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The Aid Enclave: Mapping an Emerging Geography of Global Health

Matthew Sparke, sparke@u.washington.edu

From the enclave as an unfinished utopia …

http://act.pih.org/page/invite/thisIbelieve

Partners in Health clinics as practical utopias in a “distopian world”

…to the enclave as parasite “Today, someone who walks from the northwest toward the

Malawi hospital ward where I watched a young woman die long ago may still pass the herbalists selling their medicines. Those approaching from the east or south must make their way between the gleaming buildings of the transnational research projects. Gates, Wellcome, the CDC, Johns Hopkins are all represented: all the big guns in international research, plus many smaller guns. The studies conducted within have been carefully vetted, stamped, and approved as ethical; there will be no more research on second-best therapies, though this restriction sometimes means the projects are not very relevant to the local clinical world. Climate controlled, well equipped, stuffed with staff and microscopes and laboratory reagents and automated specimen processors, the research buildings make for a striking contrast with the hospital they surround. It is sometimes hard not to see them as parasites feeding on an emaciated host.”

Claire Wendland, 2008

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So how does the enclave emerge and spread as a parasite?

 Economic Enclaving

 Political Enclaving

 Ethical Enclaving

Economic Enclaving

 The creation of the “emaciated host”   SAPs & ongoing aid conditionalities in PRSPs   Accumulation by dispossession   Disease

 The economics of the “parasite”   Enclave pay versus local pay   Enclave as tax free haven   Enclave of entrepreneurial intermediation (macro & micro)

  Enclave as targeted investment opportunity   Enclave as expatriate compound of privilege

Economic enclaving: Investment Ops - targeting areas for ‘product’ development - verticalization as alternative to state corruption - biomedical investment in ideas about an ‘IV’ injection

http://www.gatesfoundation.org/regions/Pages/default.aspx#/?action=region&id=0

Triangulate on the enclave }

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Economic enclaving: compound privilege - the place of privilege

“I was paid a salary of $23K…the Nigerian project manager … was paid less than $400 a month…the watchmen as little as $50 a month. Further I was provided free housing…, and because my project provided house was inside the NGO compound, the office generator supplied my fully furnished house with electricity…and the project’s compound supervisor doubled as my steward helping me with shopping, cooking, cleaning my house and washing my laundry. Compared with the palatial quarters of expatriates working for bigger agencies like USAID or UNICEF, my house was relatively humble. Many expatriates’ houses are far more luxurious than anything they could afford in their own countries….I remember feeling particularly empowered controlling a fleet of vehicles, … and I was especially fond of our white Toyota Land Cruiser.”

Daniel Jordan Smith, 2009

Economic enclaving: compound privilege - the place and pace of privilege

“The NGOs bore the brunt of the anger at reconstruction because they were intensely visible, slapping their logos on every available surface along the coast, while the World Bank, USAID and government officials dreaming up Bali plans rarely left their urban offices. It was ironic, since the aid organizations were the only ones offering any kind of help at all – but also inevitable, because what they offered was so inadequate. Part of the was that the aid complex had become so large and so cut off from the people it was serving that the lifestyles of the staffers became … a national obsession. Almost everyone I met commented on what priest called the “NGO wild life”: high-end hotels, beachfront villas and the ultimate lightening rod for popular rage, the brand new white sport utility vehicles. All the aid organizations had them, monstrous things that were far too wide and powerful for the country’s narrow dirt roads. All day long they went roaring past the camps, forcing everyone to eat their dust, their logos billowing on flags in the breeze – Oxfam, World Vision, Save the Children – as if they were visitors from a far-off NGO World. In a country this hot, these cars with their tinted windows and blasting air conditioners were more than modes of transportation; they were rolling microclimates.” Naomi Klein, 2008

Economic enclaving: compound privilege - the place and pace of privilege

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Economic enclaving: compound privilege - the time-space of privilege

Prominent features of the research practices were intrusion and control. We interrupted school activities, enlisted and numbered the children and turned them into 'study subjects'. The research hierarchy expanded the close association between bodily discipline and knowledge, already present in the rural schools, beyond the limits of the locality: the emissaries of the government and the university in the capital city arrive in a government car and, rescinding the existing regime of bodily discipline and inducing even teachers to break their routines, access the children's bodies, inflict pain and extract blood. When the collection of medical specimens was extended to the village, this hierarchical order of research expanded further, intruded into domestic life and incorporated the children's families: from the distant city and from overseas, researchers travel in big cars to the end of the tarmac road, follow dirt roads, branch into footpaths, and plough through the bush as far as they can drive; further on they move on foot, into a family's homestead, where they enter hastily and noticeably without social purpose; they enter the house of a mother, examine her child and take some of its bodily fluid with them. Research confronts the people in the village with a hierarchy of power, wealth, education and mobility, which embraces global spaces spanning from Africa to Europe, village to capital city, wealthy to poor, powerful to marginalized, in which they themselves are at the periphery and at the bottom.

Wenzel Geissler, 2005

Political enclaving:  Macro: a return to imperial projects

  A new scramble for Africa?

•  Flags & logos

•  Body-counts

  The enabling public-private global governance ‘ecosystem’ of WHO, UN, WB, WTO, G8, Gates, NGOs and IHRs/TRIPS

 Micro: a return to pastoral power “Several funding mechanisms of PEPFAR, such as the “New Partners Initiative”, are specifically designed

to facilitate US FBOs to set up treatment and prevention programs in Africa. Indeed, in some countries, evangelical congregations are dispensing treatment. Even without the explicitly religious dimension that is so particular to PEPFAR, other HIV programs also target reproduction, body and soul. Pregnancy is an important “entry point” for reaching HIV positive women who can be given preventive drugs to stop transmission to their child and enrolled in treatment programs, and those who are on treatment are exhorted to adhere properly to their drug regimens through counselling, self-help groups and therapy “clubs”. For those who are not HIV positive, “life skills and HIV prevention programs teach youth to respect themselves, to respect others, including the opposite sex, and to practice personal responsibility” Vinh-Kim Nguyen, 2009

Ethical enclaving:

 Spaces of ethical compensation   VK Nguyen: PEFAR as an indulgence for GITMO

 Spaces of biomedical correctness   Adrianna Petryna: treating the ‘treatment naïve’ body right

 Spaces of moralization   The problem with Saint Paul

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Ethical enclaving: the marginalization of miraculation

“Paul Farmer is a sort of saint… I have the highest respect for him. He is a great man who has done more good in the world than I will do in a hundred lifetimes…. He has saved so many lives…. But, we cannot replicate what he has done personally globally….”

Daniel Wikler, 2009

Ethical enclaving:

Farmer: Reframing morals as ethics as ideals for collective global struggle against dispossession

“I know it's not enough to attend only to the immediate needs of the patient in front of me. We must also call attention to the failures and inadequacy of our own best efforts. The goal of preventing human suffering must be linked to the task of bringing others, many others, into a movement for basic rights.” Paul Farmer, 2008

Breaking out of the enclave