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Why Nation-States and Journalists Can't Teach People to Be Healthy: Power and PragmaticMiscalculation in Public Discourses on HealthAuthor(s): Charles L. BriggsSource: Medical Anthropology Quarterly, New Series, Vol. 17, No. 3 (Sep., 2003), pp. 287-321Published by: Wiley on behalf of the American Anthropological AssociationStable URL: http://www.jstor.org/stable/3655387 .

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CHARLES

L. BRIGGS

Department

of Ethnic Studies

University

of

California,

San

Diego

Why

Nation-States

and

Journalists

Can't

Teach

People

to Be

Healthy:

Power

and

Pragmatic

Miscalculation

in

Public

Discourses

on Health

For

Feliciana

This article

analyzes

how

Venezuelan

public

health

officials

collaborated

with

journalists

in

producing

information

about cholera

in

January-

December

1991. It

uses

Michael Warner's

(2002)

observation

that

such

public

discourse involves

a

contradiction:

it must

project

the

image of

reaching

an

actually existing public

at

the same

time that

it creates

multiple

publics

as

it

circulates.

The

analysis

explores

the

language

ideologies

that hide

complex

sets

of practices,

networks,

and

material conditions

that

shape

how

public

discourses circulate.

At the same

time that

epidemi-

ologists

targeted

poor

barrio residents, street vendors

offood

and drink,

and

indigenous

people

as

being

"at

high

risk,

"

health

education

messages

pictured

women in

well-equipped

kitchens

demonstrating

cholera

prevention

measures.

The

gap

between these

ideal

audiences

and

the

discrepant publics

created

by

their circulation limited

the

effectiveness

of

prevention efforts

and created

a

substantial chasm

between

public

health

institutions

and the

publics they

sought

to

reach.

[public

discourse,

epidemics,

health

education,

social

inequality,

Latin

America]

ow should we understand the concept of "public" that is embedded in no-

tions

of

"public

health"?

Although

care

is often taken

to define the

concept

of

"health,"

"public"

seems

to be

relegated

more

frequently

to common-

sense

understandings.

It

is

contrasted,

of

course,

with

individual,

thereby

distin-

guishing

clinical medicine

from

public

health.

It is often

equated

with

"society"

in

general,

or all

of

the

people

who

live

in

a

particular

political

unit.'

This

range

of

meanings

seems

to

emerge

from

a central narrative

that informs discussions

of

pub-

lic health-the

idea

that

19th-century epidemics

of infectious diseases

induced

North American and

European

nations

to

undertake

a

sanitary

revolution.

According

to this

account,

these countries were

spared

from

epidemics

of cholera and other

epidemic

diseases thatcontinued to

plague

other

regions by

a new

type

of

relationship

MedicalAnthropologyuarterly

7(3):287-321.

Copyright

2003,

American

Anthropological

ssociation.

287








MEDICAL

ANTHROPOLOGY

UARTERLY

between states

and citizens. As

Charles

Rosenberg

(1962)

and

other researchers

have

articulated,

he nation-state ame to define the taskof

protecting

he healthof

citizens as one of its basic

functions,

and

permanent

nstitutionswere established o

provide

technologies

andinfrastructuresor environmental anitationand for con-

ducting

disease surveillanceand control.

The

narrative lso

suggests

that he

public

acceptedresponsibility

or

adoptinghygienic

practices,

ordering

domestic

spaces,

and

abdicating

authority

over

disease

prevention

and treatment o health

profes-

sionals.

As a

number

f writers

uggest,

he stateassumed he

right

andthe

duty

o

bring

members of

racialized

and

immigrant

communities-who were seen as

being

ignorant

of or

rejecting

hygiene

and

nstitutionalmedicine-under the

scope

of this

revolution

see

Kraut

1994;

Rosenberg

1962;

Shah

2001).

The

state husclaimed

pri-

maryresponsibility

or

producingwhat I have referred o as sanitarycitizens(see

Briggs

with

Mantini-Briggs

2003),

individuals

who

(1)

conceive

of the

body,

health,

and

disease

n termsof

medical

epistemologies;

2)

adopt

hygienic

practices

for

disciplining

heir

own

bodies and

interacting

with

others;

3)

and

recognize

the

monopoly

of the medical

profession

in

defining

modes of

disease

prevention

and

treatment.Other

ndividuals

becamewhat

I

refer

o as

unsanitary

ubjects-persons

who

were

expected

o

have

failed

to internalizemedicalized

epistemologies,bodily

practices,

and deferral o

health

professionals.

Their

bodies and domestic

spaces

were

subject

o what Jaber

F.

Gubrium ndJames

A. Holstein

(1997)

refer o

as

de-

privatization,

such that the state could

inspect

their homes at will

and

attempt

o

transformbodily,culinary,child-care,andotherpractices.Invisits to theirhomes,

public

health

nurses

identified

health

as

a

key

dimension

of

the

process

of

trans-

forming

mmigrants

nto citizens.

Once

the

germ

theory

of

disease

began

to

gain acceptability

among

public

health

professionals,

Judith

WalzerLeavitt

(1996)

suggests

thatthe state ncarcer-

ated

Mary

Mallon

("Typhoid

Mary")

or

more

than hree

decadesas a

meansof

im-

pressing

on

the

public

the

obligations

of

citizens

in

the new biomedicalorder.The

sanitary

evolution hus

placed public

health at

the

center

of

how the

state

andciti-

zenship

came to be defined at the

same time that

it

imagined

he

public

as divided

into distinct

types

of individuals

and

groups

on the

grounds

of

health.

P.

Stanley

Yoder(1997) has suggestedthatwhenhealtheducation ormspartof international

health

programs,

he

constructionof

populations

as

responding

o

culturalnorms

that

mpede

the assimilationof

scientific

knowledge

can be extended

to

entire

so-

cieties.

L. W. Green

(1999)

traces he

shift

in

attemptsby

the

state

to educate

he

pub-

lic in health

following

World

War II. He

suggests

that as

biomedical

technologies

became the

focus,

health

education

came

to be seen as a means

of

enhancing

the

public's knowledge

and use of

medical

resources,

thereby producinggood

con-

sumersof health services.

Beginning

in

1974,

however,

a

new

emphasis

on

health

promotionpartially

shifted

the

center of

attention

rom

the needs of

public

health

institutions o those of

populations.Enhancing

communityparticipation

n

public

health

has

become an

increasingly mportant

ocus

(see

Minkler

and Wallerstein

2003).

It is

often

suggested,

however,

that this

is

one of the main

areas

n

which

both

states and

publics

have

failed.

In its

influentialThe Future

of

Public

Health,

for

example,

the Instituteof

Medicine

suggests

that"thisnation

has

lost

sight

of

its

public

health

goals

and

has

allowed

the

system

of

public

health

activities

to fall

288








POWER AND PRAGMATIC MISCALCULATION IN PUBLIC DISCOURSES ON

HEALTH

into

disarray"

1988:1).

Suggesting

that "the

content of

public

values

and

popular

opinions"

orms

one

of the two

major

actors hat

shape

the

way

that

public

health

issues

are

addressed

and

the success

of such

efforts,

the

report

argues

hat

the

prob-

lem lies not

only

in the need for more health-related

knowledge

on the

part

of

members f the

public

butalso in

how

they

have

ost trust

n

public

health nstitutions.

One institution hat

is

often cited

in

explaining public perceptions

of

health

and

health

institutions

is the

media.

As

Simon

Chapman

and

Deborah

Lupton

(1994:25)

observe,

surveys

often

suggest

that the media

provides

most

people's

major

source of informationabout health.

Nevertheless,

Green

(1999)

suggests

thatthe

penchant

of

reporters

or

portraying

medicine and

public

health

negatively

has fostereda

skeptical

attitudeon the

part

of

many

members

of the

public.

Writers

such

as

Eva Benelli

(2003)

argue

that

ournalists

often

pay

undue

attention

o

un-

proven medical claims, thereby creating public pressureto shape public health

policies

and

expenditures

n

problematicways.

In

a

study

of radio

programs

hat

promote

natural

medicines

n

Ecuador,

Ann

Miles

(1998)

points

out

thatthe media

can

actually

ncrease

acceptance

of consumerism

and

scientific

authority

under

he

guise

of

urging

resistance o

biomedical

practices.

Health

officials

(like

other

pub-

lic

figures)

often

complain

in

private

that

journalists

distort

their

words,

subject

them to

unfair

criticism,

and fail

to

report

what

is

truly mportant.2

n

an

article hat

appeared

n

Public Health

Reports,

renowned science and

health

reporter

Laurie

Garrett

esponds

o criticisms

hat

reporters

ncrease

public

panic,

impede

medical

responses by rushing

to

the scene of

emergencies,

and

politicize

health issues-

that s, that"themediaareeitherenemiesortroublesome ools thatneed to be cod-

dled

nto

dispersing elpful

nformation

gainst

ts

better

wisdom"

2001:88).

She

ar-

gues,

instead,

for

a

relationship

of

mutual

respect

between

public

health officials

and

reporters.

Nevertheless,

neither he

notion

of

ignorant,

ambitious,careless,

or

skeptical

journalists

nor

disrespectful

and

paranoid

health

professionals

provide

even

the

ru-

diments

of

a framework

hat

can be used

in

explaining

how information irculates

between biomedical

nstitutions,

he

media,

and

public

audiencesor

the

problems

that

emerge

from this

relationship.

My

focus in

this article

s

precisely

on

the

way

that received models of this

process systematically

misconstrue hese discursive

interactions.Language deologies that constructhow healthprofessionals alk to

reporters

and how

journalists

pass

messages

along

to the

public

fail

to

capture

he

status

of

this informationas

public

discourse,

as words and

images

directednot

at

circumscribed,

opresent

audiencesbut at

strangers.3

draw

on a

recent article

by

Michael

Warner

2002)

that

develops

a

sophisticated

understanding

f the

com-

plex

and

contradictory

haracterof

public

discourse:

although

its

producers

see

themselves as

speaking

to "the

public,"

a defined

and knowable

population,

audi-

ences

for

public

discourseare

producedby

the

circulationand

reception

of the dis-

course andthe material

underpinnings

hat

shape

these

practices.

This

contradiction etween

models

and

processes

of discourse

creates

mpor-

tant obstacles to the circulationof

health-related

messages

as

they

move between

public

health

institutions,

he

media,

and

publics,

often

leading

to

the

failure

of

programs

that

attempt

to build

public

awareness

of

prevention, screening,

and

treatment fforts and even at

times to

widespread

kepticism

n

some

social

sectors

of all

government

health

messages.

Note

that

these

debates about

the

role of the

media

in

circulating

health-related nformationdeal

primarily

with

questions

of

289








MEDICALANTHROPOLOGY

UARTERLY

content-the

extent

to which

media

reportsaccurately

onvey

biomedical

knowl-

edge

and describe

extant

health

conditions.

My

interest

here is

both with content

and with

process-the

routes

of

circulationand

the

way

that

public

health

authori-

ties and

reporters

often buildmodels that

project

how

messages

ought

to circulate

and embed hese

projections

nto

health-related

nformationtself.

Taking up questions

of how

public

discourses are

produced,

circulated,

and

received

opens up

new

vantagepoints

on an

issue

that has received

a

great

deal of

discussion of

late,

that

of

health

nequities.

Works

by

such scholarsas Paul Farmer

(1992,

1999,

2003),

Jim

Yong

Kim

et al.

(2000),

Vicente Navarro

(1998),

and

RichardG. Wilkinson

(1996)

point

to the

role

of

social

inequality

n

shaping

the

distribution

of

morbidity

and

mortality

within

and

between

populations.

What

Farmer

1992)

refers

to as

"geographies

f

blame,"

characterizationshatblame ill

health on individual

and

collective

behavior and cognition, can draw attention

away

from

questions

of access to

health services and institutional acism. The In-

stitute

of

Medicine

published

a massive

report

hat

argues

hatracialized

minorities

in the

United

States-particularly

African Americans

and Latinos-receive infe-

rior treatmentas

compared

with

Whites for a

wide

range

of

diseases,

even when

controlling

for such

factors

as

socioeconomic status

and

type

of

health insurance

(Smedley

et al.

2002).

Tracing

he

way

that

public

discoursesabouthealthare

generated,

circulated,

and received

goes

beyond simply producing

anothermeans

of

showing

how

such

inequalities

are

ustified.

It also

suggests

that

multiplepublics

are

created

by

these

discourses,therebymakingideas aboutpopulations"at risk"and healthinequali-

ties seem natural.

n

the "mediated

ocieties" n which we live

(see

MartinBarbero

1987),

that

s,

where

our notions of

ourselves and even

of

society

itself are

shaped

by

media

representations,

econstructing

ommonsense

understandings

f

public

discoursesof health

can better

equip

us to rethink

"the

public"

n

public

health.

My

focus is

on

a 1991

program

aimed at

preventing

a cholera

epidemic

in

Venezuela.

I draw on

materials

collected

in

the

course

of several

years

of research

conducted

collaboratively

with

Clara

Mantini-Briggs,

M.D.

(see

Briggs

with Man-

tini-Briggs

2003).

Much

of the

focus of the

larger

study

was

on a

rainforestarea n

eastern Venezuela

in

which

some five

hundred

people

categorized

as

indigenas

(indigenous people) died from cholera in 1992-93. Hundredsof hours of inter-

views were conducted n this

area,

nearby

cities,

Caracas,

and

other urban

areas,

and

with

public

health

nstitutions n

the United

States,

Geneva

(WHO),

and else-

where. This article

analyzes

a

corpus

of 221

articles

that

appeared

n

national

newspapers

starting

n

early

February

1991

when the first cases

were

reported

n

Peru

and

the

time

thatcholerawas

reported

n the

Venezuela

by

the

press

(Decem-

ber

4,

1991).

Sources

also include nterviewswith

public

healthofficials and

health

educationand

promotion pecialists,

ournalists,politicians,

and

membersof vari-

ous

publics regarding

official

statements,

health

education,

press

coverage,

and

public reception.

The Circulation of

Public

Discourses

Research

on the

circulation

of

health-relatednformation

must contendwith a

numberof

complexities.

These

efforts

are

ordinarily enerated

n

institutional on-

texts,

and

they

are most

frequently

associatedwith the state. How

exactly

does the

290








POWERAND PRAGMATICMISCALCULATIONN PUBLICDISCOURSES N HEALTH

state

place

material into

public

circulation? What

are the

dynamics

that

shape

such

information's

shifting

relationship

o

the state

in

the course

of

its discursive ife?

This

process depends

on

what

Louis

Althusser

(1971)

termed

interpellation.

His

celebrated

xample

s of a

policemancalling

out:

"Hey,

you "

Insofaras we

recog-

nize

ourselves

as the

person

addressed

by

this

statement

and

turn

around,

we

are n-

terpellated

as the

subject

of state

discourse. Information disseminated as

a

means

of

preventing

infectious diseases

entails

the

interpellation

of members

of

popula-

tions

deemed

to be "at

risk,"

such

that

they interpret

he discourse as

being

about

them. How

do

health-related

messages interpellate

heir

audiences?

What

eads

to

interpellative

misfires?

Recent

work on

social

suffering

(see

Kleinmanet

al.

1997)

has

emphasized

the social and

political-economic

effects of different

ways

of

representing

he ex-

perienceof

illness. The

manner

n

which victims, villains, andheroes are narra-

tively

constructed

rants

political agency

to some

and silences

or

subordinates th-

ers. As

these

representations

ecome

public

discourse,

he

pragmatic

ffects of the

social

images

and

attributions

of

agency they

contain

operate

differently

than,

for

example,

in

doctor-patient

nteractions.Their

producers

cannot

determine

n

ad-

vance

the

precise

nature

of this

public,

how

information

will

reach

t,

how the dis-

course

will

continue to

circulate

(if

it indeed

does),

and

the

multiple ways

that

it

will be

received.

Even

authoritative

messages

arethus

subject

o

a

complex

process

that cannot be known in

advance-no matterhow

much

money

and time are

de-

voted

to

attempts

o

determine

routes

of

circulation

and

modes of

reception.

How,

then, is the public that is entailedin the notion of public healthconstituted,and

how

does this

process

affect

the

power

of

elites

to

circulate

representations

f

so-

cial

suffering

and to

controltheir

political

effects?

In

developing

a

framework

for

the

analysis

of

public

discourse,

Michael

Warner

suggests

that

"the

pragmatics

of

public

discourse

must

be

systematically

blocked

from view"

(2002:84).4

Warner

eveals how the

production

of

public

dis-

course revolves arounda numberof

fundamental

ontradictions.To become

pub-

lic,

a

discoursemust addressa

public

as a

collection of

"already

xisting

real

per-

sons"

(2002:82)

with

some

known,

specifiable

commonalities,

and its

success

depends

on the

interpellation

of

the discourse

by

persons

who

recognize

them-

selves notsimplyas individualreceiversbut asmembersof acollectivitythat s ad-

dressed

by

the

discourse. Because this

public

is

projected

as

being

known in

ad-

vance,

the

problem

for

the discourse

producer

can be

construed as

"getting

people's

attention,"

mparting

knowledge

to

them,

and

persuading

hem to

change

theirattitudesand

behavior.

Nevertheless,

public

discourses

are,

n

Warner'

terms,

self-creating

and

self-

organizing-the

public

is

actually

created

through

he circulationof

discourse as

people

hear, see,

or

read it and

then

engage

it

in

some

sort of

way.

Public health

authorities,

even when

they

hire

advertising

irms

or

give press

briefings,

cannot

accurately

predict

who will

comprise

the

public

for a

given program

or how it

will

be constituted-such as

through

interest,

disinterest, ridicule,

or

protest.

This

"autotelic"

Warner

002:51)

process

of

reification s not accidental

ut

constitutive:

the

production

of

public

discourse

projects

an

imaginary

public

that

only

comes

into

being

as a

communicative

ntity

once the

discoursecirculates.

Nevertheless,

t

must

be

imagined

as

real in the

course

of

both

production

and

reception-"people

do

not

commonly

recognize

themselves as

virtual

projections"

Warner

002:82).

291








MEDICALANTHROPOLOGY

UARTERLY

This

"imaginary"

uality

raises

a

second

constitutive

contradiction.

Like

a

Hollywood

studiothat

attempts

o maximizemovie

sales,

public

discourses

engage

to

varying degrees

in a

process

of totalization

or

universalization,

purportedly

reaching

outto all

possible

readers, isteners,

or viewers.

Although

hey may

be di-

rected

to

specific

"groups"

or

"populations,"

uch

as

"women," "smokers,"

or

"youth,"

public

health

discourse

differs

from a

presentation

n a

school

gymnasium

by

virtue

of its address

o

strangers,

o

individuals

who

become

part

of

the

public

by

virtue

of

their

reception

of

the

messages.

Nevertheless,

Warner

notes,

"there

s

no

speech

or

performance

addressed o a

public

that does

not

try

to

specify

in

ad-

vance,

in countless

highly

condensed

ways,

the

lifeworld of

its

circulation"

(2002:82).

This is

not to

say,

however,

that

publics

are

simply brought

nto

being

by

the

insertionof

images

of

imaginary

publics.

Warner

oes

on to

suggest

that

his

process is shaped by "material imits-the meansof productionanddistribution,

the

physical

textual

objects

themselves,

the

social conditions of access to them-

and

by

internal

nes,

including

he need

to

presuppose

ormsof

intelligibility lready

in

place,

as well as

the social

closure entailed

by

an

genre,

idiolect,

style,

address,

and so forth"

2002:54-55).

All

public

discoursesare

by

definition

exclusionary,

because featuresof their

content,

discursive

organization,

mode

of

transmission,

and

so

forth,

restrict he

range

of

people

who

are

likely

to

come

in

contact with and

interpellate

hem. One

crucial

dimensionof

the

contradiction ies

in

hiding

its

relationship

o

capital.

Al-

though

public

discourse

pretends

o

travelwherever t needs

to

go

to

reach

he

pub-

lic, it is reallya commodity n a market, herebysubjectto constraintson produc-

tion

costs,

access to

media,

and the

political economy

of

reception (particularly

access to

communicative

technologies,

media,

electricity,

dominant

languages,

and

formal

education).

Here

we can build

productively

on

Warner's

nsights-and

avoid the mistakensense that

these

discoursesare free

floating-by

examining

he

institutional

ettings

n which

health-related

messages

are

produced

and circulated

as well as the forms of

symbolic

capital

(Bourdieu

1991)

required

o

participate

n

this

process

n

particular

ways.

Finally,

Warner

2002:69)

suggests

that a

peculiar

featureof

moder

public

discourse

is its

need to

represent

he

paths through

which

it intends to

circulate.

Definitions of social groupsand theirrelationship o the state and otherprojected

groups

s

reformulated

n

the

complex process through

which

messages

are

gener-

ated

in institutions

and

picked

up

by

the media as

well as the

likelihood

that

par-

ticular

groups

will

receive

these

messages,

understand heir

contents,

assimilate

them

behaviorally,

and

succeed in

preventing

the disease.

Differences

between

populations

n

terms

of

their

relationship

o the

circulationof

health-relatednfor-

mation can

be

crucial

determinants

f

their

citizenship

status-at

the

same time

that t

shapes

understandings

f the

state

and

state

power.

Recent

work in

linguistic

anthropology

on

language

ideologies-beliefs

about the nature

of

communicative

processes

and

the

people

and

technologies

on

which

they rely

(see

Kroskrity

2000;

Schieffelin

et al.

1998)-provide

interesting

perspectives

on

these

questions.

Stacy Leigh

Pigg

(2001)

has shown how

language

ideologies shape

what

people

think

they

can

say

in

English

versus

Nepali

about

AIDS and

sex,

thereby

creating

hierarchies f

texts

and

forms

of

knowledge.

Here,

I

suggest

that the

language

ideologies

that

commonly guide

state-media-public

dialogues

about

health

oversimplify

the

processes

through

which

public

discourse

292








POWER AND

PRAGMATIC MISCALCULATION IN PUBLIC DISCOURSES ON HEALTH

is

produced,

circulated,

and

is

received.

Linguistic anthropologists

have also fo-

cused on

questions

of

the

circulationor recontextualization

f

texts and the in-

tertextual

elationship

his

process

creates.

Influenced

by

M. M. Bakhtin

(1981)

andPierreBourdieu

(1991),

CharlesL.

Briggs

and RichardBauman

1992)

suggest

that,

at the

same

time that

ntertextual-

ity

and recontextualization onstitute

centralmeans of

creating

social

power

and

control,

they

remain

open

to subversiondue to

a fundamentaldialectic in the

way

they

connect discourses and contexts

(see

also

Silverstein

and

Urban

1996).

Par-

ticipants

can either

privilege

the

intertextual inks

between

successive

contexts,

the

degree

to which the content

is deemed to

remain stable as

it

circulates,

or the in-

tertextual

gaps,

the

differencesthat

are seen as

having emerged

as information

s

recontextualized.

Questions

of

capital-material

and

symbolic-shape

this

proc-

ess in multiple ways, including rights to insert discourseinto public arenas,to

deem

some accounts authoritative

nd

subordinate

or

exclude

others,

and

to

use

particular epresentations

f

health

n

locating

the

populations

hat

hey

interpellate

(or

fail

to

interpellate)

n

political-economic

terms.

My analysis

suggests

that he-

gemony

shapes

and

limits-but does not

mechanically

determine-how this

proc-

ess

takes

place.

It

thus

provides

us

with a

fascinating

window on

both

the nature

and the limits of the

power

that he

stateandmedia exert on

publics.

The

Daily

Dance of

Journalists

and

Public Health Officials

Cholerabecame a subjectof globalpublicdiscourse hrougha seriesof Inter-

national

Sanitary

Conferencesheld

between

1851

and

1938.

In

the

Americas,

the

Pan American

Sanitary

Code of

1924

required

nationalhealthauthorities

o

notify

both

the

Pan

AmericanHealth

Organization

PAHO)

and

neighboring

ountriesof

the existence

of cases of

"regulated"

r

"controlled"

iseases,

cholera,

yellow

fe-

ver,

plague,

and small

pox. Starting

in

1946,

the World Health

Organization

(WHO)

became the

global

clearinghouse

or

epidemiological

statistics,

which

are

circulatedworldwide n

WHO's

Weekly

Epidemiological

Record.

Venezuela

officially

adopted

these

reporting

requirements

n

1939

in

its

"Rules

Governing

Obligatorily Reported

Diseases." The same

legislation

that

committed he countryto turning nformation egarding"regulateddiseases" nto

global public

discourse also set

up

an

official

regime

for

controlling

the

national

production

and

circulation

of

information bout

hem:

"All data

hatofficials of the

[Ministry

of]

Healthobtain

regarding

bligatorilyreported

diseases are

by

theirna-

ture

private,

[and]

officials who reveal

them

are

subject

to"

either

fines

or

impris-

onment

(MSAS 1967:454),

a

strongwarning

regarding

unauthorized

isclosures.

The first

cases of

cholera

n

South

America

n

the 20th

century

were

reported

in

Peru

in

late

January

1991. Peruvianhealth

authorities

eported

322,562

cholera

cases and

2,909

deaths

n

1991,

and

epidemics begin

in

Colombia and

Ecuador

n

Marchand Brazil

n

April.

In

all,

391,220

cases

and

4,002

deathswere

reported

or

1991 in the Americas

(WHO 1993).

Venezuelan

public

healthauthoritiesdid not

announce

any

cases in

the

country

until

November

29,

and

they

only

reported

15

cases and

2

deaths in

1991.

The

official

tally

for 1992

was

2,842

cases and 68

deaths

(WHO 1993);

because

only

laboratory

onfirmed

cases were

reported

o the

World Health

Organization,

hese

figures

do

not

represent

he full

scope

of

the

Venezuelan

epidemic

(see

Briggs

with

Mantini-Briggs

003).

293








MEDICAL

ANTHROPOLOGY

UARTERLY

Long

before

it

announced

he first cholera

cases,

efforts

by

the

Ministry

of

Health

and

Social Assistance

(MSAS)5

to

promote

the flow

of

information

about

cholera

was

coupled

with

deep

concern with

its

regulation.

MSAS

(1991a)

pub-

lished an

organizational

chart that modeled a hierarchical low of information

about

choleracases from

hospitals,

clinics,

and

otherfacilities

to

district

epidemi-

ologists

and thence to

regional

and national

epidemiologists.

The chart makes it

clear

that

only

the

minister

of health and the directorof the National Office

of

Epidemiology

have the

right

o

disclose information boutcholera o otherstate

of-

fices

or

to

parties

outside

the

government,

ncluding

the

press.

These

officials,

re-

spectively

PedroPaez

Camargo

and

Lufs

Echezuria,

were thus

designated

as

the

sole official

spokespersons

on

cholera. These

laws

and

guidelines

refer

to

the

cir-

culation

of information

during epidemics.

Nevertheless,

they

conferredon

high

MSAS officials a virtualmonopolyover the productionof authoritative nforma-

tion about cholera from

February

until

early

December

of

1991-that

is,

before

any

cases were

reported.

Starting

n

early February,

articles were

published

almost

daily

in

the

two

benchmark

newspapers,

El

Nacional

and El

Universal,

and

they appeared

re-

quently

in

national

tabloids,

the

regional press,

and

television and radio news

re-

ports.

International ews

services,

including

Agencia

EFE,

Associated

Press,

the

New YorkTimes News

Service, Reuters,

and United

Press

International,

arried

storieson the Latin

American

cholera

epidemic

thatwere

picked

up by

Venezuelan

papers.

Larger

dailies

soon

assigned

their own

reporters.

El

Nacional was

particu-

larly strong

n its

reporting

of

public

health,medical,andscientific issues. In

early

1991,

it

boasted

nearly

a

dozen

reporters

who

specialized

n

this

area,

all of whom

had been trained

by

Aristides

Bastidas

n

a

program

hatcombined

undergraduate

study

n

journalism

at

the UniversidadCentralde Venezuela with

a

lengthy

ntern-

ship

at

El

Nacional.

Interviewswith

these scientific

reporters

uggest

that

hey

did

not define

their

role

in the

disseminationof

informationabouthealth ssues

in

opposition

o thatof

medical

and

public

health

professionals-they

rather

saw

themselves as

forming

part

of

the

scientific/medical

ommunity.

sabel

Machado,6

who

worked or

El

Na-

cional for more than20 years,pointed o thedegreeto which thesejournalists den-

tified

themselves

with health

professionals:

"We were almost

like unauthorized

physicians

(medicos

piratas),

because

people thought

hatwe

knew;

they

asked

us,

when

something

was

bothering

them,

and

we had to

say

that

we didn't know "

(personal

communication).

El

Nacional

reporter

Roberto Guzman

described

the

beginning

of

the

cholera

epidemic

n

these terms:"It

surprised

s-we were

practi-

cally

defenseless

against

an

attack rom this

disease

(mal),

which

is

a

plague"

per-

sonal

communication).

These

reporters

requently

used

the first

person plural,

as

Guzmanuses

it

here,

in

constructing

a

"we"that ncluded both

public

health

pro-

fessionalsand

scientific

reporters.

ournalists

rojected

he

sense

that

eading

public

healthofficialssimilarly iewed hemas members f the same eam.Machadonoted:

They

really

helped

us

outa

lot,

theygave

us the

bulletins,

we

called hem

very

day.

I

had hecell

phone

number f the

minister

f

health,

'd

call,

"Look,

what's

new,

has

anything

appened?"

e hadaccess o

everybody....

We

had he ad-

vantage

hat

hey

knew

us

already,

we

weren't

ust anybody

who was

calling

them.

personal

ommunication]

294








POWER AND PRAGMATIC

MISCALCULATION

IN

PUBLIC

DISCOURSES

ON

HEALTH

Referring

to

a

more recent

epidemic,

that of

dengue

fever,

she defined

the role of

scientific

reporters:

Our function as reporters s to educate,that is, indirectlywe are educatingthe

population.

Because

when

you

keep insisting

about

dengue-"don't

leave

open

containersof

water,"

inding

an

angle

to

make

t

newsworthy,

and

you

keep

insist-

ing, you

are

really educating....

Our

[work]

was a

grain

of sand

n

the middle of

all this.

[personal

ommunication]

By

emphasizing

the

need to

find

new information

that

would make each

cholera

story

interesting

and

newsworthy,

"as

much

for

the

reporter

as for the

public"

(Guzman,

personal

communication),

this

statement

opens up

one

dimension in

which

reporters placed

themselves

alongside

"the

public"

rather than health

profes-

sionals.

(See Chapman

and

Lupton 1994

on how this

concern

with

newsworthiness

shapes

health

coverage.)

Public health

officials

had a

rather

different view

of

reporters. Although

they

sometimes described the

press

as

playing

an

important

role

in

transmitting

infor-

mation to

the

public,

in

private they expressed

a

combination

of

fear and distrust.

Journalists,

they

claimed,

were

most interested

in

finding

fault with

MSAS

efforts,

and successes

generally

were

not

reported.

The

press

was often

characterized as a

weak

mediating

link

that

included

uninformed,

gullible,

and

sometimes

unscrupu-

lously self-serving

individuals who often

distorted the

words of

health

profession-

als

and

passed

on

misinformation.

Such accusations sometimes

emerged

in

public.

On May 17, 1991, for example, Paez Camargo asserted that a mayor "alarmed by

the health

problems

in

his

jurisdiction

and in order

to

draw

the attention of the

authorities,

turned

some

reporters

from

the

region

into

innocent

dupes"

who trans-

mitted false

reports

of

cholera cases

(El

Nacional

1991c).

Even

when

they

were

credited with

being

helpful

and

getting

the

story right, public

health officials

con-

trastively

constructed

journalists

as

standing

outside the health

arena.

Reporters played

a

key

role

in

turning

official

statements into

public

dis-

course.

As Stuart Hall

points

out,

professional

concern with

separating

"fact" from

"opinion"

or

"rumor,"

obtaining

objective

and authoritative

sources,

and

generat-

ing

stories

rapidly

to

meet

deadlines all

lead

journalists

to

depend heavily

on

insti-

tutions, which generate news on a regular basis (Hall et al. 1978). Guzman,

Machado,

and their

colleagues

left their

offices

each

day

at

about

ten in

the morn-

ing

and had

to

be

back

by

two or

three

in

the afternoon with

sufficient material

to

be

able to write two or

three

articles and submit them

to

their

editor

by

6:00

p.m.

Public health

institutions based their

claim to

constitute the

primary

sources

of authoritative

information not

simply

on

the medicalization of

infectious dis-

eases but on their

special

relationship

to

PAHO and WHO

(and

thus

transnational

health

authorities, institutions,

and

discourses)

and the national

legislation

that

spelled

out their

control

over

the

production

and

circulation of

public

information

about

public

health.

Because

the

government

employed

most

epidemiologists

and

controlled the

production

of health

statistics,

the central role

of

epidemiology

in

creating

authoritative

cholera

stories-and

the

power

of

social statistics in

spark-

ing popular

imaginings-rendered

this

symbiosis

between

reporters

and

institu-

tions

especially pronounced.

Moreover,

the

journalists

who

covered cholera

regularly

saw

themselves

as

specialists

in

scientific

matters

and

they

accordingly privileged

medicalized views

295








MEDICALNTHROPOLOGY

UARTERLY

of

health.

Both in their

desirefor

ready

sourcesof information nd theirown scien-

tific

ideologies,

reporters

reatly augmented

he

ability

of

high

public

health offi-

cials

to

construct hemselves as the sole

legitimate

source

of authoritative

nforma-

tion about cholera. Paez

Camargo

and Echezuriathus became what Hall et al.

(1978)

referto

as

the

"primary

efiners"of

the cholera

story.They

shaped

he

lan-

guage

that would

be

used in

producing

cholera

narratives,

hey proposed

he

meta-

phors

thatwould

shape

perceptions

of

the

disease,

and

they

decidedwho would be-

come charactersn the

story

and

what

sorts

of roles

they

would

play.

Reporters xplicitly placed

public

health officials

in

this role when contrast-

ing

their statementswith

extraofficalaccountsof

cholera

cases. El

Mundo

publish-

ed

a United Press International

tory

in

which the Panamanian

minister

of

health

declared

that "if

every

Panamanian

..

starts o

give

information,

we're

going

to

have anarchyhere, and in the end you [reporters]won't know, nor will interna-

tional

organizations

know whom

to believe"

(United

Press

International

1991).

Here,

an official not

only

discredits

a

single

rumor

but

attempts

o

banishalterna-

tive

sources

of

the

production

of

discourse aboutcholerafrom the

public

domain.

When

clinicians,

community

eaders,

or

others

provided

nformation,

eporters

m-

mediately

called Paez

Camargo

or

a

regional

health

official,

if

the

report

was

from

"the

interior")

n order

"to confirm it."

Ratherthan

emphasizing

he

intertextual

links

between

official

and

alternative

contributions,

ournalists

stressed the

gaps,

making competing

sources

of

information

eem

maximally

ar

apart-rumors

ver-

sus scientific

proof.

Scientific

reporters

hus

played

a crucialrole

in

medicalizing

publicdiscourseabouthealth.

WHO cholera

guidelines

state

that

"when cholera is

newly

suspected

in an

area,

he

InternationalHealth

Regulations

require

hat he

diagnosis

shouldbe

con-

firmed

by laboratory

nvestigations

as

soon as

possible"

(1992:1).

To

invoke

Bruno

Latour's

(1988)

term,

such

stipulations

urn

microbiological

aboratories

into

obligatorypassage

points

in

the

production

of biomedical

knowledge.

Once

MSAS refurbished

laboratory

n

the

NationalInstitute

of

Hygiene

(INH)

to

proc-

ess

cholera

samples,

ts

directordeclared

hat "it is

up

to the

INH,

with the

support

of

its

investigations,

o

say:

'cholera

has

begun'

"

(Diaz

Hung

1991a).

In her

arti-

cle,

reporter

Veronica

Diaz

Hung

turned

MSAS's

representation

f

how cholera

discourseoughtto circulate nto "news"and ratified ts claimto determinewhich

information was

authoritativeand which

should

be

expelled

from

the

public

sphere.

Here

we see one

of

the

key

characteristics f

public

discourse

n

operation:

at

the

same time that

reporters

reated he

circulationof

biomedical

nformationas

newsworthy,

hey

covered

up

their own

and their

editors' roles as the

gatekeepers

who

turned

tatements

uttered

by

officials

over the

telephone

or to

small

groups

of

reporters

nto

public

discourse-and

excluded other

ypes

of

information nd

other

classes of

speakers.

Tying Cholera to Poverty, Street Vendors, and Indigenas

As

they

imagined

the

course of a

cholera

epidemic

in

Venezuela,

public

health

officials

and

reporters

rojected

hree

populations

as

being

"at

high

risk"

or

cholera.

First,

los

pobres

(the

poor)

were

designated

as

a

key

population

n

which

choleracases

would be

concentrated.Either

he

poor

or "residents f

marginal

bar-

rios"

appeared

n

55 of

the

articles n the

sample,

often

as

the

main

focus.

Minister

296








POWERAND PRAGMATICMISCALCULATION

N

PUBLICDISCOURSES

N HEALTH

Figure

1

Hillside barrio in Caracas, contrasted with middle-class apartment buildings. Photo

(Frasso)

courtesy

of

El

Nacional archives.

Paez

Camargo

suggested

that "cholera

s

an undemocraticdisease because

it af-

fects

a

very

specific part

of the

population

in

which

hygienic

variables are ex-

tremely

marked"

Bracamonte

1991).

Poverty

was

thus constructednot

simply

in

economic

but in

behavioral erms.

Reporters mmediately

picked

up

on

this

con-

nection and

expanded

t. MarleneRizk

(199

la)

suggested

thatcholerawas associ-

ated with

"a

grave

deterioration f

environment,

housing,

and culture

hat

has be-

come moreaccentuatedwith thecrisisof recentyears."

Discussions of

poverty

and

cholera

n

the

press

focused

particularly

n urban

cerros

(poor

hillside

communities)

or

barrios

marginales.

The

juxtaposition

of

barrioswith

marginality

onveyed

a sense of

people

who standoutside democratic

politics,

the

formal

economy,

the

law, education,

and

morality.

In

pinpointing

"the

poor"

as

being

at

high

risk

for

cholera,

public

health

officials

and

reporters

hrust

cholera nto

the

middle

of

the

rapid

rise

of

social

inequality

n

the

country.

The

per-

centage

of

the

population iving

in

poverty

is estimated o have increased rom

24

percent

n 1981 to

59.2

percent

n

1990

(Marquez

t al.

1993:146,

155).

These

arti-

cles were often accompaniedby photographsof barrioneighborhoods,children

playing

in

the

street

(naked

oddlers

providing

a common

motif),

people

bathing

n

open spaces,

and

areas cluttered

with

garbage

and/or

rubble.The

photograph

e-

produced

n

Figure

1,

for

example,

creates a

striking

visual contrast

between

the

hillside barrio

dwellings

and, behind,

the

middle-class

apartment uildings,

com-

plete

with

giant

satellitedishes.

297








MEDICAL

NTHROPOLOGY

UARTERLY

'7,

'.

A;

'

l

'

,

i

.

'

.

Figure

2

Chicero,

eller

of

rice

beverage,

Caracas.Photo

(Luigi

Scotto)

courtesy

of

El

Nacional

archives.

Second,

some

of the

most strident

criticism

was

directedtoward street

ven-

dors

who

sold

hot

dogs

and

hamburgers,

omemade

candy,

drinks,

ruit,etc.;

they

appeared

n

33

of

the articles.

Trying

to

convince the

public

not

to

buy

food from

these

vendors

figured

centrally

n

both health

educationand media efforts.

Report-

ers used

strong

negative imagery

in

suggesting

that street vendors were

breaking

not

only

sanitary

codes

by

using

contaminatedwater and

unhygienic

practices

n

preparing

heir fare

but

also

moral

strictures.AsdrubalBarrios

(1991b)

describes

one Caracas scene: "this reality beats plainly in darkalleyways where [people]

play

with the health of

citizens

in

the

domainof foodstuffs and also in the

domain

of

pleasures,

converting

one of these

comers

into a

pimping

strip

where

ladies

of

the

night

catch

the

innocent."

When

their

customers

continued to

purchase

these

foods

and

beverages,

spokespersons

and

reporters

lso

focused on

the

alleged

ignorance,

abasement,

and

willfulness of the

customers.

Photographs

often featured

ong

lines of

carts,

cha-

otic

throngs

of

customers,

and

foodstuffs

exposed

in

open spaces.

The

chicero

(vendor

of a

homebrewed

rice

beverage)

featured

in

Figure

2,

for

example,

is

shown crouchingover a plasticor metal bowl thatis placeddirectlyon the side-

walk,

next to his

rustic,

hand-decorated

art.

The

framing

of

the

photograph,

with

customers

bounded

in

front

by

a

dilapidated

ection

of

sidewalk and in

back

by

hurried

passersby,

along

with the

indiscrete

pose

in

which the

chicero

is

caught,

seems

to

add irrefutable

isual

confirmation

o the

interpretivemessage presented

by reporters

nd

public

health

officials.

298








POWER

AND

PRAGMATICMISCALCULATIONN PUBLICDISCOURSES

N

HEALTH

Figure

3

Indigena woman from Zulia State with child in clinic. Photo (Jesus Castillo) courtesy

of El Nacional archives.

Third,

ndigenas

also

became

potential

bearers

of

the disease.7

Appearing

n

26

articles

in

the

sample,

indigenas

figured

especially prominently

n

the media

once the first cholera

fatality

in

Venezuela

was deemed

to be an

indigena.

The

strong

moral

one

used for the

poor

and

street

vendors

was

juxtaposed

with the lan-

guage

of culture

in

suggesting

why indigenas

were

particularly

at

high

risk

for

cholera.

"Indigena

ulture"

was constructedas

the

antithesisof "thenationalsoci-

ety."Indigenaswereassociatedwithvernacular ealingpractices-and thus asbe-

ing

ignorant

of and

rejecting

biomedicine-and

portrayed

s

being

unhygienic,

no-

madic,

and unconcernedwith

the

health

of their

amilies

(see

Briggs

with

Mantini-

Briggs

2003).

When

he was

pressured

o

close

the borderwith

Colombia,

Paez

Camargo

countered

that

"Closing

the

border

is

an idea that

makes

no

sense,

because the

Guayu

ndigenous

ethnic

group,

which is the

one

that

has been affected

by

the dis-

ease,

is

geographically

and

culturally

a

single entity,

which feels the

same

in

Co-

lombia as

in

Venezuela and has no

concept

of

physical

border"

Zambrano

1991).

Any

resident

who

did

not

recognize

the

importance

of the

Venezuela-Colombia

borderwas not a

participant

n the

political

life of the nationand could make

only

weak claims

to substantive

citizenship.

Paez

Camargo

made

the

statement

during

an

epoch

in

which

indigenas

were

pressing

or

recognition

of their

political,

territo-

rial,

and

human

rights

n

the

course

of

"500

Years

of

Resistance" ctions

countering

the

"Columbian

Quincentennary."

his

construction,

made

in

a

press

conference

by

a

cabinet-level

official,

seems to

imply

that

political parties

and

government

299








MEDICALANTHROPOLOGY

UARTERLY

institutions

need

not

respond

o

such

demands

or

political

representation

ecause

indigenas

had

excluded

themselves

rom the

political process.

These sorts

of

gen-

eralizations

were

extended once cholera cases

appeared

in

this

region.

Paez

Camargo

declared,

or

example,

that"it is

very

difficult to workwiththis

popula-

tion,

because

it is

itinerant,

and

its distinctculturemakes

people

fear the

measures

taken

by

our

physicians"

(Linares 1991).

In

photographs,

ndigenas

were com-

monly portrayed

n

poor

rural

settings,paddling

canoes,

and

doing

artsand

crafts.

Figure

3

actually

appeared ust

after

the first

case

was

reported.

It

pictures

an

indigena

woman

from Zulia

State

and

her

child.

In all

three

cases,

these

powerful

visual

images

naturalized

onnections be-

tween

the disease

and these

populations

n

several

ways.

First,

the

frequent

uxta-

position

of

articleson

the "threat"

f

cholerawith

photographs

f the three

popula-

tions (83 in all) createda visual image thatgot attached o widespread ear of the

disease.

Cholera

ust

seemed

to

be

naturally

associatedwith these

groups.

Second,

barrio

residents,

street

vendors,

and

indfgenas

were

not

pictured

cleaning

their

neighborhoods,

tockpiling

anti-cholera

materials,

or

giving

anti-cholera

alks

but

rather

as

merging

with

the

scenes

of

urban

decay

that

surrounded

hem.Health

pro-

fessionals,

on the

other

hand,

were not

only

well

dressed and

pictured

n

orderly

and

sanitized

environments,

but shown

actively working

to

prevent

an

epidemic.

Figure

3

embodies

this

contrast

n

a

single photograph.

While the

professional

s

caught

in

an

active

pose,

seemingly trying

to reach out and

help

the

child,

the

woman

stares

off

into the

distance,

not

moving

and

seemingly

unmoved,

thereby

visually conveying the stereotypesof the passive indigenawho lacks agency and

the will

and

ability

to

help

herself

or

her

child.

Photographs

ppearing

n

newspa-

pers,

along

with

similar

mages

on television

broadcasts,

hus

helped

createa chol-

era

"geography

of

blame"

(Farmer1992),

reify

it

as a directreflection

of

social

re-

ality,

and imbue

it

with

strong

affective

significance.

These

powerful

mages

were

used

in

creating

a

coherent

story

that

explained

he course

of

a cholera

epidemic

n

Venezuela,

all

before the first

cases

were

reported

n

the

country.8

The

Health Education

Program

Starting n February1991, responsibilityfor organizinga healtheducation

and

promotion

programdesigned

to inform

"the

public"

aboutcholera and

induc-

ing

it

to take

steps

aimed at

preventing

an

epidemic

was located in

two

MSAS

of-

fices.

First,

the

Division of

Social Health

Promotionof the

CommunicableDis-

eases

Program

was

charged

mainly

with

creating

he manuals hatwould be

used

in

training

health

professionals

and

other

personnel

n

cholera

prevention

and treat-

ment and

with

working directly

with

community

representatives

nd members

of

the

public.

The team

consistedof

individualswith

undergraduateraining

n

the so-

cial sciences

and

educationand

one

journalist; hey

were

all

supervisedby

an

epi-

demiologist. They

took manuals

producedby

WHO and PAHO on

the control of

infectious

diseases,

community

participation,

and cholera

prevention

and turned

them into

booklets

produced

for

health

professionals

and

manuals to

be

used

in

training

community

representatives

nd

employees

in other

nstitutions.

A

Module

of

Cholera

Instruction

MSAS

1991d),

published

n

March

1991,

was

prepared

or

use

in

workshops

designed

to

transformndividualswho

were not

health

professionals

into

disseminatorsof

cholera

prevention

information.The

300








POWER AND PRAGMATIC

MISCALCULATION

IN

PUBLIC

DISCOURSES

ON HEALTH

topics

discussed include the

history

of

cholera,

Vibrio

cholerae,

the status of

hu-

mans

and

their

excretions

as

cholera

reservoirs,

linical

symptoms,

reatment,

re-

vention,

environmental

hygiene,

and

how

to involve

community

members

n

pre-

vention

programs.

The

popular

audience

projected

or the text

is

markednot

only

by

the nontechnical

anguage

and

the stated

goal

of

providing

"basic nformation"

but

also

by drawings

that

turn

Vibrio

cholerae into

little bacterial

monsters,

com-

plete

with

hair,

eyes,

hands,

and

jagged

teeth. Two

booklets,

a Manual

of

Norms

and

Procedures

or

the

Prevention and

Managementof

Diarrheal Diseases and

Cholera

(MSAS 1991b)

and

EnvironmentalSanitationMeasures

or

Preventing

Cholera

(MSAS 1991c),

both

released

in

May,

were

designed

for

distribution

o

physicians

and

other health

professionals.

They

used

a

specialized

lexicon,

and

they

lacked

anthropomorphic rawings

of

Vibriocholerae. One

of

the

goals

of the

ManualofNormswas to "extend hroughall of theareasof Public Health heunifi-

cation

of

basic,

current

knowledge

and

strategies

to

pursue

in

the

fight against

choleraand

all

diarrheal iseases"

MSAS

1991b:

1).

These three

publications

seemed

to

become

important ymbolic capital

for

the

professionals

who

secured

them,

indicating

their access to MSAS centralof-

fices;

further

distribution

was thus

impededby

the desire

on

the

part

of

individuals

to hold

onto their

symbolic

value.

Once cases were

reported

n

Venezuela,

the Di-

vision

of

Social Health

Promotion,

n

collaborationwith

PAHO,

initiated

projects

in

Delta Amacuroand Zulia

States.

The

research hat

they

conductedunder

these

auspices

consisted

primarily

f

focus

groups

with

public

healthofficials that

aimed

at

eliciting

ideas and

evaluating strategies.

They

also worked

alongside epidemi-

ologists

in

teaching

cholera

prevention

techniques

to

residents,

particularly

n

Zulia.

Second,

the Office of

Public Relations was

charged

with

created

pamphlets

and

posters

for

mass

distribution nd

getting

cholera

prevention

materials

nto the

mass

media.

Their staff

consisted

primarily

of

persons

trained

as

journalists

and

graphic designers.

Newspapers presented

prevention

nformationwithin

articles

and as

separate

ections

(often

intended o be cut out

and

pasted

on

walls),

such as

the

following publication

of

WHO's

"golden

rules" or cholera

prevention:

Measures

or

Avoiding

Cholera:

?

Wash

vegetables

with water

and

vinegar

or half an hour.

?

Cook fish and seafood

well.

?

Avoid foods

purchased

rom street

vendors

comidas

ambulantes].

?

Wash fruitbefore

eating.

?

Boil

drinking

water en

minutesor freeze filteredor

bottledwater.

?

Also

wash kitchenutensils

with boiled water.

?

Wash hands with

soap

and

waterbefore

preparing

ood,

serving

children,

[and]

aftergoingto thebathroom,akingcareof someonewho is ill, or

cleaning

up

after

children.

*

Combat

lies;

since

they

come to rest on

feces and

contaminated

water,

[they]

be-

come vehicles of

transmission.

Use

insecticides,

and

deposit

trash n

plastic

bags

and

keep

them

shut.

*

Use

bathroomsand

atrines.

301








MEDICALNTHROPOLOGY

UARTERLY

*

Prepare

powdered

milk with boiled

water

or drink

pasteurized

milk.

[El

Na-

cional

1991d]

Radio and television stationsalso presentedhealth educationinformationon a

regular

basis. These succinctrecommendationswere decontextualized

nddehisto-

ricized,

appearing

o

apply

equally

to

everyone

and

to bear

no

direct

relationship

o

current

vents.

Once

the

first official case

was

reported

by

MSAS

on December

3,

1991,

both

of these

offices

stepped up

the

pace.

Posters were

placed

in

public

spaces,

and

workers

passed

out

pamphlets

on

the street

and in bus terminalsand

clinics. The

Christmas,

New

Year's,

and

Holy

Week

holidays

were

the

focus of

particular

oncern

due to fear that

the massive number

of

people

travelingduring

those times

would

spread

cholera

hroughout

he

country.

Reporters,public

health

officials,

and

politicians

deemed

the

stakes

for

the

health educationprogram o be high. Theyunderlined hecentralityof "individual

responsibility"

see

Gonzalez

1991a).

A

regional

official

declared,

"it

won't

help

at

all

if we health

authorities

make

the effort

to

fight against

he disease

if

the com-

munity

doesn't

support

us

by

paying

attention o

the recommendations"

Azocar

1991).

Diaz

Hung

(1991b)

quotes

Milagros

Polanco as

saying

that

"if

the

people

fail

to follow

the basic

hygienic

norms,

everything

will

be lost." Politicians

articu-

lated the

importance

of

health education

through

he

language

of

citizenship

and

civic

participation.

Caracasofficials

attempted

o

mobilize "the

community"by

settingup

"anti-cholera

ommandos"

onsisting

of

a

local

official,

a

physician,

and

five

neighborhood

eaders for each

parish

n

order

to "make

each

citizen into an

ally"

(Gonzalez

1991b).

A

member

of

Congresssuggested

that

each citizenmust ransform

imself nto

a

guardianfiscal]

of

his

own

home,

place

of

study

or

employment,

nd

community,

o demand

ompliance

ith he

rules hathavebeen

ssued;

nd

when

we canmake ure hat

ur

neighbor

rotects

himself

dequately,

e are

protecting

urselves s

well.

[Rivero

G.

1991:

4]

Messages

presented

as

part

of

the health

education

program

hus

embodied

what

has

been

observed o be a

general

eatureof

the

public

service announcement

ype.

They

tend to

"support politically

conservative

predisposition

o

bracket

off

ques-

tions about hestructure f society-about thedistribution f wealthandpower,for

example-and

to

concentrate nstead

on

questions

about

the

behaviorof individu-

als

within

that

(apparently

ixed)

structure"

Tesh

1988).

To

whom was the health

education

"campaign"

irected?

This

question

may

seem

silly

at first

glance.

The use of the

mass mediaandthe

placement

of

posters

n

public

spaces

would seem to

target

all

Venezuelans. Constant nvocations

of la

gente

(the

people),

la comunidad

enezolana

(the

Venezuelan

community),elpais

en

general

(the

country

n

general),

and

la

mayoria

de

los

venezolanos

(the

major-

ity

of

Venezuelans)

constructed

he

target

audience

explicitly

and seemed to

pro-

ject

the actual

range

of

dissemination

of

the healtheducation

nformationmaterial.

Nevertheless,

et us recall

Warer's

(2002)

suggestion

hatone of thecontradictions

that

springs

rom

deological

constructions

f

public

discourse nvolvesa

discrepancy

between claims to

be

addressing

veryone

and

the

embedding

of

implicit messages

that

define

an

implied

audience.This

contradiction

was most

apparent

n

televised

messages

that

showed

well-dressed women

demonstrating

hygienic

measures in

well-equipped,

middle-class

itchens.MSAS

cholera

prevention

amphlets

imilarly

302








POWER

AND

PRAGMATICMISCALCULATIONN

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DISCOURSES

N HEALTH

often

projected

images

of

middle-class,

light-skinned,

nuclear families.

In

one

case,

a

woman dressed

n

such a

fashion as to

mark

her as

Wayuu

(indigena

from

Zulia)

was shown

demonstrating

holera

prevention

echniques

n a

modem,

well-

equipped

kitchen-even

though

politicians,public

health

officials,

and

ournalists

had characterized"the

Wayuu"

as

being poor

and

premoder.

The

pamphlet

was

designed

for

distribution

among indigenas

who

lived

in

Zulia and

surrounding

states.9

Even

basic,

widely

disseminated,

and most

highly

decontextualized nforma-

tion,

such

the Golden Rules

and

otherbasic

preventionguidelines,

seemed to

pre-

suppose

the

inclusion

of

vegetables,

fish

and

seafood, fruit,

and

powdered

milkin

diets and

sufficient

funds to

be

able to

purchase oap,

pesticides,

plastic bags,

vine-

gar

to

wash

vegetables,

and

gas

to

boil

water for

consumption

and for

washing

utensils.Manyhomesnotonlylackedfreezersbutbathrooms, atrines,andrunning

water. The

nearly

40

percent

of

the labor

force

engaged

in

the

informal

economy

spent

substantial

parts

of

their

day

on the

street;

telling

them to avoid foods

pur-

chased from

streetvendors

might

seem like

asking

these

individuals o

go

hungry

(not

to mention

hreatening

o

deprive

he membersof

a substantial ector

of

the

in-

formal

economy

of their

primary

source of

income).

The

media

campaign

thus

seemed oblivious

to the

economic constraints hat

rendered he

implementation

f

such

procedures

difficult

or

impossible

for

the

majority

of

Venezuelans.

The

health education

program

was

thus structured

by

a fatal

contradiction.

The

epidemiological

message

suggested

that

f

you

are

poor,

a

street

vendor

or

one

of theircustomers,or an indigenayou are "athigh-risk" o get cholera.If you are

middle- or

upper

class and not

racially

marked,

you

are

very

unlikely

to

get

the

dis-

ease. The

primary

audience

for

health

education,

as defined

by

the

middle-class

images

in

many

of

the

messages

and

seeming

economic

prerequisites

or

enacting

the

preventionguidelines,

was

unlikely

to

interpellate

his

information,

because

ts

membersdo not

consider

themselves to be

dirty

or

ignorant

and

they

had been

told

that

hey

were

not

likely

to

get

cholera.

Several

obstacles

thwarted

people

who

fit

the

high-riskprofile

from

interpel-

lating

the

message.

First,

they

could not

recognize

themselves in the health

educa-

tion

discourse-they

were

not

projected

as

part

of

its

public.

Second,

to

interpellate

oneself as in need of cholerahealtheducationwas to acceptanimageof oneself as

premodem,dirty,

ignorant,

superstitious,

mpoverished,

and a threat o

the

health

of the

body

politic. Accepting

a

denigrating mage

of

oneself

is

a

high price

to

pay

for

getting

information

Third,

he

explicit

message

that

no

intertextual

aps

were

acceptable

between state

discourses

and

public

responses

was

contradicted

y

this

tremendous

gap

between

"news"

and

"pedagogy,"

a

hiatus

that assumed

quite

dif-

ferent

forms and

proportions

or

the

middle

class,

on

the one

hand,

and

people

pro-

jected

as

being poor,

street

vendors,

or

indigenas,

on

the other.

The

surveillance

conducted n

poor

and

indfgena

communitiesand

of

street

vendors

was used in

measuring

he

success or

failure of

health education

efforts.

Justas

epidemiologists

visited

poor

neighborhoods,

treet

vendors,

and

indigena

communities o

assess

conditions,

Guzmandescribeshow

reporters

became

ama-

teur

epidemiologists:

We arrived

t

poor

homes

ranchos),

t

unhealthy

wellings,

ndwe asked

he

womenhow

hey

were

toring

water,

nderwhat

onditions,

he

characteristicsf

303








MEDICAL

NTHROPOLOGY

UARTERLY

the

dwellings....

A

poor

homecan

be a

perfect

ulture

in

the

biological

ense]

for

cholera

wreaking

havoc. So we

went

and asked

the

women,

the

housewives,

we looked

at

the

children,

we

took

photos

of the little

naked

hildren,

with

heir

bellies wollenbysymptomsf malnutrition.personalommunication]

Veteran

cholera

reporter

Marlene

Rizk

drew on

such observations

n

assess-

ing

the

results

of

health educationefforts:

"None

of these measures

s

being

com-

plied

with,

and it

only

takes a

trip through

he center

of

the

city

[Caracas]

where

every

day

the numberof street

vendors ncreases

or a visit

to

any

barrio,

where

the

minimum

hygienic

conditionsare

missing"

(1991

c).

Reporters

and

officials do not

seem to have visited middle-class or

wealthy

homes

or

to have

inspected

restau-

rants

n

well-to-do

neighborhoods

before

deciding

that

he

program

had

failed.

This

structural

process

of

misrecognition

(see

Taylor

1994)

effectively

pre-

vented all parties from interpellating these messages, from believing that they were

directed

at them

and that

they

meshed with their

own

perceived

social

locations

and identities.The health education

program

hus constituteda

classic

Batesonian

double-bind

n

which the overt

message

is

contradicted

nd

overridden

by

an

im-

plicit metamessage

Bateson

et al.

1972).

Resisting

Unsanitary

Subjecthood

Medical

anthropologists

have

argued

that we

should

not assume that state

power

or

processes

of

medicalization

urns

patients

and

publics

into

dupes

who

passively

accept

dominantconstructions.Studies of women's

responses

to

repro-

ductive

technologies,

for

instance,

suggest

that

people respond

n

complex,

prag-

matic,

sometimes

contradictory,

nd often

unpredictable

ways

to

hegemonic

ide-

ologies

and

practices

(see

Ginsburg

and

Rapp

1995;

Lock and Kaufert

1998).

Accordingly,

if

my analysis

were to end

here,

therebygiving

the

impression

that

publics simply

accepted

he contentof

choleradiscourseand the

hegemonic

model

of

its

circulation,

would

leave out crucial

elements

of the

story.

Just

as

the state was

using

cholerato

shape

an

image

of

the

poor,

popular

ec-

tors used

the

disease

to

shape

public

opinion

of the state.

Stepped-up epression

af-

ter the

February 7,

1989

popular

nsurrection

ugmented

he

uncertainty

f life in

poor

neighborhoods.

The

coup

attempt

organized

by

Lt.

Colonel

Hugo

Frias

Chavez

on

February

4,

1992

may

have

failed,

but it created a more

visible

space

for

debating

the role of the

government

and

evaluating

ts

policies.

Popular

mistrust

contributed o the

tendency

to

regard

choleraas a smokescreen

cortina

de

humo)

conjuredup

to

keep people

from

thinking

about the crisis and

criticizing

the

gov-

ernment.10

The

location of

some

specific

sites of

resistance

are

interesting.

When Cara-

cas

officials

urgedcommunity

representatives

o

join

them

n

establishing

an "anti-

c6lera

commando,"

ome read

these

attempts

o enhance

community

participation

as anattempt o placethegovernment'shealthobligationson thepublic:

The

neighborsomplain

hat

he

anti-cholera

ampaign

asbeen ocused

n such

a

way

hat t

appears

s

if the

only

one

responsible

or

all

of this s

thecommon

iti-

zen.

"Doesn't he

government

lsohave

responsibilities

o

assume,

uch

as

sup-

plyinghospitals,leaning

he

streams,

nd

providing

he

population

ith

drinking

water?"

Gonzalez

1991b]

304








POWERAND PRAGMATIC

MISCALCULATION

N

PUBLICDISCOURSES

N HEALTH

Second,

some communities eem to have felt

that

surveillanceand control

were

di-

rected

not

at cholera

but at

them,

and

they

sometimes

actively

resisted.Public offi-

cials

complained,

for

example,

that

Wayuu

communities "arm themselves

and

confronthealthcommissions"

Montes

de Oca

1992).

One

of

the

most

pervasive

and

visible sites

of

resistance

lay

with our

old

friends,

the

street

vendors. Unable

to

get

their

responses

into the

public sphere,

they

largely

voted

with

their

feet-they

continued

o

sell

their

products

even

in the

face of

criticism and

prohibition.

The

sale and

consumption

of

food and drinkon

the

street

grew

markedly

n the

1980s and

1990s.

In

the

face

of

massive underem-

ployment,

unemployment,

and

steep

price

increases,

many

workers

had

been

driven

out

of the

formal

economy

and

into the

ranks

of

vendors,

whereas

others

used

sales

to

supplementwages.

Datanalisis,

an

economic

consulting

firm,

esti-

mated that 39 percentof the populationworkedin the informalsector in 1992.

Many

of

their

customersfaced

longer

work

schedules,

longer

commutes,

and/or

the

need

to work

more

than

one

job.

For

them,

cheap

food

purchased

on

the street

helped

meet both

temporal

and

economic

constraints.Criticism

by

reporters

and

public

health officials of

vendors

and

theircustomers

cut

"formal"

apitalism,

glo-

balization,

and

government

policies

out

of the

picture.

In

making

a

fetish

of the vendors'

transactions,

he

health

education

program

transformed

pervasive

social and

political-economic effect

of

globalization

nto

the

cause

of increases in

infectious

diseases.

But

these

conditions were

part

of a

process

that

has

engulfed

many

Latin

Americancities in a structural

haos so

deep

that the statecould no longer effectively claim the abilityto maintainorder(see

GarciaCanclini

1989).

This

inversion of

cause

and

effect,

the transformation f

global

structural

processes

into

faulty

individual

decisions,

and

the

adoption

of

medical

profiling

procedures

were

accomplished

by

cholera discourses even be-

fore

Vibrio

cholerae

appeared

n

Venezuela. MSAS

seemed

to be

completely

out

of

touch.

This sense of

misrecognition

discreditedMSAS in the

eyes

of

many.

An

El

Nacional

poll

conducted n

April

1991 found that

only

1

percent

of

respondents

thought

that

hospitals

were

"well

prepared"

or an

epidemic,

27

percent

believed

that

hospitals

were

"somewhat

prepared,"

nd 72

percent

thought

that

they

were

"notprepared t all"(ElNacional 199lb). A JulyElNacionalpoll reportedhat50

percent

of

respondents

believed that

cholera"had

ndeed

come to

Venezuela,"

but

that

MSAS was

"hiding

he

cases."

Only

36

percent

stated

thatMSAS

was

telling

the

truth,

while 14

percent

said

they

didn't

know

(Rizk 1991b).

A

newspaperpoll

conducted

n

February

1991

suggested

that

65

percent

"said

hat

they

do NOT be-

lieve

that

the

authoritieswill do

everything necessary

for

prevention

of the dis-

ease."

The data

revealed a

striking

gender

gap:

women outnumbered

men more

than

two to

one

among

the ranksof

skepticalrespondents,

while

nearly

eight

times

as

many

men

believed

thatMSAS

efforts

were

sufficient

(El

Nacional

199

a).

Reporters

ometimes framed

criticismsof

MSAS and its

top

officials in their

own voices. El Nuevo

Pals

captioned

a

photograph

of a

broadly

smiling

MSAS

minister

as

follows:

[Rafael

Orihuela]

eaves he

[Presidential]

alace

wearing

is best

smile,

n

spite

of

the

resurgence

f

infectious

iseases,

uchas

dengue,

malaria,

nd

cholera,

generated

y

the

complete

ackof

attention

nthe

part

f

the

government

f

President

305








MEDICAL

ANTHROPOLOGY

UARTERLY

Perez o healthssues

the

MF

International

onetary

und]

s

only

nterestedn

payment

f thedebtand

handing

verstate

ndustries).

Gonzalez 992]

The richly parodic article accompanyingthe photographcountered Ori-

huela's contention that "Venezuela

can relax"because the

government

had

con-

trolled

he outbreak f cholera

by

asserting

hat"newoutbreaks f malariaandden-

gue,

newly

rebornThirdWorld

diseases,

along

with cholera"

presented

clear and

present

dangers.Photographers

ometimescontributed

o

these

critiques.

A

photo-

graph

by

Eresto

Morgado uxtaposedpiles

of

trashand

filthy

waste

water n

asso-

ciation with a

huge sign

that marks he scene

as

a

project

of

the

Caracas

city

gov-

ernment.11

Here,

images

that the state imbued

with

moral

and

political meanings

seemed

to

get

turnedback

on

the state. Subversive

readings

also

emerged

n

televi-

sion

comedy programs

hat

parodied

official statements.

Itwould, however,be unwise to exaggerate he extentof thisreportorial esis-

tance. Journalistsdid not

challenge

MSAS officials'

status

as

the

primary

definers

of cholera

discourse,

nor

did

they

elevate

critiques

of

public

discourseabouthealth

and the social

spaces

in which

they

were

generated

o the level

of

equally

valid

sites for the

production

of cholera

nformation,

hift the

basic termsof

their

stories,

or

challenge

dominant

equations

between cholera and

social

inequality.

Critical

public

voices were subordinatedn termsof the relative

frequency

with which

they

spoke

(much

less than

MSAS

officials),

their

placement

n articles

(generally

to-

ward the

end),

and the

types

of

discursive acts

they

were

permitted

o

perform

(such

as

criticizing

MSAS

proposals

rather

han

offering

their

own),

a common

way

that

inequality

structuresmedia

discourse

(see

van

Dijk

1991).

In

short,

the

media

left

the

hegemonic

model for circulation

of

medical and

public

health nfor-

mationand ts

authority

ntact.

Nor did these criticisms result

in

a

shift

in

the

way

that

agency

was con-

structed

n

cholera news: when

reporting

he "news"about

cholera,

reporters

ast

both Vibrio

cholerae and

MSAS

officials

as

agents,

as

the forces thateither

caused

or

could cause

things

to

happen,

while

the

public-and particularly

he

poor

and

indigenas-were

constructed

as

patients

(here

in

the

grammatical

sense

of

the

term),

therebyreplicating

another

general

eature

of

discoursesof social

inequality

(see van Dijk

1989).12

Herein ies anotherbasic contradiction f thehealth educa-

tion

program.Having already

established

hat the

poor,

indigenas,

and streetven-

dors

lacked

agency

and, therefore,

could not

change

in

ways

that would

enable

them to

get

out

of

cholera's

way,

the health

education

program equired

hem to do

just

that. While the

press

may

have

occasionally relayed

voices that

pointed

out

this

contradiction,

t

did not

fundamentally

revise its

picture

of

passive

unsani-

tary

subjects.

In

short,

hese criticismsdid

not

dislodge reporters

rom their

role in

elevating

high

MSAS officials

to

the

status of the

primary

definers

of

cholera

discourse.

Rather,

irculating

riticisms

helped

construct

he

ournalists'

ole as thatof

objective,

neutralcollectors of facts.

They

could seem to

align

themselves with the

people,

therebyclaiming

the

right

to

ventriloquize

he reactionof the

public

to MSAS dis-

course,

and

confirmtheirrole

as the

public's watchdog,

as

doing

the work

of criti-

cally assessing

the truthand value

of official

statements.

Oddly,

one

important

o-

cus of

popular

criticism of

the circulationof

public

discourseon

cholera seems to

have been overlooked

by journalists-how

people

resisted media

representations

306








POWER

AND

PRAGMATICMISCALCULATIONN PUBLICDISCOURSES N HEALTH

and

the

power

of

the media to

legitimize

MSAS's

authority.

Reportingpopular

criticisms

of

MSAS

can

thus be seen

as

a

strategy

of

dissimulation,

as

playing

their

part

in

keeping

the

pragmatics

of

public

discourse-particularly

the

press's

own

practices-"systematically

blocked from view"

(Warner 002:84).

How Public Discourses

Circulate: Idealized Links and

Pragmatic

Gaps

The

public

health officials and scientific

reporters

we interviewed

largely

sharedan

ideological

construction

f

how

public

discourseaboutcholerashouldbe

produced

and

circulated. Authoritative nformation

about the disease emanated

from

privileged

sectors

of

MSAS,

particularly

he National Office

of

Epidemiol-

ogy

and

the INH

national reference

laboratory,

and

the international nstitutions

that

shape

health

policies

and

practices,PAHO

and

WHO.

This information hen

moved

through

hree circuits.

First,

health

profession-

als,

particularly

hose

employed

by

MSAS,

received technical information rom

manuals,

the

Boletln

Epidemiologico

Semanal

(Weekly

Epidemiological

Record),

circulars,

and the like.

Second,

the

Division

of

Social

Health Promotion

then

passed along

nontechnical

nformation,

uch

as

the

Module

of

Cholera

Instruction,

posters,

and

brochures,

o

employees

in other

nstitutions,

ommunity

eaders,

and

other

persons

who

are

not

health

professionals.

Some

of

this information

also

found

its

way

to

"the

public"

via

the media.

Finally,

statements

by

the

minister

of

health and

the

director

of

the National

Office

of

Epidemiology,

as

articulated

n

press conferencesandtelephonecalls, wererelayedas news by reporters o their

audiences. Both

journalists

and

public

health

officials

point

to

how

this

informa-

tion should be

received-it should

be

comprehended,

assimilated

into

ways

of

thinking

about

hygiene,

food

procurement

nd

preparation,

he

environment,

and

so

forth,

relayed

to

family

members,

coworkers,

and

neighbors,

and

embodied

in

action.

When

it

operatescorrectly,

his

process

should

be characterized

y

intertex-

tual links

alone-no

gaps

should

appear.

Such

transformations

s

lexical

register

shifts

from

scientific

terms

to

a

nontechnical

vocabulary,

ransitionsbetween

or

beyond

institutions,

changes

of

communicative

channel,context,

and

participants

shouldnot creategaps,becausecontinuitywas definedin termsof the stabilityof

semantic content.

Gaps

in

these

circuits were

problematic, eflecting

either

igno-

rance

(an

inability

to recontextualize his

information)

or willful

resistanceto

an

educational

process

on

which the

health

of

the nation

and

its

citizens

depends.

Be-

cause both media

coverage

and

public

health

nformation

was

aimed at the

public

and

therefore

accessible

to

everyone,

the

failure

of

individuals o

gain

this informa-

tion and

use

it in

preventing

cholera-breaks

in the

transmission

circuit-were

theirown

fault.

This

language

deology

systematically

blocks from

view

the

way

that

the

ide-

alized

process

of

discourse

production

and

circulation

tself created

a

vast network

of

gaps

and communicative

barriers,

along

with the material and

symbolic

in-

equalities

o which

it

was

tied.

Thus,

the

image

of a

horizontal,

unidirectional

low

of

information

masked

the

creation

of

quite

vertical

structures

f

knowledge

and

status

n

a numberof

ways:

First,

the

temporality

of

circulation

of

public

discourse

s

crucial,

n that

peo-

ple

gain

access

to

messages

at

different

imes

and

accordingly

use them n

claiming

307








MEDICAL

ANTHROPOLOGY

UARTERLY

different

social

positions.

(The

concernwith

"being

n

the

loop"points

to

the

desire

for

enhancing

one's own

relationship

o the

temporality

of

circulation.)

Epidemi-

ologists

and

INH

microbiologists

enjoyed

temporal priority

over other MSAS

health

professionals,

who,

in

turn,

supersededreporters;

he information

inally

reached their audiences and

persons

with whom viewers

and readersconversed.

Health

promotion specialists similarly

trained

community

leaders

who

then,

in

turn,

educated

heir

neighbors.

This

image

of circulation urns ime into social

hier-

archies.

Second,

as

Pigg

(2001)

points

out for HIV/AIDS education

in

Nepal,

the

ranking

of texts

in termsof

their

provenience

in

Geneva

or

Washington

versus

Ca-

racas),

lexical

register,

and

degree

of

detail

project

a hierarchical

view

of

audi-

ences,

creatinggradations

of

knowledge

and

capacities

for

assimilating

health-re-

lated nformation.

Third,

a

person's

own

social

standing

was marked

by

the

person

from whom

he or she received

information

the

minister

of health versus a

reporter

versus a

health

promotion

worker versus

a

community representative).

The farther

you

were

located down the discursive

chain,

the less

authority

and

agency you

were

projected

as

enjoying.

Some

people

can

produce

cholera discourse

and

sort

authoritative

rom

illegitimate

nformation;

thers

(e.g.,

clinicians)

can transmit t

with

authority.

Still others

(such

as

community

eaders)

can

only

transmita

popu-

lar

understanding

f

it.13

Otherscan

only embody

the information

n

theirbehavior

and

transmit

t

within their

mmediatesocial

environments.

Fourth,recipientswereprojectedas ratifiedhearerson the basis of construc-

tions of

implied

audiences,

reducing

others

to

the status

of

ideologically

excluded

overhearers.

At

the same time that Camacho

nsisted,

with

reference

o

her scien-

tific

reporter

peers,

that

"we

always

share the

idea

that

we are

writing

for

every-

one,"

she

clearly

specified

hatthe readersof El

Nacional

were

primarily

students,

teachers,

professors,professionals" personal

communication).

Nonprofessionals

and

persons

with limited

educational

opportunities

did

not

figure among

her

im-

plied

readers.

As I

have

suggested

above,

pronouns

and

other discourse features

projected

he three

"at

high

risk"

groups

as

being

third

parties

who were referred o

but

not addressed

by

El

Nacional stories.

Locations within this projected process of discourse circulation were also

graphically

projected

n the

accompanying

photographs.

Health

professionals

were

pictured precisely

in

their

roles

in

actively

circulating

discourse about

cholera

and/or

effecting

material

preparations-processing

laboratory amples, stockpil-

ing

resources,

examiningsanitary

nfrastructuresnddomestic

spaces,

and

the

like.

They

seemed

to form

part

of

the

very

event of

circulation

as

they

look at the

camera

or

fit into the

bodily

frame

of the

meeting,

tour,

or

other

performance

of

cholera

prevention.

Barrio

residents,

ndigenas,

and street

vendors

seem

to

have

been

al-

ways

caught

n

the act.

Rather han

staring

nto the

camera

or

focusing

on

preven-

tion

activities,

they

seemed

to

embody

its

antithesis-bathing

in

the

open,playingnext to

piles

of

garbage, serving

food

in

spaces

surrounded

by

crowds, cars,

and

urban

decay,

or

just living

in

the

wrong

part

of the

city. They

were

entirely

out

of

the

loop,

not

only failing

to

play

any

active role

in

circulating

cholera

prevention

discourse but

seeming

to be

entirely

unaware

of

or resistant

to

it. The

projected

readers

of

El

Nacional

(with

the

exception

of

health

professionals)

were

strikingly

absent,

seldom

appearing

in these

photographs.

Because

they

were

reading

308








POWER

AND

PRAGMATIC

MISCALCULATION

N

PUBLIC

DISCOURSES

N HEALTH

authoritative nformationabout

cholera as

conveyed by

authorizedscientific

re-

porters,

their

role

in

acquiring

nformation

regarding

cholera

prevention

would

seem to

have

gone

without

saying

(or

rather

photographing).

This

fragmentation

rocess

does not

emerge simply

from these

projections

of

where different

players

are

expected

to fit

into

the

process.

Officials

and

reporters

also commented

explicitly

on

the

degree

to which

participants

were

performing

their

parts

adequately.

Recall Paez

Camargo's

criticismof

reporters

who

had been

turned

nto

"innocent

dupes"by

a

politician

concocting

cholera

cases;

he

implicitly

suggests

that

they

behave

properly

when

taking

only

official

statementsas news

sources.

Reporters

ometimes

returned

he

favor

by criticizing

MSAS

officials

for

failing

to

provide

useful, accurate,

and

timely

informationabout

cholera,

as in El

Nuevo

Pais's

parodic

characterization

f

Minister

Orihuela's smile.

Reporters

morecommonlyratified hepositionof publichealthofficials as not only beingin

the

loop

but

ensuring

ts

properoperation;

Diaz

Hung

(199

la)

thus

suggested

that

"The alse

alarm

hat

cholerahas arrivedhas

circulated everal

times.

A

few hours

later,

you

hear the

minister

of

[M]SAS,

Pedro

Paez

Camargo,

disproving

the

ru-

mor."

Assessments also focused on

differences

associated

with

the

degree

to

which

these

imagined

hierarchical odes

were

reflecting

cholera

prevention

discourse

be-

haviorally.

Both MSAS

officials and

reporters

visited barriosand

indigena

com-

munities and

inspected

their

homes and

neighborhoods

ust

as

they

observed the

street vendors' carts.

Rizk's

(1991c)

indictment:"None

of

these

measures"has

been transposednto actionby streetvendorsor barrioresidents.Hereagain,mid-

dle-class readers

remain

invisible-neither

epidemiologists

nor

reporters

visited

their

homes,

workplaces,

or

neighborhoods

o see

if

their behavior

reflected

the

preventionguidelines.

Interestingly,

Camacho

old me that

t

was

easy

to

interview

members

of

the

working

class and

gain

access to their

homes,

but

middle-class

residentswould seldom

even

consent

to

be

interviewedabout

cholera

or

other

epi-

demic

diseases. She did

not mention

attempting

any

inspections

there. The

state

and the media made

little effort

to

deprivatize

he lives of the

middle class

through

health

surveillance,

and

t

does not

appear

hat t would have been

easy

to

do

so.

Now we

come back

to

Warner.

Public

discourseaboutcholera

did not

simply

reachthepublicbutdefined fourdifferentpublics:barrioresidents,streetvendors,

indigenas,

and

sanitary

citizens

of the

middle class.

These

"groups"

were

not de-

fined

by

cholera

or

its

epidemiological

trace-no

cases had

yet

been

reported

n

Venezuela.

They

were

defined

not

only through

he

referential ontentof

these dis-

courses,

the

descriptions

of

their

beliefs,

habits,

environmental

onditions,

etc.,

but

also

by

the

place

that

they

were

assigned

in

this

idealizedcirculation

of

public

dis-

course. These four

publics

were

defined in

contrast

to both

health

professionals

and

reporters.

The

journalists

placed

themselves within

the

public

health

"we,"

whereas

officials

positioned

hem

much

closer to "the

public.")

These

gaps

undermined he

idealized

mage

of

discourse

circulationas well

as

its

pragmatic

enactment.

Located at

the

very

end

of

a

discursive chain

that also

formeda

social

hierarchy-and

portrayed

s

lacking

the

cognitive,

attitudinal,

nd

material

prerequisites

or

successfully

bringing

he

circuit o

completion-it

would

seem

that

people

cast in

the

cholera

story

as

barrio

residents,

ndigenas,

and

street

vendors were

expected

to fail.

Calls for

fostering

community

participation

were

thus

issued in

bad faith.

And

if

preventing

a

cholera

epidemic

was

deemed to be

309








MEDICALANTHROPOLOGY

UARTERLY

contingent

on

getting

these

three

sectors

to

embody

public

discourseabout

cholera,

then

the

"campaign"

s a whole

appears

o have

been

designed

in such a

way

that

its

outcome

would

be,

at

best,

uncertain.

Unnamed,

unstigmatized,

and

interpellated

as the

designated

audience for

denigratingdepictions

of the

other

three

publics,

sanitary

citizens

seldom

seemed

to

challenge

the

way

they

were

positioned

in this

projected

process. Many

of

the

people

who

got

thrust

nto the barrio

resident,

street

vendor,

and

indigena

slots,

on

the

other

hand,

sought

to redefine the

way

that

they

were

interpellated

by

cholera

public

discourse.

Many

individuals

definedtheir

position

by

rejectingaspects

of its

content,

from its more

blatantly

stigmatizing

social featuresto even the idea that

cholera-qua

disease-existed

at

all.

Many

people

challenged

the

regime

of truth

that

cast

MSAS as the

locus

of

production

of

knowledge

and

their own

relegation

to apassiveanddependent ole.

But

it is

clearthat

many

ndividuals

reconfigured

he referential ield in which

cholera

signifiers

were

located,

using

images

of

the disease

as means of

evoking

corruption,

he indifference

of

state

officials to

their

needs,

the

failure

of state

nsti-

tutions

to

provide

adequate

services,

and the lack

of

adequate obs

and

housing.

They thereby

subversively

cast

themselves as

producers

of

cholera

discourse,

as

people

who could

see

what

was

really

going

on. At

the

same

time,

this

transgres-

sive

mode

of

interpellation

hifted

not

just

ideas abouthow

cholera

discoursecir-

culated but its

very political

definition. Discourse became less

a

referential

and

cognitive process

of

the

coding

and

decoding

of

free-floating

signifiers (presum-

ablytied to "real" eferents) han a set of practices hat weregrounded n material

reality,

such

as access

to

food,

running

water,

sewage

facilities,

adequate

housing,

and

health

care.

Rather han

challenge

the constitutionof

multiple

publics

or their

inclusion

in a

particular

ector,

most individualswho

talked

back to

public

health

officials

seemed to

challenge

the

dominant

model as to how

public

discourse

ought

to circulateand how a

seemingly

linear,

horizontal

process

created

discontinuous,

hierarchically

arranged

categories

of

knowledge

and knowers.

Kitzinger

(1998)

suggests

thateven

when audiences

are

skeptical

of

media

coverage

(and

thus

of

re-

porters's

sources),

the

media

may

still

constitute he

primary

ource

of

information

about

an

issue.

Nevertheless,

this

case

suggests

that the

force of

subversive

read-

ings also springsfrom people's ability to questionhegemonic projectionsof the

routes

of

circulation

of

public

discourses

and/or how

they

are

positioned

within

them.

Evidence rom other

SouthAmericancountries

egarding

esistance o official

discoursesaboutcholera

suggests

thatthe

Venezuelan

experience

s

hardlyunique.

Marilyn

Nations and

Christina

Monte

(1996)

document

the

highly

stigmatizing

nature

of

the

anti-cholera

discourse

producedby

the Brazilianstate and how it

led

to

widespread

rejection

of health

education

recommendations.Rudi

Colloredo-

Mansfeld

(1998)

suggests

thateven

as

indigenous

residents

of

Otavalo

n

Ecuador

were

gaining

economically

on

their

neighbors

hrough

ransnational ales of

hand-

craftsand

culture,

an outbreakof cholera led to their

depiction

as

"dirty

Indians"

who

would

naturally

be

"at

risk"

for

the

disease.

Marcos Cueto

(1997)

suggests

that

poor

Peruvians

challenged

stigmatizing mages

by placing

cholera n a

much

wider

geopolitical

frame.And this

sort

of

relationship

between

states, classes,

and

cholera is

hardly

confined to Latin

America or

the

late twentieth

century.

Morris

(1976:95)

suggests

with

respect

to

the 1832

cholera

epidemic

in

England

that the

310








POWER AND PRAGMATIC MISCALCULATION

IN

PUBLIC DISCOURSES

ON HEALTH

middle and

upper

classes reacted

strenuously

o

what

they

saw as a threat o

their

privileges. Contrastively,

"from a

working-class viewpoint

this reaction was a

threat to

their normal life

and

legitimate rights

far more serious

than

anything

promised

by

cholera tself"

(see

also

Delaporte

1986;

Evans

1987).

Conclusion

Thus,

problems

with

public

discourseson healthcannot

simply

be blamed

on

ignorant

or

manipulative ournalists

or

on

paranoid

and

disrespectfulpublic

health

officials.

In

the

example

I have

described,

hese

parties

were

largely

in

agreement

regarding

an

ideological

view

of

how

health-related nformation

s

produced

and

how

it circulates.

Health

professionals

often

get angry

over

reporters'penchants

for extractingwords from institutionalcontexts andplacing them in new textual

settings, eading

to

such

charges

as "I've been

misquoted"

or

"You

took

my

words

out of

context."

The

point

is that

ragmenting

discourse s

par

or the course-the

way

it circu-

lates

through

complex arrays

of

institutionaland

noninstitutional

ettings, regis-

ters,

genres,

channels,

and

participants;

moreover,

health

professionals

are

just

as

guilty

in

this

regard.

Theirrecontextualizations re

legitimized by

the

ideology

of

referential

tability.

In

Latour's

(1988)

terms,

they

claim

to

have created

mmuta-

ble

mobiles,

packets

of

information hat

can

travel around

without

changing

their

meaning

as

they

move from

Washington

o

Caracas

and

are

recontextualized

n

a

variety of manuals,posters, pamphlets,press briefings, and public service an-

nouncements.

As

Geoffrey

C. Bowker and

Susan

Leigh

Star

(1999)

argue,

even

such seem-

ingly

water-tight

entities as

diagnostic

categories carry

the

history

of

the

institu-

tional sites

they

have visited within

them,

no matterhow much

they may

seem

to

be

impervious

o recontextualization.The

way

that these

juxtapositions

of

micro-

biological,

clinical,

and social information

hat

emerge

in

cholera

manuals,

pam-

phlets,

and

press briefings

are

interpreted

nd

the

social

effects

that

they

createare

highly

sensitive

to

changes

of

context, channel,

genre,

and

personnel.

Claims

by

health

professionals

that it

is

only reporters

who

fragment

information

about

health-even as they turnprojectionsof horizontalandlineartransmissionnto a

wealth of

hierarchically

rdered ocial

categories-seem,

shall

we

say,

naive.

Let us returnhere to the issues with which I

began

this article:health

nequali-

ties,

the

need for

greaterpublic

involvement

in

public

health,

and the

distinction

between

sanitary

citizens and

unsanitary

ubjects.

Starting

n

the nineteenth

cen-

tury,

states that claimed the mantle of

modernity

also claimed

the

right

to

use

health

as

one of

the

key

bases

for

creating

normative

definitions

of

citizenship.

Since that

time,

statediscoursesabouthealthhave

differentially nterpellated eo-

ple

on

the

basis of

their

perceived

relationship

o

hygiene,

medical

knowledge,

and

ways

of

preventing

and

treating

diseases.

Public

healthhas thus

involved,

since its

moder

inception, ways

of

addressing

"the

public"

thatcreatea

range

of

publics.

Health discoursehas thus

played

a crucialrole

in

defining

and

naturalizing

ocial

inequality.

Recent work in medical

anthropology,

he

history

of

medicineand

pub-

lic

health,

medical

sociology,

science

studies,

and other fields has

helped

us

grasp

the

many ways

that

differential access to biomedical

technologies

and

clinical

practices

and the circulation of

stigmatizing images expands

social

inequality,

311








MEDICAL

NTHROPOLOGY

UARTERLY

often with

fatal effects.

At least in the

present

case,

models of

the manner n

which

health-related nformation

s

produced

and circulatesand

attempts

o

control

this

process

provide

a means of

creating

and

naturalizing

ocial

inequalities.

Latour

1993)

argues

hat

purifying

and

hybridizingpractices mplicitly

con-

nect

science

and

society

at

the

same time

that

they explicitly

pretend

o

separate

them.

This

distinction

can

help

us

grasp

the

problem

at hand. The more

officials

and

reporters

uggest

that

one's location in the circulationof health discourse

is

contingent

on individualdifferences

in

knowledge

and

acceptance

of biomedical

knowledge,

the more these circuits

get

intertwined

with

material

nequalities

and

stigmatizing mages.

Drawing

on

visual

cultural tudies

(see

Burgin

1996;

Sturken

and

Cartwright

001),

I

argue

hat

photographs

lace particular

ocations

n

projec-

tions of discursive

circulation,

stigmatizing

mages,

and material

nequalities

to-

gether n thesameframe.Howyou get placedvis-a-vis maginedpublicsand mplied

readers-and thereforehow

your

speech

and behaviorare

read in

relationship

o

diseases-turns out

to

both

shape

and be

shapedby

your

access to

sanitary

nfra-

structures ndhealthcare.

My analysis suggests

that

the

dominant

deology

regarding

he circulationof

public

discourses,

at

least when

applied

to

public

health,

further

undermines

he

health

of

the most

medically

underserved

populations.

But does

it

really

serve the

state-or

at

least

public

health

professionals

who

are

working

to address

these

problems?

Recall the

rising emphasis

on health

promotion,

he

Instituteof Medi-

cine's

(1988)

call for more

public

involvement

in

health,

and the

growing

influ-

ence of policies thataccordsubstantialweightto communityparticipationnhealth

programs

see

Minkler and

Wallerstein

2003).

If,

as

MartinBarbero

1987)

sug-

gests,

our

perceptions

of

self,

society,

and

the

state

are

fundamentally

mediated,

then

public

discourses about

health

shape

basic

conditions of

possibility

for

fash-

ioning

new

state-public

relationswith

regard

o health.

Insofaras

the

ideologies,

pragmatics,

nd material

elations

hat

shape

the

cir-

culation

of

health-related

nformationcreate chasms between health

institutions

and

publics-and

between

people perceived

as

sanitary

citizens and

unsanitary

subjects-getting

communities

to

collaboratewith

public

health

institutions

and

clinicians

will

be

an

uphill

battle.Efforts

by progressivepractitioners

o

creatively

seek ways of fosteringhorizontalcollaborations hatpromotecommunity nvolve-

ment are

hinderedwhen the airwaves

and

newspapersproject

discursive hierar-

chies that

distance

public

health

professionals

and clinicians

from

publics, particu-

larly

when

they

place

the

very

participants

n

projects argeted

at

disease-burdened

communities

at the end of

circuitsof information nd

power.

When

the state

extols

the

virtuesof

citizen

involvement n health

and

then

createsdiscursive

chasms

that

effectively

makes

t

impossible

to

shapepublic

discoursesabouthealth

and

even

to

be credited with

understanding

hem,

distrustof

public

health institutions

would

seem to be a

foregone

result. In

an era in which

social

inequality

is

expanding

unrelentingly

and health

inequities

are far from

disappearing,

his

contradiction s

fatal for both

underserved

ommunitiesand

public

health

nstitutionsalike.

It

would be

presumptuous

o

purport

o

provide

a formula for

confronting

these

problems

on the

basis

of

a

single study.

Not all diseases are

reported

n the

same

way,

not

all health

professionals

and

reporters

harethe same

language

de-

ologies,

and

these connections

do not

have the same

political

andmedical

effects

in

all

parts

of

the

planet.

ndeed,

we

needa

great

deal

of

comparative

esearcho

establish

312








POWER AND PRAGMATIC

MISCALCULATION IN PUBLIC

DISCOURSES

ON

HEALTH

the

broader

parameters

f these

processes.

But

I

do

think

t

possible

to offer some

tentative

suggestions.

First,

as

Warer's

(2002)

article

suggests,

Venezuelan

public

health

officials

are not the

only

ones whose

attempts

o

place

information nto

public

circulation

are

guided

by

a

rathernaive idea as

to

how this

process

works.

Models

of

horizon-

tal, linear,

and

unidirectional lows of information

egitimize implicit

hierarchical

structures

ar

beyond

the

country's

borders

see

Patton

1996).

Second,

hierarchies f

biomedical

knowledge

do not lend themselvesto

iden-

tifying

who

is most

capable

of

deciphering

he

complex

pragmatics

of

public

dis-

courses

about

health. More

accurately

anticipating

he

social effects

of

health-re-

lated

public

discourses

requires

the involvement

of

people

who

understand

how

discourse circulates in

all

phases

of

the

design

and

implementationprocess,

not

simply

in

deciding

how booklets or

pressreleasesare worded.

Third,

this is

an area

in

which

community-based

participatory

esearch

is

sorely

needed.

It

may

seem

bizarreto

suggest

that members

of

the

most

under-

served communities

should

help

shape

how

high

officials

presentpublic

informa-

tion

about

health.

Nevertheless,

such involvement

is not

only

crucial for

rooting

out

stigmatizing mages

but also for

uprooting

he

hierarchical elations

created

by

placing

the

people

who

face the

worst health

conditions as the final link

on a

pro-

jected

information

chain.

Why

not

include

people

who are

"experts"

n

reading

how information s

interpellated

within their own

communities?In

doing

so,

we

might

learn

a lot

more about the full

range

of

publics

that

emerge

as

discourse

about health circulates.Nevertheless, inviting popular participation n shaping

how

health-related

ublic

discourse

s

disseminated hould form

part

of efforts to

break he hold of

hegemonic

models

and

practices-not

to make them more effec-

tive.

The state tries to

speak

to the

people

about

other

topics,

such

as democratic

practices, drugs,

ecology,

education,

and crime. In

the United

States and other

countries

n which

neoconservative

movementshave

gained ascendancy,

he

per-

ceived failureof

liberal

programs

aimed at

inspiringpublics

to act in

ways

thatthe

state

deems

to

be rationalhave

provided

neoconservative

ritics

with

arguments

o

eliminate

services

for the

growing

ranks

of the

poor-or

to make

them more inac-

cessible andpunitive.Creatingdiscursiveblueprints hat leadto suchfailures, or,

more

precisely,

to

the

perception

hat

they

have

failed,

contributesnot

simply

to

preserving

he

"kinder,

gentler"

hegemony

of

the

welfare state

but

to

regimes

that

eliminaterestrictions n economic

exploitation

and

enact "race-blind"

olicies

that

suppresspublic

challenges

to

discrimination. f

healthhas

been crucial or

shaping

notions

of

citizenship,

publics,

and

the state for

nearly

two

centuries,

health

spe-

cialists can

play

a

key

role in

challenging

these

attempts

o

rationalize new

in-

equalities.

This case

sheds new

light

on

a

problem

that

has

generated

a

great

deal of re-

search

and

theorizing

in

anthropology

in

recent

years,

how

states

generate

hegemonic

discourses,

heir

political

economic

effects,

and

possibilities

for resist-

ing

them.

Along

with

medical

historians,

sociologists,

and

specialists

in

women's

and cultural

studies,

medical

anthropologists

have

challenged

the

modernist

sepa-

ration

of science and

society

(see

Latour

1993)

in

demonstrating

ow

states,

trans-

national

corporations,

and

international

gencies

shape

constructions

of

diseased

and

healthy

bodies

(e.g.,

see

Briggs

with

Mantini-Briggs

2003;

Cohen

1998;

313








MEDICAL

NTHROPOLOGY

UARTERLY

Lindenbaum

1998;

Martin

1987, 1994;

Pigg

2001;

Rapp

1999).

Scholarshave also

demonstrated

ow

medical

deologies

and

practices

both

reflect and

shape

political

economies

and structure elationsof

inequality

see

Das

1995;

Farmer

1992,

1999,

2003;

Kimet al.

2000;

Nichter

1987;

Scheper-Hughes

1992).

The

present

case

points

to

a

dimension of these

processes

that

is

not ade-

quately

revealed either

by

sensitive

analyses

of how

images

locatedin

health-re-

lated

discourses

egitimize power

relations

and

forms of

inequality

or

by

illumina-

tions of the

broader

political-economic

and historicalfactors

that

shape

diseases

and their

social

effects.

When

medicalizedconstructionsbecome

public

discourse,

grasping

their

social, cultural,

political,

and medical

consequences

also

entails

analysis

of the

political economy

of

the

complex pragmatics

ntailed

n

their

pro-

duction,

circulation,

and

reception.

Following

Warer,

I have

argued

that

neither

theimagesthemselves nor the broader ontextsin whichtheycirculateprovideac-

curate

ndicators

of how

they

will

be read

or how

they

will

affect

peoples'

lives.

Such

analysis

is

a

key prerequisite

o

understanding

how states

create

power

through

discourseas

well as

how

people

resist

them.

I would

thus

urge

a new focus of

concern

for medical

anthropologists

who

seek to

understand

discourses of

health

and disease

and their

political-economic

underpinnings

and

effects.

Developing

this

desideratum

will

be most

fruitful

if

medical and

linguistic

anthropologists

engage

more

widely

in

dialogue-and

if

training

n

medical

anthropology

ncludes

grounding

n

discourse

processes.

There

is a double

motivation

or

developing

a

political

economy

of the

complex

pragmat-

ics of health-relateddiscourses.This sortof analysiscan help us understand ow

the

state and

media create dominant

conceptions

of

health,

disease,

and the

body

and some of

the

ways

they

are resisted.But it

can

also

assist

us in

identifyingways

in which

we

are

nfluenced

by hegemonic

formulations. nsofaras

anthropologists,

medical or

otherwise,

hemselves

rely

on

simplistic,

inear

models of

discourse,

we

run the risk

of

helping

the state and other

dominant nstitutions onceal

the

effects

of dominant

discourses-and

strategies

or

challenging

hem-from

view.

NOTES

Acknowledgments. hisarticlehasbenefited romexcellent riticism rovided y

three

reviewers for

Medical

Anthropology

Quarterly,

ellow

members of the

Health and

Race

Group

at

the

University

of

California,

San

Diego

(Hector

Carrillo,

Steven

Epstein,

Natalia

Molina,

Lisa Sun-Hee

Park,

David

Naguib

Pellow,

and

Nayan

Shah),

Vincanne

Adams,

and

audiences

at

the Instituto

de

Altos Estudios

en Salud

Piblica

"Amoldo

Gabald6n"

Maracay,

Venezuela),

the

Department

of

Anthropology

of

the

Universidad

Aut6noma

Metropolitana-Iztapalapa

(Mexico

City),

the Escuela

Nacional de

Salud

Piblica

(Habana,

Cuba),

and the

Faculty

of

Medicine,

Universidad

de la

Cuenca

(Cuenca,

Ecuador).

Employees

of

the

(then)

Ministry

of

Health and Social

Assistance,

journalists,

politicians,

and

many

others

gave

generously

of

their

time

in

documenting

he

cholera

pre-

vention

program.

Maria

Alejandra

Romero

helped

compile

the

newspaper

sample,

Jansi

L6pezassisted n quantifying heirthematic oci, andEstrellaMantiniand LicetVillanueva

transcribed he

interviews.

Financial

support

for

the overall

project

was

provided

by

the

JohnSimon

Guggenheim

Memorial

oundation,

he

National

cience

Foundation,

heSo-

cial Science

Research

Council,

heNational

Endowment

or

the

Humanities,

he

Wenner-

Gren

Foundationor

Anthropological

esearch, nc.,

and the Academic

Senate

of

the

University

of

California,

San

Diego.

Clara

Mantini-Briggs,

MD,

served as

my

collaborator

in

the

overall

research

project

andenriched his

articlewith her ideas and

criticisms.

314








POWER

AND

PRAGMATIC MISCALCULATION IN

PUBLIC DISCOURSES

ON HEALTH

Correspondence

ay

be addressed o the authorat the

Center

or Iberian

nd Latin

American

Studies,

University

of

California,

San

Diego,

9500 Gilman

Drive,

La

Jolla,

CA

92093-0528.

1.

In

TheFuture

of

Public

Health,

the

Instituteof Medicine

suggests,

for

example,

that

"Publichealth s whatwe, as a society,do collectivelyto assure heconditions nwhichpeo-

ple

can

be

healthy"

1988:1).

2. With

regard

o

media

coverage

of

health

ssues,

also see Arkin

1990,

Chapman

and

Lupton

1994,

Convissoret al.

1990,

Dorfmanand Wallack

1993,

Joffe

and

Haarhoff

2002,

Leask

and

Chapman

2002,

Miller et

al.

1998,

U.S.

Department

f

Healthand

Human

Serv-

ices

1991,

andWallack 1989.

3. To be

sure,

collaborationsbetween

public

health

professionals

and

advertising

pe-

cialists are

of

tremendous

mportance

see,

e.g., Lyles

2002).

I

do

not treatthem

here

be-

cause

they

did

not

enter nto the anti-cholera

program

hat

I

analyze.

4.

Warer's

essay

is,

of

course,

part

of

a much

larger

discussion of

public spheres,

publiccultures,and"counterpublics"see Fraser1992).Forexamples,see Calhoun 1992)

and GaonkarandLee

(2002).

5.

The institution as

now

been

renamed he

Ministry

f Health

and

Social

Development.

6.

Like

all othernames of

persons

nterviewed

n

connection

with this

study,

this name

is

fictional.

7.

I

place

the

term

indigena

in italics

throughout

his article

n

order

o

indicatethat

t

does not refer to

a

bounded,

discrete social

group. Dividing

Venezuelans nto discrete

and

nonoverlapping indigenous"

nd

"nonindigenous" ategories

s less a reflectionof a

perva-

sive

and

elementary

ocial

difference hana tool

for

imposing

racial

categories

andthe forms

of

social

inequality

hat

go

with

them.

8. Comer et al.

(1990)

argue

that readers

process

visual

images

differently

rom text.

Images

holda

"positioningpower"

hat

generates

affective

responses

hatare moreresistant

to reflectionand

deconstruction.

9.

This

information

s

drawn from a

2003 interview that Clara

Mantini-Briggs

con-

ductedwith

a

memberof the

formerDivision of

Social HealthPromotion eam.

10. Both

this

phrase

and

the

notion of

un invento

(a

lie)

emerged

repeatedly

n

public

health officials' accounts of

their

attempts

o

measure

public

views

of

a

possible

an

epi-

demic. Our

nterviews

suggest

that

some membersof

the

working

class

continued

o

believe

thatthe cholera

epidemic

was a fiction

concocted

by

the

government

o

draw

attention

away

from its own

problems ong

after

cases

were

reported

n Venezuela.

11.

This

photograph

ppeared

n El

Nacional on

September

29,

1992.

Although

t

thus

falls outside of the storiesthatappearedprior o thetimethatthefirstcases werereportedn

Venezuela,

other

photographs

hat

similarly

criticize

the

governmentappeared

during

the

period

of the

sample

(February

o

early

December

1991).

12.

Rosenberg

(1989:5)

argues

that

the

attribution

f

agency

to

diseases is common:

"Once articulatedand

accepted,

disease entities became 'actors' in a

complex

social situ-

ation."Also

see Tomes

2000.

13.

The

contested

positioning

of

reporters

here

is

interesting.

Although they

claimed

the

ability

o transmit

ealth

nformationmore

echnically

nd

authoritatively

han

"the

public,"

health officials

lumped

them

together

with

other

nonprofessionals.

But

reporters

laimed

a

mode of

discursive

agency

that

no

other

actors

possessed-the

ability

to

draw

on

multiple

sources

and discover

how

to

make

nformation

newsworthy.

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