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- Herausgeber: John Wiley & Sons
- Kategorie: Geisteswissenschaft
- Sprache: Englisch
Public health erupted into the world's consciousness in early 2020 with the Covid pandemic and its multiple social and economic consequences. What had been until then, for most people, a remote and specialized field of expertise suddenly became the very basis for the government of lives. The Worlds of Public Health analyzes the moral and political issues at stake in the practice of public health today, including the influence of positivism, the boundaries of disease, conspiracy theories, morality tests, and the challenges posed by the health of migrants and prisoners. This exploration transports readers from South Africa, the country most impacted by the AIDS epidemic, to Ecuador, with the supposedly highest maternal mortality rate in Latin America; from the scientific controversies concerning the so-called worm wars in Kenya to conflicts between doctors and patients around Gulf War syndrome in the United States; from lead poisoning and public housing in France to the Covid-19 pandemic worldwide. Through these case studies, Didier Fassin argues that, ultimately, public health is a politics of life, revealing the different and unequal ways in which life is valued - and either protected or not - in contemporary societies.
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CONTENTS
Cover
Dedication
Title Page
Copyright
Acknowledgments
Introduction: Problematization
Notes
The Birth of Public Health – 14 April 2021
Notes
The Truth in Numbers – 5 May 2021
Notes
Epistemic Boundaries – 12 May 2021
Notes
Conspiracy Theories – 19 May 2021
Notes
Ethical Crises – 26 May 2021
Notes
Precarious Exiles – 2 June 2021
Notes
Carceral Ordeals – 9 June 2021
Notes
Readings of the Pandemic – 16 June 2021
Notes
References
Index
End User License Agreement
Guide
Cover
Table of Contents
Dedication
Title Page
Copyright
Acknowledgments
Introduction
Begin Reading
References
Index
End User License Agreement
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Dedication
To all those who work to ensure that unnamed truths are spoken and faceless voices heard
The Worlds of Public Health
Anthropological Excursions
Lectures at the Collège de France (2020–2021)
Didier Fassin
Translated by Rachel Gomme
polity
Copyright © Didier Fassin 2023
The right of Didier Fassin to be identified as Author of this Work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.
First published in French as Les Mondes de la santé publique. Excursions anthropologiques. Cours au Collège de France 2020-2021 © Seuil 2021.
First published in English in 2023 by Polity Press
Epigraph from Politics, Philosophy, Culture: Interviews and Other Writings, 1977–1984, by Michel Foucault, 1988, used with permission of Routledge; permission conveyed through Copyright Clearance Center, Inc.
Polity Press65 Bridge StreetCambridge CB2 1UR, UK
Polity Press111 River StreetHoboken, NJ 07030, USA
All rights reserved. Except for the quotation of short passages for the purpose of criticism and review, no part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publisher.
ISBN-13: 978-1-5095-5829-2
A catalogue record for this book is available from the British Library.
Library of Congress Control Number: 2022948491
The publisher has used its best endeavours to ensure that the URLs for external websites referred to in this book are correct and active at the time of going to press. However, the publisher has no responsibility for the websites and can make no guarantee that a site will remain live or that the content is or will remain appropriate.
Every effort has been made to trace all copyright holders, but if any have been overlooked the publisher will be pleased to include any necessary credits in any subsequent reprint or edition.
For further information on Polity, visit our website:politybooks.com
Acknowledgments
This course of lectures was prepared during my tenure of the Annual Chair in Public Health at the Collège de France, to which I was elected in 2019. These lectures, and the resulting book, offered me an opportunity to immerse myself in a field I had moved away from – public health – and to revisit it on the basis of research conducted several years ago, while also drawing on material that was new to me. Words cannot express my debt to all those I met, with whom I worked, and among whom I sometimes lived, in Ecuador, South Africa, the United States, and of course France, and to those with whom I studied, and then for a time practiced and taught, public health, before moving into social science. I am grateful to Sandrine Nikel and Julie Clarini for having supported the project at Le Seuil, and to John Thompson for having manifested from the outset his interest in its English version. It has once more been a pleasure to collaborate with Rachel Gomme on the translation and to work with Munirah Bishop for the final steps. I also thank Sarah Dancy for her attentive copyediting. For obvious reasons, this exploration has a particular significance, since it took place during a time when the world faced a major health crisis. A substantial proportion of the lectures was actually written when I was confined alone in an environment highly favorable to reflection and writing, the Institute for Advanced Study in Princeton.
IntroductionProblematization
Problematization does not mean the representation of a pre-existing object, nor the creation by discourse of an object that does not exist. It is the set of discursive or non-discursive practices that introduces something into the play of true and false and constitutes it as an object for thought.
Michel Foucault, “The concern for truth,” 1988
Public health erupted into the world’s consciousness early in 2020. In the case of France, the moment can even be precisely dated: 17 March, the first day when the majority of the population was confined to their homes. For what is unique about the Covid1 epidemic is not the nature of the infection, which is of course serious, though less contagious than measles and not as lethal as AIDS, but the way societies reacted to its emergence. The pandemic, and the responses to it on every continent, generated a worldwide upheaval in human activity. In many other countries, lockdown was an experience without precedent, apart from its echoes of some aspects of the response to outbreaks of plague in the late Middle Ages and cholera in the early nineteenth century. Health policing, with its arsenal of prohibitions, requirements, checks, and sanctions, was the most widespread manifestation of public health, even once people began to be vaccinated. But it took many other forms: social distancing, the wearing of masks, the practice of testing, the isolation of patients, the tracing of contacts, the recurrent and swiftly refuted announcement of treatments, fierce and often unequal competition in the search for a vaccine, daily public counts of cases and deaths, intrusive and ineffective surveillance measures, not to mention the exceptional provision for both economic and social support aimed at preventing business failures, limiting lay-offs and mitigating the consequences of the abrupt destitution of many families. The implementation of these policies was accompanied by hesitations and reversals, debates and controversies, martial declarations and contradictory assertions, flagrant lies and lethal obstructions. In much of the world, everything that keeps societies in motion suddenly began to revolve around questions of health. Public health, which for many until then had been no more than an abstraction, an obscure administrative matter, a rather unappealing field of expertise, became the principle for the government of lives – a “government of living beings,” as Foucault puts it.2 His phrase should, however, be taken literally – more so than he himself does – considering it as the government of human beings inasmuch as they are living beings who must, “at all costs,” as the French president articulated it, remain alive.
It so happened that, a few months before the first cases of Covid were diagnosed, I was elected to the Annual Chair in Public Health at the Collège de France. My course was due to begin on 29 April, six weeks after lockdown was imposed. It was therefore postponed and took place a year later, albeit in almost identical conditions owing to both a new wave of the epidemic despite the beginning of vaccination, and a renewed, although less draconian, lockdown. For, contrary to the hopes of many and the predictions of some, the infection still loomed in the present. In the interval, however, my course had gained a new significance. Its subject, public health, hitherto barely recognized, had become the central topic of conversation and concern, insinuating itself into the everyday lives of each and every one, and equally into national politics and international relations. But it raised the question of how to tackle this topic that had suddenly invaded both public and private space to the extent that it absorbed almost all the attention of the media, politicians and citizens. Should I refocus my analysis purely around the pandemic, which lent itself to an anthropological reading on many levels, but would mean letting go of the richness of this multifaceted, diverse field? Such an approach risked giving in to the lure of presentism, forgetting that public health has a long history that could inform present anxieties. It would also mean consenting to a form of ethnocentrism, losing sight of the fact that many societies were struggling with other, more serious health issues. I therefore decided to take an alternative approach. I started from a banal and little-known scene illustrating various aspects of public health which I analyzed through a number of case studies over the course of the lectures, and I ultimately showed how each of these aspects sheds a different light on the Covid pandemic.
The scene in question is the emergence in France of the epidemic of childhood lead poisoning in the late 1980s. It can be considered both in terms of social production, the result of harsher immigration policies and a slowdown in housing policy, and in terms of social construction, through the fumbling, digressions and resistances of the actors involved. As a linking thread through the lectures, this investigation enables me to explore some seemingly unusual but nevertheless fundamental dimensions of public health: the power of positivism, the boundaries of disease, conspiracy theories, morality tests, and finally the challenges posed by the health of migrants and prisoners. The exploration transports readers from France, which has the highest level of prison suicides in Europe, to South Africa, the country that has been the worst affected worldwide by the AIDS epidemic, and Ecuador, which announced that it had the highest official maternal mortality rate in Latin America; from the scientific controversies of the “worm wars” in Kenya to confrontations between physicians and patients around Gulf War syndrome in the USA; from exotic pathologies at the Institut Pasteur to colonial psychiatry at the École d’Alger; from the origins of psychic trauma in World War I to the enumeration of deaths during the 2003 heatwave in France. The journey ends with an examination of the Covid pandemic in light of each of the dimensions explored in the preceding lectures in order to propose a new reading of it – revisiting it from an anthropological point of view.
Anthropology, as I understand it, is a way of looking at the world otherwise, of reflecting, like Ulrich, Robert Musil’s “man without qualities,” that “it might just as well have turned out differently.”3 It is an exercise in intellectual dishabituation. In order to accomplish this, it can draw on more than a century of research by anthropologists who have explored multiple facets of human activities and relations in diverse places around the world, from the Nuer of South Sudan to the Nambikwara of Brazil, as well as among various groups in their own societies, from the anti-witches of the Mayenne Bocage region in western France to the Canadian experts in Alzheimer’s disease, and have thus learned that everything that seems self-evident in one context may appear completely differently in others.4 But this cultural relativism does not lead them to become hunters of the exotic: quite the opposite. As Jean Bazin emphasizes, when faced with alterity they strive to reduce it by familiarizing themselves with the social worlds in which they conduct their research, whether geographically remote or close to home.5 This practice helps to make intelligible phenomena that experts have defined as imaginary, such as chronic Lyme disease, by showing that they result from the impossible confrontation between the authenticity of patients’ suffering and the authority of doctors’ knowledge. It also contributes to the explanation of phenomena that arouse anger or derision, such as paranoid beliefs around AIDS, which can be shown to have a heuristic value as they provide clues to interpret lines of cognitive fracture in contemporary societies. But it also leads the anthropologists to defamiliarize themselves with their own social world, making what is taken for granted less self-evident. For example, it can prompt them to wonder about the belief in the single, neutral truth of numbers in describing health, when the validity of randomized trials is contested or when disputes arise around the interpretation of mortality statistics, or to question the existence of a separate field of migrant health, as if exiles presented specific pathologies when in fact their poor health is a product of the way they are treated by the so-called host society. Thus, the anthropologists know, through their own experience and from that of those who have preceded them, that there are many ways of being in the world, and that the one that has long seemed the only right way is not necessarily more right than others.
It is such a shift of gaze with regard to public health that I have proposed in this book. Hence the subtitle “anthropological excursions.” An excursion, the dictionary tells us, is “the action of traversing a region to explore or visit it.” The word, which first appeared in both English and French during the sixteenth century but only became common much later, derives from the Latin excursio, meaning “journey,” “incursion,” and, in the figurative sense, “ramble” or “digression.”6 This idea of exploration, freedom, and adventurous investigation points to the method of my inquiry. It explains my frequent preference for a narrative form, after the manner of what could be the tale recounted by a traveler in the “worlds of public health.”7 Here I speak of worlds not in the sense of particular geographies or specific activities, but rather as sets of questions that arise for society in the language of public health, and which to a certain degree revolve around common stakes – the desire to quantify, the legitimization of knowledge, the meaning of conspiracy theories, the rationales of immorality, and disparities in the treatment of exiles and detainees.8 The word “stakes” is important. And it should be understood more broadly than it usually is, in the sense of what is socially at stake, of what is being staked in and for society. The corresponding issues are not predetermined or set once and for all. On the one hand, they are subject to negotiations, debates, and arguments, struggles to bring them to light or conversely to conceal them, among the agents and institutions involved. On the other, the researcher who analyzes them is himself part of constituting and recognizing them. In the studies I present, I shall consider the stakes from this dual viewpoint, internal and external, whereby public health emerges simultaneously as a mirror held up to society and the reflection society returns to that mirror.
This methodological and theoretical choice to enter into the subject via the stakes is thus a matter of both using a prism that refracts public health into a series of images and, conversely, understanding how broader questions can be grasped through the images thus refracted. “The Truth in Numbers” invites reflection on how the work of quantification claims to represent social and health facts. “Epistemic Boundaries” examines the clash between lay and scientific conceptions of illness that are based on competing legitimacies. “Conspiracy Theories” reveals reactions of distrust of authorized knowledge and official power. “Ethical Crises” exposes mechanisms of violation of rights and diversion of public goods for the benefit of private interests. The studies on “Precarious Exiles” and “Carceral Ordeals” open a way to understand the genealogy and sociology of government of groups subject to various forms of state surveillance and repression, through two categories that have become central to thinking contemporary societies: migrants and prisoners. The refraction of public health into these multiple stakes thus offers a new approach to understanding it, without exhausting the spectrum. It is always an open reading.
This approach differs substantially from those that have dominated social science studies of public health. The most traditional considers public health as a set of knowledge and practices around collective management of disease, and its emergence and development can be traced back through time to Greco-Roman antiquity.9 But most of the research that takes this approach is limited to shorter time periods and more precise topics, whether they be epidemics, specific methods such as statistics, or particular institutions such as psychiatric asylums. Their contribution to knowledge in this domain is invaluable. Working through a genealogical reading, Foucault broke with this approach in two ways.10 On the one hand, he placed public health within a larger context of management of populations. What he names biopolitics comprises the work of both knowledge and action that is legitimized by the very concept of population, notably the science of demographics that makes it possible to count births, deaths, life expectancy, individual mobility, and practices of governmentality such as family planning, social security, and control of migration. On the other hand, he established a discontinuity in the traditional, more-or-less linear account of public health. This is the shift from sovereignty as the right to kill to biopower as the duty to make live, which arose during the eighteenth century as a signature of modernity. Nevertheless, despite their manifest differences, the historical and genealogical approaches, each in their own way, tend to confer a degree of unity and even coherence on their subject: public health in the first case, biopolitics in the second.
What I am trying to do here is different. I propose neither a homogeneous representation of public health nor a consistent theory of biopolitics. Rather, I break down this amorphous matter into a range of stakes that I aim to identify, so that the different pieces gradually brought together sketch an image of public health like an incompletely assembled jigsaw puzzle. The argument is that public health is, no more than science or religion, a coherent ensemble, and rather than trying to give it an artificial unity, which always comes down to a catalogue of missions or, symmetrically, to a paradigm erasing its discrepancies, it is more heuristic to explore what is at play through its various dimensions. Indeed, each stake unveils games of power and knowledge involved – in the production of biostatistics, the legitimation of diseases, the imaginary of conspiracies, the emergence of crises, and more specifically the treatment of migrants and prisoners.
The Covid pandemic represents a life-size experimentation of this approach as each fragment I have proposed to study finds its place in the composite image presented in the final lecture, shedding a distinct light on the pandemic. The fetishization of numbers is put to the test by the contradiction of those produced. Epistemic borders are drawn between recognized and invalidated clinical trials. Conspiracy theories flourishing everywhere reveal a loss of trust not so much in science as in government. Ethical crises occur around the uneven distribution of resources. Migrants and prisoners are made more vulnerable and, paradoxically, more at risk for being confined at the very moment when the rest of the population is under lockdown. Finally, while the debate has been mostly around health versus wealth, or between the critique of the measures adopted for their effects on the economy or for their consequences for democracy, it is more urgent to address the considerable inequalities in morbidity and mortality that have been established, and perhaps even more those to come in terms of lives lost and lives ruined.
At this point I have to acknowledge the dilemma I was presented with when I found myself writing in the context of the pandemic – in other words, just as a major public health event was emerging. On the one hand, if I waited for the circumstances to “cool down” before rendering an account of them, I risked exposing myself to the criticism often addressed to the social sciences, particularly anthropology, of never being there when history is being made before researchers’ very eyes. But on the other, if I offered analyses “in the heat of the moment,” there was a danger of running after a present that was changing almost daily, where one day’s assurances might be contradicted the next, without giving myself time to take the distance appropriate for scientific reflection. By linking my final study to those presented in the preceding lectures, I felt it was possible to present a reflection free of both the rush to act, which tends to become an invitation to avoid thinking, and the urge to condemn that ultimately neutralizes any possibility of genuine critique. Having written most of the first seven lectures before the start of the pandemic, I therefore retained their form and their theses,11 reserving my reflections on the health crisis for the final lecture – “untimely meditations” on current events, which made it possible, I hope, to read these events otherwise.
Notes
1.
Among the various ways of referring to the disease caused by the coronavirus designated SARS-CoV-2, I have chosen to simply use the term “Covid.”
2.
The title of Foucault’s 1979–80 course at the Collège de France is somewhat deceptive, since the series actually focuses on the government of the self and subjectivation through submission to pastoral power.
3.
Ulrich is the protagonist of Musil’s book (1996 [1955], vol. 1, p. xx), who in the first drafts of the work was tellingly and ironically named Anders (“the Other”) and is thus gifted with “a sense of the possible.” As Jean-François Vallée notes (2004, pp. 28–29), Musil’s writing is entirely geared toward producing an “effect of strangeness, or at the very least, ‘defamiliarization’” in the reader.
4.
The allusions here are respectively to the work of Edward Evans-Pritchard (1940), Claude Lévi-Strauss (2011 [1955]), Jeanne Favret-Saada (2015 [1977]), and Margaret Lock (2013).
5.
Making a distinction between alterity and difference, Bazin argues (2008, p. 48): “However strange, and sometimes absurd, human actions appear to us initially, there must be a point of view from which, once they are better known, they prove to be merely different from our own: it is this that renders the description of them anthropological.”
6.
See Rey (2001), Gaffiot (1934) and Brown (1993).
7.
This choice to narrate is partly justified by what Laurent Demanze (2019, p. 113) calls “the democratic power of storytelling,” which I use in a slightly different sense, since my aim is, through narrative, to meet with a broader audience and thus facilitate their access to the research.
8.
These worlds are distinct from the “social worlds” that interactionists such as Anselm Strauss (1978) have theorized, which are constituted around activities that involve technologies and evolve within organizations.
9.
See, for example, George Rosen’s classic history (1958).
10.
See, of course,
The History of Sexuality
, vol. 1 (1978 [1976]).
11.
Readers who followed the lectures online will note some differences between the spoken and written versions. This is because the written lectures were a little too long for the Collège de France’s one-hour format. In addition, some parts of the preface were included in the spoken version of the first lecture, since the point of them was to introduce the course. The final lecture has been substantially augmented in the book, in order to construct a partial history of the pandemic that a reading more distant in time might have obscured. In other respects, the two versions are very similar.
The Birth of Public Health14 April 2021
Expert knowledge and social sciences. – Refusal of a theory of public health. – The exploration of what is at stake in public health as a way to understand contemporary societies. – A paradigmatic case study. – From a rare disease to a silent epidemic. – Two approaches, two languages, two policies. – Discovery and invention. – Work and workers. – Ignorance, negligence, and resistance. – A public secret. – Culturalist variations. – Political economy and moral economy. – Social construction and social production of public health.
This course has a curious history, caught up as it has been by history itself. Taking public health as its subject, it was brought up short last year by the advent of a public health crisis on an unprecedented scale. The Covid pandemic made it impossible to present the lectures and of course, more broadly, paralyzed the economic, cultural, and social life of France as of most other countries in the world. It thus revealed all the more starkly the pertinence, and indeed urgency, of studying the hitherto somewhat indeterminate domain of public health. Epidemiologists and statisticians, biologists and doctors, economists and political scientists have engaged with it, sometimes as counselors to princes and sometimes criticizing their decisions, expressing themselves with caution or with confidence, warning of disaster or promising panaceas, exhorting the populace to adopt rules of good conduct, and influencing, through their analyses and opinions, decisions that could have considerable impact on the lives of millions of people.
In this concert of experts, what role could be played by historians, sociologists, anthropologists – those represented as social scientists though they by no means account for the entirety of this field? They are certainly not experts, and what they engage with is perhaps precisely that which resists expert knowledge. It is not that they contest its importance in managing a crisis as serious as the one that is currently convulsing the world, and whose aftershocks will continue to be felt for years to come. But through their research and their reflections, they maintain that, in order to contend with such an event, a society needs something more than just expert knowledge. Another realm of knowledge is possible, perhaps more distanced, or rather engaged in a different way, seeking less to tell people what must be done than to understand what is at stake, in the belief that such an understanding has political as well as ethical implications. In response to the pandemic, the interruption of the normal activities of businesses, schools, universities, theaters, festivals, entertainment complexes, sports clubs, and research institutes, the suspension of civil liberties and fundamental rights, such as moving around, meeting, protesting, the introduction of intrusive mechanisms for surveillance of behavior and repression of deviance from the norm, the ban on family members being at the side of the sick and dying, the drastic restrictions imposed on funerals – all of these elements of the response to the pandemic highlight the seriousness of the political and ethical stakes and call for an approach distinct from that of the experts. There is a need to think a world in transition, in which public health is a catalyst. Social sciences – whether history, sociology, or anthropology – offer keys to interpretation that draw on perspectives from other times and other places, the study of empirical material and a tradition of critical reflection.
It is this other gaze that is offered in this course. Do we need to begin with a definition of public health? A literature review published twentyfive years ago already listed around sixty, but the most frequently cited is Charles-Edward Winslow’s classic 1920 definition: “Public Health is the science and the art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health.”1 There are of course more recent definitions that put forward more sophisticated modalities and are more democratically expressed, but none of them escapes the normative and administrative functions of a discipline that is designed to serve public action toward collective well-being in the matter of health. It is easy to understand why the British historian Dorothy Porter states, in the introduction to her reference book on the field: “For many students the idea of studying the history of public health provokes a very big yawn.”2 How, then, are we to avoid the anthropology of public health provoking the same bored reaction? How do we spare readers a discussion of the definition of the field of public health, its ideology, its procedures, and its politics, with the ultimate aim of proposing a general theory of it?
In his lecture “The birth of biopolitics,” which is in truth an inquiry into the origins of liberalism rather than the birth of biopolitics – as he himself recognizes in the summary he wrote at the end of that year’s course – Michel Foucault, who wanted to show how liberalism was constructed in opposition to the state, or at least on the basis of a limitation of its prerogatives, imagines his interlocutors reproaching him for doing “without a theory of the state,” and he responds: “Yes, I do, I want to, I must do without a theory of the state, as one can and must forgo an indigestible meal.”3 I think that if anyone ventured to construct one, a theory of public health would risk precisely resembling an indigestible meal: the list of its activities is to be sure a copious menu but hardly enticing, mingling as it does public hygiene, health education, epidemiological monitoring, the fight against infections, disease prevention, the protection of the environment, the control of medicine, care for people with disabilities, the inspection of working conditions, the administration of the medical and paramedical professions, and much more.
But Foucault’s ironic remark should not be misunderstood. Refusing to make a theory of state does not mean refusing to think the state, or more precisely the practices involved in its activity. What Foucault intends is rather to reject the idea that there can be “an essence of the state,” that it is possible to begin by asking the question of what is this “political universal” called the state. For, according to Foucault, the “state is nothing else but the mobile effect of a regime of multiple governmentalities,” and what merits study are its practices. Following a similar approach, what I propose in this course is to address public health not as a total social fact, to use Marcel Mauss’s famous formula, but via a range of partial social facts in which it is or has been engaged. The question I shall attempt to answer is not “What is public health?” but, rather, “What are the stakes – theoretical and epistemological, political and moral – that can be illuminated by problems deemed to be concerns of public health, and how do they contribute at the same time to constructing the field of public health?” More broadly, what can they contribute to the understanding of contemporary societies?
To begin at the beginning: the birth of public health. Birth here should not be understood as the origin of the discipline or field that is called public health. I undertook that genealogical enterprise in an earlier work going back to Roman, Inca, and even precolonial African societies.4 My aim now is rather to grasp the moment when, in specific circumstances, it emerged as a new reality in the social world, the moment when it was recognized. Here I return to a historical and sociological inquiry I undertook in the early 2000s, in Paris and the Seine-Saint-Denis department, into an epidemic undoubtedly singular in that it involved not a microbe but a heavy metal – lead. I shall focus more particularly on lead poisoning in children.5 This study will form a guiding thread through this series of lectures. As historian of medicine Elizabeth Fee writes, “childhood lead paint poisoning is … a classic public health problem, reaching beyond science into politics, economics, education and race.”6 To this list, I would readily add morality and ethics.
As a classic problem, then, childhood lead poisoning has been one of the most comprehensively studied public health issues for more than a century, and has given rise to an entire scientific industry, particularly in the United States. However, it is the little-known tale of its history in France that I intend to relate. I shall do so in a way that takes account of two aspects that are manifested in any health issue. On one side, there is its social construction by agents, human or nonhuman, physicians, and experts, as well as bioassays and statistical tests that led to the recognition of its existence, its seriousness, and its causes; on the other, there is its social production via structural phenomena woven from the combination of history, economics, law, population distribution and housing policies, that resulted in the risk to the lives of young children owing to the presence of lead in their environment. Because childhood lead poisoning is a genuinely paradigmatic case, I shall address it with a degree of detail that I feel is necessary in order to unpack its multiple dimensions.
In 1987, the main French pediatric journal, the Revue de pédiatrie, published a seven-page article entitled “L’intoxication par le plomb chez l’enfant. Un problème toujours actuel” [“Lead poisoning in children: A problem that has not gone away”].7 The author reports three clinical cases observed in a Paris hospital, the most tragic of which concerns “the child Sylla B., aged two years and three months, brought to the emergency room on 7 March 1986 in a deep coma.” His parents are described as being “of Malian origin.” A year earlier the child had been treated for iron-deficiency anemia, and it was noted then that his growth was severely retarded. In the days before his hospitalization he was suffering from “abdominal pain” and “uncontrollable vomiting.” All tests, including a lumbar puncture and toxicology screening, were normal, but the scanner showed a “diffuse cerebral edema,” for which antiviral treatment was started in the hypothesis that this was a case of herpes simplex encephalitis. The child, whose condition did not improve, was transferred to intensive care where, for a month, pediatricians were still unable to establish a diagnosis of his severely impaired consciousness. Finally, almost by chance, an abdominal X-ray revealed “micro-opacities in the rectum” that pointed to the possibility of lead ingestion. When questioned, the parents admitted that the child “consumes flakes of paint from a window in the apartment” in which the family was living. Analysis of lead blood levels indicated a level of 3,720 μg/l – more than ten times the maximum level deemed safe at that time. Despite treatment with chelating agents, which bind in the blood with heavy metals to form compounds that can be excreted in the urine, it was too late and the child died only a few hours after administration of the medication began. As if to justify the difficulty in establishing a diagnosis, Cohen observes: “Lead poisoning has been known for a long time. In France, it is rare in children.” It is true that a literature search conducted four years earlier found only ten cases in a quarter of a century in the French pediatric literature. In order to facilitate the recognition of lead poisoning in children, Cohen therefore formulates recommendations, stressing the need to remember the possibility of this pathology when presented with certain symptoms, since it is easily diagnosed from a simple blood test as long as the practitioner has it in mind. And Cohen even gives a list of “products containing lead that could cause poisoning in children,” in which he includes, haphazardly lumped in together, “newspapers and printed materials,” “enameled artisan pottery,” “smoke and ash from burning metal shelving,” “ballpoint pen casings, lead from red, yellow and orange colored pencils,” “metal packaging like that on toothpaste tubes,” “eye shadow from Africa or Asia.” Remarkably, “paint” arrives only at the bottom of the list with the note that, although banned “since the beginning of the century,” lead can still be found in paint in “pre-1940 dwellings.” This is how childhood lead poisoning was seen in 1987, as a rare condition caused by the ingestion of a variety of more or less out-of-the-way products, giving rise to serious neurological manifestations and seen in hospitals by pediatricians.
In 1999, an eighty-page report entitled Plomb dans l’environnement. Quels risques pour la santé? [Lead in the Environment: What are the Health Risks?] was published by the National Institute for Health and Medical Research (Inserm, Institut national de la santé et de la recherche médicale).8 The outcome of a “collective expert assessment,” it was put together by twelve specialists in epidemiology, biostatistics, economics, toxicology, neuropharmacology, biochemistry, genetics, pediatrics, occupational medicine, and public health. The authors focus particularly on the effects of lead on children’s cognitive functions, discussing around forty studies from all over the world that almost all show negative statistical correlation between the presence of lead in the blood, even at levels substantially lower than those then authorized, and the results of psychomotor tests, educational achievement, and behavior in class. In addition, meta-analyses, which gather and synthesize series of studies using similar methods, confirm that, even at very low levels, the presence of lead in the blood is associated with a reduction in children’s IQ. Furthermore, a survey of 3,445 children aged from 1 to 6 years old, extrapolated to the whole of the population on the basis of census data, estimates that in France 85,500 children in this age bracket present “saturnine impregnation” at levels considered to be toxic. As far as the origin of the contamination is concerned, the experts emphasize that “paint is considered to be the principal cause of childhood lead poisoning,” derived “largely from the ingestion of toxic flakes and dust.” In order to combat childhood lead poisoning, it is therefore recommended that children affected be identified and removed from their unhealthy environment. Two “strategies” are proposed, within the framework of a national program of “surveillance,” to identify contaminated children. The first, ecological, involves identifying a “risk environment,” such as dilapidated buildings, and then measuring the blood lead levels of those who live there; the second, clinical, is based on identifying “children at risk” when they come for a medical appointment, by asking parents how old their housing is. Depending on the strategy adopted, there are two possible interventions. The first, collective, consists in identifying all housing constructed before 1948 and in serious disrepair, and carrying out the necessary remedial work. The second, individualized, consists in identifying the children who have been contaminated among those exposed, and offering the families rehousing or the refurbishment of their apartment. The cost of the operation is between 1.7 and 3 billion euros if the issue is approached through substandard housing, and only between 0.4 and 0.8 billion if it is tackled on the basis of screening children, because in the latter case only the housing in which cases have been detected need to be dealt with. This is how childhood lead poisoning was viewed in 1999: a common problem, the consequence of exposure to paint in old housing, manifested in a statistical risk of cognitive disorders, which should be the focus of nationwide screening for both dilapidated housing and contaminated children, and requires urgent action to renovate the housing in question.
Only twelve years separate the hospital pediatrician’s article from the expert committee’s report, but what they discuss and the way they discuss it seem to belong to two entirely different worlds. From being a rare pathology of which a few cases have been observed, childhood lead poisoning has become what some are already calling a silent epidemic, presented as a national priority. In pediatrics, little Sylla’s illness was the subject of a tragic narrative that followed the protocol for presentation of clinical cases in medicine, from his hospitalization to his death, passing through the long diagnostic quest through progressive elimination of possible causes of impaired consciousness, with that which led to the child’s death finally being suggested and recognized too late. In the expert assessment, estimates of lead contamination in populations of children are derived from statistical studies which, on the one hand, reveal that even low levels of lead in the blood increase the probability of learning difficulties, even when the children concerned show no symptoms, and, on the other, establish on the basis of a random sample an estimate of the number of children contaminated in the country. A story on one side, figures on the other. A single case for the former, a population for the latter. An extremely serious disease for physicians, a quantified risk in the view of epidemiologists. A tragic anecdote in one case, a statistical calculation in the other. Pediatricians emphasized the importance of signs such as anemia, abdominal pain, and neurological disorder, and focused their questions to parents on tracking down the absorption of paint flakes. The experts look for absorption even in the absence of any discernible manifestation, and select children by asking parents how old their housing is. The former used biological and radiological examinations; the latter drew on maps of dilapidated old housing. The ones spoke of diagnosis, the other of strategies. Two procedures, two languages, two policies.
But two realities too. How are we to understand that childhood lead poisoning moved from an incidence of ten cases in twenty-five years (incidence measures new cases) to a prevalence of 85,500 cases a few years later (prevalence indicates the cases existing at a given moment)? There is of course a difference in the mode of calculation as incidence corresponds to cases actually observed (the ten children were seen in the hospital), whereas prevalence refers to estimated cases (the figure of 85,500 children is an extrapolation based on a sample). Does this spectacular rise in little over a decade indicate a sudden increase in exposure of children to lead, as has sometimes been observed at specific sites following a change in water supply or close to highly polluting factories? Were there new sources of contamination via air, water, or soil? Were there more disadvantaged families forced to live in dilapidated buildings whose internal fixtures were coated in old paint? Surely not. All the studies indicate on the contrary that, during that period, the banning of lead in gasoline had significantly reduced the presence of lead particulates in the air. Moreover, the old lead pipes that had been used in water storage and supply were being gradually replaced. And the most rundown housing in large cities was increasingly subject to demolition and development projects, easily organized because it was often in the city center where real estate prices were highest. And while there was no cause for triumphalism, the blood lead level of the general population was steadily falling.9 How then is this inflation in lead poisoning, from 10 to 85,500 cases in twelve years, to be explained? This remarkable development is in fact due to the existence of two totally different approaches. The passive approach, of receiving children usually suffering from serious manifestations in the hospital, was replaced by an active approach, based on identifying children who were exposed, precisely before they presented such a disturbing clinical picture. The former is the approach of clinical medicine, the latter that of public health. But it should be noted that public health derives here from two quite distinct processes, whose results converge: on the one hand, the discovery of unrecognized cases, and, on the other, the invention of new cases.
Indeed, a systematic effort was initially made to identify children who had been contaminated, through targeted surveys either of dilapidated housing (the ecological method) or in healthcare facilities (the clinical method). An example of the first is a 1985 study of fifty-two individuals living in two blocks where cases of lead poisoning had been diagnosed at the hospital: four of the seven children under the age of 6 had high blood lead levels, and core sampling of the walls revealed the presence of lead at disturbingly high levels. An illustration of the second method is a 1986 survey of eighty-two children who were seen at a mother and child clinic, whose parents were asked how old their housing was: 9 percent of these children presented severe lead poisoning.10 The process at work in these two studies can be described as one of discovery. Children who presented abnormally high blood lead levels, at a time when the threshold was fixed at 250 μg/l, had their contamination identified; some even presented clinical or radiological signs that had hitherto gone unnoticed. They were, as it were, sick without knowing it, or without being diagnosed by medicine, but were recognized as such by the study. The coordinated effort of a few health professionals thus made it possible to identify 1,500 new cases of symptomatic poisoning in five years in the Île-de-France region alone. This was 150 times the number of observations French pediatricians had reported over a quarter of a century, but still less than 2 percent of the estimate established by the expert committee a few years later. How is this persistent disparity to be accounted for?
What is at play in this saturnine inflation is an entirely different process, arising out of a redefinition of lead poisoning. In the late 1970s a study of the general population conducted in the state of Massachusetts revealed a negative statistical association between levels of lead observed in children’s teeth, on the one hand, and various cognitive functions, on the other. This was the start of a series of studies conducted in different countries which established that, even at very low levels of saturnine impregnation, when the children concerned did not present any symptom or sign of disease, there was a statistical risk of reduced IQ, poorer test performance, lower school results, and attention deficit observed by teachers.11 Pediatricians had already reduced the maximum permissible blood lead level from 350 to 250 μg/l a few years earlier. On the basis of these epidemiological studies, the internationally accepted threshold was then set at 100 μg/l. It is arithmetically self-evident that the lower the threshold, the higher the number of children whose blood lead level is considered excessive. The high figure given by the expert committee’s report is largely a consequence of the modification of this threshold. But this modification has considerable effects on the very definition of childhood lead poisoning. In pediatric manuals, it was described as a disease, with its digestive symptoms, neurological complications, radiological signs, its often-difficult diagnosis, its sometimes-gloomy prognosis, and its disputed treatment using chelating agents. In the epidemiological literature, it now appeared in the form of the probability of IQ points lost, higher average scores on mood evaluation scales, higher school absence rates, more frequently reported inappropriate behavior in class. Some, admittedly controversial, studies even identified a statistical association between lead poisoning in childhood and deviant acts in adolescence, which was explained in terms of aggressive tendencies that were alleged to result from damaged neuronal function; this led some in the United States to attribute the high level of delinquency and criminality observed among poor families to the presence of lead in their environment.12 But is this still the domain of pathology? Is the problem now not more social than medical? However that may be, a second process was emerging: the invention of a new reality that was no longer within the clinical field, but related rather to what is known as biostatistics, or, perhaps more correctly in this case, sociostatistics. No longer a disease diagnosed by pediatricians, but a problem identified by epidemiologists.
It is thus this twofold process of discovery, revealing hitherto unrecognized cases, and invention, redefining the nature of the problem itself, that explains the rise from ten to 85,500 affected by childhood lead poisoning in little over a decade. But these 85,500 children cited by the epidemiological approach substantially differ from the ten treated by medicine. They have in fact nothing in common in terms of pathological manifestations and prognosis. The most remarkable paradox of this development is that the more the number of children presenting with high blood lead levels rose, the more the number suffering from lead poisoning disease fell. While at the beginning of the twenty-first century the former numbered several tens of thousands, the latter had practically disappeared from hospitals. It would be tempting to say that pediatricians are now justified in asserting that childhood lead poisoning is a rare disease, at the very moment when experts state, on the contrary, that it is a priority issue. In fact, the development of a national monitoring system has made it possible both to identify many more children with high blood lead levels than before, and moreover much earlier, and in principle at least to remove them from their harmful environment. In short, and curiously, there are many more cases, and far fewer sick children. And it is now no longer children who are being treated, but housing. This dissociation between cases and patients demonstrates the work that has been done by public health. This work comprises both the extension of the domain of childhood lead poisoning, via the dual process of discovery and invention, and the management of the problem, through identification of children exposed and intervention in housing. A combined transformation, then, of knowledge and practices.
But for there to be work, there have to be workers. This is where the testimony of those involved is particularly interesting. In the collective memory of health professionals, everything began in August 1985 when the 2-year-old daughter of a Malian couple was admitted to a Paris hospital, this time with chronic anemia, retarded growth, and abdominal pain. Until that point the rare cases of childhood lead poisoning seen by pediatricians in France had been treated medically. Then, when children had recovered, they would return home with their parents, who would be advised not to let the child eat paint flakes, and would be seen a few months later to confirm that they continued to improve. No one seemed to be concerned that returning home implied more exposure to lead. The clinical case would be, as it were, closed without any social follow-up. Sometimes later appointments revealed renewed contamination, or new pathologies among brothers and sisters, without any preventative measures being taken, which could lead to grave consequences. But in the case of the little Malian girl, things turned out differently.
The young pediatrician, who had worked in sub-Saharan Africa, knew that iron-deficiency anemia can be caused by geophagy, a habit that involves ingesting soil and, by extension, mineral substances – a habit that is frequent in children from this part of the world. She therefore questioned the parents, who stated they had noticed that their little girl was eating paint flakes. To the surprise of the medical team, a blood lead-level test then confirmed the diagnosis of lead poisoning. But this time the pediatrician was not satisfied with medical treatment alone: convinced that dilapidated housing was the cause, she asked for a housing inspection. Unusually for hospital practice, the social worker asked for and obtained authorization to visit the parents, in the 11th arrondissement of Paris. Once there, she discovered a scene she would never have imagined in the heart of the capital: in the inner courtyard of a crumbling apartment complex, a first building where the walls were supported by shaky beams and the floor of the second story had partially collapsed, then a second, smaller building in an equally disturbing state of disrepair. Several African families were living in this squat, with young children among whom new cases of lead poisoning were discovered. The social worker contacted the district’s mother and child protection unit, asking them to take over aftercare of the children and rehousing the residents of this slum. However, the physician at the clinic was initially reluctant: she was unaware of this pathology and thought it was unlikely that housing played a role. But when she was told of other cases in a block close to the first, she became interested, though she thought that the source of contamination was probably the tap water. At the time, only lead poisoning from contaminated water was taught in medical schools.13 Even the teams at the City of Paris Health Laboratory who had been called in were circumspect: childhood lead poisoning did not form part of their body of knowledge, less so paint toxicity. The disease was seen as a curiosity, and lead in buildings had disappeared, it was thought, when lead white was banned. It would be several years before the seriousness of the problem and the role played by housing were recognized. But a link had been established between the worlds of the clinical medicine and public health, thanks to the intuition of a hospital pediatrician and the perseverance of a social worker.
Epidemiological studies were undertaken. Their methods were basic, but their results were conclusive. The two studies mentioned above, of the fifty-two members of families in the first squat identified and the eighty-two children seen at the mother and child clinic, correspond to what is called descriptive epidemiology. Other studies sought to identify the source of the lead poisoning, for example by comparing forty children seen at the mother and child clinic and living in unhealthy conditions with forty children seen for health checks who were deemed to represent the general child population. This study showed that only the former presented high blood lead levels, and it corresponds to what is designated as analytical epidemiology. But in both cases, this is a quite rudimentary form of epidemiology given that, at the same time in the United States and Australia, studies of several thousand subjects were being conducted using sophisticated tests and statistical regressions that made it possible to take into account each of the variables under consideration.
Be that as it may, it might be imagined, in view of the French studies, that the growing number of contaminated children being identified through efficient screening by childcare workers and social workers, and the increasingly evident link with old paint found in samples taken in housing, would be enough to prove that they were dealing with a worrying situation with a well-understood mechanism. There would be all the more reason to think so because there was then a substantial body of scientific literature in English, dating back to the early twentieth century but rapidly growing at that time, thanks to a renewed interest in childhood lead poisoning when it was shown that lead was toxic at levels much lower than had been imagined, and to the proliferation of preventative initiatives.14 Such was not the case.
There were indeed many levels of resistance, on the part of both municipal authorities and medical bodies. On one side, the City of Paris housing directorate faced a shortage of social housing in the capital. Rehousing families was especially difficult, first, because it was the public lessors who made the final decision, and, second, because these were immigrant families who were subject to diversity quotas – which no one dared to call ethno-racial diversity – that could not be exceeded. There was little interest in restoring the dilapidated housing, both because it was thought that refurbishing and repainting it was a matter for tenants or landlords, since it was private property, and because such an initiative would involve substantial budgets which, in a context of growing xenophobia, the city’s elected officials were not inclined to devote to foreigners, especially from African countries. In this situation, the municipal authorities attempted to downplay the importance of the problem and contest the reality of the source, in order to avoid Paris being associated with an image of unhealthiness, and their intervention arousing hostile reactions among their electorate. On the other side, the General Directorate of Health showed a mixture of incredulity, faced with this alleged epidemic of an unknown disease, and condescension with regard to the local practitioners who had sounded the alarm but had little scientific legitimacy. Lead poisoning, and the islands of dilapidated housing inhabited by povertystricken communities, seemed like a vestige of the nineteenth century, at a time when the health authorities were beginning to have to deal with emerging diseases that were of much greater concern to public opinion, primary among them AIDS. As for the High Committee on Public Health, the body responsible for analysis and recommendations, its environment committee was chaired by a toxicologist with links to the paint industry, who was the first listed author of an article asserting that cases of childhood lead poisoning were rare and observed only among children of African families, suggesting their way of life as the culprit. The denial of the toxicity of lead paint by the industry and its lobbyists might seem surprising, given that these paints were banned in 1948; four decades later, revealing the risk should not have affected this sector of the economy. In reality, however, the sale and use of lead-based paints continued long after the 1948 regulation, which only concerned professionals, at least until 1993 when they were completely and definitively banned. In other words, for forty-five years the recognized toxicity of these paints, which had led to them being banned for professional decorators, had not resulted in any measure governing non-professional use.
The combined efforts of a range of actors, from both the academic world and the voluntary sector, were therefore required to finally overcome these resistances. The Department of Public Health at the Bichat Faculty of Medicine worked in collaboration with the mother and child clinic to organize screening that resulted, in 1990, in the identification of the 1,500 cases cited above: the epidemic of lead poisoning was now indisputable. Members of two nongovernmental organizations, Médecins sans frontières (Doctors Without Borders) and Migrations santé (Migration and Health) took a research trip to the United States to study policies for combating childhood lead poisoning. On their return, also in 1990, they organized workshops at which researchers from North America spoke about their experience of prevention. The responsibility of paint was finally recognized.15 Over the subsequent period, a national program was introduced and, eight years later, the law against exclusion was passed, with one section devoted to combating childhood lead poisoning.
After decades of ignorance or negligence, and despite the resistance of public authorities and industry, it thus took only a few years for the rare disease responsible for serious and sometimes lethal neurological
