global health as a right to medication and has increasingly focused long-term intervention in terms of an implementation of health care delivery systems (cf. Biehl 2007; Farmer 2003), even as long-standing and emergent configurations of poverty, need, and disease go unproblematized.
In studies of urban poverty, for example, the paucity of public resources for health and education, the rise of incarceration, and drug-related violence have generated powerful representations of poor urban neighborhoods. These representations have consequences for attending to life within them. Elaborating the notion of “advanced marginality,” urban sociologist Loïc Wacquant has argued that the precarization of labor, along with “state policies of social retrenchment and urban abandonment,” have transformed poor urban neighborhoods from places “bathed in shared emotions and joint meanings, supported by practices of mutuality, to indifferent ‘spaces’ of mere survival and relentless contest” (Wacquant 2008, 241).
But such a representation may elide textures of life and the fragile efforts in self-making that are occurring in circumstances of poverty and how those efforts complexly articulate with institutions. And further, this representation does so through a specific relationship to time: it creates a break between the past and present in order to represent the past (see Strathern 1995). Thus, against the representation of “collective oekumene” in the past, the poor urban neighborhood of today is represented as a “social purgatory” or “territory of perdition” (Wacquant 2008, 233), in which the poor engage in “informal individual strategies of ‘self-provisioning’” (p. 244). Such spaces of perdition, then, call for mechanisms of social and political incorporation to “reintegrate” these spaces back into the fold of a recognizable form of life.
Recent critiques of humanitarian reason have engaged the political and moral stakes in these representations of pervasive suffering and alienation. Didier Fassin, for example, argues that a new moral economy centered on humanitarian reason has marked a shift in the way in which “we” have come to describe and interpret the world. Representations of exclusion and suffering mobilize moral sentiments of compassion, indignation, and care, and these moral sentiments have political value, which entails specific forms of intervention (Fassin 2012). For anthropologist Miriam Ticktin, a politics of care is an antipolitics insofar as it preserves the social order rather than generates a radical political critique (Ticktin 2011). Based on the universality of suffering and pain, this politics in fact operates selectively through compassion for suffering bodies recognized as morally legitimate.
These critiques illuminate how categories of suffering and trauma migrate across domains. In the process, they begin to define new fields of intervention and redraw lines of inclusion and exclusion. Attending to the ways in which violence and harm are existentially experienced, however, shifts the anthropological exercise. Rather than focus on representations of the suffering subject to trace a general moral shift, globally speaking, an anthropological writing that acknowledges suffering engages and responds to a specific life and world. This engagement opens thought to the experience of time in relation to violence as well as the concealments and boundaries in everyday life (see Kleinman et al. 1997; Das et al. 2000). For friends, family, and neighbors in La Pincoya, acknowledgment of the effects of present-day economic precariousness falters when an anthropologist holds up a representation of collectivities and intimate relations that existed in the past in order to emphasize what was “lost.” Rather, the past presents in specific ways and moments. These effects, or affects, are refracted through relational modes and their boundaries in the present, and invest relationships with different hopes, desires, and limits.
Through these refractions, I engage moral projects in everyday life, in which care is a problem rather than a given. I take care as being diffuse and not definable in any simple way. Attending to care is similar to attending to violence, in which, as Veena Das remarks, “contests around the question of what can be named as violence are themselves a sign of something important at stake” (Das 2008, 284). To attend to care as a problem in everyday life, rather than a category with defined borders, has implications for my relation to ethnography. Everyday life is a scene to which I am drawn, rather than a set of routines, practices, or interviews that I observe, evaluate, and extrapolate judgments from. It also has implications for how I understand and engage the moral. While there might be a great deal of moralizing in everyday life, the struggles in caring for others and the complex affects that compose a discovery of limits are existentially experienced in ways that implicate the moral fabric of self-making (Kleinman 2006, 2010). Throughout this book, I engage care as a problem within intimate life, which is itself layered with institutions. I consider the moral not in terms of moral judgments but in the very ways in which self is implicated with others.5 This implication is where limits are experienced.
How might such limits appear in ethnographic engagements with poverty and disease? Unsettling any sentimentalized notion of the family and challenging the taken-for-granted affects that “should” manifest among intimate kin, anthropologists have elaborated such limits around the problem of abandonment. For example, Nancy Scheper-Hughes's discussion of child death in a setting of poverty and extremely high infant mortality highlights the complexity and range of what might constitute abandonment. A small error or a moment of inattention can have fatal consequences: “so much greater vigilance is required to keep an infant alive, even the smallest lapse in maternal attention and care can sometimes be fatal” (Scheper-Hughes 1992, 360; see also Das 2010b). But simultaneously, given the pervasiveness of child death and the often overwhelming circumstances of poverty, “a good part of learning how to mother on the Alto includes knowing when to let go of a child who shows he wants to die” (p. 364). In the lives of Alto women and in the face of multiple dangers to life, death is not opposed to life; rather death is a “valid part of existence, so that death, too, must be lived” (p. 364). A play of life and death is at work in the relationship between mother and infant; abandonment here cannot be understood solely as a discrete moment with intentionalities ascribed to it.
Focusing on the shaping of intimate relations by market forces and medical technologies, João Biehl's discussion of abandonment centers on the domestic triaging of the mentally ill and unwanted (Biehl and Eskerod 2005). The normative family is a parapolity—a “state within the state”(p. 185)—engaged in a “making live” and “letting die” of its family members (see Foucault 1978). Those deemed unproductive, economically speaking, are actively ejected from the family and relegated to zones of abandonment—a social and biological death. These works raise a further set of important questions: How is ethnographic method implicated in understandings of accountability, care, and abandonment? How do modalities and temporalities of engagement with ethnographic sites shape descriptions of the dynamics of care? How do anthropologists come to know the shifting lines of the normal and abnormal, and what are limits to an anthropological knowing?
When I first started my research as a graduate student in anthropology and a medical student, I was interested in the high prevalence of depression in Santiago, which had reached 29.5 percent in primary care. According to the World Health Organization, this prevalence of depression was the second highest in the world (WHO 2001). Psychiatrists and public health officials initiated a national depression treatment program for the diagnosis and treatment of low-income women. This program was cast as both part of a national project of moral healing and an intervention for the health of the poor. The project fit key-in-lock within a critical inquiry of the biopolitical state and the medicalization of the family, in which the woman as mother is responsible for the well-being of her children, the future of the population. But situating myself in La Pincoya, I grew uneasy with a project that focused almost exclusively on citizenship and a circumscribed medical intervention. A whole range of relations and circumstances seemed to be eclipsed through a focused critique of the normative family and “the neoliberal state.”
This local density of relations suggested a different reading of Foucault's writings on medicalization, the family, and the biopolitics of the population. In “The Politics of Health in the Eighteenth Century,” Foucault traces how medical politics “has as its first effect the organisation of the family, or rather the family-children complex, as the first
