A review of The Causes of Cholera: Public Health in Post-Transition Vietnam, by Martha Lincoln.
In 2007, a series of anomalous cholera outbreaks occurred in Hanoi, Vietnam. The appearance of this “nineteenth century” disease confounded public health experts and citizens alike: cholera is not endemic to this region of the country, and its appearance contravened a national public health system that, despite critical resource constraints, has prided itself on controlling such infectious diseases.
In this dissertation, Martha Lincoln offers a meticulously researched and thoughtful account of this contemporary cholera episode. Through a deft combination of research methods and empirical materials, she examines contestations over the causes of the episode that occurred between 2007 and 2010. In doing so, she not only sheds light on broader social and political anxieties afflicting post-transition Vietnam, but also demonstrates how scientific knowledge is produced (or not produced) within shifting regimes of economic and moral value. This is what is most crucial about The Causes of Cholera. It is not merely an attempt to link causal explanations of disease to practices of social blame and exclusion. Certainly, the dissertation offers a considered, ethnographic study of the ways that cholera narratives and public health responses map onto existing social hierarchies in Vietnam. But it is also a critical historical account of public health and medical expertise in Vietnam: one that exposes the curious temporalities of disease episodes and situates them within what are always political currents – of microbes, humans, capital, and ideas. Taken together, this research offers an outstanding example of how to integrate a variety of methodologies and sources to make sense of disease.
Lincoln begins the analysis by presenting the “field” in which her research took place, explaining her attempts to assemble a research site in what is an internally complex city whose residents are stratified according to ambiguous and contested socioeconomic categories. Lincoln describes her efforts to locate and interview “officially” poor households in order to fill a gap in public accounts of cholera outbreaks. Along the way she provides a compelling deconstruction of the category “poor.” She shows how the metrics of poverty have shifted: from a socialist assessment of the poor as victims of economic exploitation, to a capitalist one that defines the poor in terms of inherent deficits that manifest in a lack of cash and commodities. Poverty has become a problem in need of technical solutions (economic development and state relief). What this means in practice, then, is that Hanoi residents aspire to the designation of “officially poor,” as a means access to scarce state resources.
Crucially, Lincoln goes beyond describing how the ambiguity of poverty posed challenges to defining her research site, to reflect on the ways in which the concept itself reflects a shifting a political and moral economy increasingly influenced by neoliberalism and increasingly blind to the subjective experiences of economically marginal citizens. As she states:
Strictly economic measurements of poverty fail to capture the social dimensions of poverty, overlooking how a household’s weak finances are interdigitated with environmental, occupational, educational, health related and other life circumstances. They fail to account for the other specific forms of misery, frustration, and vulnerability that are an outcome of forms of political and economic marginalization (p. 46).
Lincoln foregrounds these social aspects of poverty throughout the dissertation. In the first chapter, Lincoln suggests that an interpretive, anthropological approach to investigating cholera and its relationship to “poverty” is particularly well suited in the Vietnamese context, where quantitative data is sometimes unreliable, often contradictory, and frequently absent or inaccessible. This is particularly true in a context of globalized capitalism that privileges investment in certain demographic groups over others, and that engenders the invisibility of those bodies and subjects who may threaten economic losses. Here we gain an important glimpse into the regimes of value that structure scientific knowledge production in Vietnam, a critical theme that runs throughout this thesis. Yet, even despite the limitations of existing information, Lincoln makes impressive use of her associations with the Hanoi School of Public Health and her relations with active epidemiological researchers and health officials to integrate statistical and biomedical data in her analysis. Through it all she complicates these materials with rich ethnographic description. The scope of her methods, then, is ambitious and compelling.
In Chapter 2, Lincoln situates her analysis in the field of medical anthropology, particularly those focused on epidemics. She pauses over the historical associations of cholera with Asia, poverty, and underdevelopment – despite the disease’s synchronicity with trends having to do with modernity. This Chapter offers an important consideration of the temporalities of cholera; namely, how its contemporary resurgence brings up a host of historical memories having to with colonialism and violence, bringing them into uncomfortable association with current processes of liberalization that the state is at pains to celebrate. Lincoln shows how cholera becomes subject to retrospective and anticipatory discourses, which cast less developed nations back in an uncivilized past while at the same time placing them in the midst of hypermodern flows of bodies, goods, capital and bacteria.
This Chapter provides a fascinating discussion of the history of cholera and its shifting ontological status. Lincoln surveys religious and scientific explanations of the disease, which ultimately culminated in the tenuous contagionist model that informs epidemiological knowledge about the disease today. Lincoln, on the other hand, posits a “post-contagionist” paradigm that seeks a multifaceted understanding of its epidemiology. This paradigm reflects her far-reaching research methods that integrate historical, environmental, political-economic, sociocultural, and biomedical understandings of the disease. From this angle we can understand Lincoln’s approach to cholera as wholly anthropological, drawing on a long tradition in the anthropology of epidemics as a means to explore the social factors that not only influence disease epidemiology, but also the ways in which it is addressed. Lincoln’s account is also deeply historical, as she describes the trajectory of cholera in Vietnam from the pre-colonial to the colonial, socialist, and transition period. Throughout this discussion she shows how knowledge and management of the disease coincided with the political and economic considerations of governing authorities over the country’s history.
In Chapter 3, Lincoln brings her focus to the 2007-2010 cholera outbreaks, situating them as anomalous in a contemporary Vietnamese society characterized by modernization and cultural and economic globalization. She argues that the outbreaks prompted a series of models of causality and blame, which, though sparking controversy were also persuasive because they adhered to existing valuations of social order and belonging. What is more, Lincoln shows that inasmuch as they persisted in media and scientific arenas, these models obscured other risk factors and precluded other more effective responses to the disease.
This Chapter is a fascinating account of the proliferation of a dubious and unsubstantiated causation model for cholera, which linked outbreaks to the consumption of street food, dog meat and fish paste (the latter two food items entail preparation methods that would preclude the survival of the cholera agent). Lincoln discusses two reasons for the widespread (though not uncontested) public and scientific acceptance of this curious model. First, inasmuch as it located disease risks in street food stalls and the informal economy, the disease became associated with market vendors perceived as being unscrupulous, profit motivated, and self-indulgent individuals with disorderly eating habits. In a fascinating analysis, Lincoln shows how this causal explanation drew on larger aspirations to civilization in Vietnam, which include moral injunctions about the proper use of public space and the appropriate forms of conduct in the city. The author’s critical intervention here is to show the ways in which calls to civilization are entangled with a capitalist valuation of private property. She further shows how these aspirations play out in a health arena that privileges the private health of orderly middle class citizens over the disorderly masses of the commons.
The second reason for the persistence of this causal model had to do with the regimes of value that structure the production and release of scientific information. We find that the Vietnamese government drew on longstanding practices of informational control to stem the production and flow of information on this “embarrassing” disease, which threatened the export and tourist economy (p. 151). Further, non-knowledge about cholera outbreaks – in apparent contradistinction to other infectious diseases like SARS and avian flu – had to do with the historical and cultural particularities of this infection: namely its association with colonialism, poverty, and war. In other words, cholera’s association with anti-modernity set the conditions for the social construction of ignorance around it. Lincoln narrates this Chapter expertly, weaving media accounts, official propaganda, blog entries, and interview excerpts with thick descriptions of street stalls and the coordinated chaos of urban Hanoi.
Chapter 4 narrates the historical development of Vietnam’s health care system, highlighting how a longstanding tradition of medical pluralism in the country came to engender the selective accommodation of biomedical models of and treatments for disease. The Chapter contains an impressive catalog of the major figures and precepts behind the hierarchically ordered Northern and Southern medical traditions in the country, and it offers a concise, historically situated analysis of the ongoing and selective adoption of biomedicine within these healing systems. Throughout the analysis, Lincoln signals the moral meanings of health and hygiene in Vietnam and their inextricability from practices of state patronage and stewardship.
With this background set, Lincoln offers five different explanations for cholera to illustrate the everyday expression of medical pluralism in Vietnam. Lincoln situates these explanations alongside the historical treatment of cholera outbreaks in Vietnam, and then moves on to provide a more in-depth description of cholera and public health from the colonial period to the present day. This analysis reveals the determining effects of the disease’s historical association with conquest, colonization, and social upheaval associated with French “modern” impositions. It further shows the remarkable triumph of the post-colonial Democratic Republic of Vietnam leadership in stemming cholera and other infectious diseases in the midst of debilitating privation. Preventative, basic health services, sanitation, vaccination, and education campaigns acted alongside free health consultations, medicines and advice to achieve significant reductions in morbidity and mortality even in a period of intense resource shortages having to do with war and postwar reconstruction. At the same time, Lincoln is careful in her analysis, showing the health disparities between north and south during the wartime and postwar period.
Further, Lincoln shows how the links between health care and morality had important ideological implications in socialist Vietnam:
The commitment of the health care system of Socialist Republic of Vietnam to universal provision in the postwar period established health care as not only a bulwark against the public health effects of poverty, but as a moral right of every citizen (p. 258).
The author’s use of historical materials in Chapter 4 is captivating, and she shows the visceral links between cholera and notions of filth, famine, and exploitation during the colonial period. These affective associations, Lincoln argues, made the control of such afflictions in the post-colonial and post-war period particularly notable achievements of the socialist government. This historical context meant that the contemporary outbreaks posed a direct challenge to the Vietnamese state, which posited the country as a modern market economy.
The final chapter plumbs the question of agnotology and unpopular theories. This Chapter reads like a detective story, and Lincoln brings together a number of alternative explanations for the causes of cholera that she gleaned over the course of her research: the relationship between socioeconomic status and cholera; changes to the health sector in post-transition Vietnam; environmental causes. Here again Lincoln provides an impressive integration of statistical, anecdotal, biomedical, and media data to present a series of counter-narratives about cholera. Visible throughout the thesis, this multidisciplinary, mixed method approach is flawlessly executed in her thoughtful consideration of unpopular theories. For instance, on her discussion of the changes to health care in post-transition Vietnam is deeply historical and comparative, illustrating the ways in which Vietnam’s culturally specific form of socialism was particularly amenable to market reforms, and, ultimately, a process of medicalization that increasingly overlooks the needs, capacities, and suffering of the poor. Lincoln’s discussion of Hanoi’s water management system (or lack thereof) and its relationship to cholera integrates public health reports, statistical data, personal communication with health experts and thick description of agricultural practices and urban infrastructures.
Taken together, these accounts constitute an important political intervention, wherein Lincoln addresses the (partially purposeful) lack of information on the cholera episode with local explanations that, while steeped in empirical experiences and corroborated by other evidence, found little expression in the public sphere. Here Lincoln holds a number of experts accountable, posing questions (shared by other critics) about the sources and validity of the data that state and global health officials both presented and acted on at the time of the outbreaks. Indeed, Lincoln ends the chapter by bringing together interview and epidemiological data to suggest that, at a national level, there is considerable underreporting of cholera outbreaks among the poor.
The agnotology that Lincoln confronted throughout her ethnographic journey – in the halls and offices of health officials and nongovernmental workers, in the homes of the urban poor, in the ministries and archives, and in the institutions of learning and education – ultimately provoked her to consider “the grammar of the silences, absences, and pauses in conversations that were the constant counterpart to data and language” (p. 312). The reader is lucky that she did. In identifying the absences, in historicizing the silences, and in ethnographically situating the pauses in conversation, Lincoln has crafted stunning account of cholera in contemporary Vietnam. Bringing diverse methods and materials together, this dissertation is an important contribution to the history and anthropology of Vietnam, critical medical anthropology, and to the social studies of science.
Assistant Professor of Anthropology
University of New Hampshire
Research Fellow, BioProperty Program
University of Oxford
Ethnographic participant observation
Interviews with urban dwellers, health experts, policymakers, and epidemiologists in Hanoi
Government statistical documents, epidemiological studies, websites (blogs) and newspapers
City University of New York. 2013. 392 pp. Primary Advisor: Victoria Sanford.
Image: Photograph by Martha Lincoln.