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Routledge Handbook of Global Sport 1st Edition John Nauright
THE ROUTLEDGE HANDBOOK OF ANTHROPOLOGY AND GLOBAL HEALTH
The Routledge Handbook of Anthropology and Global Health provides an overview of the complex relationship between anthropology and global health. The book brings together a diverse group of scholars who consider the intersection of anthropological concerns with health and disease as understood and intervened upon by the field of global health. The book is structured around five sections: (1) social, cultural, and political determinants of health; (2) knowledge production in anthropology and global health; (3) persistent invisibilities in global health; (4) reimagining a critical global health; and (5) new horizons in anthropology and global health. Within these five themes a range of topics is explored, including:
• rare diseases
• medical pluralism
• universal global health protocols
• HIV
• health security
• indigenous communities
• (non)communicable diseases
• decolonising global health
The Routledge Handbook of Anthropology and Global Health is an essential resource for upper-level students and researchers in anthropology, global health, sociology, international development, health studies, and politics.
Tsitsi B. Masvawure is an Assistant Professor (anthropology and global health) in the Department of Integrative and Global Studies, The Global School, Worcester Polytechnic Institute, Massachusetts. She has a PhD in Anthropology and is a feminist scholar, and global health researcher who studies gender, sex and health (primarily HIV) in southern Africa.
Ellen E. Foley is a Professor in the Department of Sustainability and Social Justice at Clark University, Worcester, Massachusetts with a PhD in Anthropology. She studies sexual and reproductive health and rights, urban health disparities, and development interventions in francophone West Africa.
ROUTLEDGE ANTHROPOLOGY HANDBOOKS
THE ROUTLEDGE HANDBOOK OF ANTHROPOLOGY AND REPRODUCTION
Edited by Sallie Han and Cecília Tomori
THE ROUTLEDGE COMPANION TO CONTEMPORARY ANTHROPOLOGY
Edited by Simon Coleman, Susan B. Hyatt and Ann Kingsolver
THE ROUTLEDGE HANDBOOK OF ANTHROPOLOGY AND THE CITY
Edited by Setha Low
THE ROUTLEDGE HANDBOOK OF MEDICAL ANTHROPOLOGY
Edited by Lenore Manderson, Elizabeth Cartwright and Anita Hardon
THE ROUTLEDGE HANDBOOK OF THE ANTHROPOLOGY OF LABOR
Edited by Sharryn Kasmir and Lesley Gill
THE ROUTLEDGE COMPANION TO MEDIA ANTHROPOLOGY
Edited by Elisabetta Costa, Patricia G. Lange, Nell Haynes and Jolynna Sinanan
THE ROUTLEDGE HANDBOOK OF SOCIAL STUDIES OF OUTER SPACE
Edited by Juan Francisco Salazar, Alice Gorman, and Paola Castaño
THE ROUTLEDGE HANDBOOK OF AUSTRALIAN INDIGENOUS PEOPLES AND FUTURES
Edited by Bronwyn Carlson, Sandy O’Sullivan, Tristan Kennedy & Madi Day
THE ROUTLEDGE HANDBOOK OF ANTHROPOLOGY AND GLOBAL HEALTH
The right of Tsitsi B. Masvawure and Ellen E. Foley to be identified as the authors of the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe.
ISBN: 9781032256375 (hbk)
ISBN: 9781032256405 (pbk)
ISBN: 9781003284345 (ebk)
DOI: 10.4324/9781003284345
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1 The ‘caste’ of decolonization: Structural casteism, public health praxis, and radical accountability in contemporary India 19 Nikhil Pandhi
2 Cultural determinants of health as a new strengths-based framework for global health: Lessons from Indigenous Australia
Sarah Bourke
3 Enhancing critical global mental health with anthropological ethnography: Lessons from studies with ‘traumatized’ migrants
Runa Lazzarino
5 ‘This is not real anthropology’: An analysis of an anthropologist-led intervention at the World Health Organization 75
Dalton Price
6 The measure of a mother: Accounting for the risk of postpartum haemorrhage in global health 89
Andie Thompson and Emily Yates-Doerr
7 Dr. Mathur’s contradictory position: Biosecurity, humanitarianism, and Indian tuberculosis physicians 104
Andrew McDowell
8 Global health anthropology pedagogy: Using book-length ethnographies to teach global health worldviews in American undergraduate courses
Pamela Runestad
9 Non-Western knowledge systems and utilization of traditional healing practices in contemporary Sri Lankan society
Chandani Liyanage, Pushpa Ekanayake, and Brianne Wenning
10 Missing trust and to miss trust: Popular responses to COVID-19 in Burkina Faso
Pia Juul Bjertrup and Landry Bambara
11 Indigenous midwifery revisited in COVID-19 times: The making of global maternal health and some anthropological lessons from southern Mexico
Paola M. Sesia and Lina R. Berrio Palomo
12 Global health, intercultural health, and the marginalization of traditional birth attendants in Ecuador
Erika Arteaga-Cruz and Juan Cuvi
13 Medical pluralism: Opportunities and barriers to good health
Meredith G. Marten and Spencer K. Seymour
Persistent invisibilities in global health infrastructures
14 Invisible straight men: Heterosexual men’s ghostly lives with AIDS in Colombia
Héctor Camilo Ruiz-Sánchez
15 The neglected chronicity of TB
Dillon T. Wademan and Amrita Daftary
16 Suitcases full of meds: Deconstructing the political economy of pharmaceutical shortages in Lebanon with anthropological tools
Anthony Rizk and Magdalena Góralska
17 First, it was women and girls, now it is men: (In)visibility in global health programs
Nolwazi Mkhwanazi and Alfred Adams
18 Muslims living with HIV in Durban, South Africa: Addressing stigma, shame, and treatment
Shabnam Shaik
5 Toward a reimagined critical global health
19 Countering amnesia: The importance of history and anthropology in global health
Sarah Howard, Sebastián Fonseca, and David Bannister
20 Decolonizing global health: A critical perspective from Latin America
Vivian Laurens and César Abadía-Barrero
21 Localising, decolonising, and the role of anthropology in a ‘New Global Health’
Megan Schmidt-Sane, Janet McGrath, Norma Ojehomon, and David Kaawa-Mafigiri
22 Global health as analytic: Making sense of the domestic COVID responses in the United States
Tsitsi B. Masvawure
CONTRIBUTORS
Cesar Abadia-Barrero, DMD. DMSc., is Associate Professor of Anthropology and Human Rights at the University of Connecticut, whose research examines how for-profit interests transform access, continuity, and quality of health care. His latest book is Health in Ruins: The Capitalist Destruction of Medical Care at a Colombian Maternity Hospital (2022).
Alfred Khehla Adams is a Medical Anthropologist and researcher with over 13 years’ experience leading public health programme implementation, research, implementation science, and project evaluation. Alfred’s research focuses on HIV, men, and masculinities in Eswatini.
Erika Arteaga-Cruz, MD, MPH is an Ecuadorean feminist physician. She is a Professor at the San Francisco de Quito University and a PhD candidate in Collective Health, Environment and Society, Simón Bolivar Andean University. She researches resistance to the industrial medical complex by Indigenous traditional birth attendants and health promoters.
Landry Bambara has a bachelor’s degree in Sociology from the Université Joseph Ki-Zerbo, in Ouagadougou, Burkina Faso. He has been part of international research projects and conducted fieldwork in the central and southeastern part of Burkina Faso. His research areas include child health, chronic illnesses, and the COVID-19 pandemic.
David Bannister is a researcher in the Department of Community Medicine and Global Health at the University of Oslo. He uses historical and ethnographic methods to examine the contemporary history of health care, the political economy of health and disease, and the social history of public health and medical science in Africa.
Lina Berrio-Palomo is Researcher and Professor at the Centre for Research and Advanced Studies in Social Anthropology (CIESAS, Pacifico Sur), Oaxaca, Mexico. She is a medical anthropologist with a PhD in Anthropology (Universidad Metropolitana UAM-I). Her research topics are sexual and reproductive health, Indigenous and afrodescendent people, and feminist anthropology.
Pia Juul Bjertrup is a Medical Anthropologist with a PhD in Anthropology from the University of Copenhagen. She researches refugee mental health, HIV and TB prevention
and treatment, epidemic preparedness, and child health care in Greece, Eswatini, Uganda, Malawi, and Burkina Faso. She has also worked with Médecins Sans Frontières.
Sarah Bourke received her DPhil in Anthropology from the University of Oxford and is a Research Fellow at the National Centre for Aboriginal and Torres Strait Islander Wellbeing Research at the Australian National University in Canberra. Her doctoral thesis won the prestigious Stanner Award in 2021.
Juan Cuvi is an Ecuadorian sociologist who studied Sociology at Universidad Central del Ecuador, Political Science at Université Paris VIII and Philosophy at Universidad del Azuay, Cuenca. He has a master’s in Development Studies from Universidad Politécnica Salesiana, Quito and over 30 academic articles on politics and the anthropology of health.
Amrita Daftary is an Associate Professor at the School of Global Health, York University, Canada and works with TB affected community organisations in sub-Saharan Africa, Southeast Asia, and eastern Europe. She teaches qualitative methods and is the founding director of a borderless TB Centre: Social Science and Health Innovations for Tuberculosis.
Pushpa Ekanayake is a Senior Lecturer in the Department of Sociology, University of Ruhuna, Sri Lanka, where she also obtained her master’s and PhD. She is especially interested in local knowledge and traditional medical systems, rural sociology, and international migration.
Elsa Fan is an Associate Professor of Anthropology at Webster University who researches how global health ideas, interventions, and objects travel across diverse social and cultural contexts. She has worked in and consulted for the non-profit and international development sectors in Asia and America.
Ellen E. Foley is a Professor in the Department of Sustainability and Social Justice at Clark University, Worcester, Massachusetts with a PhD in Anthropology. She studies sexual and reproductive health and rights, urban health disparities, and development interventions in francophone West Africa.
Sebastián Fonseca is a medical doctor (Pontificia Universidad Javeriana, Colombia) with a PhD in Global Health and Social Medicine. His research at “C3W” examines how global health history often neglects other health cultures rooted in situated perspectives of socialism or socialist health in regions like Latin America.
Magdalena Góralska is a PhD candidate at the Institute of Ethnology and Cultural Anthropology, University of Warsaw, where she studies Lyme disease. She coordinates the EASA Medical Anthropology Europe network. She has extensive research experience in Europe, the Middle East, North America and Asia, studying media, political and healthrelated controversies.
Servando Z. Hinojosa received his PhD in Anthropology from Tulane University and is a Professor of Anthropology at The University of Texas Rio Grande Valley. His research focuses on Maya healing practices and health in Turkey. His latest book is Maya Bonesetters: Manual Healers in a Changing Guatemala (2020).
Sarah Howard is an anthropologist who has conducted long-term research in Ethiopia, and a researcher on the Wellcome Trust-funded “Connecting Three Worlds” project that is pio-
neering a new history of global health and incorporating the socialist world. She is currently working on a monograph exploring everyday aspirations in rural Ethiopia.
Leah Davina Junck is an anthropologist fascinated with what the integration of computational technologies into peoples’ lives means for our ability to relate to one another. She studied at the University of Cape Town. Leah is editor of the journal Anthropology Southern Africa and has published articles in The Conversation.
David Kaawa-Mafigiri is a Senior Lecturer in the School of Social Sciences, Makerere University, where he lectures in the health track focusing on global health, structural drivers of infectious diseases and community-based health initiatives to promote health among vulnerable populations. He is a medical anthropologist with public health training.
Eva-Maria Knoll is a medical anthropologist and Senior Researcher at the Institute for Social Anthropology (ISA) of the Austrian Academy of Sciences. Her research focuses on the intersections of anthropology, health, life sciences, mobility, and island studies in the Indian Ocean world, with special expertise in the Maldives.
Runa Lazzarrino is a sociocultural and medical anthropologist conducting research in the fields of migration and health. Runa is based at Oxford University, Medical Sciences Division, working on a digital health study, and collaborating with Middlesex and St. Mary’s Twickenham Universities on gender migration and creative methods in trafficking aftercare.
Vivian Laurens is a PhD student in Medical Anthropology at the University of Connecticut. She researches the relationship between the right to health and peacebuilding in post-conflict societies, particularly how the right to health and the indigenous epistemology of Buen Vivir affect the peacebuilding efforts of civil society in Colombia.
Chandani Liyanage is a Professor of Sociology and founding director of the Center for Disability Research, Education and Practice at the University of Colombo, Sri Lanka. She obtained her master’s degree from the University of Colombo and PhD from Delhi University. She researches illness, disability, and traditional medicine.
Tsitsi B. Masvawure is an Assistant Professor (of anthropology and global health) in the Department of Integrative and Global Studies, Worcester Polytechnic Institute, Massachusetts. She has a PhD in Anthropology (University of Pretoria, South Africa) and is feminist scholar and global health researcher who studies gender, sex and health (primarily HIV in southern Africa).
Meredith Marten is a medical anthropologist and Associate Professor of Anthropology at the University of West Florida. She has an MPH in International Health and Development, Tulane University, and a PhD in Anthropology, University of Florida. She researches global maternal and infant health, HIV policies and programs, and health policy.
Andrew McDowell is an Assistant Professor in the Department of Anthropology at Tulane University, New Orleans, USA. He completed a PhD in Sociocultural Anthropology at Harvard University and held fellowships at McGill University, the National Center for Scientific Research in Paris, and Harvard Medical School’s Center for Global Health Delivery-Dubai.
Contributors
Janet McGrath is a medical anthropologist and Chair of the Department of Anthropology at Case Western Reserve University. She researches HIV risk, women’s health, HIV prevention, and access to HIV treatment. She co-founded the Center for Social Science Research on AIDS with the School of Social Sciences, Makerere University, Uganda.
Nolwazi Mkhwanazi is a Professor of Anthropology and Deputy Director of the Centre for the Advancement of Scholarship at the University of Pretoria. Nolwazi’s research focuses on youth sexuality, sex education, and sexual health interventions. Her current project is called Reimagining Reproduction: Making Babies, Making Kin and Citizens in Africa.
Norma Ojehomon, MPH, is a doctoral student in the Department of Anthropology at Case Western Reserve University. She has worked as an advisor and consultant for USAID and PEPFAR programs in Africa, Asia, and Central America. She researches global health institutions and their intersection with local knowledge and power.
Nikhil Pandhi is a doctoral candidate and queer-feminist researcher in the Department of Anthropology at Princeton University. His fields of inquiry include anti-colonial and caste studies, critical race studies, Dalit studies, Black studies, and BIPOC queer-feminist studies. His research draws on intersectional epistemologies/methodologies, including long-term ethnography in South Asia.
James Pfeiffer is a Professor in the Department of Global Health in the School of Public Health at the University of Washington, Seattle, with a joint appointment in the Department of Anthropology. He has over 30 years of research experience in implementation science, medical anthropology, and public health in Africa.
Dalton Price is an anthropologist and final-year PhD researcher at the University of Oxford. His research spans global health, bureaucracy, and migration in Latin America and the Middle East. Dalton has worked in humanitarian, development and governmental spaces with the World Health Organization, German Development Institute, and World Economic Forum.
Małgorzata Rajtar is an anthropologist and sociologist. She is an Associate Professor and Head of the Rare Disease Social Research Center at the Institute of Philosophy and Sociology, Polish Academy of Sciences. Her research interests include medical anthropology and sociology, bioethics, science and technology studies, and health and religion.
Mayssa Rekhis is an anthropologist and Medical Doctor who received her PhD from the School for Advanced Studies in Social Sciences, Paris, and her MD from the University of Tunis-El Manar, Tunisia. She is a lecturer and program director of the Master of Global Health at Gothenburg University, Sweden.
Anthony Rizk is a PhD candidate in the Department of Anthropology and Sociology, Geneva Graduate Institute, Switzerland. Situated mainly in political economy and the anthropology of medicine and the biosciences, he studies, in his doctoral research, the reorganisation of microbiology, hospital infection control, and pharmaceutical distribution in the midst of Lebanon’s 2019 financial collapse.
Héctor Camilo Ruiz-Sánchez is an Assistant Professor at the University of Connecticut. He has experience in ethnographic and anthropological work in urban contexts in Colombia and the United States. He combines participatory action research (PAR), anthropology, public health, and the arts to engage in collaborative research with often-overlooked communities.
Pamela Runestad is an Assistant Professor of Anthropology at Elon University, USA. She is a medical anthropologist and Japanologist who researches the intersection of infectious disease, food, health, and citizenship. Her work spans the fields of global health, Asian studies, and food studies. Runestad’s forthcoming book explores HIV in Japan.
Helle Samuelsen is Associate Professor at the Department of Anthropology, University of Copenhagen, Denmark. Her research focuses on medical anthropology and global health, with special focus on health systems and the relationship between citizens and the state. She has over 25 years of research experience in Africa, particularly Burkina Faso.
Megan Schmidt-Sane, PhD, MPH is a medical anthropologist with interdisciplinary training and experience in global health. She is a Research Fellow with the Health and Nutrition cluster at the Institute of Development Studies in Brighton, United Kingdom. She researches precarity, uncertainty, and vulnerability to illness and disease in urban sites.
Paola M. Sesia is a Researcher and Professor at the Centre for Research and Advanced Studies in Social Anthropology (CIESAS), Mexico. She has a PhD in Anthropology (University of Arizona) and master’s in Public Health (University of California, Berkeley). She researches Indigenous peoples reproductive health, obstetric violence, and midwifery in Mexico.
Spencer Seymour is a PhD student in Anthropology at the University of Florida. He received his MA from the University of West Florida. He studies medical pluralism, interactions between Western biomedicine and traditional healing in West Africa and India, and postcolonial Christian medical missionaries in Benin and Togo.
Shabnam Shaik obtained her PhD in Medical Anthropology from Rhodes University. Her interests include medical pluralism, exploring the relationship between culture and mental health, visible and invisible disabilities, and labour. Her PhD research focused on understanding the experiences of Muslims living with and affected by HIV/AIDS in Durban, South Africa.
Andie Thompson is a PhD candidate in Anthropology at the University of Amsterdam and an investigator on the ERC-funded research project ‘Global Future Health’. Andie researches the science of toxic stresses and exposures to political, social, and built environments, including the intersections of science, policy, and activism on reproductive justice.
Lea Pare Toe obtained her PhD in Anthropology from the University of Aix-en-Provence, France, and works as a researcher at Institut de Recherche en Sciences de la Santé in Burkina Faso. She researches perceptions of health and disease and the interactions between healthcare systems and communities.
Dillon Wademan conducts research on TB and HIV treatment and prevention at the Desmond Tutu TB Centre, South Africa. He is a member of the South African TB Think Tank. Dillon’s research focuses on children’s experiences of novel TB treatment formulations and on improving acceptability of TB treatment.
Brianne Wenning is a Lecturer in Global Health at the Kent and Medway Medical School, University of Kent and Canterbury Christ Church University, UK. She has an MSc in Medical Anthropology, Durham University and a PhD in Social Anthropology, University
of Edinburgh. She researches well-being and happiness among asylum seekers and refugees in Cameroon, the United Kingdom, and The Gambia.
Emily Yates-Doerr is an Associate Professor of Anthropology at Oregon State University. Her research interests concentrate on health, food justice, and social inequality. She recently served as the PI of an ERC-funded multi-sited research project ‘Global Future Health’ that studied the rollout of maternal nutrition interventions.
ACKNOWLEDGEMENTS
Like all large projects, this handbook could not have happened without contributions large and small from a great number of people. Tsitsi and Ellen would like to thank, first and foremost, all of the handbook contributors who engaged this volume with patience, curiosity, and a great spirit of collaboration. This handbook project started in 2021, in the midst of the COVID-19 pandemic; this was an incredibly difficult time for most of us, which makes the commitment of our contributors to this project all the more admirable. Many thanks, too, for your perseverance through many rounds of review and revision! We would also like to thank our editors at Routledge and the anonymous external reviewers who improved the conceptualisation of the volume from its earliest phases as a book proposal to identifying the key strengths of individual chapters. Your incisive reviews make this a better book.
Tsitsi would also like to thank several mentors from the disciplines of both anthropology and public health who have contributed to her growth as an interdisciplinary scholar, researcher, teacher, and practitioner. These include Paul Terry, Isak Niehaus, Joanne E. Mantell, and Ellen Foley, whose insights and support over the years have been invaluable. Many thanks to Jeremy Jones, a most reliable brainstorming partner for all things anthropological, and to Inathi and Ivai Jones, who remind her daily of the importance of maintaining a work-life balance.
Ellen would like to acknowledge the many collaborators and research participants she has worked with in Senegal, Burkina Faso, Côte d’Ivoire, and France. They have showed her, firsthand, the many faces of global health and they are a constant reminder of the very real stakes of global health projects and politics. Ellen also thanks the Harris men for giving her the time and space to work on this and so many other academic pursuits.
INTRODUCTION
Tsitsi B. Masvawure and Ellen E. Foley
... it was the insistent, questioning stance of anthropology—the uncomfortable science— that helped me to understand.
—Paul Farmer, Infections and Inequality (1999), p. 95
Anthropological entanglements with global health
As anthropologists who teach and research in the interdisciplinary field of global health, we often find ourselves in spaces where we have to explain what anthropology is and how we approach global health. In June 2023, for instance, Tsitsi Masvawure participated in a threeday “Teach Global Heath Summer Institute”1, which is partly funded by the Consortium of Universities for Global Health.2 Approximately forty scholars who teach undergraduate courses in global health at institutions in North America, Africa, Asia, and Latin America attended the workshop. Participants covered a range of disciplines, including anthropology, public health, epidemiology, nursing, urban planning and an even wider range of subject matter expertise, such as medicine, ecology, biodiversity, health policy, maternal and child health, disaster relief, chronic diseases, land use conflicts, and harm reduction. Many participants were from institutions with experiential learning opportunities in global health for students that entail spending several weeks abroad. It was clear from conversations with various participants that each discipline approaches global health differently and that an analysis of structures of power and inequity is not necessarily a central focus – as it is in anthropology – of many global health academic programs.
The week prior to attending the summer institute, Tsitsi had given a virtual presentation on the added value of ethnographic methods in global health. This was part of a week-long course on qualitative methods offered by McGill University’s Summer Institutes in Global Health.3 Masvawure’s talk was aimed at encouraging participants – many of whom are quantitative researchers – to appreciate that anthropological research findings provide programmatically meaningful insights and should not be dismissed as being “mere anecdotes” because of their small sample sizes. These two events, occurring only a week apart, point to the robustness of global health as a field and highlight the presence of anthropologists in a variety of global health spaces and roles: as teachers and researchers, in these instances. Masvawure is currently assisting in the establishment of a graduate program in global
health at her institution, which is a science and technology school that is well known for its engineering program. These examples show that anthropologists have unique opportunities to explain the fundamental tenets of our discipline to others and highlight how anthropology can advance and enrich the field of global health. More importantly, however, we have strategic opportunities to radically transform what is taught in global health programs.
Ellen Foley’s work has also brought anthropology into conversation with other disciplines in the context of ‘doing’ global health work. Over the past year, for instance, she has worked with a diverse team of medical geographers, public health experts, HIV prevention outreach workers, and women substance users in Senegal to design and execute a needs assessment for sex workers and other vulnerable women who use heroin, cannabis, and opiates. She is also part of a team of social scientists, statisticians, and epidemiologists examining how social networks in Senegal, particularly mother-daughter relationships, have influenced the uptake of the COVID-19 vaccine. In her recent work, she has examined a novel self-injectable long-acting contraceptive, the Sayana Press®, to explore the rise of gadgets and innovation in global health that privileges investment in technology at the expense of investments in infrastructure (Bendix et al., 2019; MacDonald and Foley, 2022). At Clark University, Foley directs the Health, Science, and Society interdisciplinary program, and she advocates for the importance of an anthropological perspective on health and disease despite the absence of an anthropology department or major at the university. In all of these activities, our work reflects the numerous vantage points of anthropologists working inside, outside, and betwixt and between anthropology and global health. As anthropologists, we consistently advocate for ethnographic attention to the complexity of people’s lives; we draw attention to the ways that social, economic, and political structures produce vulnerability to disease and inequitable health outcomes; and we emphasize how cultural frameworks render experiences of health, healing, debility, and illness meaningful.
Similarly, the contributors to this handbook are anthropologists whose research and professional practice intersect with global health in a variety of ways: some are situated in stand-alone global health academic departments while others are teaching courses on global health in traditional departments, in public health schools, or in interdisciplinary programs. Several contributors work outside of academia in the non-governmental sector or civil society space. Yet still others inhabit multiple spaces and roles simultaneously. For instance, some teach, research, and serve as consultants for international organizations simultaneously. Our handbook contributors are not unique in their engagements with global health, and they are continuing a tradition started many decades ago by anthropologists, such as the late Paul Farmer, who work as both scholars and practitioners, seek out interdisciplinary collaborations in their work, and are deeply committed to health equity. These, indeed, are some of the aspirational goals of global health.
Why anthropology and global health?
This handbook provides readers with accounts of how anthropological engagement with global health is transformative both for the discipline of anthropology and for global health as a domain of research, policy, and intervention. The core questions and approaches of anthropology reveal how the field of global health operates, and they bring keen ethnographic insight into the wide range of health challenges that global health aims to address. At the same time, global health – as a continuously shifting field with tremendous ramifica-
tions for people’s lives around the world – pushes anthropological inquiry in new directions. From the fetishization of metrics (Adams, 2016) to performance-based financing of health interventions (Fan, this volume), global health’s paradigms and politics demand attention and interrogation from anthropologists. Anthropologists are also grappling with strategies to bring the core values and insights of our discipline to bear in global health, and they are finding that this often does not look like doing “real anthropology” (Price, this volume). This handbook provides readers with theoretical and ethnographic insights into the field of global health and situates global health in a wide variety of contexts: indigenous Australia, post-economic collapse Lebanon, East and South Asia, Central and Latin America, Europe, the United States, and Africa.
As varied as these settings are, many of the anthropological arguments cohere around a few central points. First, the handbook contributors challenge biomedicine’s hegemonic position in global health. The dominance of biomedicine in global health produces innumerable biases and gaps and delegitimizes alternative ontologies and epistemologies of health and healing. Many of the handbook chapters highlight the incommensurability between biomedical modes of understanding and treating disease and the lifeways of people around the world. Second, anthropology’s deep commitment to understanding place and context produces depictions of health and disease different from those of the other disciplines engaged in global health research. Handbook readers will encounter these ethnographic accounts and be reminded that knowledge production is an eminently social process shaped by the positionality of the researcher and their relationship with research participants. This anthropological insight extends beyond the realm of knowledge production and is equally applicable in the realm of global health interventions.
Anthropology’s insistence on local specificity serves as a counterweight to global health’s pursuit of universal solutions to global health challenges. From TB treatment in India to global recommendations for the prevention of hemorrhage during labor and delivery, our handbook contributors offer compelling evidence of the shortcomings of health interventions divorced from local realities. However, many handbook contributors also recognize that anthropologists often fail to make their findings accessible to the very actors who have the power to transform global health practice. From participation in policy meetings to collaborations with frontline practitioners, many of the handbook contributors issue a call to their fellow anthropologists to ensure that their findings are relevant to a wide audience. Several contributors highlight successful – if sometimes tenuous – collaborations and partnerships between anthropology and global health. These chapters show how anthropologists are actively tapping into local expertise and connecting local communities to policymaking spaces locally and nationally. Some authors write as insiders who have been, or who are, embedded in organizations involved in global health policymaking at an international level. Their firsthand accounts provide models of how anthropological approaches can be integrated into the global health arena at different scales.
Third, anthropologists’ moral and ethical commitments to anti-racism and social justice and to standing in solidarity with the communities in which we work offers an important point of departure for engaging with global health. Anthropology has long reckoned with its colonial past, and anthropologists still contend with the ways that these colonial antecedents continue to influence the discipline (see Beliso-DeJesus et al., 2023 for a very recent commentary on this topic). The colonial and neo-colonial roots of global health have also been the subject of much debate, including recent calls to decolonise global health in
response to COVID-19 vaccine inequities. There are now multiple calls to decolonise all aspects of global health that are drawing attention to the overwhelming asymmetries in global health funding, research, publishing, and agenda setting between the global North and the global South (see Abimbola et al., 2021; Charani et al., 2022; Danya, 2022; Opara, 2021). The willingness of anthropologists to interrogate and confront the history and colonial legacy of anthropology offers a model to global health professionals as they face the challenge of decolonising global health.
These anthropological insights offer a variety of audiences new ways of apprehending global health in all its complexity. If global health was once a somewhat obscure field, the COVID-19 pandemic has catapulted it into public awareness as an arena of research and practice. From young to old, rich or poor, we all have a stake in global health. We expect that the handbook will appeal to a large audience withinboth anthropology and global health, but also far beyond these disciplines, such as among health policy makers. There is widespread interest and curiosity about the global health machinery and policymaking dynamics. The highly visible successes (e.g., rapid vaccine development) and failures (e.g., vaccine inequity) of the COVID-19 pandemic serve as a useful backdrop to take stock of the state of the world’s health and to review successes and failures of previous transnational pandemic responses and policies (see Masvawure, this volume). This handbook provides many rich moments for such reflection. Several chapters explore ‘familiar’ concerns, such as the HIV/AIDS pandemic, tuberculosis, and maternal health interventions, and they contain bolder theoretical positions that help us view these issues with more critical eyes. The handbook also advances anthropological inquiry by foregrounding a range of new and urgent concerns for global health, such as the role of artificial intelligence, human rights and health equity for new migrants arriving at Europe’s borders, and rare diseases that cause suffering to millions around the world. The handbook helps parse out new and future pathways for global health.
This handbook builds on a solid foundation of existing scholarship on the intersections of anthropology with global health, such as Janes and Corbett’s review essay (2009) published in Annual Review of Anthropology, that suggests that anthropology can contribute to global health in four ways: explaining health inequities, examining the local impact of global technoscience, interrogating health policy, and analyzing the health effects of the “reconfiguration of the social relations of international health development” (p. 170), particularly in relation to the increasing role of non-state actors. This article is, to the best of our knowledge, the first such review of anthropology’s entanglements with global health, which is itself a field that took shape in the 1990s. In 2013, several eminent anthropologists published books on anthropology and global health. One of these, Global health: An anthropological perspective, co-authored by Merrill Singer and Pamela Erickson, is targeted at a student audience. The authors offer the following three reasons for why an anthropological perspective is needed in global health: to ensure that human subjectivities and insider perspectives are not “lost in the epidemiological and public health analysis of health statistics”; to provide “a useful corrective to the tendency in global health to view disease and intervention in narrowly medical and technical terms and not pay sufficient attention to the human elements of cultural beliefs”; and to help “situate the local within political-economic and political-ecological global contexts” (2013, p. 16).
Paul Farmer and colleagues made the case in their 2013 edited volume, Reimagining global health, that anthropology is a “resocializing discipline” because it focuses on asking why questions, which are often glossed over by public health and other quantitative sci-
ences. Asking why allows us to expand on what can be known (knowledge production) and what can be done (action and activism). Anthropology resocializes global health by drawing on social theory to help explain why health inequities exist and persist. Paul Farmer famously used the terms “social suffering” and “structural violence”, as examples of this resocializing potential of anthropology, to interrogate three things, namely, how “social forces cause pain and harm to individuals”, how “society and its institutions (un)intentionally exacerbate social and health problems”, and how illness is experienced and felt by individuals (2013, p. 30). In a much earlier paper, Farmer had urged anthropologists to “study both individual experience and the larger social matrix in which it is embedded in order to see how various large-scale social forces come to be translated into personal distress and disease … such suffering is structured by historically given processes and forces that conspire to constrain agency” (1996, p. 261). Farmer uses the word “social” in an expansive way to encompass economics, politics, institutions, and interpersonal relationships as well as culture, historical forces, and globalization. From this perspective, therefore, it can be argued that one of the greatest benefits of incorporating anthropological perspectives into global health is that it helps humanize those who are suffering by locating the cause of their suffering in social institutions rather than in individual actions. Anthropology’s descriptive and explanatory powers make it well suited to studying global health. João Biehl and Adriana Petryna call for a “critical global health”, which they describe as an approach that “inhabits the tension between critique of and a critique in global health, sustaining a space for critical inquiry and action, understanding and doing” (2016, p. 135). A critical global health, they further argue, is people-centered and captures the fact that “people and the worlds they navigate and the outlooks they articulate are more confounding, incomplete, and multiple than dominant analytical schemes tend to account for”; they further note that ethnography is key to this critical global health because it “can chronicle lived tensions between theory and practice and invoke both alternative conceptual frameworks and new kinds of imagination” (ibid). Vincanne Adams reinforces the call for a critical global health by arguing that anthropology is relevant because of its ability to “document what gets hidden or remains invisible to other disciplinary practices”. Adams states: “Often, what is sitting right in front of us is not seen until the ethnographic lens sheds light upon it. In this sense, critical global health focuses not just on people, but on the institutions, objects, and materialities that fuel visibility and invisibility” (2016, p. 192). Anthropologists are having robust conversations about the moral imperatives and ethical shortcomings of global health as well as how our discipline can enrich the “data-driven” approaches that are the mainstay of this field. Knowledge production, particularly how we come to know what we know and whose knowledge counts, are key themes for many anthropologists engaging with global health.
Yates-Doerr and Maes (2019) offer a much more recent take on anthropology’s entanglements with global health. They note that anthropology has an ‘awkward’ relation with global health because anthropologists actively work within global health even as they critique it. They argue that anthropologists are well placed to engage with global health because the discipline’s methodological approach is based on “not knowing” anything with confidence. This means that anthropologists can “instead follow, empirically, how global health is brought about in practices” rather than assume that they know what global health is and entails. It is this “not knowing” that makes anthropology well suited to engage with and counter the assumptions of global health.
The anxieties that some anthropologists might have with the field of global health are clearly captured in the 2022 book, Global Health for All: Knowledge, Politics and Practices, edited by Gaudilliere, McDowell, Lang, and Beaudevin. The authors unapologetically state: “global health’s practices of knowing and doing are forms of neoliberal rationality and economization that disguise the political processes of technocratic governing and apportioning of collective resources in vocabularies of evidence-based intervention, efficiency, inclusion and operability” (2022, p. 8). The authors further note that, even as they participate in the field of global health, anthropologists are ever aware that global health operates in tandem with neoliberal reforms, philanthrocapitalism, and reinforces hierarchical social, political, and economic relations between the Global North and the Global South.
Assembling the handbook
As scholars who both do research in Africa, a continent that continues to be maligned as plagued by disease and dysfunction, we were both hyper-attuned to the clarion call to ‘decolonise global health’ when we embarked on this project. We therefore actively sought out contributors who would provide a wide range of vantage points in terms of disciplinary home, geographic location, topics of expertise, and stage of career in addition to gender and race. Consequently, we took several steps to ensure transparency and equity in the handbook. We circulated the call for papers as widely as we could, including via regional anthropology groups, such as the Anthropology of Southern Africa, Association for Middle Eastern Anthropology, Society for East Asian Anthropology, European Anthropological Association, the Society for Medical Anthropology, and the listserv Anthropology Matters. We sent many emails to anthropologists around the world to invite contributions from far outside our personal networks. We intentionally chose not to solicit contributions from the ‘usual suspects’, that is, the biggest names in American academia or our closest scholarly colleagues and friends. We wanted the handbook to reflect diversity in terms of the geographic location and professional affiliations of the authors. We were largely successful in this regard: we have contributors from nearly every continent and chapters that span every continent, excluding Antarctica. We are excited to include chapters that focus on global health in Africa, Asia, Australia, Europe, South America, and North America. We also have contributions from several doctoral students and early career professionals.
In trying to be representative, we grappled with the question of what constitutes4 a ‘scholar from the Global South’. Many of our contributors inhabit multiple spaces and identities such as being born in the Global South or having heritage in a Global South country but are now based in the Global North indefinitely. Can these scholars still speak about, or for, the Global South despite no longer residing there? We also have scholars who were born in the Global South but have access to many privileges due to their race, class, or ethnicity which puts them out of touch with the struggles of the masses. Can these scholars write about or speak for the Global South? Furthermore, we have scholars who were born in the Global North but study the Global South. Many of these scholars bring numerous years of field experience in the Global South to bear on their analysis of global health as it takes shape in the places where they do research and work. How should they be classified? The anonymous reviewers of the handbook proposal raised similar questions. One suggested that our proposed list of contributors skewed too heavily in favor of Africa and another commented on the fact that both editors were from North American institutions. Fair critiques if one ignores the fact that Africa is arguably the recipient of most global
health interventions or that one of the handbook editors was born, grew up, and studied in southern Africa before moving to the United States as an adult. At their core, we believe that these questions are ultimately about ‘authenticity’ and about who can ‘truly’ represent another. These questions defy easy answers. We therefore urge readers of this handbook not to get distracted by the fact that we have many contributors who are affiliated with institutions in Europe or North America as this masks the multiple ways that diversity is reflected in this handbook.
Common anthropological themes in global health
The chapters in this handbook provide a snapshot of some of the key themes in the anthropological scholarship on global health. The handbook is divided into six parts as follows: determinants of health, knowledge production, engaging local knowledges, invisibilities in global health, reimagining critical global health, and new horizons in global health. Each section of the volume adds nuance to and insights into ongoing enquiries about how anthropology and global health interact. This handbook asks these questions as we emerge from the global COVID-19 pandemic, and it considers the wide range of threats to human health and health equity on a global scale. The handbook chapters imagine more fruitful modes of engagement of anthropology with the often problematic, yet crucially important, field of global health.
Determinants of health: Social, cultural, political
Anthropologists working in the domain of health and illness have a long tradition of challenging biomedicine’s narrow clinical focus and highlighting the social, cultural, ecological, and political contexts that shape human health. The first section of the handbook reiterates anthropology’s stance that the forces that enable and compromise health lie far outside the biomedical model. Collectively, these chapters showcase the deeply contextualizing impulses of anthropology and how anthropology provides breadth and depth to understandings of how health, health disparities, and vulnerabilities to disease are produced.
Nikhil Pandhi provides us with an account of a highly visible component of India’s health system: the female community health workers known as ASHAs (Accredited Social Health Activists). By centering the ASHAs’ political protests in the midst of the COVID-19 emergency, Pandhi reveals the complexities of forging a decolonial global health from the existing framework of post-colonial social, political, and economic inequalities. The exploitation of Dalit women’s labor in the service of protecting the nation’s health demonstrates how imagining a liberatory global health confronts challenges at multiple scales. Making sense of gender, caste, and class exploitation of community health activists – who are championed as a model of diversity and equity in global health – allows us to see the inadequacy of decolonial stances that fail to engage in a critical analysis of power, politics, local history and context.
We see a potential alternative in Sarah Bourke’s chapter on cultural determinants of health in Australia. Rather than imagining a diverse and equitable global health workforce as one in which women of color are incorporated into existing structures, Australian efforts to center Indigenous frameworks of health and wellness overturn the ontological supremacy of epidemiology and biomedicine. Recognizing that culture stands as a significant force requires moving beyond a notion of culture as a barrier to uptake of biomedical practices
and, instead, privileging Indigenous perspectives and emphasizing the assets of Indigenous people and communities. Bourke provides an overview of Mayi Kuwayu, the first largescale, longitudinal, epidemiological study in Australia that is owned, governed, and operated by Indigenous people and focuses on identifying cultural determinants of health and well-being. As Bourke explains, data from Mayi Kuwayu have shaped national health policy, which represents a significant first step in recognizing the significance of culture to health and in advancing self-determination, autonomy, and healthy equity for Indigenous Australians. The chapter offers a compelling model of how to operationalize emic notions of culture and health in epidemiological research and how previously marginalized people provide leadership in identifying research priorities and methods.
Historically the realm of mental health replicates many of the clinical, expert-oriented, top-down approaches that handbook contributors identify in other domains of global health. Runa Lazzarino’s chapter on migrant experiences demonstrates that a global mental health must account for the macro-level forces and structures that shape voluntary and involuntary migration without erasing social actors’ experiences and worlds. She suggests that a critical global mental health is possible through bottom-up epistemological and methodological innovations that include non-Western-centric, community-based, and non-cognitive interventions. Lazzarino argues that the medicalization of trauma is disempowering and too often provides ethical and political justification for problematic, top-down interventions that reinforce dependency and victim status of migrants. Ethnographic accounts of the experiences of trafficked individuals and migrant parents demonstrate the limitations of the biomedical trauma paradigm. Lazzarino makes a strong case for the ways that anthropology can contribute to a critical global mental health, but she also warns that anthropologists must remain in dialogue with frontline practitioners in order for their insights to be relevant.
Each of the chapters in this section argues that richly contextualized data that reflects the social, cultural, and political contexts within which individuals pursue health and experience illness and suffering are crucial for ensuring that global health advances equity rather than reinforcing health disparities. Elsa Fan’s chapter on HIV services in China rounds out this discussion by showing how performance-based financing – one of many global health practices designed to improve efficiency and optimize health spending – can undermine the ability of community organizations to meet community health needs. Fan shows how donor priorities around the numbers of individuals tested for HIV conflicted with the desire of community activists to foster long-term relationships with men who have sex with men (MSM) who are often lost to care. Using positive HIV tests as a performance indicator prompted donors to stop financing programs for injection drug users and sex workers, as it was too costly to conduct the volume of tests necessary to detect new cases of HIV. Fan’s research demonstrates how the turn in global health to metrics, outputs, and cost-efficiency undermined attempts to embed HIV prevention work in deep contextual awareness of the social, emotional, and health needs of MSM and other key populations.
Knowledge production in anthropology and global health
A persistent dilemma for anthropologists working in global health is the very different ways that medical professionals, epidemiologists, and other global health experts understand health challenges. If anthropology is the most ‘radically contextualizing’ of all disciplines, to paraphrase Paul Farmer, many of the core disciplines in global health pursue understandings of health that are either narrowly clinical or universalized to the point of
inapplicability in specific contexts. Several of the handbook chapters highlight the modes of knowledge production that the authors encountered in their work within global health, and they examine how this evidence informs policies, programs, and interventions that miss crucially important dimensions of the social production of health and disease.
Dalton Price’s chapter takes us inside the World Health Organization (WHO) to show us the constraints on anthropological knowledge production and sensibilities in global health. His account of a WHO anti-microbial resistance program reveals it to be neither synonymous with Western biomedicine, as is often assumed by critiques of global health, nor a product of ‘real anthropology’. Instead, Price traces the ongoing negotiations between the biomedical foundations of global health and the insiders-outsiders who advocate for new logics, ethics, and practices inside the WHO. He explains that these new logics and practices tend not to fly under the banner of anthropology but, rather, under the broad umbrella of qualitative research, community engagement, and social and behavioral programming. Price makes a compelling case that anthropologists seeking to influence the field of global health must not only stay attuned to the complexity of ways of knowing and acting that inform programs but also recognize that this arena disproportionately values biomedical knowledge.
Thompson and Yates-Doerr examine knowledge production in global health by examining the origins of WHO’s recommendations for preventing hemorrhage in childbirth. Their research shows that evidence from studies in the Global North informed the universal recommendations despite cautions issued by their authors about the limitations of their findings. The WHO study team’s interpretations of these findings produced guidelines that characterized birth as a risky endeavor requiring a universal application of a global health intervention. Their ethnographic research reveals the ways that the application of these guidelines without attention to context can fail to protect maternal and child health.
McDowell’s chapter on tuberculosis research and clinical practice in India demonstrates that anthropologists are not the only actors excluded from processes of knowledge production in global health. McDowell describes how, in the 1990s, India shifted from clinical treatment of TB oriented toward alleviating suffering to a global health TB program focused on interrupting TB transmission through test and treat protocols. As this transition took place, Indian clinicians and TB experts, who had once been at the forefront of TB science, were demoted to outdated and under-skilled data gatherers. The chapter traces the tensions between the global priorities of TB control and the clinical commitments of Indian physicians to caring for their patients. Despite their inability to subvert the protocols of global TB control, Indian physicians collected clinical evidence to demonstrate that vulnerable patients did not benefit from DOTS therapy and were often lost to care. The efforts of these clinicians, and the eventual reformulation of India’s TB program in 2020 based, in part, on their findings, demonstrate the complex and contingent ways that differently positioned actors can produce knowledge and shape the global health agenda.
Runestad turns our attention to the pedagogy of global health. What does it mean to teach students about global health, what kinds of anthropological expertise are most useful to students learning about global health, and how can students make use of anthropological thinking as non-anthropologists interested in health? In her conceptualization of a global health worldview, Runestad describes how teaching ethnography in global health courses can help overcome misconceptions in global health: that it is relevant only in non-US contexts, that it involves powerful actors who ‘help’ less powerful others, and that it is primarily
about disease control. The chapter makes a compelling case for embedding anthropological theory, methods, and analyses inside the teaching of global health to ignite student curiosity about the social production of health and disease and to convey anthropology’s relevance for understanding global health challenges and imagining effective modes of engagement. Runestad offers a road map for anthropologists looking for ways to impart anthropological common sense to broad audiences of students studying global health.
Engaging local knowledges
Anthropology is perhaps best known for being the discipline that truly listens to its interlocutors and that takes seriously what people have to say about themselves. The predominance of epidemiology and infectious disease medicine in global health means that the identification of global health problems and solutions often takes place at great social distance from experiences of vulnerability, health disparities, and suffering. If anthropology prides itself on providing ‘experience-near’ accounts of health and illness, global health tends to generate medical truths that are far from these lived experiences.
The potential of ethnographically rich accounts of health, illness, and care-seeking to transform global health practice is a recurring theme in this section of the handbook. While biomedicine is the hegemonic form of medical therapy globally, Marten and Seymour’s chapter reminds us that biomedical care is often unavailable, and other forms of care may have greater social and cultural resonance and prove highly effective. They make a case for global health to engage far more seriously with non-biomedical healing traditions and to recognize the ways that medical pluralism – the availability and use of multiple healing traditions – can alleviate suffering and complement biomedical solutions to global health challenges. Furthermore, they demonstrate that in some cases the pursuit of medically neutral or even dangerous alternative therapies stems directly from the challenges of getting biomedical care in underfunded health systems with low-quality care.
The centrality of medical pluralism is amplified in Liyanage, Ekanayake, and Wenning’s chapter on biomedicine and Ayurvedic medicine, which itself serves as a broad category that includes Siddha, Yunani, and Indigenous healing traditions. Liyanage et al. argue that accessibility and affordability shape many treatment decisions in Sri Lanka, and that many Ayurvedic practitioners fear both loss of prestige and integrity of their healing traditions in light of biomedicine’s dominance. Like Marten and Seymour, they make a case for changing Ayurveda’s second-class status and working towards more effective integration of Ayurvedic practice in the health system. In the context of the COVID-19 pandemic in Burkina Faso, Bjertrup and Bambara shift our attention to the ways that longing for public services and uncertainty about the state’s capacity and intentions constitute a shifting backdrop against which citizens assess health information and prevention measures. Local situational knowledge, presented here in an eloquent discussion of ‘missing trust’, offers national and global health experts rich insight into how communities respond to epidemic control. Engaging with this kind of knowledge may spark innovation in the design and development of shortand long-term interventions that acknowledge the needs and longings of local communities. While global health sometimes assumes a neutral posture vis-à-vis non-biomedical healing traditions, Sesia and Palomo trace the decades-long process by which the Mexican state marginalized Indigenous midwives as it implemented the global safe motherhood initiative. Despite the legal protections in place for Indigenous people to practice their medical traditions, Indigenous midwifery faces overwhelming constraints stemming from the state’s
commitment to medicalizing birth in the name of improving maternal health. Sesia and Palomo explain how despite decades of marginalization, in the context of the COVID19 pandemic, traditional midwives provided crucial, life-saving services while the formal health system was in crisis. When fear of hospital births due to COVID kept women from seeking services, traditional midwives filled the gap in maternal and neonatal care. This account of the numerous contributions of Indigenous midwives demonstrates the necessity of reimagining how indigenous midwifery and ethno-obstetrics could be situated within the Mexican health system.
In a similar vein, Cruz and Cuvi discuss anthropology’s capacity to serve as a tool for domination and also as a tool for cultural resistance. Although anthropology served to legitimate colonialism and marginalize indigenous cultures in central and Latin America, the first generation of Ecuadorian anthropologists critiqued the cultural hegemony of the state and the erasure of Indigenous peoples. Cruz and Cuvi discuss interculturality as a legal framework for equity, respect, and constructive exchange between cultures in central and Latin America, but they note that, in reality, it is often a technocratic exercise that fails to challenge the cultural domination of white-mestizo society. In the context of health and medicine, this has meant ancestral or Indigenous medical traditions are formally recognized by the Ecuadorian state, but this very integration has served as a mechanism of appropriation. As in Mexico, this conflict has converged in attempts by the Ecuadorian state to medicalize labor and delivery by relegating Indigenous midwives to secondary roles; traditional birthing practices are under constant threat of marginalization. These ongoing struggles for cultural autonomy in the face of a hegemonic and colonising global, capitalist biomedicine remind us of the stakes of anthropology’s commitment to working in partnership with communities and doing research from a standpoint of solidarity.
Invisibilities in global health
One of anthropology’s key strengths is its insistence on seeing things that are often overlooked by other forms of research. This vantage point often allows anthropologists to push back against accepted truths and dominant assumptions in global health. The authors in this section each highlight something that has fallen out of view of mainstream global health policy, programs and practice, thereby demonstrating anthropology’s ability to call attention to people and problems that otherwise may face erasure.
In his depiction of HIV in Colombia, Héctor Ruiz Sanchez portrays a national AIDS response that has been shaped by gay activism and outdated assumptions about the people most vulnerable to HIV. Straight men (and their medical providers) assume that their sexual orientation shields them from HIV, which leaves them vulnerable to infection. Those who contract HIV live ‘ghostly lives’ as they hover on the edges of HIV treatment and care that was imagined for different constituents. Ruiz-Sanchez argues that the dilemmas these men face demonstrate the stagnation of a once-progressive HIV response that has failed to update its surveillance mechanisms or include newly affected populations into its programs. While heterosexual men’s gender identities are an obstacle to accessing prevention services and health care, diagnoses of HIV and AIDS have the power to disrupt straight men’s lives in ways that can ultimately protect their health.
Two other chapters in this section move the discussion to southern Africa and add to our understanding of the in/visibilities that characterize the global campaign to eliminate HIV infections. Shabnam Shaikh presents the explanatory models and treatment patterns
of Muslims living with HIV in Durban, South Africa. She finds that Islamic ideas about piety and illness can induce stigma and shame among people living with HIV (PLHIV), yet some of her interlocutors also report that prayer, faith-based rituals, and Islamic medical treatments greatly enhance their spiritual, social, and physical well-being. Despite receiving almost no policy attention or programmatic outreach, Shaikh’s chapter counters the invisibility of Muslim PLHIV in South Africa and offers insights into how to reach Muslims in need of prevention information, testing, treatment, and support services.
Meanwhile, Mkhwanazi and Adam’s chapter on the failure of the Accelerated Saturation Initiative (ASI) for voluntary medical male circumcision in Eswatini highlights a different pattern of visibilities and omissions. The Soka Uncobe initiative was one of the largest and most ambitious public health campaigns ever implemented in Eswatini to the tune of $US 15.5 million. It was also a dismal failure; in the first year 11,000 of a targeted 152,000 circumcisions took place. Numerous accounts of this failure have already been published, but Mkhwanazi and Adams question the prominence of cultural explanations and the emphasis on Swati men’s resistance in these analyses. They contend that the most glaring omission in these accounts – the most troubling invisibility – is the absence of frank discussion about the US origins of this initiative and the ways that it served the interests of the global health community rather than the priorities and concerns of Swati citizens. In their analysis, Mkhwanazi and Adams dissect the failure of Soka Uncobe, and they reveal that the global health logic that enabled target-driven programs did not serve the best interests of Swati men and rendered their bodies disposable, yet ultimately blamed them for the programmes failure.
Wademan and Daftary also emphasize how widely accepted paradigms in global health can fail to fully capture patient experience and suffering. Global tuberculosis (TB) programs have made it a priority to identify and treat active, transmissible TB cases as an acute infection. Yet the reality for TB survivors, many of whom have latent TB, is that they will experience recurring infections. Wademan and Daftary’s analyses of individuals living with TB and living post-TB reveal the limitations of a binary conceptualization of active versus latent TB and acute versus chronic disease. They demonstrate that the lifelong risk of TB infection and reinfection alongside the long-term psychological and physiological vulnerabilities caused by TB render it a chronic condition. Their call to global health – to recognize and treat TB as a chronic condition with long-term debilitating effects – offers a road map for meeting the ongoing needs of TB survivors and acting in allyship with TB- affected communities.
Rizk and Góralska’s chapter on pharmaceutical shortages in Lebanon provides a pointed reminder of the dire medical consequences of neoliberal market failures. In the wake of disastrous economic crisis, pharmaceuticals and other essential medical supplies disappeared from Lebanese pharmacies seemingly overnight. This humanitarian crisis, which received little media attention, sparked innovative strategies for getting drugs and essential supplies to Lebanon outside of formal channels, often in the suitcases of travelers entering the country from abroad. Behind the desperate attempts of patients and their families to procure pharmaceuticals lies the stark realities of profit-seeking pharmaceutical companies that leveraged the state’s financial collapse to seek the end of pharmaceutical subsidies and the deregulation of drug prices. This ethnography of pharmaceutical scarcity and absence allows Rizk and Góralska to highlight otherwise hidden social structures, hierarchies, relationships of dependency, and power imbalances. They suggest that global health equity may require reimagining the global political economy of pharmaceutical flows and engaging in pharmaceutical resistance via more local and sustainable solutions to meet growing pharmaceutical demands.
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squad’s prime targets were Benny Bellanca, who lived in Jersey City, and Pietro Beddia, who resided in Westchester.
Both men were suspected of being involved deeply in the international narcotics traffic—with connections in France and Italy— but agents were unable to make a case against them and they remained untouchable. Perhaps they would have continued their operations for years, except that O’Carroll played a hunch.
The case began to take shape when Agent Angelo Zurlo, tailing a suspected narcotics pusher on New York’s Lower East Side, saw his man enter a small olive oil and cheese shop on Christie Street near Delancey. He noted the name and address of the shop in his notebook and later made a memorandum of the incident which went into the Bureau’s cross-indexed file. Some months later, Narcotics agents following another suspect saw him enter the olive oil and cheese shop on Christie Street. They made a memorandum, also, which went into the files.
In the summer of 1952, O’Carroll was checking the files when he noted the two memos mentioning the small shop on Christie. Further investigation revealed it had been owned by Alphonse Attardi before he was sentenced to serve an eight-year prison term for a narcotics violation in Galveston, Texas, in the early 1940s. Attardi had completed the sentence, but Immigration authorities were studying the possibility of extradition proceedings, inasmuch as Attardi was Italian by birth.
Attardi at this time was sixty years old, 5 feet 3, and weighed about 140 pounds. He had the appearance of a meek and humble little shoemaker, and he scarcely fitted the part of an underworld character. He had an engaging, warm personality, and he was known in the Mafia as “The Peacemaker” because of his knack for compromising disputes—but that was before he had served time in prison.
O’Carroll decided to pay a call on Attardi, who he learned was living in a cheap, transient rooming house on 16th Street just off Third Avenue. It was after midnight one warm night when he strolled down Third Avenue in the shadows of the old El to 16th Street. Even
the softness of the night could not hide the shabbiness and the squalor of the area.
O’Carroll entered the rooming house and climbed two flights of stairs. He knocked on the door and then tried the doorknob. The door swung open, and at that moment the agent knew that Attardi was in a bad way financially. If he had had a bankroll, he wouldn’t have left the door unbolted—not in this dive.
He saw Attardi sitting up in bed, a skinny gnome of a man wearing only undershirt and shorts.
“Who is it?” Attardi said. “What do you want?”
“Take it easy,” O’Carroll said. “I’m a U.S. Treasury agent. I just want to talk to you.”
Attardi switched on a light over the bed. “What do you want to see me about?” he said. “I’m clean.”
“Have you got any narcotics in this room?” O’Carroll asked him.
Attardi shook his head. “No. You can search the room if you like. I’m out of the business.”
O’Carroll pulled up a chair beside the bed and sat down. He began to talk about Attardi’s connections with well-known underworld figures, asking him why it was that he had been convicted in Houston while others in the mob had gone free.
As they talked, bitterness began to creep into Attardi’s voice. He had taken the rap in Houston—and then his pals had deserted him. They didn’t even try to communicate with him while he was in prison. His wife had become ill and no one had come forward to help her. She had died. He had even lost the little olive oil and cheese shop on Christie Street.
“Now I have nothing,” he said.
“Maybe we can help you,” O’Carroll said. “I can’t make any promises, but if you help us we may be able to help you when your deportation case comes up.”
Attardi shook his head. “I can’t do it. I’d be dead if I worked for you.”
O’Carroll continued talking of the injustices done to Attardi by his old pals, insisting that he owed them nothing since they had deserted him. But Attardi continued to say no.
At last O’Carroll said, “Well, I’ll leave my name and telephone number. If you ever need help—I’ll be glad to talk to you.” He wrote his name and telephone number on a slip of paper and handed it to Attardi.
For six months O’Carroll heard nothing from Attardi. He made no move to see the man again. He had planted the seed, and whether it took root depended on what went on in the mind of the skinny little ex-convict.
But in early December Attardi called the Narcotics Bureau office and Agent George O’Connor took the call. He explained that he wanted to talk to O’Carroll and he would be waiting for him on Delancey Street near Christie.
That afternoon O’Carroll and O’Connor drove to Delancey and parked near the street number mentioned by Attardi. A few minutes later the hoodlum walked from a doorway and ducked into the car with them.
The agents had assumed that Attardi had made the call because he was frightened over the prospect of being deported to Italy But it wasn’t deportation that was on Attardi’s mind. He had fallen in love. He had met a twenty-two-year-old waitress in one of the mean little restaurants on the Lower East Side—and this girl had become the most important thing in his life. They wanted to get married, but he had no money.
Attardi said he was willing to put the agents onto some Puerto Ricans living in Brooklyn who were dealing in narcotics. If the price were right, Attardi would help knock off the gang.
The agents listened to Attardi’s story and then O’Carroll shook his head. “It’s no deal,” he said. “We want better cases than that. We want to go to the top.”
Attardi was frightened but he also was in love. And so he began asking how the agents could protect him if he did agree to work with them. He flatly refused to do any buying of narcotics himself.
At last it was agreed that Attardi would introduce an undercover agent to some of his friends who were in the peddling business. Then it would be up to the agent to handle the deals, Attardi’s role being to vouch for the agent as “one of the boys.”
Undercover Agent Joe Tremoglie, a big, curly-haired man, was chosen to work with Attardi. Tremoglie’s parents had come to the United States from Sicily and Joe spoke fluent Italian. He knew the underworld, its mannerisms, superstitions, and nuances. He had about him a conspiratorial air that seemed to appeal to criminals and to disarm them.
Attardi’s first assignment was to introduce Tremoglie to a cafe cook on Newberry Street who was pushing narcotics on the side. The agent made a small purchase and then let himself be seen in the right places with Attardi—who began to introduce him as a distant cousin.
As the weeks passed, Tremoglie met narcotics pushers and wholesalers. He played poker with them. Slowly he moved up the ladder until one day he was introduced to Benny Bellanca, who took an immediate liking to him after Tremoglie had given the right answers to all the questions. He liked him so well, in fact, that they discussed the possibility of Tremoglie going to Europe as a courier to bring back a load of heroin.
He met Pietro Beddia, too, and an intensive surveillance by Narcotics agents disclosed a link between Bellanco and Beddia.
At the end of ten months of work by Tremoglie, the trap was set. Arrangements were made for Tremoglie to make a series of purchases during one afternoon and night on a timetable that was worked out to the minute. For twelve hours, Tremoglie raced from one meeting place to another, making the prearranged purchases of narcotics. And at 3 o’clock in the morning twenty of the leading
narcotics dealers in the New York area—including Bellanca and Beddia—had been rounded up.
Alphonse Attardi wasn’t around for the trials. He took his $5,000 reward money plus expenses—plus his bride—and faded from the scene. All he would tell agents was that he planned to buy a little place in the country and settle down to make an honest living.
The underworld finally figured out that it was Attardi who had sprung the trap on them, and defense counsel for the accused men demanded that he be produced by the government for questioning. But Narcotics agents could honestly say they knew nothing of Attardi’s whereabouts. They didn’t want to know.
Informers have given valuable aid to the Customs Service in its drive against smuggling, and there are many Alphonse Attardis— each with his own motive—who work with the agents.
Under the law, the Customs Service is permitted to pay up to $50,000 for information leading to the seizure of smuggled goods. The system provides that the informer may receive 25 per cent of the net recovery in any case in which he provides the original information leading to arrest and conviction for smuggling or fraud. Net recovery means the amount which goes into the Treasury of the United States as a result of a disclosure. For example, suppose Customs agents seize from a smuggler a diamond necklace that is worth $10,000, the appraisal being based on the American selling price. The necklace is forfeited and sold at public auction for $8,000. Assuming expenses of $400 involved in the case, then the net recovery is $7,600, of which the informant is entitled to $1,900.
The theory behind such payments is that the government has made a good bargain when it can pay an informer $1 and then have $3 left over for the Treasury—money which would have been lost without the cooperation of the informant.
There was one Customs informer working in Europe who received the top reward of $50,000 three times by uncovering the smuggling of huge shipments of diamonds into the United States. He refused to accept payment in Europe—but waited until he had
$150,000 in credits with the U.S. Treasury Then he came to the United States, received the money, and settled down to live the life of a country gentleman in the West.
And the rewards were tax free—as are all payments made to informers.
THE VIOLENT BORDER
Customs agents in the Laredo Tenth Customs Agency District—which includes the 2,000 miles of border and Gulf coastline from New Mexico into part of Louisiana—spend much of their time battling the smuggling of narcotics and marihuana from Mexico.
Federal officers estimate that the business of peddling narcotics to addicts grosses at least a half billion dollars a year for the underworld, and the total may be much more. No one actually knows the amount of narcotics which is smuggled successfully into the United States. Some Customs agents estimate that law enforcement officers seize less than 10 per cent of the total. One agent said, “If I thought that I was getting ten per cent of the total being smuggled, then I could sleep well at night.”
Even though the size of the narcotics traffic is unknown, there is no doubt about the tremendous profits to be made from the illegal sale of drugs. Addicts will beg, borrow, steal and kill to obtain money with which to satisfy the terrible craving for narcotics once they are “hooked.”
Unofficial estimates place the number of narcotic addicts in the United States at about 50,000. The average heroin addict requires something like ten grains per day to satisfy his needs. This means that over a period of a year the average heroin addict will use about 7.6 ounces of the drug—or a total for all addicts of about 380,000 ounces of heroin or a substitute drug. In their best years, Federal and state law enforcement officers have been able to seize only a fraction of this estimated total.
Several years ago the Mexican marihuana dealers took no responsibility for delivery into the United States; all arrangements for
smuggling across the border had to be made by the purchasers who came from the States. But in recent years there has been a change, and the Mexican operators have been willing to make deliveries to New York, Chicago, Detroit and other cities. Jack Givens, Supervising Agent for the Laredo district, believes this change in delivery method is an indication that the supply of marihuana in Mexico has outgrown the demand. This has put the pressure on the Mexican operators to give their customers better service, resulting in the delivery system.
In recent years some of the United States marihuana operators have begun to bypass border operators. They have been driving to the interior of Mexico, making their own deals with the growers and bringing the stuff back into the United States themselves. Customs inspectors are always on guard against marihuana being smuggled in automobiles—hidden in upholstery, in luggage compartments, in door panels, or in secret compartments built into the cars.
Customs agents believe that most of the heroin and other narcotics smuggled into the United States come by way of Europe from the Middle East and Far East. But Mexico still is one of the favorite routes for the narcotics syndicates seeking to reach the American addicts. In addition, Mexico remains the major exporter of marihuana. The Mexican government has been cooperating with the United States in seeking to suppress the traffic, and there is a close working relationship between the American agents and the Mexican police. But the long and rugged boundary between the two countries makes it impossible to cover every smuggling point on the border
Supervisor Givens has only thirty-nine agents and seventeen Customs enforcement officers assigned to him for the entire territory. The enforcement officers are a police force used primarily for guard duty and surveillance work under the agents’ direction.
This small force, despite the geographic difficulties, has a high esprit de corps. Each man works many hours overtime each month with no expectation of compensation. The records show that the agents average approximately 120 hours of overtime each month in excess of the overtime required of them and for which they are paid. Often the men find themselves working overtime knowing that their extra effort will be rewarded with pay averaging 19 cents an hour.
Why do they do it? One agent explained it in this way: “There’s more than money in this work once you become involved in it. Once you start working on a case, you simply cannot walk away from it at the end of eight hours. You have a feeling of achievement when you do break up a marihuana ring or pick up someone who is dealing in heroin.”
Patrolling the Mexican border has been a major problem for Customs since the frontier days. In 1853 the Customs Mounted Patrol was organized, and horsemen rode across the deserts and through the mountains on lonely patrols to intercept cattle rustlers, smugglers and aliens trying to slip across the border. The mounted guard inevitably gave way to the automobile. But the horsemen rarely had more hairraising experiences than those of the modern agents mounted on wheels. Such an incident occurred on August 7, 1960, in one of the wildest chases in the memory of Customs agents along the TexasMexico border.
It began when Agent Fred Rody, Jr., received a tip that an American was in the red-light district of Nuevo Laredo, trying to arrange for the purchase of 20 pounds of marihuana—obviously to be smuggled into the United States.
Further checking disclosed that the man was John Vaccaro, a known narcotics dealer working out of New Orleans. Vaccaro had been convicted of a marihuana violation in New Orleans and been placed under surveillance earlier in the year when he had visited Laredo. At that time agents had tried to intercept Vaccaro, suspected of smuggling marihuana, but in a wild chase on the highway Vaccaro pulled away from their car, even though their speedometer was registering 120 miles an hour. He also succeeded in eluding the police roadblocks which had been thrown up in front of him.
Agents kept a close watch on Vaccaro’s car after Rody received his report. Finally they saw someone approach his automobile and place a suitcase in the front seat of his car. Then they saw Vaccaro, his wife, and their fourteen-year-old daughter enter the car.
When Vaccaro drove down San Bernardo Avenue and then onto U.S. Highway 59, he was followed by agents in three automobiles. When the Vaccaro car slowed in heavy traffic, the agents bracketed his
car with one car in front, one behind, and the other alongside. Agent T. S. Simpson leaned out of his car and shouted, “Stop! We are Customs agents.”
Vaccaro pulled his car to the side of the road and slowed down as though to stop. Suddenly he slammed his foot on the accelerator. His car leaped forward between two of the agents’ vehicles and roared off on the left side of the highway, forcing terrified drivers to swerve into the ditch to avoid a collision. The agents gunned their cars in pursuit.
Simpson and Rody watched the speed indicator on their automobile reach 110 miles an hour, but Vaccaro’s car still pulled away from them.
Agent Grady Grazner in a 1957 police interceptor-model Chevrolet moved past the Rody-Simpson car and slowly began gaining on the Vaccaro vehicle. His speedometer was reading 130 miles an hour when he moved up behind Vaccaro’s automobile with his siren screaming. Grazner nudged Vaccaro’s automobile with his bumper and signalled for Vaccaro to pull over and stop. The woman and girl in the car were looking out the rear window, screaming and motioning Grazner to pull away from their car.
For several miles the cars raced along at well over 100 miles an hour. Grazner fired four warning shots into the air trying to force Vaccaro to stop. He was afraid to fire directly into the vehicle because of the women inside.
Gradually Grazner’s car moved up on the fleeing automobile. As the front wheels of Grazner’s car reached the left rear wheels of Vaccaro’s car, the marihuana dealer suddenly swerved. The blow of his car knocked Grazner’s vehicle to the side of the road. The car rolled over six times and bounced a distance of 471 feet. The only thing that saved Grazner’s life was the fact that he was strapped into the seat by a safety belt.
Police had been alerted ahead by radio. In the little town of Ferret, Texas, Vaccaro saw the roadblock ahead. He tried to bypass it by darting down a dirt road, but he was overtaken and brought to a halt.
Police found only fragments of marihuana in the Vaccaro car. When a search of the highway was later made by a helicopter, the pilot
spotted a suitcase lying beside the road. Vaccaro had left his fingerprints on the suitcase when he tossed it out of his speeding automobile. It was stuffed with marihuana.
When Customs agents took Vaccaro into custody, Grazner said, “Why did you try to kill me? You might have killed your wife and little girl too.”
Vaccaro spat on the agent and said insolently, “What in the hell are you talking about?”
Vaccaro was sentenced to twenty-five years in prison for this venture into violence.
The city of Laredo, Texas, dozed in the blazing noonday sun on an August day in 1957. Not many people were on the sun-baked streets at this hour, and even the Rio Grande had slowed to a lazy trickle. The only visible activity was at the Customs stations at the International Bridge spanning the river between Laredo and its twin city, Nuevo Laredo, on the Mexican bank of the river. The bridge was one of the major communications links between the United States and Mexico, but with the sun high in the heavens even the traffic across the bridge was moving at a listless pace.
At this hour, Dave Ellis, agent in charge, walked from his office in the old courthouse and sauntered to a battered automobile parked on a side street. He slipped behind the wheel and drove at a leisurely pace to the eastern edge of the city, where he turned off the street and parked beside the loading platform of a vacant warehouse. He switched off the engine, lit a cigarette and sat waiting.
When Ellis arrived at the office that morning he had found a cryptic note on his desk which said: “Meet me at the usual place.” It was signed with the code name of one of the most reliable informers in all of northern Mexico.
Ellis hardly looked the part of an experienced Customs agent. He was nearing forty, but he looked ten years younger. The horn-rimmed spectacles he wore gave him an appearance of grave studiousness.
What few people knew was that Ellis’ boyish face was deceiving. He had been toughened in a hard school of experience. He had survived a bullet through his chest leading a platoon into battle on Okinawa in World War II, and he had been with the first contingent going into Korea at the end of the war when no one was quite certain whether the Japanese were going to surrender or make a fight for it. He had returned home in 1946 to pick up his interrupted career as a Customs agent and had earned a reputation as one of the hardestdriving men in the field.
One lesson he had learned well was that no agent could operate successfully without reliable sources of information. That was why he waited patiently on this hot day to hear what it was that his tipster had on his mind. He had been at the rendezvous point only a few minutes when a car drove up beside his own and a Mexican got out, entered his car and began talking rapidly.
The Mexican was one of the key figures in a network of informers which the Customs agents had organized south of the border to help combat the smuggling of heroin and marihuana. The informers were a part, or on the fringe, of the Mexican underworld. They cooperated with the American agents for one reason only—U.S. dollars. If the information they provided resulted in the arrest and conviction of a smuggler, along with the seizure of the contraband, they were paid for the information from a special Customs contingency fund. In the case of marihuana, the payment was $5 for each pound of the weed, cannabis sativa, which was seized.
Ellis talked with his informant for perhaps thirty minutes. After the man returned to his car and drove away, Ellis headed back to the courthouse.
As he entered his office, an agent asked, “What was it all about?”
Ellis said, “My man tells me Muno Pena has a big marihuana deal going—one of the biggest. He’s getting ready to send a million dollars’ worth of the weed across the border—and we’ve got to stop it.”
The agent gave a low whistle. “So Muno Pena’s at it again. I thought he had had enough.”
“His kind never give up,” Ellis said.
At the end of World War II, Pancho Trevino had been the kingpin in the Mexican marihuana and narcotics traffic, operating out of Nuevo Laredo. Muno Pena was a competitor but on a fairly small scale until, in 1952, the Mexican government got on Trevino’s trail and threw him in jail. With Trevino behind bars, Muno Pena moved to the top. Pena remained on his home grounds in Mexico and never ventured north of the border. He had a highly organized syndicate and lieutenants who carried out his orders in the United States.
Ellis first ran into the Pena syndicate’s operations in 1955 when he was transferred to Houston, Texas, and went to work to break up a marihuana smuggling ring which included a former Houston police officer. After weeks of collecting evidence during days and nights of tailing suspects and checking records of tourist courts, hotels and telephone calls, Ellis and his colleagues had pieced together a case against the smuggling ring. In a Christmas-night raid they seized 75 grams of heroin, and in two other raids seized 250 pounds of marihuana. Eleven men and women were arrested and convicted in this operation, which was one of the biggest roundups ever made by Customs officers in the Southwest.
The Houston raids had hurt Pena badly, but now he was back on the scene with a scheme to make a quick fortune—if the tipster who had called Ellis knew what he was talking about. Ellis was reasonably certain the information was correct.
According to the Mexican informant, Pena had gone to the farmers in the Monterey district south of Nuevo Laredo and purchased their entire crop of marihuana, a ton of the stuff. He had brought it to his ranch near Nuevo Laredo and processed it in one of the adobe sheds on the place.
Trusted workers had placed armfuls of the dry weed on fine-mesh screens and rubbed it by hand. The fragments of leaves filtered through the screens onto sheets, leaving on the screens only the rough stems which later were burned. The fragmented leaves, as fine as cigarette tobacco, were carefully weighed into one-pound lots. Each lot was placed in a paper bag, which in turn was placed inside a plastic container and sealed with strips of adhesive tape. Then the plastic bags, in lots of thirty, were placed in cotton sugar sacks and stacked in
a shed to await shipment. Now Pena was working on a deal to ship the entire lot to a distributor somewhere in the vicinity of Chicago. He had decided not to parcel out the processed marihuana in small amounts to buyers from the United States. Instead, he was going to bypass the middlemen and take the lion’s share of the profits himself.
Ellis knew that a ton of “wheat” (the underworld term for marihuana) would produce about 1,000 pounds of the narcotic weed suitable for rolling into cigarettes. A pound of marihuana would make approximately 1,000 cigarettes. This meant that the retail value of Pena’s shipment would run somewhere in the neighborhood of a million dollars. Never before had so bold a scheme been attempted in marihuana smuggling.
The important element missing in the informant’s information was how and when Pena planned to move the marihuana. Ellis had sent his man back to Nuevo Laredo to get this information if possible. Without these facts, Pena held the upper hand. Ellis had only fifteen agents to cover the 400 miles of border in his district—and there were thousands of places where marihuana might be smuggled across the river
This time the tipster ran into a blank wall. He learned that the sacks of marihuana were still stacked in the shed on Pena’s ranch. But that was all he could learn, except that in the past Pena had smuggled shipments of marihuana across the Rio Grande at a bend in the river about five miles upstream from the little West Texas town of San Ygnacio. When the water was low, the carriers were able to walk across the stream. If the river rose from sudden rainfalls, the marihuana was floated across the river on inflated inner tubes or on inflated rubber boats. In each case, an automobile was waiting at a designated spot to receive the contraband.
Ellis ordered a continuous surveillance of the river bend. For more than three months agents kept watch in relays, hiding in the mesquite near a small roadside park on top of a hill overlooking the sweep of the river. But the watches were fruitless. Each time Ellis inquired about the sacks of marihuana at Pena’s ranch, he was told they were still there.
In December, Ellis was reading the routine reports from New York of marihuana seizures that had been made in the city. These reports
were circulated periodically to all agents-in-charge throughout the United States. There seemed to be nothing unusual in this particular batch of reports until Ellis came across an account of the arrest of one Wilfredo Fernandez, who had been caught with 16 pounds of marihuana in his possession. The line which drew his attention said that the marihuana was packed in one-pound lots in paper sacks which had been enclosed in plastic and sealed with adhesive tape. Ellis sensed that, somehow, Muno Pena had outwitted him, and the very thought enraged him. He sent a message to New York for more information on the arrest of Fernandez and where he had obtained the marihuana.
Fernandez, it developed, had been arrested in November for possession of cocaine. When his apartment was searched, agents came across the packaged marihuana. Fernandez sullenly admitted that he had bought it in Chicago from a dealer he knew only as “The Lawyer.” The Lawyer had taken him out on Lawrence Avenue, where they had met a man who appeared to be a Mexican, driving a stake truck with a green body. The Mexican had taken the marihuana from a large cotton sack—and then driven away. He had never seen the Mexican before and didn’t know where he lived.
“He was a skinny fellow about five feet eight tall, and he had black hair and a pale complexion,” Fernandez said. “That’s all I know.”
Ellis knew in his heart that this marihuana had come from Pena. And later he was to learn how cleverly Pena had outwitted him. Pena had stacked the sacks of processed marihuana in the shed on his ranch where any of the workers could see them as they passed by. But what the workers didn’t know was that one night Pena had removed the marihuana to a hiding place known only to himself and substituted other sugar sacks which looked identical.
One night Pena had taken the sacks to the river, where he met a confederate. They had carried the sacks across the river to the highway where the confederate had hidden his automobile, to which was attached a U-Drive-It trailer. The marihuana was stacked in the trailer and then covered with a mattress, a set of bed springs and a few household articles. These were lashed down with a tarpaulin over them—and then the driver headed north. To all outward appearances,
he was a worker moving with his household goods from one job to another.
Ellis asked Chicago Customs agents to check on long distance telephone calls made in November by The Lawyer. And within a few days he received a list of names ranging from barkeeps to uncles, aunts, and cousins, horse track bookies, and pool parlor operators.
Meanwhile, agents in Laredo had been checking on Pena’s associates and on his family. They made a list of everyone known to have any connection, even casually, with Muno Pena.
It was when Ellis checked these two lists of names that he found there was one name which appeared on both lists. The name was Isuaro Garza. The agents’ information was that Garza was married to Muno Pena’s sister. Mrs. Garza and her three children lived in Laredo and maintained a home there. But Garza, for some months, had been living on the outskirts of Kenosha, Wisconsin. Occasionally Mrs. Garza and the children would drive north to spend a few days with Garza. They never stayed for long and always returned to their Laredo home. No one seemed to know what Garza was doing in Kenosha.
Ellis thought he knew what Garza was doing there. He was certain that Garza was the man from whom The Lawyer had obtained the marihuana—and that Garza was Pena’s man, making deliveries in Chicago from the 1,000 pounds of marihuana smuggled across the Rio Grande.
Ellis was so positive of this connection that he appealed to Washington for permission to take six agents from the Laredo office— men long accustomed to working on this type of case—for an investigation of Garza. But headquarters was in the midst of an economy wave. Ellis was told that funds were tight and that it would be impossible for him to take six men from Laredo on an uncertain mission. However, he was given authority to go to Kenosha himself and to take along one aide. If he could make a case against Garza within ten days, well and good. But at the end of ten days he must return at once to his post in Laredo.
Ellis chose Agent G. L. Latimer to accompany him. The two set out for Kenosha, driving day and night, through a snow storm which was sweeping the Middle West. They located Garza’s home. He was living
in a small white frame house just outside the northern edge of the town.
“There were two or three feet of snow on the ground,” Ellis recalls, “and it looked like we were going to have to stake out the place by living in sleeping bags. But there was a motel nearby which was closed for the winter. We got permission from the owner to slip into the court from which we could see Garza’s house. We were sure he was our man—but we wanted to know who was calling for the marihuana and where it was hidden. We wanted to catch the whole apparatus if possible. So day and night we watched Garza’s house.”
Occasionally Garza would leave the house for a trip to the grocery store, to go to a movie, or to visit in the city. The agents were unable to detect him making any deliveries. But on the tenth day—the last day of grace for Ellis and Latimer to be away from their Laredo posts—a car drove up to the white frame house. A man entered and shortly came out carrying a package which he stowed in his automobile. When he had driven a short distance from Garza’s home, he was halted. Ellis found the package filled with marihuana. It was in a paper sack enclosed in plastic and taped with adhesive.
With this evidence, a search warrant was obtained and the agents advanced on Garza’s house. It was nearing midnight when Ellis knocked at the door. A light came on and then the door was opened and a voice said, “Who is it? What do you want?”
Ellis shoved the door open, revealing a skinny Mexican standing in his long-handled underwear, shivering from the cold.
“We are U.S. Customs agents,” Ellis said. “We have a warrant to search this place.”
Isauro Garza submitted meekly. A loaded pistol lay on a table near his bed, but he gave no resistance. The agents found 720 one-pound sacks of marihuana hidden in closets and in the attic—the largest haul of marihuana ever to be made in the United States. Its retail value was $720,000.
Garza feigned surprise over the discovery of the marihuana. He told officers he “had no idea what was in the sacks.” He said a man named Tony called at his home one day and left a truckload of sacks.
Tony asked him to keep them for him. Another fellow named Pepe came from Chicago three or four times. “He picked up some of the stuff and gave me $600 for rent and expenses—but I didn’t know what it was all about,” Garza said.
A jury thought otherwise. Garza was sent to prison for five years. And Muno Pena? He had lost another round to Dave Ellis, but he continued his operations on a smaller scale. Customs agents are waiting for the day when he places one foot across the border—and then he’ll be out of circulation for quite a while.
A DIRTY BUSINESS
A cunning and ruthless hoodlum, two crooked Customs employees, two Greek narcotics peddlers in Shanghai and a supporting cast of killers, goons and dupes formed one of the greatest narcotics syndicates the United States has ever known. Over a span of less than two years in 1936–1937, this gang smuggled into the country narcotics believed by Customs agents to have had a retail value of at least $10 million. Their system was so simple that it was almost foolproof. Almost ... but not quite.
The prime mover in this profitable operation was Louis “Lepke” Buchalter—a name which perhaps doesn’t mean much to the younger generation. But in the prohibition era and the years of the depression, Lepke built a fantastic financial empire on a foundation of terror, violence and murder combined with a genius for organizing. He was, in many respects, more powerful and more successful than “Scarface” Al Capone and dozens of other hoodlums of the times who were more publicized in the nation’s press.
Louis Lepke Buchalter rose to power in the shadow of the Jazz Age, the era which evokes sentimental memories for so many Americans. But Lepke’s world was about as sentimental as a tommygun.
He was a small, slender man—5 feet 7—with a dark complexion and black hair which he parted on the side. He was soft-spoken and seemingly humble in manner. He had large brown eyes that appeared as soft and gentle as the eyes of a fawn. But his eyes only masked the evil in this man who schemed and killed until he ranked at the top of the list of U.S. criminals.
By all odds, Lepke was the most brilliant—and the most dangerous —of the criminals. It was Lepke who showed the underworld how to infiltrate and take over control of labor unions, and how to become silent partners in the management of industries. It was Lepke who put murder on a wholesale basis with an organization that became known as Murder, Inc. It was Lepke who found the chink in the U.S. Customs Bureau’s defenses against narcotics smuggling—and who made narcotics smuggling almost a pleasant pastime.
Lepke is worth at least a footnote in any history of our times because he symbolized an era of graft, corruption and violence the likes of which the nation had never known before. He was born on February 6, 1897, in Manhattan’s Lower East Side, one of a family of eleven children. The family lived in shattering confusion in a small, crowded apartment over the hardware store owned by the father, Barnet Buchalter.
Lepke’s mother called him “Lepkeleh,” the Jewish diminutive for “Little Louis,” and his friends shortened the nickname to Lepke. He was not a bad student in grade school. But he quit school after finishing the eighth grade and for a time worked as a delivery boy at $3 a week.
His father died when he was thirteen. The family broke up and scattered. The other ten children went on to become respectable, useful citizens. But not “Little Louis.” He rented a furnished room on the East Side and turned to crime. He organized raids on pushcart peddlers, stole from lofts, picked pockets, and lived by his wits. He was sent to the reformatory and to prison for short terms for larceny, but he always returned to the old life. He had ambitions to become a big shot in New York’s underworld.
In the early 1920s, Lepke joined an East Side mob headed by “Little Augie” Orgen. But while most of the underworld scrambled to satisfy the country’s unquenchable thirst for bootleg whiskey, Lepke convinced Little Augie that it was safer, smarter and more profitable to specialize in labor racketeering and in selling “protection” to businessmen.
If an employer was having trouble with strikers, Lepke would see to it that the recalcitrant workers were beaten up by his goons and that
