Even with a shared conceptualization of medical research as a transaction, there is still gray area in defining the type of transaction. An object moving from one person to another can fall anywhere within the extremes of giving voluntarily, with no expectation of anything in return, to forcibly taking something without payment. Some might frame this as a choice between Mauss’s gift or Marx’s commoditization.33 On the one hand, medical research could be characterized as being dependent upon commoditization of pieces of the body such as blood, skin, urine, and stool.34 These items were physically separated from an individual, had a value, and were exchanged between the person who “produced” the substance and the researcher who valued it. On the other hand, it’s doubtful that these exchanges were wholly about commoditization. The anthropologist Parker Shipton has argued persuasively that in Luo country in western Kenya, “there is no systemic ‘gift economy’ or ‘commodity economy’ but rather exchanges that weave in and out of these principles.”35
Moral economy may perhaps be a more appropriate framework for considering these transactions. The anthropologist Ruth Prince describes how the term captures “the shared mores and values with which people evaluate their relations with others, from economic transactions to the obligations informing social hierarchies and patterns of accumulation, including relations between political elites, states, and citizens.”36 It should come as no surprise that as blood and other valuable substances moved from a body to outside a body, there were often disagreements about what type of exchange was taking place, whether it was equitable, whether the person was to trusted.37 These transactions allowed for judgments to be made about researchers, for trust to be established and relationships to be created—all out of a transfer of bodily products from one person to another. However, if the exchanges of medical research were sometimes considered gifts and other times considered commodities, it meant that there were countless opportunities for miscommunication. Modern findings about medical research in the West African nation of The Gambia found that scientists and communities often came to “radically different framings” of the exchanges they were participating in, which could lead medical researchers to believe “that what they take from subjects is a gift rather than part of a transaction, and thus act in ways that from the other side appear to be stealing.”38 If a participant believes she is participating in an inequitable exchange and may have been the victim of theft, it is no surprise that conflict often results.
Research as a Space of Conflict
“Conflict,” broadly defined, runs through each of the chapters; nearly every case study has moments of tension or places where research is put in jeopardy. The reasons were not always clear, since many of the projects at first glance look benign. These moments of conflict illuminate two important points. The first is that disagreements between researchers and East African participants were frequent, but that the arrangement of power was unpredictable. The fact that there was conflict indicated that people were not the docile subjects some past accounts have implied, and power was rarely effectively exerted upon subjects for very long. More frequently, participants demonstrate an ability to resist effectively, or at least mitigate, the control of individual researchers or larger projects. (I am wary of labeling these cases of researcher and community conflict as “resistance” since the term is too often used as shorthand for resistance against the colonial state. I am far more comfortable explaining it in terms of the very real dissatisfaction and discontent bubbling up because of specific projects, particular researchers and discrete interactions.39) The second point about conflict is less obvious, and often overlooked in the literature about colonial science. That is, that colonial researchers were frequently in conflict with each other and that their disagreements illustrate the diversity of opinions existing within a supposedly unified and homogenous organization. The information presented throughout the book on the divisions in colonial opinion forces us to develop a more nuanced perspective on how colonial science functioned in East Africa.
One of the limitations of my argument is that I cannot speak to divisions within a community, and whether the resistance researchers perceived as all-encompassing was actually so unified. In many of these case studies, if there were significant fissures in villagers’ opinions (breaking on the lines of gender, class, religion, ethnicity, age, etc.), the data I have do not reveal it. This does not mean such fissures did not exist, but the dissent in these communities was widespread enough to present what looked like a unified front to bewildered and frustrated researchers. If the divisions in public opinion had been big enough, it seems someone—the researchers, the chief, a sympathetic villager—would have tipped the medical workers off. Researchers had no qualms about trying to appeal to whatever sympathetic factions they could find, but the data rarely reveals such divisions. It is also worth noting that I do not formally address how gender shaped (and shapes) the medical research encounter in East Africa. This is not an inadvertent oversight, but a result of the data I was able to gather: a majority of the researchers and participants available to be interviewed were male. Among the women I did speak with and who emerged in the archival documents, I was not able to discern themes or arguments on the basis of gender that felt adequately evidenced. It is a topic that I hope to pursue in the future, especially given the rich materials provided by Dr. Hope Trant, who is discussed in chapter 5.
Research and the Production of Everyday Ethics
This book’s final argument is that what came to be the norms of medical research—the accepted practices, how work actually got done, and the myriad compromises and modifications that required—were the product of negotiations. Clearly stated, researchers and participants were both responsible for establishing the norms of day-to-day medical research practice. East Africans regularly surprised and frustrated researchers by being such active research participants, and their preferences and demands forced researchers to modify scientific plans. Africans absconded from projects that didn’t fulfill their needs, shut down projects that didn’t align with their interests, or modified them in ways that better accommodated their own expectations of fair benefit, acceptable risk, or norms of the body and healer-patient relationships. As one example, plans to take blood in the middle of the night to test for lymphatic filariasis were abandoned after people refused to participate. Instead, blood was taken in the early evening, even though this was a less accurate method for testing and led to biased and problematic results.
In recent years, the distinguished medical anthropologist Arthur Kleinman has called for a shift in medical ethics so that they are “the outcome of reciprocal, participatory engagement across different worlds of experience.”40 I agree with the sentiment, but I disagree with one of the assumptions: that current medical ethics are not the result of participatory engagement. Many, if not all, of the case studies in this book show that East Africans have made their preferences known, shaped practices in the field, and worked to create new forms of medical ethics that accorded with their own wishes and expectations. The “everyday ethics” governing medical research interactions in East African communities are the result of what the anthropologist Wenzel Geissler terms an “ethics of collaboration.”41 While formal ethics as stipulated in various human rights documents are well intentioned, they tend to discount or ignore “what happens when one person responds to the other in open-ended, face-to-face relations that occur within the field.”42 In response to this shortcoming, anthropologists have introduced the terms “everyday ethics” and “field ethics” that focus on “the ethics guiding the everyday life of research.”43 A few words of caution here: by arguing that African subjects were active in establishing norms, I am not claiming that these interactions were fair, just, or ethical. Research was often deceptive, coercive, and exploitative, and there were power differentials between government-sanctioned researchers and colonial subjects/East African citizens that we must remain attentive to. Although I do use the terms “everyday ethics” and “field ethics,” they are problematic precisely because they sound benign, and may allow us to be too complacent when discussing exchanges that were deeply unequal.
Book Scope and Organization
The temporal and geographic scope of this book is unusual in that historians