO and UNICEF, this is difficult to judge because detailed statistics on childhood deaths attributed to vaccine-preventable diseases were not available until recently - these were reported under the general category of infectious diseases. Further, mortality for vaccine-preventable diseases may decline because of the availability of better nutrition or more effective treatment. Even now there are reasons to take the data on the incidence of vaccine-preventable diseases and the case-fatality ratio with caution, as will become clear later. In any case, 40 percent of infant mortality in India occurs in the first twenty-eight days - only part of which can be tackled through Tetanus Toxoid vaccine administered to the mother during pregnancy. Some attempts have been made to assess the impact of immunization on the reduction of mortality, but these face the same problems of the availability of reliable data. See M. A. Koenig, V. Fauveau, and B. Wolyniak, "Mortality Reduction from Health Interventions: The Case of Immunization in Bangladesh," Population and Development Review 17 (1) (1991): 87-104.
40. Illana Lowy, "Yellow Fever in Rio de Janeiro," Medical History 34 (1990): 144-163.
41. Mark Nichter and Mimi Nichter, Anthropology and International Health: Asian Case Studies (Amsterdam: Gordon and Breach, 1996).
42. Peter Aaby, "Assumptions and Contradictions in Measles and Measles Immunization Research: Is Measles Good for Something?" Social Science and Medicine 4 (15) (1995): 673-686;
43. Peter Aaby and B. Samb, "Measles and its Control: Dogmas and New Perspectives," in Health and Disease in Developing Countries, ed. Kari S. Lankinen et al. (London: Macmillan Press Ltd., 1994);
44. Harold V. Wyatt, "Proactive Poliomyelitis: Neglected Clinical Observations from 1914 to 1950," Bulletin of History of Medicine 55 (1981): 543-557;
45. Wyatt, "Unnecessary Injections and Paralytic Poliomyelitis in India," Transactions of the Royal Society of Tropical Medicine and Hygiene 86 (1992): 546-549;
46. Wyatt, "Mothers, Injections and Poliomyelitis," Social Science and Medicine 35 (1992): 595-598.
47. Theodore M. Porter, Trust in Numbers: The Pursuit of Objectivity in Science and Public Life (Princeton, N.J.: Princeton University Press, 1995).
48. The use of the first person plural here refers to the collective work done by the entire Indian team on the project on Social Science and Immunization.
49. Ranendra K. Das and Purnamita Dasgupta, "Childhood Immunization in India: A Macro Perspective," Economic and Political Weekly: Special Issue on Social Science and Immunization (in press).
50. Ranendra K. Das and Purnamita Dasgupta, "Childhood Immunization in India: A Macro Perspective," Economic and Political Weekly: Special Issue on Social Science and Immunization, Ibid.
51. M. A. Zacher, "Health Surveillance as a Public Good," in Global Public Goods: International Cooperation in the 21st Century, ed. Kaul, Grunberg, and Stern, 272-283.
52. Lester Coutinho, Suman Bisht, and Gauri Raje, "Numerical Narratives and Documentary Practices: Vaccines, Targets, and Reports of the Immunization Program," Economic and Political Weekly: Special Issue on Social Science and Immunization (in press).
53. See Das and Dasgupta, "Childhood Immunization in India";
54. Coutinho, Bisht, and Raje, "Numerical Narratives and Documentary Practices";
55. Jishnu Das and Saumya Das, "The Provision of Preventive Health Care: The Case of Immunization," mimeo, 1999. For instance, in their study of preventive health care in Salang, a village in the hilly regions of Garhwal, Das and Das report that, matching age for the number of doses of antigens received, 51 percent of children in the village were partially immunized and 45 percent were unimmunized. These figures point to areas where coverage is low and show that aggregate figures for a country can hide significant variation.
56. See UNICEF, "The State of the World's Children 1999," available on website .
57. I dare to state this despite confident assertions in the UNICEF documents, which give precise figures in the reduction of child mortality attributed to immunization programs. The very precision of the figures is suspect. Handerson states that "Deaths from those six diseases (measles, tetanus, whooping cough, tuberculosis, polio and diphtheria) have been slashed by 3 million a year, and at least 750,000 fewer children are left blind, perplexed, or mentally disabled." Handerson, "Immunization: Going the Extra Mile."
58. Contrast this with the careful computation of the burden of disease in Murray and Lopez, who, despite a massive effort covering documentation from all Primary Health Centers in Maharashtra, were compelled to caution that the data on India were not reliable. Christopher J. L. Murray and Alan D. Lopez, The Global Burden of Disease Study (Cambridge, Mass.: Harvard School of Public Health, 1998).
59. See adverse reaction testimonials downloaded from website on 14 September 1999.
60. Terrel M. Hill, "Synthesis of Lessons Learned: Experience of Universal Childhood Immunization," 1998, downloaded from website on 14 September 1999.
61. Veena Das, "Hunger," Seminar (1) (1998): 67-75;
62. Veena Das, "Food Security and Secure Livelihoods: A Case Study of Bilaspur Division," mimeo, 1998.
63. I should note here that the Pahadi Korvas are classified in administrative discourse as a "primitive tribe" and are entitled to certain special developmental assistance over and above that available to members of "scheduled tribes" according to constitutional provisions. The headman was also a member of a scheduled tribe. Hence the indifference to the Pahadi Korvas did not stem from marked differences in status and rank but from differential control over the resources in the village.
64. India is relatively self-sufficient in vaccine production. The universal program in immunization has received logistic support from UNICEF but it does not depend upon external aid. Where the program is entirely funded by external aid, as in some African countries, the program can become hostage to international conflicts. Thus, the programs devised by international agencies such as UNICEF and WHO are themselves vulnerable to international politics over which they may not have control.
65. Byron Good, Medicine, Rationality, and Experience: An Anthropological Perspective (Cambridge: Cambridge University Press, 1994).
66. Sjaak van der Geest and Susan Reynolds Whyte, eds., The Context of Medicines in Developing Countries (Dordrecht: Kluwer, 1988);
67. Nichter and Nichter, Anthropology and International Health.
68. M. Mamdani and G. Walker, Essential Drugs and Developing Countries: A Review and Selected Annotated Bibliography, EPC publication no. 8 (London: School of Hygiene and Tropical Medicine, 1985).
69. Nina L. Etkin and L. Tan, eds., Medicines: Meanings and Contexts (Philippines: Health Action Network, 1994);
70. Sjaak van der Geest, Susan Reynolds Whyte, and A. Hardon, "Anthropology of Pharmaceuticals: A Biographical Approach," Annual Review of Anthropology 25 (1996): 153-178.
71. Etkin and Tan, Medicines: Meanings and Contexts, 2.
72. van der Geest and Whyte, The Context of Medicines in Developing Countries, 9.
73. Paul Farmer, AIDS and Accusation: Haiti and the Geography of Blame (Berkeley: University of California Press, 1992).
74. Nancy Scheper-Hughes, Death without Weeping: The Violence of Everyday Life in Brazil (Berkeley: University of California Press, 1992).
75. Jishnu Das and Saumya Das, "Health Seeking and the Poor: Evidence from India," mimeo, 1999.
76. A. M. Alam, F. U. Ahmed, and M. E. Rahman, "Misuse of Drugs in Acute Diarrhea in Under-Five Children," Bangladesh Medical Research Council Bulletin 24 (2) (1998): 27-31.
77. See also Anant Phadke, Drug Supply and Use (New Delhi: Sage Publications, 1998).
78. Etkin and Tan, Medicines: Meanings and Contexts.
79. M. A. Domin, "Highly Virulent Pathogens - A Post Antibiotic Era? British Journal of Theatre Nursing 8 (2) (1998): 14-18.
80. Das and Das, "Health Seeking and the Poor."
81. Marc Augé, An Anthropology for Contemporaneous Worlds, trans. Amy Jacobs (Stanford: Stanford University Press, 1999), 8.
82. Paul Farmer, Infections and Inequalities: The Modern Plagues (Berkeley: University of California Press, 1999).
83. Renée C. Fox and Judith P. Swazey, The Courage to Fail: A Social View of Organ Transplants and Dialysis, 2d rev. ed. (Chicago: University of Chicago Press, 1978);
84. Margaret Lock, "Transcending Mortality: Organ Transplants and the Practice of Contradictions," Medical Anthropology Quarterly 9 (3) (1995): 390-399.
85. Rayna Rapp, Testing Women, Testing the Fetus: The Social Impact of Amniocentesis in America (New York: Routledge, 1999);
86. Marilyn Strathern, After Nature: English Kinship in the Late Twentieth Century (Cambridge: Cambridge University Press, 1992).
87. Gísli Pálsson and Paul Rabinow, "Iceland: The Case of a National Human Genome Project," Anthropology Today 15 (2) (1999): 14-18;
88. Paul Rabinow, Making PCR: A Story of Biotechnology (Chicago: University of Chicago Press, 1996);
89. Paul Rabinow, French DNA: Trouble in Purgatory (Chicago: University of Chicago Press, 1999).
90. For an important critique of the manner in which the concept of belief is deployed in medical anthropology, see Good, Medicine, Rationality, and Experience.
91. One of the most interesting anthropological studies that shows the entanglement of these processes in the case of India is Lawrence Cohen, No Aging in India: Alzheimer's, The Bad Family, and Other Modern Things (Berkeley: University of California Press, 1998).
92. The team of researchers is Ranendra K. Das, Renu Addlakha, Jishnu Das, and me, and is assisted by Charu Kumar, Shashi Bhushan Singh, and Bhrigupati Singh. We are conducting a pilot study of forty households in two neighborhoods in Delhi. A weekly morbidity survey on the incidence and prevalence of disease, the type of medical care, and the cost of health care is conducted. A verbal examination of the cases with two physicians, Dr. Karuna Taneja and Dr. Samir Singh, helps us to arrive at some judgment about the likely diagnosis, the efficacy of treatment, and the necessity of the expenditure incurred. Patients who are judged to be at risk of irreversible damage if present regimes of treatment continue are given a choice to consult either of the two doctors free of charge.
93. In a similar study in Salang, a remote access village in the hilly region of Garhwal, Jishnu Das and Saumya Das found that steroids were given by the practitioners in the informal health sector for such conditions as weakness. See Das and Das, "Health Seeking and the Poor."
94. In one case we found a patient who had been taking a drug called APC for thirty years. It appears that this combination of Anacin, paracetamol, and codeine, which was commonly used in the 1930s and was available as a nonprescription drug, is still being manufactured and sold through the informal sector of health care, though we do not know the composition of this medicine.
95. For a detailed study of the use of inappropriate medications in a district in India, see Anant Phadke, Drug Supply and Use (Delhi: Sage Publications, 1998).
96. Pálsson and Rabinow, "Iceland: The Case of a National Human Genome Project," 16-17.
97. See also Rabinow, Making PCR,
98. Rabinow, French DNA.
99. George E. Marcus, Ethnography through Thick and Thin (Princeton, N.J.: Princeton University Press, 1998).
100. Kleinman, "Experience and its Moral Modes";
101. Fox and Swazey, The Courage to Fail.
102. Pálsson and Rabinow, "Iceland: The Case of a National Human Genome Project."
103. Arthur Kleinman, Patients and Healers in the Context of Culture: An Exploration of the Borderland Between Anthropology, Medicine, and Psychiatry (Berkeley: University of California Press, 1980);
104. Kleinman, The Illness Narratives: Suffering, Healing, and the Human Condition (New York: Basic Books, 1988).