Mental Health, Madness, and Psychiatry: a study guide and annotated bibliography

PDF HERE

General Introduction to the Study Guide

This reader is a study guide and a work book for those who are familiar with some ideas, images, or theories of madness or “mental illness” (and perhaps also psychiatry), but feel a lingering skepticism and doubt about what they mean. What are the first images that come to your mind when you think of the word “madness?” If it’s more familiar, go ahead and substitute the word “insanity” or “craziness” for “madness”. What about “mental health,” “mental disorders”, “chemical imbalances”, and “delusions”? Can you think of any other words that seem related to these, but are missing?

It is more important than ever that we all talk about what “mental health” is and how we relate to it. Let’s look at some basic facts. The number of people who are diagnosed with a mental disorder is steadily growing every year, especially when looked at globally. According to the World Health Organization (WHO), over 450 million adults have a diagnosable mental disorder worldwide. They also report that the number of suicides increased by 60% over the last 45 years. Mental disorders apparently account for “8.8% and 16.6% of the total burden of disease due to health conditions in low- and middle-income countries“. So, something must be done, right? We need “more mental health services”, as many activists and others are apt to say. But what does that mean? Medication? Yoga classes? More hospital beds? Free or affordable therapy?

Calling for “more mental health services” starts to look somewhat questionable when one looks at a number of other facts. In the 1970s, WHO found that those diagnosed with schizophrenia —often called the most debilitating of all mental disorders— fared better in developing countries than in the U.S. In a repeat of this study, they found the same results. A number of follow-up studies found that patients who had weaned themselves off the antipsychotics, which were supposed to “fix their brains” had fared much better than those who continued to take them. When faced with these facts, simply calling for “more mental health” starts to look unsatisfactory.

We also live in a time when patient-centered groups, and groups of those who identify with unusual experiences typically seen as “crazy” (hearing voices, extreme mood expressions, seeing things, having “strange beliefs”) organize themselves in social groups, study groups, support networks, and antipsychiatry activist groups. The mere existence of such groups already wears upon the more extreme claims made by psychiatry that, for instance, “psychotic” patients will flounder in their undertakings and live solitary lives trapped in a world of fantasy. This uneasy feeling deepens when we see that some such groups have publicly accused psychiatric treatment to be unhelpful, unnecessary, and, in some cases, torturous. Others have argued that psychiatry is operating as nothing more than a police force, incarcerating the unwanted or unsightly from the streets to sedate them or simply hold them in hospitals or asylums out of sight, and, for their less unsightly patients, providing simple drug fixes to the complex problems wrought by political and economic systems.

This is a very personal document for me. I have heard talk about this thing “madness” for as long as I can remember. Multiple members of my family have undergone interventions for their “madness.” Sometimes that meant taking pills; sometimes it meant getting taken away to a hospital or treatment center against their will; other times it meant going to those places willingly; but it always meant that the person diagnosed and the people closest to them had to rethink their life, their personality, and relationships. I too have undergone psychiatric intervention in my life, unwillingly and willingly. The effect these treatments have had on my life is immense. I have also had a number of bizarre or extreme experiences, which, up until recently, I had always been afraid or felt unqualified to talk about, in large part due to my feeling threatened and delegitimized in my experiences with psychiatry and clinical psychology.

This study guide is for those who feel similarly doubtful, uncertain, or uneasy about the way we talk about “madness” or “mental disorders.” It’s for those who have been diagnosed, hospitalized, and drugged and feel like their psychiatrist doesn’t know best, but they aren’t sure how to express that; it’s for those who have seen a family member or friend “treated” for mental illness and were confused or dissatisfied by the process; it’s for those who have never had interface with psychiatry, but feel like madness or mental illness has touched them, and they don’t know what to make of that feeling; it’s also for those who feel like they know enough about mental health, and what to do about it. They won’t find any easy answers here. This guide is not structured so that the reader will walk away with a cohesive ideology or belief; it was made to initiate and facilitate a process of questioning and doubt, and hopefully of discovery.

My hope is that people use this guide either for self study or for aiding in the formation of critical mental health reading groups or film groups. The reader is organized into 10 units. One could either decide to study a little bit from each unit, focus entirely on a unit of particular importance to you or your group, or do the entire thing. At the beginning of each unit, you will find a summary of the themes and questions explored, and, at the end, a couple questions you are invited to use as a note-taking device. Most will have a primary text to introduce the themes and ideas in a general way. This will be followed by a few optional texts, podcast episodes, films, or other media that go deeper into the themes. There will be hyperlinks for all the texts, podcasts, and more on the pdf (with the exception of the films, which you will have to find on your own). As a rule, the main text and materials will be shorter and more like a survey of the problem/question of that unit. The optional texts will either be primary documents or somewhat denser secondary texts illuminating one or two aspect of the general theme. In many cases, the primary texts are interviews or surveys of a theme.

The units and the optional texts within them are merely suggestions, and, if excluding something, mixing-and-matching, skipping units, or changing the order would help facilitate your understanding, please do it. The LISTEN, SEE and WATCH sections offer podcast, song, art, and film recommendations for opportunities for learners of different types to use what they feel most comfortable with to approach the questions at hand. A general warning for what is to come: we have not excluded texts which discuss many unpleasant and challenging topics including child abuse, suicide, self-harming, and rape. Please use your own discretion as you continue.

Every section will feature at least one text or work by a person who feels they have passed through/live with “madness” or has had a psychiatric label forced upon them. This is necessarily a difficult category to pin down, as you shall see. I let the writers themselves define what it means to them to be mad, and did not use any diagnostic system or nosological schema (classification system for defining and organizing diseases) to decide who warranted inclusion or not. I see such people as primary authors and thinkers on the pathway to understanding and not as case studies for one to examine at a distance (as if there are the works by the “normal” authors about madness and then ones by crazy people for one to check their ideas against).

I’ve designed the guide in three parts with a particular narrative structure in mind, even though the parts as I’ve conceived them will blur into one-another. The first part is largely negative, in that it is meant to challenge dominant beliefs about mental health. Sometimes this is done through critique, other times it is done through illuminating alternatives to the normal, accepted ideas. The world seems over-saturated with ideas and facts about mental health. This “ever more facts” model serves above all to bury the essential problems related to madness under a mountain of detail. So first, this guide will challenge beliefs already held by most people in American society, and since most of these beliefs come from psychiatry (directly or indirectly), the first half will largely be about psychiatry and the process of labeling and treating someone as “mad” (roughly units 1-5); the second cluster of units (units 6-7) will then offer up unique perspectives on “madness,” will outline some reform and harm reduction efforts of the past and present within psychiatry, and potential alternatives to our practices of “mental health;” the last part (units 8-10), will focus on the experiences of those who have experienced something they’ve called madness, and will look outwards, to try to draw connections and remove the question of madness from its imposed isolation in medicine and draw new lessons from it. The entire guide is permeated through and through with the voices and experiences of the “mad”. Through their voices, I hope that readers will experience a guided, soft, break down, because it is only by breaking down that we can open up space to hear those voices that are desperately calling out for us to listen.

PDF HERE

Below, I will include books and texts that were either too long, or cost money so that they didn’t make it into the final copy of the bibliography. I will continue to add to this list. The “units” correspond to those in the bibliography, to make it easier for anyone who wanted to follow up on a particular idea or interest.

Suggested Further Reading

Unit 1
  1. Escher, Sandra; Hage, Patsy; and Romme, Marius, “VOICE HEARING: A QUESTIONNAIRE”, http://www.hearingvoices.org.nz/attachments/article/59/Maastricht_Interview_for_voice_hearers.pdf
  2. Leudar, Ivan and Thomas, Phillip, Voices of Reason, Voices of Insanity: Studies of Verbal Hallucinations, London, Routledge, June 22, 2000.
  3. Luhrmann, T. M.; Padmavati, R.; H. Tharoor and A. Osei “Differences in voice-hearing experiences of people with psychosis in the USA, India and Ghana: interview-based study”, Luhrmann.net, April 3 2014, http://luhrmann.net/wp-content/uploads/2012/02/bjp-hearing-voices.pdf
  4. Morin, Roc. “Learning to Live With the Voices in Your Head”, The Atlantic, Nov 5, 2014, https://www.theatlantic.com/health/archive/2014/11/learning-to-live-with-the-voices-in-your-head/382096/
  5. Scull, Andrew. Madness in Civilization: a Cultural History of Insanity, from the Bible to Freud, from the Madhouse to Modern Medicine. Princeton University Press, 2015.
  6. Thiher, Allen. Revels in Madness: Insanity in Medicine and Literature. University of Michigan Press, 1999.
Unit 2
  1. Conrad, Peter. Medicalization of Society: On the Transformation of Human Conditions Into Treatable Disorders. Johns Hopkins University Press, 2007.
  2. Greenberg, Gary. The Book of Woe: the DSM and the Unmaking of Psychiatry. Plume, 2014.

Unit 3
  1. Littlewood, Roland, and Maurice Lipsedge. Aliens and Alienists: Ethnic Minorities and Psychiatry. Routledge, 2014.
  2. Metzl, Jonathan. The Protest Psychosis: How Schizophrenia Became a Black Disease. Beacon, 2011.
  3. Warren, Carol A. B. Madwives: Schizophrenic Women in the 1950s. Rutgers University Press, 1991.
Unit 4
  1. Biehl João. Vita: Life in a Zone of Social Abandonment. Univ. of California Press, 2008.
  2. Foucault, Michel. History of Madness. Edited by Jean Khalfa. Translated by Jonathan Paul Murphy, Routledge, 2009.
  3. Foucault, Michel, Psychiatric Power: Lectures at the Collège de France, 1973–1974, Picador; June 24, 2008. Retrieved from: http://rebels-library.org/files/psych_power.pdf
  4. Whitaker, Robert. Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill. Basic Books, 2010.
Unit 5
  1. Gilman, Sander L. Disease and Representation: Images of Illness from Madness to AIDS. Cornell University Press, 1994.
  2. Mills, China. Decolonizing Global Mental Health: the Psychiatrization of the Majority World. Routledge, 2014.
  3. Mirowsky, John, “Subjective Boundaries and Combinations in Psychiatric Diagnoses”, The Journal of Mind and Behavior, Summer and Autumn 1990, Volume 11, Numbers 3 and 4, http://www.brown.uk.com/brownlibrary/MIROWSKY.htm
Unit 6
  1. Cooper, David. Psychiatry and Anti-Psychiatry. Routledge, 2013.

  2. Hornstein, Gail. To Redeem One Person Is to Redeem the World: the Life of Frieda Fromm-Reichmann. Other Press, 2005.
  3. Laing, R. D. The Divided Self: an Existential Study in Sanity and Madness. Penguin Books, 1969.

Unit 7
  1. Romme, Marrius A. J., et al., editors. Living with Voices: 50 Stories of Recovery. PCCS Books in Association with Birmingham City University, 2013.
Unit 8
  1. Cvetkovich, Ann. Depression: a Public Feeling. Duke University Press, 2012.
  2. Frame, Janet. Faces in the Water. Women’s Press, 2000.
  3. Gotkin, Janet, and Paul Gotkin. Too Much Anger, Too Many Tears: a Personal Triumph over Psychiatry. HarperPerennial, 1992.
Unit 9
  1. Burstow, Bonnie, et al., editors. Psychiatry Disrupted. Theorizing Resistance and Crafting the (r)Evolution. McGill-Queen’s University Press, 2014.
  2. Hall, Will. Outside Mental Health: Voices and Visions of Madness. Madness Radio, 2016.
  3. LeFrançois, Brenda, et al., editors. Mad Matters: A Critical Reader in Canadian Mad Studies. Brown Bear Press, 2013.
  4. Shimrat, Irit. Call Me Crazy: Stories from the Mad Movement. Press Gang Publishers, 1997.

Unit 10
  1. Deleuze, Gilles, and Félix Guattari. Anti-Oedipus: Capitalism and Schizophrenia. University of Minnesota Press, 2008.
  2. Sass, Louis. Madness and Modernism: Insanity in the Light of Modern Art, Literature, and Thought. Harvard University Press, 1994.

*Image is of Agnes Richter’s jacket in the Hans Prinzhorn Collection in Heidelberg of art works created by past and present psychiatric patients.

The Fragrance of Citizenship // The Acridity of Others: Towards Health Skepticism—Bellum Primer Two

Take a journey with us to the upscale night-life district in Uptown, Minneapolis. Look at the glittering golden tinsel above the vulgar racist depictions of Chinese-Mexican men on Chino-Latino; see the stupidly bright light-up guitar above the mall announcing the existence of a now-closed “Famous Dave’s BBQ;” sit on a bench on Hennepin Avenue and ask yourself what the appeal of a dance night in a renovated civic building called “The Mansion” that would host the hateful cowboy cop David Clarke could possibly be to your demographic.

Go down just a few blocks to Lyndale Avenue and enter the Uptown VFW post 246, once the nightly home of a scene familiar to many white Midwesterners: older veterans getting trashed and singing shit songs from the 60s and a mixed younger crowd appreciative of the ironic lifestyle and cheap beer getting trashed singing awful 90s songs.

The first thing you see is some 20-something laughing uncontrollably, when, after one powerful inhale, he sneezes half onto his hand, half onto the glasses on the table. His friend, taken entirely by surprise, knocks his table’s half pitcher of Bud Light Lime all over the floor and table. The bartender takes a break from squeezing old lemon slices with her unwashed hands and comes over now, noticeably peeved, takes the rag, which she’s folded in half so nobody can see that she used it earlier to wipe up a small nosebleed, and begins furiously wiping one part of the table, leaving some sections totally soaked. The most adventurous —no worries, still heterosexual!— and drunkest couple in the group emerge from the bathroom after having just fucked, and, wiping the little bit of cum and excess fluid from their hands onto the inside part of their shirts, see the mess their comrades have created and rush with all haste to buy more alcoholic fluid for the group to guzzle in solidarity. An older man stops scratching his staph infection under his leather jacket and saunters by with a crooked smile, patting all the funny kids on the back, telling them he used to be just as clumsy as they were. They all laugh and grab a handful of nuts along with the small flecks of feces on top of them, which, microbially speaking, comes out to about 40 E. coli per gram, 11,500 enterobacteria, and 30,000 coliforms, giving the whole raucous crew a raucous case of diarrhea the next morning.

“But wait!” You think, “Surely our health administration is aware of these probable crimes and is sending out some grumpy nerd with a clipboard to investigate these potential atrocities!” But then the thought comes to you: “No! It is in fact you, the sinister authors, who are spinning tales and riling me up against this fine establishment to extract exactly this reaction! Why do you hate bartenders and veterans?” True, the story is fictional, but it could happen, anywhere, at any time, given the right people (or perhaps the wrong ones) and enough whisky shots.

And yet, the health department does not conduct regular investigations to check for E. coli infested bar nuts, nor for chlamydia trachomatis bacteria in semen wiped on the fabric of booths, nor for staphylococcus bacteria on the tops of tables. The City of Minneapolis did however commission an unannounced investigation on 17 “adult entertainment clubs” in Minneapolis called the “Environmental Health Assessment in City-licensed Adult Entertainment Establishments Testing for sources of contagion” following “Complaints from public and concern from City inspectors.” In addition to strip clubs, three well-known gay bars and clubs were investigated as well. This was quickly followed up by a second “worker-centered” report by the University of Minnesota’s Urban Research and Outreach-Engagement Center, commissioned and funded by the Health Department, which involved interviewing twenty-four workers on conditions and practices within the clubs. As a result of the first report, the city will soon be passing more strict regulations on the clubs and workers.


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Figure 1: Screenshot of a slide from the city’s PowerPoint on the raids. Look, a stain with an envelope next to it! This Sherlock doesn’t mess around!    http://www.ci.minneapolis.mn.us/www/groups/public/@clerk/documents/webcontent/wcmsp-195573.pdf

The narrative produced by the Health Department is fragile, and, examined even superficially, appears as a humorous exercise in hyperbole and panic. Three consecutive panels on a PowerPoint produced by the city of Minneapolis are obviously leading for any reader paying attention. The first panel, called “Epidemiological Risk,” defines “OPIM”s or “Other Potentially Infectious Material” as “fluids [including] semen and vaginal secretions […] in which disease could be present and Come into contact with an entry point (hangnail, broken skin, eyes, lips, mucous membranes, etc.);” the second panel, “Disease Concerns,” simply lists unrelated infectious diseases like Zika, Ebola, and HIV; and the third, “Testing for semen: field sampling procedures” informs the reader that investigators used black lights and blue lights with orange goggles to search for semen in the adult establishments.

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Figure 2: A black light, a glove, a bottle, another envelope. Watch out! There’s some very serious science stuff going on here!

Not once do they say that they have ever found HIV infected semen in any of the strip clubs, not to mention Zika or Ebola, but they let the reader draw the conclusion that it could be there. Take a moment to consider all the hypotheticals the Health Department required to retroactively convince the public that these raids and investigations were necessary: semen potentially could be infectious; such potentially infectious fluid could contain HIV, Zika, or (gasp!) Ebola; strip clubs could have infectious semen and be a source of contagion. We can play this game, too: blood is a OPIM and could be infectious; infectious blood could contain HIV or Ebola; members of the Health Department could have nosebleeds or small cuts on their fingers and could be a source of HIV or Ebola throughout the city. Therefore, a raid is necessary.

As entertaining as that would be, we are in no way advocating for more raids or investigations, but rather in order to question why we do it in the first place when no credible risk exists. But we can’t stop there. We need to ask: what do we even mean by “credible risk” when it comes to health and sanitation? And to go further: what is “hygiene?” or “sanitation?” or “health” for that matter? It should be unsettling that we tacitly accept the authority of institutional powers (the Health Department, the CDC, local health commissions, public health administrations, or the police acting for them) to conduct operations in their names without being able to define them. That will be our task here: to try to figure out what it is we are talking about when we use these hygiene-related terms and how they function in the world.

We do not intend to offer here a history of the Health Department, the CDC in the United States, nor of global health or epidemiological governing agencies. What we can do, however, is offer tools for understanding the ways in which various governing agents (like the Health Department, but also the police, or even civilians) make use of the concepts of “hygiene” and “health.” In doing so, we can begin to parse out not what they mean abstractly —as if there could be a universal standard for “clean”— but functionally.

a) Making the other visible: an outline of hygienic technologies of power

It is in protecting extreme indigence from the necessities to which it would otherwise be compelled to submit, and in enforcing police regulations – important alike to the health, the manners, and the morals of the lower orders – that the power of government is most beneficially exerted. Like the laws of quarantine or of public cleanliness, such regulations are necessary to enforce those salutary rules, which…indigence [is] too often unwilling to obey.

—Dr L. C. A. Motard, Essay on General Hygiene

If we were able to go back in time in our supposedly advanced Western Civilization and observe people eating at the dinner table in, say, medieval Europe or colonial America, we would likely find much to be disgusted by. The peasants and poor people especially would likely strike most of us as filthy. Depending on the time and place, former citizens of the empires, kingdoms, and colonies could be seen blowing their noses into their tablecloths, killing animals in the dining room, eating with their unwashed hands, or farting and pissing quite openly. Some of you readers would perhaps not be offended by one or all of these scenarios, but many of you probably would by at least one.

Does that mean that blowing your nose into a handkerchief, killing animals in a factory, eating with a fork, and excusing yourself to fart and pee are necessarily more hygienic and clean? There are too many other factors to consider for us to make blanket statements, but what we will say is that the older, more “filthy,” habits can be done in such a way that they are not the direct cause of illness or the spread of contagion (if that is our basis for something being “unclean”); and also that one can eat with a fork covered in infectious material, or get sick from eating bad meat killed in a clean location, or get ill from holding gas in for too long. The latter set of practices are not, abstractly considered, objectively more “sanitary” or “healthy” than the former.

The main difference between these sets of practices is perceptual: when we say that eating with your hands is “filthy,” it is more so because we believe that by not eating with our hands, we have advanced into a cleaner, and more civilized, position (this is a selective logic: we eat sandwiches and cookies with our hands). In a general sense, when someone uses the word “hygienic” or “clean,” they are implicitly or explicitly establishing a binary: hygienic vs unhygienic, clean vs dirty. One is supposed to feel shame if they fart in front of others, and thus most do not do so in public. Some may even call it “dirty” or “unhygienic,” but what do these words mean when farting does not put one at risk of contracting or spreading an illness? At the same time, one is not ashamed to put their fingers in an uncleaned bowling ball and then eat chicken wings when those same fingers are potentially covered with infectious bacteria. Some may call this practice “unhygienic,” but many would do it without thinking twice. Farting is an especially interesting example, as it went from being seen —in France and Germany, at least— as unhygienic not to fart, because doing so could upset one’s stomach, to eventually being seen as “dirty.” In everyday usage, “sanitary,” “hygienic,” “clean,” and “healthy” have a moral meaning, and are not necessarily correlated to objective factors like the quantity of infectious bacteria, since “[m]otivation for social consideration exists long before motivation from scientific insight.” Those who use these terms in this moral way do so in order to distinguish themselves from those below them who do not act as they do.

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Figure 3: A 19th century ad for Pear’s Soap depicting a dark-skinned native discovering civilization in the form of soap.

This operation is what Norbert Elias referred to as “the civilizing process.” According to Elias, the higher classes within civilization need to socially and aesthetically distinguish themselves from the lower classes, or from other, outmoded social classes, as when the bourgeoisie distinguished themselves from the withering aristocracy. The term “civilize” —along with “cultivate,” “police,” and “culture”— was a part of a lexicon of technical terms used to govern and regulate the appropriate behavior of the citizens of states. As Mark Neocleous notes in his Fabrication of Social Order, “proper” behavior is etymologically derived from the same root as both “propriety” and “property.” These then form a constellation of symbols in which what one must morally or legally do is intimately connected with what is seen as the cleanest, most hygienic thing to do, which is connected to what one has: “[t]hat property is intimately connected to cleanliness is illustrated by the converse assumption that poverty is intimately connected to dirt and disease.” In Elias’ account, once the higher class has adopted a new practice to distinguish itself from the peasants, the practice slowly drifts downward until it becomes standard morality. Over time, these practices become so essential to the fabric of social life that adults adopt a variety of “naturalist” explanations:

Much of what we call ‘morality’ or ‘moral’ reasons has the same function as ‘hygiene’ or ‘hygienic’ reasons: to condition children to a certain social standard. Molding by such means aims at making socially desirable behavior become automatic, a matter of self-control, causing it to appear in the consciousness of the individual as a result of his own free will, and in the interests of his own health or human dignity.

One task, then, is to find out when agents are using the neutral “hygienic” and “healthy” to make moral or social claims about the world.

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Figure 4: A 2011 ad for Nivea with highly racialized overtones depicting a black man “re-civilizing” himself through the use of cosmetic products.

Yet, even when there are supposedly objective factors like a quantity of harmful bacteria or the presence of a virus, these social forms of affect control can be very difficult to isolate and consider alone. Due to their complexity, these “unhygienic” practices become coded in a variety of ways: Elias writes of how the desire to sniff something stinky can be coded as a “remnant of childhood;” certain behaviors can be coded in national discourses, like eating with different utensils (e.g. chopsticks in Japan, fork in the U.S.) versus eating with your hands (as in Ethiopia); others can be coded in religious, political, or racial vernaculars. The most drastic shift of the civilizing process described by Elias occurs during the colonial period. At this point, a fold was introduced into the concept of “civilized,” and, with it, “hygienic” and “healthy:” affluent Europeans needed to make sure that the distinction between the civilized people and savages was clear, while also distinguishing themselves from the less civilized among them. The practices we talked about above (like using a fork) become a kind of “social technology” for denying humanity to those who are denied access to them or who live differently, both outside and inside the imagined limits of civilization.

One of the principal forms of ordering the regimentation between different groups takes place in the field of representations of health and cleanliness. It consists in being able to say: “you are dirty” or “you are (potentially) contagious.” Such images are not hard to call to mind: sex workers contagious with STIs; madmen smearing shit across walls; the poor living in rat-infested, wet hovels; the savage impotently performing magic to stop the spread of disease; or, if you remember back just a few decades, gay men with AIDS acting recklessly. There may, in fact, in individual cases, exist a disease or a practice that facilitates the spread of illness, but that is not what is at stake. What matters here is that bacterial or viral cleanliness is thoroughly mixed up with social cleanliness, an ideal that cannot be made equivalent to a particular state of health or sickness, but is nevertheless bound up tightly with it. Mark Neocleous argues that physiological and social health coalesce into the symbol of dirt:

As matter out of place, dirt is essentially disorder[…] Indeed, dirt is an offense against order, evidence of imperfection and a constant reminder of change and decay. Eliminating it is thus an attempt to organize and stabilize the environment. As crime came to be one of the strongest reminders of disorder, so it came to be thought of in terms of dirt and garbage.

There is environmental dirt, which must be cleared, but also human dirt, which must likewise be cleaned up. This connection is illuminated in the term “mental hygiene,” popular in the 20th century among social hygienists. There is no possible way for one to literally have a “dirty” or “unhygienic” mental state or brain, if by that we mean that it is a source of contagion (or stench for the proponents of the miasmatic theory), which indicates that the word “hygiene” has the capacity to mean only “correct” and “right,” distinct from any association with infectious material. This does not mean that hygiene is just being used as a metaphor in this case. Hygiene cannot be considered separately from the ways in which we represent otherness, nor from the practices we participate in to separate the morally good from the corrupt.

This relation was perhaps most clear in the early to late 19th century, before the spread of Pasteur’s theories and the subsequent rise of bacteriology, when the hygienist movement was at its peak in Europe and the UK. The hygienists were holistic health reformers with an orientation towards the whole environment, and the lifestyles of the individuals who lived in them. They believed in the “miasmatic” theory of disease, which presupposed that disease was spread in a gaseous form, and was thus identifiable by its smell. That fetid odor in the nostrils is the disease entering to infect you. In The Foul and the Fragrant: Odor and the French Imagination, Alain Corbin tells us that, in this stench-based model, “[i]nvasion by disease could be diagnosed both by the loss of a healthy odor or by the appearance of a morbid one.” The various figures of the lower classes became so deeply associated with dangerous smells that, in French, the vulgar word for “prostitute” is “putain,” which derives from the word for “stinky.” One’s particular smell, in this paradigm, was a result of environment, food, and the air they breathed. With this circular logic, the hygienists could bolster the public’s beliefs about the lifestyles of the homosexual, distributing literature that he smells of cum and musk, because of the secret, filthy private life he led; that the ragpicker smelled rotten because of their proximity to trash; and that the African smells “differently […] because he is fond of putrid foods.” These theories both bolstered the common citizen and administrators’ beliefs that they could recognize these outsiders via olfactory sense alone, and also instilled a deep terror, since breathing these airs could infect or even kill you.

The hygienists, though only briefly given the kind of power they sought, nevertheless contributed widely to social perceptions of otherness by granting scientific legitimacy to the “civilized” prejudices about the poor, sex workers, the insane, homosexuals, or the colonized. They also, in various contexts, gained access to administrative authority over towns and cities where they were able to enact their reforms. These reforms were geared toward eradicating, or at least controlling, the “contagion environment.” The hospital, the prison, and the ship became the laboratories of hygienic reform and sanitary regulations due to their semi-enclosed nature and their reputation for being spaces of contagion. The problem was that, in the towns and cities, this threat could arise from anywhere at all. Overcoming that transition was no easy matter. First, a successful sanitary system requires near constant vigilance and surveillance to make sure there are no deviants contributing to the spread of disease or filth. In the 19th century, this usually took the form of an administrative agent or welfare agent visiting spaces and noting the conditions on a regular basis. This was much easier in the hospital, for example, where authorities would constantly be present. Besides educating the public, the terrifying information that was spread about the disease or potential disease in question and its supposed proximity to “problem people” probably served the additional functions of encouraging citizens to perform additional surveillance on their neighbors, to report prostitutes, to exclude mad family members, and to fear outsiders.

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Figure 5: “‘The kind of ‘assisted emigrant’ we can not afford to admit.’ So reads the caption to this 1883 Puck drawing, which shows members of the New York Board of Health wielding a bottle of carbolic acid, a disinfectant, in their attempts to keep cholera at bay.” Image and text found at: http://www.pbs.org/wgbh/nova/body/short-history-of-quarantine.html

The aspirations of the hygienists lay mainly in city planning. The threats from contagion could come from anywhere, so the hygienists wanted control over as much infrastructure as possible in order to prove that, under their watchful eyes, illness could be slowed or halted, and disorders decreased. They wanted to prevent overcrowding by constructing open and clear passageways, they wanted to drain bogs and swamps to clear the air of the putrid stenches, they wanted vents in every building and drains on every street. Their plan was to deodorize the world, and rid it of disease, but also of sloth and laziness, of which stench and dirt were signs, and so, on the whole, to incrementally increase the orderliness of the cities. Only some were granted the power to design infrastructure and reform public health policy in domestic cities, including perhaps most influentially Edwin Chadwick in London, but their recommendations and ideas played a role in the further development of public health policy and of infrastructure and architecture, particularly of factories and other workplaces.

White Man Burden is to teach cleanliness described in a Pears Soap advertisement 1890s
Figure 6: “The White Man’s Burden” ad from Pear’s Soap promises again to bring civilization to the uncivilized through soap and cleaning.

We haven’t yet mentioned the colonies, that other ground for experimentation in medical policing. The colonies of Europe and America, populated as they were by people thought of as subhuman, were ripe territories for testing out new practices and theories in the administration of hygiene and health on large groups of people. The colonists were able to take risks they couldn’t take on full citizens of their national states. Further, because the very bodies of the colonized were considered unruly, disorderly, and unhygienic, hygienic administration in the colonies was not an accidental or extra feature of colonial rule, but a primary form of governing. It is in the colonies, when the civilizing process is conceived as internally complete and externally expanding, where the boundaries of citizenship are decided through “national borders, immigration restriction lines, quarantine lines, racial cordons sanitaires and the segregative ambitions of a grafted eugenics and public health.” In other words, lines dividing the “unhygienic” from the “hygienic” were the very same borders dividing the citizen from the savage:

public health and hygiene offered not just metaphors and rhetoric (or the ‘pretexts’ as Proctor writes of the Nazi enclosures of Jews in Warsaw) for cleansing and purifying, but were the actual modes and tools of management for colonialism, nationalism, and in the interwar period, racial hygiene and eugenics: these were all part of the project and the imperative of public health.

It is in the colony also that the deep connection between hygienic and racial discourses is most clearly illuminated. As Alison Bashford writes, practices of segregation are “both hygienic – that is, […] part of public health – and racial – […] part of the systems and cultures of race management, including[…] the management of whiteness.”

It would be easy to say that once Pasteur “discovered” the microbe, science and hygiene corrected itself from the hygienist diversion, but that is simply not the case. The Pasteurians emerged out from the very same social milieu, participated in projects with the hygienists, and saw themselves as carrying their legacy forward. More importantly, the reorientation towards the microbe did not eradicate social, racial, sexual, or other preconceptions from science, nor did it put it on a path progressing away from them toward “pure science.” The same figures who formally were feared for their “miasmic threat” (the sex worker, the poor, the homosexual, or the African, among others) were now feared because of their “potential bacterial threat.”

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Figure 7: How much has changed? This 2017 Dove ad for shampoo shows a black woman taking off a brown shirt and revealing white skin and a white shirt.

The mechanism of social differentiation via hygienic practice described above as the “civilizing process” could be seen as a form of segregationist stigma designed to separate the “potentially contagious” from the “healthy.” The target of this operation is the dangerous individual or group, e.g. the prostitutes, the mad, or the homosexuals. In Pasteur’s bacterial paradigm, the stigma does not disappear. Instead, it is situated in the discourse in such a way that it appears as accidental. No longer is the individual the target, now it is the disease entity, or the bacteria itself, in question. It is not a group that acts and makes others sick, but a bacterial agent. Individuals are only to be considered as members of a population, which, depending on a number of factors at times including location, status, ethnicity, familial status, gender, and medical history, are at variable levels of contagion risk. The individual is still visible as a subject, but only as a peripheral figure mediating the isolated visibility of the microorganism. If we think about the way AIDS was tracked by medical authorities along with the way it affected queer life in the US, it’s clear that these two forms of hygiene/public health policing operate in tandem, and that there was no moment in which one replaced the other. AIDS was certainly tracked as a disease agent, with consideration given to its prevalence in various locations, how it spread, and its rate of contagion, but individuals marked as AIDS carriers were simultaneously subjected to exclusions and social stigma. The public health authorities, in this case operating publicly under the data-driven model, were able to claim that any stigma experienced by the individual is merely accidental to their practice. This logic is hard to accept when one considers that AIDS was originally called “GRID,” or “Gay Related Immune Deficiency.”

This shift of focus away from the diseased and onto the disease resembles what Didier Fassin sees as the shifts in perception between the clinical model of health and the public health model. In his “Public Health as Culture,” he defines public health as “the cultural activity through which a biological fact […] is constructed as a social fact, an infantile epidemic with its figures and images, its economic and ethnic characteristics, its etiological models and its practical answers.” There, he describes a situation in which cases of lead poisoning in 1980s France were transferred as an issue affecting individuals and their bodies to being an epidemiological, public health issue affecting populations. It was “now an issue of population, risk, thresholds, collective measures instead of individuals, symptoms, biology and medicines.” With this new object in mind, those claiming ownership over the illness no longer apply the tools of the doctor for examining the body, like the x-ray, but the tools of the public health expert for screening populations and measuring risks, like surveys on buildings, calculations of poisoning rates, and comparative studies.

This data collection is part of a process in which the public health expert naturalizes the disease by inscribing the epidemic as a part of a natural course of things. This power over the perceptual limits of the disease gives them enormous power over how it will be understood and reacted to. In the case of lead poisoning in the text, the threshold of a “dangerous” amount of lead in the body was continually lowered from its original quantity until the amount of people with the new, lower amount was considered an “epidemic.” Without ascribing pessimistic or conspiratorial intentions to public health authorities, it’s clear that there are material benefits for their practice when a disease becomes an epidemic: funding will likely increase and they will be given more discretionary powers over how the crisis will be averted. In addition, because a lower threshold means more minor cases of poisoning, the rates of recovery will likewise be higher than if they only included the most serious cases. Their position also gives public health authorities the ability to make claims about the origin and cause of the disease. The majority of those with lead poisoning in the case study were of African origin. Instead of looking at the amount of lead in the cheap, overcrowded housing buildings, these investigators made claims that immigrants of West African origin were tolerant of “geophagy,” or eating dirt and mineral substances. This assumption, based off preconceived anthropological theories of the ethnic group in question, displaces the question of appropriate housing, and implicitly places the blame on a shared ethnic habit.

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Figure 8: This 2014 cover for Newsweek magazine similarly evokes racist stereotypes (connecting Africa and a chimp) and supposed ethnic habits (eating and smuggling bushmeat) to the spread of a disease. That such habits were later proven to have been overstated and unrelated to the spread of Ebola is unimportant, rather they served the function of more deeply connecting the “African” with the dreaded disease. Read this great article for more analysis specific to Ebola: https://jezebel.com/from-miasma-to-ebola-the-history-of-racist-moral-panic-1645711030

We’re getting ahead of ourselves. One might say at this point that public health administration today is not related to the other practices from the past. This will be our next task in this piece: to take the line we’ve briefly drawn from the hygienists through the Pasteurians, and extend it to the social purity and social hygiene movements, and into modern-day public health administration. The lines are in many cases already drawn for us. Many of the same individuals participated in multiple groups at the same time, as when the hygienists worked with the Pasteurians, and in the case of the merger between members of the “Purity Crusaders” and the “Sanitarians” in the “American Social Hygiene Association” (ASHA) in the Progressive Era (~1890-1920). Further, the former social hygiene organizations didn’t just disappear: they were either absorbed into one or another governmental or philanthropic organization, or merely changed names, as was the case for the American Social Hygiene Association, which is now called “the American Sexual Health Association.” Using the critical health models we’ve combined in this section, we will, in the next three sections, examine specific cases in which hygiene or health was the driving operator or ordering principle of government. For the sake of consistency and detail, we will look at public health discourse that centers in on the intersection between sex and disease: in section b, we will further examine health administration in the 19th century, looking at the implementation of the Contagious Disease Acts; in section c, we’ll come back to the US, and how the social hygiene reform organizations handled the control of venereal disease and prostitution during and after WWI; finally, in section d, we will arrive in the present usage of hygiene and sanitary laws and ordinances to regulate spaces and actors associated with sex and the potential for disease in the US. In all of these cases, public health is the name for a practice that defines the limits of the status or the appropriate activity of citizenship through representations of cleanliness and dirtiness, personified most often in the figure of the “prostitute,” and the diseases she is supposed to carry. We hope that our observations can be exported and applied to hygienic language that makes no reference to sex, and that our criticism of policing done in the name of “sanitation” can instill a skepticism in the reader and become a tool to make further use of.

“Well,” you may be thinking, “it’s simple! If these bastards say that the poor, the sex workers, and the insane live in garbage huts and ruins, then so be it! I welcome this filthy garbage life!” We see the attraction of such a position, and, before we continue, we feel it necessary to make it clear that to conclude that the solution to the “health problem” is to denounce bourgeois morality, and cast ourselves into unhygienic, unhealthy authenticity is not so simple. This was arguably the conclusion of an older article from the anarchist collective Crimethinc called “Washing … And Brainwashing. ‘Cleanliness is Next to Godliness’” from their book Days of War, Nights of Love. They begin well enough by correctly making the connection between the idea of cleanliness and social differentiation: “we can see that cleanliness has been used as a standard of worth by those with power to ascribe social status.” But soon after arguing that we have all foolishly bought into the idea that “being ‘clean’ according to social norms is desirable in itself,” they begin making the argument that not being clean is therefore laudable. They walk on this fence for the rest of the essay, unsure of whether “cleanliness” is a wholly abstract and meaningless social norm of power, or if there really is something to it, and that, by opposing it and the sanitation products sold to us to attain it, we can embody an authentic working class position by embracing sweat and stink.

The authors of that essay had other polemical intentions in mind, but we feel that the piece demonstrates a tendency of critiques of sanitation and health to imagine that “anti-sanitary” or “anti-health” positions are possible, or desirable. We will not follow this line of thinking. Nor, following Foucault in The History of Sexuality, will we affirm, in our analysis of the regulations aimed at “prostitutes,” the existence of a “liberated sexuality.” Sexuality was invented as a site of the regulation of practices and knowledge. We’ll have more to say of this in the conclusion, but it’s important that we not allow ourselves to stray into the seductions of the negative pole in a binary territory. We will try to stay focussed on how agents use sanitation and health to govern, so as not to reproduce (even negatively) another abstraction of “true hygiene” or “true health.”

  b) Case I: The Contagious Disease Acts (1860s) and regulation

Although the regulation of diseases and the health of populations extends far back into the reaches of the Middle Ages, a recognizable combination of public health operations with their requisite medical and moral explanations took shape in the mid to late 19th century in the British Empire. The Contagious Disease Acts were passed by Parliament in 1864 following a commission into the treatment of venereal diseases in the British Armed Forces, and were amended twice in the course of the decade before being repealed in 1886 after a lengthy campaign against them by middle class feminist reformers and local acts of resistance. The stated goal was to reduce the spread of venereal diseases in spaces where they could most easily be spread. The main target of the Acts were “prostitutes” in port and army towns, and the women of the colonies. The Acts granted the power to police officers to arrest suspected prostitutes, confine them in lock hospitals “until better,” issue penalties to them, and subject them to obligatory venereal disease tests. Who exactly these “prostitutes” were depended on the discretionary gaze of these same police officers, who were authorized to subject any suspected women in public space to their regulatory measures. The women in figure 9 do not have the make-up nor clothing of the stereotypical image of the Victorian prostitute, but the title “The Great Social Evil” and the text clearly identifies them as such (“gay” here refers to their status as prostitutes and not homosexuality). In this way, the moral and sexual identity of women was determined on a case-by-case basis by the police in the name of disease control for the nation.

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Figure 9: “The Great Social Evil.”

The Contagious Disease Acts represent a pivotal moment in a broader movement for public regulation of health. Other systems, strongly resembling the Acts, already existed for decades or even centuries in the colonies and on university campuses in the British Empire. The Acts can be seen as the climax of the 19th century “regulationist” policy movement. This movement aimed at the control of the spread of disease, but it also made broader moral and social claims as the limitations and effects of such control. The regulationists believed, reflecting widely shared truisms, that men were endowed with uncontrollable sexual urges, while women mostly passively engaged in sexual activity out of domestic obligation, with the possible exception of the “disorderly prostitutes.” Prostitutes, in this view, were a necessary evil, who existed to satisfy the insatiable urges of men, protecting the purity and sanctity of unmarried women, who, in contrast to men, deserve to be severely punished for promiscuity. The implementation of the Contagious Disease Acts was situated in these broader presuppositions. The purpose was not to repress or put an end to prostitution, but to control its practice and concentrate it into easily monitored “vice zones” or private brothels. Public space was the target of this control, and private spaces of prostitution, unless they were especially disruptive to the public, were not subject to the same level of regulation that the so-called “streetwalkers” were.

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Figure 10: “Running the Gauntlet”

The sexual double standard is made apparent in figure 10, an image called “Running the gauntlet–A scene in front of a popular hotel in New York City at five o’clock P.M.,” by John N. Hyde published in Frank Leslie’s Illustrated Newspaper on May 16, 1874. The men stare and ogle the woman, raising their eyebrows in interest as they puff their pipes, with indifferent, but confident surveilling eyes. The woman, following the highest standards of etiquette of the day, strides forwards without looking, maintaining her disinterestedness in the opposite sex, and a tacit acceptance of the gaze of unknown men.

Not only did the Acts codify the sexual double standard that only constructed female extra-marital sexuality as illicit, but, because any woman who appeared sufficiently dangerous or sexualized could be registered as a prostitute once suspected, they also served to codify social and domestic norms ordering the lives of women in general by policing their appearance, their behavior around men, and their ability to inhabit public space at different times. According to Philip Howell, the majority of women confined and registered were “apprehended for casual assignations or even more or less innocent flirtations.” One can also deduce this fact from the protests against the practice of registering and arresting suspected prostitutes at the end of the century. One author wrote in The Telegraph about the proctors at Cambridge:

Cambridge is . . . no fit place for a decent and respectable woman to live in. […] Young girls, of stainless character and modest manners, have been seized in the streets, their garments half torn off by their brutal assailants, scoffed at as prostitutes, subjected to humiliating examinations by medical men and foully insulted by the cross-questioning of their secret judge, and, after suffering this most abominable and lawless treatment, have been released, with or without punishment, utterly unable to vindicate themselves.

On the other side, social purity advocates, including the largely middle-class feminist alliance credited for the repeal of the ordinances, were disgusted that such regulations served the purpose of providing “clean women” for young men to satisfy their urges with. These protests from both sides —those who viewed such laws as protecting vice by not repressing prostitution and those who saw them as affronts on the liberty of young women— strengthen the general picture of a broad system of regulation targeting all women in public to varying degrees of severity.

This is not to say that the problem with such laws was that they accidentally targeted “normal girls.” In the end, it’s impossible to say how many “real prostitutes” were locked up or affected in comparison with “normal girls,” precisely because the idea of the prostitute was a plastic and imprecise term symbolizing potential disease and disorder. The prostitute —equivalent to the “streetwalker”— was more than just an occupation, she was a symbol for all the potential disorders of society and of the body. Because she blurred “the boundaries between public and private worlds, between the commercial and the conjugal,” she symbolized the subversion of the norms that determined female sexual behavior and lifestyles: she stayed out late on the streets searching for sexual partners, and, mirroring her status as disruptive agent of the social body, was a carrier of diseases that ruined the biological one. The Contagious Disease Acts appear in this light not so much as a regulator of venereal disease as the expression of a balance between the representation of prostitution as a social evil and a faith in their utility as the outlet for young men’s desire. It’s a balance mirrored in today’s average citizen’s pity of the presupposed “plight” of the common prostitute’s life circumstances combined with his disgust with the fantasized conditions of her occupation. The concern and discourse around venereal disease and the nationalistic fear of it spreading throughout the Empire’s forces codified the intersection of sexual and domestic norms and needs, granting them a scientific and medical legitimacy that magnified and glorified the defense of the family by positioning it as the protection of the nation.

The ordinances and the discourse surrounding them served manifestly different ends in the colonies. There the Acts legitimized “negative perceptions about the sexuality of non-white and working-class, recently emancipated women.” The Venereal Disease and Contagious Disease Ordinances were passed in the 1850s in colonial Hong Kong with nearly identical language and purpose to the first Contagious Disease Act: to register prostitutes and inspect or confine women believed to be carriers of contagious diseases. One difference is that these ordinances reached further than the domestic ones by licensing brothels in addition to individual prostitutes. More importantly, however, was the introduction of a new racial fold. The ordinances were targeted specifically at women who catered to Europeans, and took measures to separate brothels which served Chinese and non-Chinese clients, thus confirming “the central importance of race in the attempt to promote or impose sexual discipline.” The brothels and their regulation, according to Phillip Howell, could be seen as inscribed within a commercial and military economy: Hong Kong was a rapidly growing colonial economy and migration hub for cheap Chinese laborers, and the license given to the brothels was an incentive in a new sexual economy saturated with these young, single men, mainly from the Chinese mainland. Soon, however, the “threat of venereal disease posed serious challenges to the security and efficiency of the colonial state, particularly where the military and naval forces was considered.”

But, Howell suggests, there’s more to this biopolitical logic than a simple balance of economic growth and the defense of the state’s security forces. Central to the implementation of hygienic regulations in the colonies was the clear distinction between the Western subject and the racialized Other, whether Chinese, Indian, African, or Caribbean. The commissioners of the Hong Kong Contagious Diseases Ordinances subscribed to a culturally relative theory of the “regulationism” described above. Their report in 1877 stated that “prostitution, brothels and the system of licensing brothels with a view to raise a revenue […] were indigenous institutions in China centuries before the present nations of Europe emerged from barbarism” and further referred to the “national Chinese system of prostitution” as being due to causes natural to China. Such views are based on and inevitably bolster conceptions of the racialized Other as essentially different, more sexual, more ignorant, more base and “natural.” This makes the Chinese, in this case, a “natural” danger to the more sanitary European, hence the necessity of spatial differentiation. Such divisions could not have had any major effect on the spread of venereal disease. Rather, they naturalized the perceived behaviors of the Other and masqueraded the pathologization of the colonized as medical and scientific fact.

For another example of the racial inscription in the language of “hygiene” and “disease,” we can turn to Denise Challenger’s analysis of the Contagious Disease Hospital in Barbados. The Bridgetown Contagious Diseases Hospital was built in 1869 in accordance with the Contagious Diseases Act of 1868, after Jamaica in 1867 and before Trinidad in 1869. It was designed to detain “women that medical authorities and police officers believed were most dangerous to the men of the British Army and Navy.” As was the case in Hong Kong with Chinese laborers, the medical authorities naturalized a conception of black civilians as “licentious” and “promiscuous” and therefore at a greater risk of contracting venereal disease then their former slave owners. The colonized Chinese subjects were said to be at particular risk because of a historical and cultural lineage of prostitution, which in turn were the result of “natural conditions.” In the Caribbean, the discourse fixates on the idea that there were “links between the high rates of VD and the way in which black civilians acted as free people” following the end of the slave system. In both cases, the ordinances codified racial and gendered differences: while the supervising officers were white men, Afro-Barbadian men were often the street patrollers of black women under suspicion of engaging in prostitution. This hierarchical system of surveillance contributed to a shift in the perception of Afro-Barbadian women as the dangerous agents of an infection that harmed both white and black men. All women were potentially suspect, and were expected to police their behavior in accordance with that fact, but this system of surveillance of discipline was most visible in the Hospital itself where women could get sent to prison for infractions like “bad conduct,” “fighting,” “indecent language,” “making noise,” “theft,” or “attempting to contact persons outside the hospital.”

The Contagious Disease Acts were repealed as early as 1886 (later in the colonies) amidst campaigns by social purity reformers, who saw the ordinances as permissive of the “social evil” of prostitution; by feminist “anti-trafficking” campaigners, who held that they facilitated trafficking; and by the Ladies National Association for the Repeal of the Contagious Diseases Acts who opposed the representation of sex workers as criminals by urging parliament to see them as victims of circumstance. Among other things, the anti-trafficking reformists fought against the sexual double standard taken for granted at the time, holding that it was the men who should be criticized or punished, because they were the ones creating the demand. In this rhetorical structure, the difference between the binary genders is still taken for granted, only the moral denunciation is reversed: the women are not immoral perverts, it’s the men whose sex drives are causing all the problems.

Let’s take a moment to acknowledge the fact that these policy reformers were not the only ones fighting the ordinances. Beneath the public reform movements, there were the women who resisted these measures everyday by running away, causing a scene, or fighting when being detained, most of whose actions have gone unrecorded. Denise Challenger begins her essay on the Contagious Diseases Hospital in Barbados with a story of women who chose prison over continued medical surveillance in the hospital through rioting. Judith Walkowitz highlights these everyday resistors and posits a simple truth that the social purists and middle-class feminists didn’t understand, namely that prostitutes “were not rootless social outcasts but poor workingwomen trying to survive in towns that offered them few employment opportunities and that were hostile to young women living alone.” Put another way, sex work was just work, and was not “dangerous.” Its practitioners were neither helpless victims nor libertines.

c) Case II: WWI and the social hygiene alliance in the US

The First World War prompted a new wave of fear around the widespread infection rates of venereal disease among soldiers, giving rise to a sanitary paradigm that looks at the outset similar to the case we just summarized in Britain: an alliance between different groups formed in 1913 in New York under the name ASHA (American Social Hygiene Association) with the goal of ending prostitution and, in this way, end the spread of venereal diseases. The major difference between the social hygienists in the United States and the British parliament at the time of the Contagious Disease Acts is that the former ultimately aimed to end prostitution, while the latter only wanted to regulate it. ASHA, while not comprising the entire social hygiene movement, was the most influential, and represented in its structure the most popular trends in the movement. It was formed in 1913 by an unlikely alliance of mostly male sanitarians on one side, who, like the hygienists discussed in section a, wanted to use science to influence policy and infrastructure to make a cleaner, better society; and “purity crusaders” on the other, who, being mostly women, were largely excluded from the political processes and means to bring about their desired “single standard” of sexual behavior, which underwent some transformations in this era.

The sexual double standard was upheld by at least some in the social hygiene movement, especially by the male medical experts. One poster, designed by the American Social Hygiene Association with the U.S. Public Health Service and the YMCA, read “Men who fail to develop self-control sometimes yield to sex temptation to indulge in sexual intercourse with immoral girls and become infected with a venereal (sex) disease. The chief venereal diseases are syphilis (pox) and gonorrhea (clap).” In this construction of gender, men are those who have powerful urges they must control, while women who partake in extra-marital sexual affairs are “immoral girls” carrying disease. Another poster in the same series informs boys that their “sex instinct” is an internal power, which if “controlled and directed […] gives ENERGY, ENDURANCE, FITNESS.” This view was not shared by all, especially the purity crusaders including one founding member of ASHA, Anna Garlin Spencer, who called for the “single sex standard” so that both agents involved in the sex act would be held mutually responsible. At the same time, Spencer also held that, because men had formerly been given a free pass on the moral consideration of their sexual practices, they were the ones who needed to level themselves to their moral standard set by chaste domestic women. The binary model of the sexes and their morals is still upheld, but it is considered a “cultural” problem rather than a “biological” one. The Women’s Christian Temperance Union —a precursor to the purity crusaders— collected pledges from men that they would stay true to the “single standard.” Figure 11 is a simple example of this new configuration, in which the woman dressed in her white wedding gown is an icon of purity and the family, moral standards which the man is expected to live up to.

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Figure 11: “Have you a right to go to the marriage altar demanding honor and purity in the girl you marry, unless you are willing to offer her a clean life?” from the YMCA collection

Despite their differences, the two groups joined with the shared goal of eliminating venereal disease and prostitution under the name “social hygiene.” The physicians and sanitarians agreed that male chastity was at least a good preventative strategy —even if they did not philosophically agree with its underpinnings— especially as treatment for VD was painful and not always effective. To achieve those ends, the strategy turned toward ending irregular sexual relations (pre/extra marital sex), which in turn would mean the reduction/elimination of prostitution. This would result in a lower rate of infection for venereal diseases, and the end of “sex slavery.” Practically, this meant introducing a new expanded definition of “prostitution,” renamed “sex crime,” which was defined as “giving or receiving the body, for hire, or the giving and receiving of the body for indiscriminate sexual intercourse without hire,” as well as new prohibitions on keeping “place, structure or conveyance” for prostitutes or “lewdness” or taking someone to place of prostitution or transporting prostitutes. Kristin Luker goes on to tell us that by 1920,

ten states had passed laws that enacted these provisions in their entirety, (including the expanded definition of prostitution) and thirty-two states had laws that enacted at least some of these provisions. This new statute definition of prostitution was simultaneously reinforced with other innovative legal strategies championed by the social hygiene movement, namely measures such as the “red light abatement acts” and the “tin plate ordinances.” “Red light abatement acts” (passed by thirty-nine states and two territories) permitted ordinary citizens to close places suspected of harboring prostitutes by injunction, and “tin plate ordinances” (passed by 18 states by 1915) made public the legal ownership of a building (on tin plates attached to the building) where prostitutes were thought to gather.

The use of “licensing” ordinances and these laws brought saloons, taxis, dance halls, and road houses under regulatory control by threatening their property, status, livelihoods, or licenses. By 1918, 32 states had laws permitting health departments to quarantine those suspected of venereal disease, and since social hygienists believed that 90% of all prostitutes were infected, and the definition of prostitution had increased, such laws could be used to detain massive groups of women (~30,000 during WWI). This required the construction of an expanded set of carceral institutions and the increase in the number of prisons, especially women prisons. New courts created by reformers dedicated to prostitution employed fingerprinting and examined women for venereal diseases, and sorted women into the workhouse, prison, public health hospital or “feeble minded” population. This combination of moral zeal and (male) medico-technical expertise and jargon allowed the social hygienists to “call upon seemingly-neutral ‘scientific’ and medical information in one era of public concern about a dreaded disease (a concern they themselves had helped kindle) to argue for a new moral, social, and sexual order.” The women’s groups were eventually abandoned, and their “single standard” was replaced by the military standard of “fit to fight,” exemplified in the 1940 war-time propaganda poster in figure 12. This further demonstrates that the standards being touted as scientific or objectively sanitary/hygienic are in reality only opportunistic.

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Figure 12: “HEALTH is a patriotic duty. KEEP FIT.” From ASHA

It’s at this point that we can bring our discussion into the present and see how the lineage of something like prostitution regulation affects modern-day public health policy. What we tried to highlight in these last two sections was that the discourse centered around notions of “sanitation” and “hygiene,” even when related to or centered on the objective existence of venereal disease, for instance, is in no way a neutral object of desire. First of all, notions of “cleanliness” are always bound to beliefs of cultural or natural superiority. This makes “hygiene” an advantageous gateway for proponents of racist or gendered configurations who desire a “scientific” or “objective” standard for their theories. We don’t mean to say that the eugenists and chauvinists of the world knowingly take and apply notions of hygiene, but rather that notions of hygiene already carry with them the idea that there exists “clean” things and people and “unclean” ones. This becomes more complicated when the “unclean” becomes associated with a figure like the “prostitute” who is herself a complex assemblage of racialized, gendered, and classed fantasies and attitudes. Second, and this is closely related to the first, hygiene cannot be wholly distinguished from moral systems and logics. One’s notion of what is “clean” speaks to the values of those who say it. Hygiene and sanitation are inherently normative and value laden, but what those values are depends on the user and their purposes. The purity reformers, for example, were able to combine their moral outrage at the double standard of the sexes with a pseudo-scientific logic identifying it as the cause of venereal disease. Lastly, the idea of “hygiene” mobilizes those who hear it into action. When one speaks of sanitation, it calls to mind with it the actions that one considers clean, as well as those one considers unclean.

It’s important to recognize here that administration through hygiene is much more diffuse today than it was in 19th century Britain. The American picture sketched above demonstrates that the policing of health or hygiene can be codified in policy, law, city codes, or ordinance; it can be carried out by police officers, licensing agencies, judges, and even everyday citizens (through complaints); and it can be positioned as if it were targeting a group (e.g. prostitutes), a disease, or a “contagious environment.” Public Health, as we’ve outlined it, is a mobile and elastic power that weaves in and out of different vernaculars and institutions, capable of reshaping or reinforcing existing racial, sexual, domestic, and moral paradigms. We must keep all these facts in mind as we return to the present day.

d) Case III: public health and spatial reconfiguration

In mid to late 2017, a debate started in Minneapolis around meeting spaces where upwards of 300 people would meet, party, hang out, or have sex, which most people locally didn’t even know existed. The conversation began to get picked up by the local paper City Pages and a few others after a raid on an underground, unlicensed gay bathhouse in January 2017 in North Minneapolis. The police, acting on behalf of the housing and fire department, rushed in one night, flashing their flashlights on the patrons, and ordered everyone out. That space, the Warehouse, was the last of the banned sex clubs. These raids make an instructive case study for how the intersection between hygiene discourse, the fear of disease, and city ordinances operate in tandem to regulate people and spaces deemed risky today.

The city codes used to boot this sex club and the others that came before it, along with the fear of disease that accompanies them, date back to the late 1980s, when HIV was still a terrifying, unstoppable disease thought to be emerging from the gay underground. To find these codes, one needs to open the Minneapolis city ordinances to Title 11 – Health and Sanitation, Chapter 219 – Contagious Diseases, Article V – High Risk Sexual Conduct. This is the code that bans such “high risk sexual conduct” in buildings constructed for that purpose across the city. The part of the ordinance that concerns us reads:

The sexually transmittable disease of acquired immune deficiency syndrome, currently found to be irreversible and uniformly fatal, is found to be of particular danger to persons in this community. The incidence of this disease is found to occur in discernible population groups. The risk factors for obtaining or spreading the disease are associated with high-risk sexual conduct. The commercial premises, buildings and structures where persons are placed at risk of infection from this disease or other communicable disease facilitated by their design or use for high-risk sexual conduct are in need of regulation, and of establishment of minimal standards for the prevention of the spread of this disease and other communicable diseases for the protection of the public health, safety and welfare of the community. [My emphasis]

It defines such “high risk” behavior as either “(a) Fellatio; (b) Anal intercourse; (c) Vaginal intercourse with persons who engage in sexual acts in exchange for money.” When the city ascertains that a space is a site of this activity, the health commissioner has the ability to “issue warning,” close the space after calling it a “hazardous site,” and “may secure a court order for the closure of the premises.” Notice it does not allow the Health Department or the health commissioner to order an immediate shut down of the space.

In practice, health code ordinances are rarely used alone. More often, as was the case here, they are used to conduct an initial investigation or raid so that the police or the commissioner can find another, simpler violation to make use of. For the gay bathhouse, there was no license. In the city’s own report on the raids on the “adult establishments” we wrote about in the first section, they note in the section “Current Regulatory Tools” that Article V is “Outdated,” has “Incorrect scientific information,” and “Lacks effective enforcement.” But these are small hurdles. They recommend that one could also make use of a Minnesota statute 145.A, Public Health Nuisance, which allows county boards to “adopt ordinances to define public health nuisances and to provide for their prevention or abatement.” When public health actors have the ability to both define what the problem is and make arrangements to solve the problem, the only thing that matters as far as the public is concerned is a convincingly scary disease or hygiene narrative to stop them from prying any further.

This method offers the city an easy way to get into spaces they might otherwise have legal difficulties getting into, and provides a simple retroactive explanation after they’ve already raided or investigated a space. It was due to sanitary violations that the FBI were able to raid and eventually shut down the Black Panther’s Chicago health clinics. In April 1970, Bobby Seale issued a directive to the Black Panthers that all chapters should open a health clinic as soon as possible. While the rollout was unequal across different cities in terms of capacity and expertise, most clinics offered basic care, check ups and referrals at no cost, while some offered ambulatory and dental services, with a broad focus on preventative care. Some clinics offered an advocacy service, so that a Panther with more experience could accompany patients to the doctor and make sure they were getting the best care, and they also held teach-ins to inform people about sickle-cell and other ailments that could potentially affect them. When the FBI felt unable to just bust in and shut the Chicago clinic down, they relied on housing and health authorities to make the move for them. First, the city of Chicago issued a directive that the clinic would have to get a license through the health board and allow unannounced inspections. The Panthers refused and the city did a “sanitation” check and was able to shut them down on health code violations.


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Figure 13: Screenshot of an article from NOLA.com connecting the double entendre “human waste” to “petty crime.” http://www.nola.com/business/index.ssf/2011/10/human_waste_petty_crime_at_occ.html

More recently, the Occupy Wall Street encampment in Zuccotti Park was raided and shut down in November 2011 due to concerns around sanitation and hygiene. An article by the New York Times called “A Petri Dish of Activism, and Germs” was published just a few days before the raid on the 15th of November. The structure with which the author builds his case for the unsanitary conditions is reminiscent of the articles on strippers as it’s just as contingent and fragile. He starts by mentioning that someone coughed, and then someone wheezed, then just a few paragraphs down quotes “the director of clinical microbiology and immunology at NYU Langone Medical Center,” who said that

the conditions could leave park-dwellers susceptible to respiratory viruses; norovirus, the so-called winter vomiting virus, which can lead to vomiting and diarrhea and which could quickly overwhelm the limited bathroom facilities in the area; and tuberculosis, which is more common in indigent populations and can be spread by coughing.

Just as was the case with the strip clubs, there are no mentions of these diseases actually existing, only the potential that they could exist. They go on to trade in the clichés and prejudices of all those who try to use notions of health to delegitimize their enemies. He mentions at one point that, although “licensed doctors and nurses often take volunteer shifts in the [medical] tent,” one could also see “shamans walking the premises,” at which point the audience is supposed to laugh at these fools who would employ primitive means to fight (potential, not-yet-existent) diseases. He ends the piece with the ultimate gesture of fear-mongering by noting that these protestors aren’t just putting their own idiotic lives at risk, but also those of good, normal people: “Of course, contagions may not be confined to the park population,” he says, before quoting a demonstrator as saying “We’re the biggest tourist attraction in New York, [a]nd we shake everyone’s hands.”

There’s more to that piece than providing a rationale for evicting the park. The derisory descriptions of the sanitary conditions and sarcastic allusions to the means available for correcting them are written so that the reader walks away with an understanding that those people are not only at risk of spreading disease, they are themselves a kind of disease. They are surrounded by filth and garbage, and are collectively the filth and garbage of the human race. The title of the article in figure 13 makes this equivalence directly when they refer to “human waste.” Human waste firstly as shit, but also human waste as in humans who are waste and shit. This was also the case with the Standing Rock “trash scandal.” After the camps were raided, and the remaining occupiers either fled or were arrested, there were piles of trash left behind. It was below zero degrees for months and much of the collected trash was frozen into the ground; the raid caused a panic and, amidst fire and riot police, trash collection was not a top priority; and many of the roads were blocked, creating massive difficulties for regular trash disposal. In the end, it doesn’t matter what the reasons were. What matters in this case is that those who would like to regard the entire affair as not only pointless, but idiotic and regressive latched onto this story about trash piles hearkening back to the age-old Western performance of superiority. We are noble, clean, and pure, and our enemies commune with garbage.

An early Bismarck article published in February 2017 called “Sanitation crews work to remove massive amounts of garbage from DAPL protest camp before spring thaw” seems to be the story that provided the fodder and the tone for the more sensational and morality-laden publications that followed. The author, Sara Belinger, informs the reader that 250 trucks worth of trash would need to be removed, and that the amount of trash was equal to six months worth of garbage “from a community the size of Wahpeton or Valley City.” No mention is made to the size of the encampment, nor to what this “garbage” consisted of, nor to the trash disposal methods already in practice at the camp, nor to how long the camp was there. These facts don’t matter, because these “objective descriptions” are anything but that. They are codes that signal to the reader that the NoDAPL encampment was the opposite of what it said it was. Belanger follows up her list of isolated sanitary violations with a statement from Morton County Sheriff’s Office Captain, saying “As bad as it sounds, we’re looking for people that may have died and could be wrapped up in a canvas or a tarp or tent.” The demonstrators were claiming to protect the environment, but, in reality, they were infecting it with their filth. Not only were they potentially guilty of killing the environment they were there to protect, they may have also killed people in the process. Hygiene is the vector through which presupposed political and historical values —the Western superiority over the imagined primitive— become inscribed in scientific and pseudo-scientific fact. It’s the symbolic vector through which piles of garbage viewed completely abstracted from all circumstance can become tentative proof that the protesting native is a danger to the world and even a potential murderer.

Returning back to our local example, it is interesting to note that the two articles on the gay bathhouses for City Pages were both written by Susan Du, the author of a mean, but supposedly sympathetic, piece on strippers following the “semen investigation” in which she referred to them as “flesh merchants.” She began the piece called “Behind the fantasy at Minneapolis strip clubs” by listing bodily fluids, calling strip clubs “filthy,” and then listing diseases some of the dancers had. Her tone in the two articles on the gay bathhouses is much more understanding. She doesn’t list the bodily fluids she can find or that she heard were there, she doesn’t examine the couches and call them filthy, she doesn’t interview the patrons and ask them what diseases they have. “How shameless, how normal” she writes, not like those nasty flesh merchants who trade in immorality and disease. She’s ostensibly sympathetic to both the underground gay sex scene and the strippers working in bad conditions, but her unfortunate, sensationalist descriptions allow the reader to come to the conclusion that strippers themselves are disgusting people. Whatever her reasoning or lack thereof, we reject any gesture that defends the honor and status of one stigmatized group by deriding and degrading another. Another article by Daniel Villarreal on the website Hornet titled “There’s a Battle Brewing That Would Bring Gay Bathhouses Back to Minneapolis” also attempts to uphold the hygiene of these bathhouse spaces at the expense of strip clubs by referring to the aforementioned semen investigations.

The sex worker once again serves as the virtual object onto which anyone can project their own fears of disease, sickness, and moral calamity; the spaces she inhabits are fluid-soaked dens of iniquity and disaster, ruining everyone who steps into them. In this case, this fantasized image works to protect other marginalized subjects and spaces. She ought to at least get paid double for this abstract labor, don’t you think?

e) So what do we do with our bodies?

Social reality is as real as biological reality. One could even say that the former is a weapon that can be used to act upon the latter. We simply need to be aware of that if we are to be adequately prepared for battle.

                                                                                      —Didier Fassin, “Public Health as Culture”

The question facing us now is “what to do with our bodies?” What do we mean by that? No matter how abstract and distant their usages have come to seem —no matter how convoluted their political meanings have become— we nevertheless acknowledge that the words health, sanitation, and hygiene speak directly to us, and to the way we imagine our bodies.

It should be clear by now that an unqualified “pro-health” or “pro-hygiene” position is dangerous. The public function of the word “sanitary” or “hygienic” today has very little to do with disease and their modes of infection, nor with the well-being of a person and their body. More often, such words indicate that a group is a potential danger (as with Occupy and the strippers), they provide a legal means to perform otherwise inhibited police operations (as with the gay bathhouses as well as the “adult establishments,” and Black Panther clinics a few decades ago), a means of defaming and ascribing moral failure to a group by associating them with garbage (as with Standing Rock, and all the other examples to some degree), and, associated with this last method, a way to highlight the values and morals of one group by taking jabs at the sanitation of another (as when writers demonstrate the cleanliness of the gay bathhouses by comparing them to the “dirtier” strip clubs).

When we say “words,” we also include the images and icons of a visual language. Above, we included some images produced by public health organizations. Today, it is clear that such posters no longer have the same relevance. Can you name a single poster released by the CDC or the Department of Health in the last ten years? We don’t mean to say that public health has lost its visual language. To the contrary, the language of hygienic segregation is so diffuse that its visual vocabulary has been widely disseminated via pop cultural products, social media “meme warfare,” and journalistic productions. During the presidential campaign for Hilary Clinton, far-right groups posted memes that showed images of trash piles and dilapidated houses in Haiti, making connections between the unsanitary conditions portrayed in the pictures and both decolonization (the incapacity of “savages” to take care of themselves) and supposed corruption in the Clinton Foundation’s activities in Haiti. When a reporter wants to discredit someone or a group without saying so, it’s usually simplest to show photos of blighted housing or unsanitary conditions, as we’ll see later in this section. The visual language of hygienic superiority is no dead language, it’s common slang.

An “anti-hygiene” position looks just as untenable as a pro-health one, and downright silly if applied too generally. Don’t get us wrong. It can be a valuable way in certain scenarios to reclaim an activity deemed filthy and immoral. There have been some wonderful gestures from this position, with the most extravagant examples coming from acts of queer resistance. In John Water’s Pink Flamingos, a group of reporters begin an interview by asking Divine whether she’s a lesbian, and go on to ask about her political beliefs to which she responds “Kill everyone now! Condone first degree murder! Advocate cannibalism! Eat shit! Filth are my politics! Filth is my life!” Antonin Artaud wrote love letters to syphilis and glorified the lowest trash above the police and psychiatrists who wanted to control him: “shit, fart of my prick/(this fart let go in the grand imprecatory style, while belching under the boots of police)” or, at another time “my existence is beautiful but hideous. And it isn’t beautiful only because it is hideous./Hideous, dreadful, constructed of hideousness./Curing a sickness is a crime.” Artaud learned to love sickness and filth. Not in themselves, but insofar as they were the exact opposite of what the doctors and psychiatrists (who arrested him, shocked his brain, and forced medication on him) wanted for him. Around the time Pink Flamingos aired, Front homosexuel d’action révolutionnaire in France made banners that read “Proletarians of all countries, caress each other!” Or: “Sodom and Gomorrah, the struggle goes on!” And finally: “Ah, it’s nice to be buggered!” The contemporary, but now defunct, network Bash Back brought this attitude into the present with slogans on their banners and proclamations of their pride in being dirty. To proudly proclaim your filth and radical distance from the safe, conservative world picture of Western hygiene is not the antithesis to the abstraction of “health,” but speaks to a different standard and conception of what it means, and the necessity of declaring one’s distance from the norm. Rarely does it mean for those who say it that one ought to embrace death and self-destruction, but more often that the moral cleanliness accepted as an objective norm is undesirable and even damaging.

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Figure 14: Divine on her political views. From Pink Flamingos.

A number of concepts have emerged in popular parlance in the course of the last decade to try to account for this gap between the necessity of adapting to the hazards of living in this world and the baggage that accompanies every way we know how to talk about remedying that toxicity. Calling for improvements to health or more healthcare without explaining what that means just wont do. After the events of Charlottesville, the American College of Physicians declared racism a “public health issue,” as have some psychiatrists. Racism as a public health issue means displacing racism as a politico-historical issue into the domain of the biologico-medical. Certainly, the effects of white supremacy on the psyches and bodies of black and brown people are traumatizing and even deadly, but that does not make them primarily an issue of “health policy.” That would be to discount the very material politico-historical processes of slavery and institutional white supremacy that got us to where we are. On the day I wrote this paragraph, February 9th, 2018, the New York Times published an opinion piece called “Is Loneliness a Health Epidemic?” in which they questioned the recent decision by British Prime Minister Theresa May to appoint a “minister of loneliness” and subsequence announcements that loneliness has become a “health epidemic.” Naturally, a neoliberal administration would not want to call attention to the tendency within neoliberal programs to create pockets of isolated and precarious workers. Whether or not that idea sticks, “loneliness” has apparently become the next buzzword of the global health administration’s progressive medicalization of all political and economic problems. If we remain unaware of these appropriations while continuing to demand more healthcare, we are creating a foundation for the medical colonization of political problems.

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Figure 15: “Racism makes me sick,” an Australian public health advertisement. It’s true that racism has bad effects on bodies, but calling it a “public health issue” can obfuscate the political history behind the racism.

Every place that Western nations have come to lay claim to, they have also brought their “health” with them. The settler-colonists cannot use the word “health” unless they first eradicate everything that resembles it. When the Western powers talk of health, one can be sure that people will be slain, practices banned, holy sites demolished, and herbs destroyed. The cultivation of civilization in the Middle Ages meant banning the use of traditional remedies and medicines, particularly those used by women, who were burned as “witches”; expanding American civilization and health meant the banning of American Indian religion and medicinal practices from the 1870s until native activists incrementally regained through struggle the ability the use peyote, perform Ghost Dances, and took back some of their ancestral lands, protection for grave sites, and the right to practice religion in the 20th century; spreading British civilization meant banning “witches” in South Africa under the Witchcraft Suppression Act of 1895 and then again in 1957, which bans “supernatural” remedies for distress; bringing civilization to New Zealand meant banning the Tohungas, the traditional healers, in the Tohunga Suppression Act of 1907. Such examples demonstrate that “health” does not exist as a single thing, and that the controversies of health are just as much controversies of politics and ways of living, not merely the absence of disease. When one points out that the Europeans sought to eradicate diseases in the colonies, they fail to mention that they did so solely to pave the way to slavery, resource extraction, and colonization.

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Figure 16: Hexenbrennung (Burning of Witches) from the “Bilder Cautio,” 1632.

Nobody should take unqualified injunctions to “improve health” seriously anymore. Calls for “self-care,” or even “radical self-care,” have been heard in its wake. What exactly this means is difficult to glean from scanning the range of its usage on social media feeds and longreads from the website Medium about topics as wide-ranging as food choices, meditation, and “letting yourself relax.” For the most part, such “self-care” offers strategies to regather one’s strength to continue working. The neoliberal subject is expected to take care to ensure their body and mind are ready for another long day of work. Some of the most cynical iterations of this concept encourage the reader to immerse themselves in an array of consumer products like soaps, chocolates, or movie streaming services. The notion of “radical self-care” seems to have been developed explicitly to combat this market driven rejuvenation of the body, at times also offering a means of incorporating an understanding of race, gender, disability, and difference into the notion of “care.” It remains to be seen whether this “radical self-care” will truly distinguish itself from the “traditional value systems of worthiness and productivity” and be able to resist “the culture that tries to marginalize, define, and shame us” rather than, say, offer practices of the body that preserve it in activist roles as long as possible. In that case, the logic would remain the same (preserve your body and extract as much value out of it as possible via such-and-such simple tips), but the realm of activity would be different (one extracts value for a job, the other for activism). Still others use the term “radical self care” to mean only “moving self-care high up on your priority list,” which makes it basically indistinguishable from simple “self-care.”

Others, often of a more radical bent, speak of “health autonomy.” We profess that we don’t always understand exactly what is meant by this concept.  What exactly is meant by “autonomous” in this context? Some highlight the need to de-professionalize health and spread knowledge of practices one can do on their own or with others to prevent illness. Some take this approach a step further and provide workshops to teach skills one would otherwise require a doctor for. Frank Coughlin, in an interview published in Mask Magazine from April 2017, talks about his disillusionment with medical institutions and doctors following his realizations about structural violence and power. “I realized the institution itself is the problem,” he says. His concept of the “radical doctor” resonates with many other ideas of what it means to practice “radical health:” one, that we recognize that all disease is social, and two, that we ought to be de-professionalizing health and decreasing our reliance on health institutions by increasing the capacity of “community organizations.” To summarize, the “autonomy” in “health autonomy” refers to a spectrum ranging from de-professionalizing skills and knowledge to the intentional construction of accessible spaces to learn these skills and provide treatment.

The polyvalency of “health,” on the other hand, remains attached to its “autonomous” iteration. If we do not immediately make clear what this “health” is we are making autonomous, we open the door to grave dangers. The de-institutionalization of the mental health system in the 1960s is an instructive case in this regard, and one which we’ve covered in more detail elsewhere. If the process of “de-institutionalization”/”de-professionalization” occurs, as it did with rise of the community mental health treatment centers and the diffusion of the diagnostic and police authority of psychiatrists, then the fundamental assumptions surrounding so-called “mental health” remain, with all their baggage. Coughlin, for example, makes it clear that “if someone is having an acute psychotic break, we may not be able to treat them. Sometimes there is a role for medication, but those are the last resort versus our first resort,” and later remarking that “People are anxious, depressed, manic, and suicidal.” We don’t quote him here in an attempt to pigeon-hole his perspective as “uncritical,” but rather to point to the danger of calling for “mental health” without fundamentally questioning the diagnostic labels and conceptual tools handed down to us from institutional psychiatry. The same could be said about “health.” The assumption of the materiality of these health/mental health concepts is widely accepted among proponents of “autonomous health.” We don’t want the “health” of this civilization, nor its mental health, which is why we ought not mistake its concepts developed in many cases for social control, scientific-racial paradigms, and/or eugenicist taxonomies as “real” in and of themselves.

In the wake of these alternative health perspectives, we propose only a healthy dose of health skepticism combined with an orientation towards health as a collective strategy, and not an individual goal. The Black Panthers offer a particularly instructive example of the possibilities of the skeptical health position. Alondra Nelson, in her preface to Body and Soul: The Black Panther Party and the Fight Against Medical Discrimination writes “Health is politics by other means,” and should be treated as such. The Panthers surely treated health with the gravity and nuance it deserved. They paid attention to the ways in which ideals of health are held up as reflecting conceptions of the “good society;” they saw how health marked the boundaries of citizenship for black Americans, declaring they lived in a state of “Medical apartheid;” and how health and politics are intertwined “vectors of power,” and thus the site of uneven encounters between racialized subjects of biomedicine and the agents of public health. They created their clinics, as we’ve already discussed, but they also popularized alternate theories for the origin and spread of disease, as well as practices of prevention users could practice on their own.

They did their best to shut down attempts to medicalize the effects of white supremacy as when they opposed the creation of the “Violence Center” in California that would have looked into the biological connections between violence and race. The skeptical health disposition questions any statement about health and hygiene that does not take the historical and the political into account. When the Panthers shut down the Violence Center, we imagine they asked “whom does this serve? What ends does this serve?” The answer could only be the institution of white supremacy that protected the position of the doctors propagating the “racial theory of violence.” The skeptical health disposition means adopting this attitude and desire to learn in context without becoming self-destructive. One can be critical of health without desiring to be ill. The gay bathhouses offered a space for people to openly engage in sex acts once considered extremely dangerous and still widely thought of as “unsanitary,” offering condoms and informational pamphlets about HIV and the availability of PrEP.

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Figure 17: The May 21, 1971, issue of the Black Panther newspaper.

The Summer 1971 of the Black Panther newspaper published an article called “America’s Racist Negligence in Sickle Cell Research Exposed by its Victims,” in which two women were interviewed on their experience with the disease. The illness narrative is one of the primary tools available for the skeptical health disposition, and the Black Panthers were especially capable of integrating a personal narrative into bigger picture. If we want to disrupt the hegemony of public health explanations for what ails us, we need more such narratives from those who carry the diseases and illnesses we’re being told to fear so much. We need to illuminate the broader circumstances that contribute to our ill-feeling, as a total picture, entwined and mutually implicated in the lives of others, without reducing these to individual issues.

How we talk about our health will continue to be a problem. Care was appealing at first because it implied an action, “to care,” rather than an abstract state, “health.” At the same time, it bears a troubling relation with traditions of sovereignty, as when the king declares his intention to “care for the people.” Care, in the vocabulary of welfare bureaucracies and empires alike, is a biopolitical regulatory principle; in our neoliberal present, where we are all asked to make our bodies and our lives as profitable as possible, care and “self-care” are just synonyms for investment. So how do we talk about our bodies and the problems we face, if not through the words and concepts we know and have available? How do we care for one another without relying on abstractions that perpetuate the bloody amnesia of colonization?

So it is that I consider
That it’s up to the everlastingly sick me
To cure all doctors
—born doctors by lack of sickness—
and not up to doctors ignorant of my dreadful
states of sickness
to impose their insulintherapy on me
their health for a worn-out world.

-Antonin Artaud, “Doctors and Patients”

Scientific objectivity was barred for me, for the alienated, the neurotic, was my brother, my sister, my father.

-Frantz Fanon, Black Skin, White Masks

*Note: The footnotes to this piece can be found in the zine version on our PDF page.

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Why We Need Mass Shooters to be Crazy

Saying the Unsayable Every Time

When the unspeakable occurs, where do we turn for answers?

Whenever a politician or pundit — the two rusty gears of the great national blah-blah-chatter-machine — informs us that a shooting is an inarticulable tragedy — an unspeakable event — one can be sure this statement will be followed by excessive explanation.

In the wake of yet another mass shooting event in the US, journalists struggle to find answers as to how or why these keep occurring. Perhaps too many people have guns, or America is too violent, or maybe we’ve just lost our faith in God.

Through all this chatter, one answer is consistently appealing to all sides: the killers are crazy, psychos, lunatics, deranged, deluded, psychotic, mentally ill, Mad. Trump only said what everyone was thinking: Devin Patrick Kelley is another symbol of a national mental health crisis.

CNN reporters Emanuella Grinberg and Eliott C. McLaughlin believe that “the warning signs were there.” [1] Which warning signs? “Domestic violence. Sexual assault accusations. Animal cruelty. Escape from a mental health facility. Threatening text messages. An obsession with guns and mass shootings” they tell us.

This continued obsession in the biographical, the subjective, or the personal, means that the systemic and the historical will once again be swept aside. Hegemonic normative systems can only reproduce themselves if they can prove that the incident of extremity and ultra-violence are explainable solely by reference to the particular and not an expression of the system itself, even if it is an extreme one.

With this in mind, there is something profoundly disturbing about that list from CNN above. Each characteristic is listed as if we the readers ought to register them as Other, as abnormal and incorrect.

Their statement contains two dangerous errors in this regard: 1. none of these forms of ultra-aggression and terror are “outside” to Western values, rather, they are integral to them; and 2. escaping from a mental hospital does not belong on a list of assaults. Wrong first because they fail to see how these forms of aggression and hostility towards perceived weakness grew out of his experience as a normal, white, straight male, and not as some bizarre abnormality. Wrong also because they lump these forms of aggression in with the drive to escape from the controlling environment of the mental hospital.

The smooth integration of this supposed proof of mental instability and abnormality in  their list is a sly trick and one which serves a specific purpose: if they can point a finger at the psychos, they can continue to ignore the violence we all let fester within and around us.

More Than Just Normal

We find ourselves incapable of reading Devin Patrick Kelley’s “warning signs” as exactly that, as warning signs. Rather, they seem like the normal objects of our collective psychic environment. We see it like this: the nice, pleasant, normal, environs we live in, and the nice, pleasant, normal young men who most confidently move around in them were produced through acts of terror and aggression; they maintain themselves through these, and the act of locating the source of these hostile tendencies in the “mad” is a part of this structure.

White identity was/is produced through both legal and discursive acts of separation on the one hand and acts of performative domination and actual terror and destruction on the other. It was constructed in the Plantation era to separate the low, the nonhuman or partly human, from the high, the Whites. When whiteness came under threat — whether from slave insurrections, mixed race revolts in the pre-revolutionary era, or black organizing in the 60s — it was reconstituted with acts of extreme violence: mass executions, bombings in the South, re-enslavement and public torture. These events clearly had a performative and demonstrative element: they demonstrated that whiteness was untouchable and perceived encroachments would not be tolerated.

Silvia Federici, in Caliban and the Witch, wrote extensively on the physical and psychical violence committed against women in the construction of what might be called the “modern” form of Western Patriarchy. [4] Patriarchy for her isn’t some wisp or spook, nor a spectral abstraction used only for pointing out the meanness of men. Federici shows that it’s a real material process of degradation and terror leveled against the autonomy and abnormal behavior of women. This process didn’t occur merely through forms of discourse, but also through the physical destruction of medicines, degrading representations of women, the burning of “witches.” In other words, through systemic  terror and aggression.

Terror — the severing of limbs, the wanton violation and destruction of bodies, the performance of absolute domination and control — is more than just a normal part of our normal value systems (what many call White Supremacy and Patriarchy), it is the ritual element required for their continued existence. It may be extreme to hurt animals, to beat your wife, or to obsess about tools of murder, but it isn’t abnormal, not here, not in the West.

The designation of a class of “mentally ill” is part of this structure itself. As Erma VIP did in her critique of Susan Du’s City Pages article on strippers, we must ask ourselves who benefits from the further stigmatization of the mad? Who will suffer on account of Kelley’s portrayal as “mentally ill?” Probably not us (Sasha), at least not directly. Because we look the way we do (i.e. white and male), our abnormalities are not often read in public (although not never) as “dangerous schizoid behavior” but more often as drunkenness, or just weird. Certainly, we could suffer on account of this perception. It all depends on how we are seen in the moment, and Kelley’s portrayal as “crazy” won’t help.

Of course, that doesn’t yet take into account how these public accusations fit into a psychic economy. The self-representation of our differences as illness and the self-doubt around our own “threat potential” are not nothing. Concern over our “condition” (at this point of cognition, the condition is already separate and no longer simply a part of who we are) and whether or not we are perhaps actually a danger, or will be perceived as one, means that we, and others in our position, will be less likely to want to reach out and either share experience or seek care when needed. As some begin to publicly argue that increasing the rate of forced commitment is necessary to solve the “mental health crisis,” suicide suddenly becomes, in the moment of distress, a more tenable and attractive option.

But “madness” and “mental illness” themselves are constructed and traversed by contradictory lines of race and gender. The further stigmatization of the umbrella group  “the mentally ill” will only foster the mentality of fear, which makes a life-or-death situation out of the encounter with a “schizo” or “psycho.”

Whiteness, in the context of the insecurities it itself has reproduced through its exclusions, lives in perpetual fear of retribution for its history. The darker the skin, the more likely the White Man will feel himself existentially threatened, and the more likely he is to call the police, who, as protectors of white society and its values, themselves perceive danger at every turn.

Even though Kelley himself was white, the “mentally ill” appellation cascades hierarchically downward, increasing the chance for others — those who are already primarily under threat — of being even more heavily policed or murdered.

Calling someone “mentally ill” is also a favorite weapon of misogynists, who see difference or vulnerability in expression as further proof of feminine weakness. Men like Devin Patrick Kelley think difference is a sign of inferiority and justify their own acts of terror with this fact.

Unfortunately, it isn’t as easy as saying “we all must love each other” or “why can’t we just accept everyone for how they are?” We can’t take refuge in beloved universals. “Civilized” is a word-weapon we Westerners have used to elevate ourselves above and separate us out from those we see as beneath us: the savages, the primitive, the diseased and pathological. [2] “Humanity,” as Achille Mbembe has shown in his Critique of Black Reason, despite its seeming universality and biological foundation, was historically never supposed to represent all living things who talked and lived in communities. “Modern ideas of liberty, equality, and democracy are . . . historically inseparable from the reality of slavery” he writes [3]. This has been true since the Ancient Greeks established the form of government we still claim to practice today. Democracy for all! Except, of course, for women, slaves, children, the insane, foreigners.

The understandable anger of those who ask why white men are never labelled terrorist quickly turns into a demand that they be seen as such. In this way, they perform the same universalizing gesture but in reverse: we are united in seeing his behavior as so abhorrent and inexplicable that we cast him out from humanity. But in the West, terror is all too human, and the more we search for “terrorists,” the less we search around and within for the foundational source of that terror.

The radical acceptance of difference means being capable of being silent, of listening, of not over-hastily subsuming the other in your ideas about them. It means valuing receptivity above performance and communicability. Those excluded from the beloved universals have been forced to learn this skill. The so-called crazy people must do it, lest they get locked up again.

It’s time the ones doing the excluding do so as well.

Why We Love Throwing Lunatics to the Dogs

Sometimes a “progressive” journalist will meekly question the dominant belief that the schizo will kill you, flay you, eat your face off, or whatever. He or she will surely cite statistical reports from the Annals of Epidemiology or the US Department of Health and Human Services that show that only a tiny percentage of violent crime is attributable to those with a mental illness diagnosis.

We refuse to play this game. The mad, the “mentally ill,” as we are now called, do not exist as a permanent, stable group.

The mad have been women who wanted to escape what had become a boring, domestic hell. Maybe they wanted to sleep with other women. Maybe they didn’t want kids. Maybe they hated their husbands. Maybe they altered or even refused the gender assigned to them at birth.

The mad have been children who found it impossible to sit still in school. Maybe their teacher was unbearable. Maybe she found his lessons degrading, insensitive, and pointless. Maybe he didn’t want to hear about the accomplishments of Europe any longer.

The mad have been black and native men and women who decided to resist unlivable or unacceptable conditions whether in 1960s urban centers in America [2], or in New Zealand [3]. This is a global phenomenon. Maybe they were too loud, too black, too scary, or too strange to be understood by the white doctors who ultimately decided who was mad and who wasn’t.

The mad have been those experiencing extreme mental or physical distress who require care. Not the expert care that originates in the minds of those who pathologize them, but situated care, deeply aligned with their world and their desired place in that world. The exact same kind of care we all need.

Yes, we need to talk about specific intersections of mental health and care, but not uncritically. By automatically assuming the existence of “the mentally ill,” the criteria for identifying them, and the need for “treatment,” and by not asking any questions about who gets to decide who is mad, about the effects of stigma, about the various labels’ historical functions, about the power relations within which they exist, about the structure and formation of the medical knowledge that make up their foundations, or about the diverse experiences of those who receive these labels, even the most progressive calls for “care” can unthinkingly reproduce power relations of domination, scientific racism, gender policing, and the isolation of the suffering.

The crisis is not insanity, nor mental illness. The crisis is our normal way of thinking and acting itself; its hegemony and our inability to admit the legitimacy of another way of thinking and living. The mad have been those who think differently, who have organized their thoughts in their own way. This act of insolence must be punished in the eyes of the normal, hence they are a natural scapegoat for society’s most extreme perversions.

The mad, whether as insolent housewife, as rebellious subject, as “bad kid”, as sufferer, or as abnormal freak are not essentially the unreasonable, the nonspeaking, the abnormal. We represent another kind of reason, another way of speaking, a different norm, and for that reason we must be represented as the truly Outside, as unpredictable violent brutes capable of random violence.

We are a threat, true, but not because of a heightened physical capacity for murder or violation of consent — that belongs more so to Jeff and John down the street — but because we live according to other standards, whatever they may be.

Notes

[1] http://www.cnn.com/2017/11/06/us/devin-kelley-texas-church-shooting-suspect/index.html

[2] Elias, Norbert. The Civilizing Process.

[3] Mbembe, Achille. Critique of Black Reason.

[4] Federici, Silvia. Caliban and the Witch.

[5] Metzl, Jonathan. The Protest Psychosis: How Schizophrenia Became a Black Disease.

[6] Cohen, Bruce. “Passive-Aggressive: Māori Resistance and the Continuance of Colonial Psychiatry in Aotearoa New Zealand.”

The Savage Peace: An Essay on Civil War and the Amnesia of Democracy

This post contains a link to the book called The Savage Peace: An Essay on Civil War and the Amnesia of Democracy, the entirety of which has previously been published to this website in segments. The book is an attempt to think about politics and history from a perspective of organizing along lines of difference rather than identity. This resulted in a number of paradoxes, which I view as irresolvable, and necessarily so. I like to think of the concept of civil war as a kind of engine or motor that can be applied at the macro or micro level. I believe it is just as useful for thinking about international politics as it is for interpersonal conflict. It is, at once, a “real” legal and political fact, as well as an outlook and a sensitivity to the ways in which we encounter difference in the world. I remain in eternal debt to Nicole Loraux, who, in contradistinction with Tiqqun in Introduction to Civil War, and Agamben in Stasis (still the two most common reference points for a political theory of civil war), consistently maintains the unstable macro/micro and legal/ethical play of civil war without attempting to resolve one in the other.

Previous Readers Take Note… I have spent a few months making some huge changes to the copy of The Savage Peace I originally uploaded here. I no longer feel positive about having the entirety of that text on the site available as posts. No worries if you enjoyed it, because it will remain available in the download section of our website. I was long dissatisfied with having left out any citation of the first edition and with the unruly length of the piece, and honestly the sloppiness of the piece. I cut it down by nearly 100 pages to just the core of the piece (even with the addition of an addendum), and have added citations. I have also struggled through the years to spread word, especially as I found it harder to stand behind some of these missteps and shortsightedness. I am in the process of figuring out what I will do with the new manuscript, but it likely won’t appear here for the reasons already stated. I still have a limited amount of physical copies of this first edition I had printed to sell at cost, 5$ (plus 3$ shipping). Email me at sashavs@riseup.net if you want one. The whole book is available to download as a PDF for free. You can also download an imposed copy to print and bootleg. Enjoy —Sasha Durakov

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Addendum—Political Paradigms Diagram

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