Filtering Inequality: Screening and Knowledge in Senegal's Topography of Hepatitis B Care.

Only a fraction of the estimated tenth or so of Senegalese who are chronically infected with hepatitis B virus (HBV) have been diagnosed. Of these, few have been assessed for their risk of progressing to potentially fatal liver disease (indicating need for treatment), and fewer still are taking antiviral drugs. A massive gap between those needing and getting treatment is widely acknowledged among experts. But given that HBV and its biomedical treatment options are largely invisible in bodies, health data, care practices, public messaging, or mass media, how can we observe, ethnographically, the effects of constraints on and inequalities in treatment? What are the stakes of access to drugs, when this access is not being sought out, claimed, or enacted? This article tackles these questions by examining how HBV is being enacted in Senegal, but not necessarily in relation to antiviral treatment. I first describe the emergence, over the past decade and a half, of an exclusionary topography of HBV diagnosis and treatment. I introduce the notion of "filtration" to describe the effects of this topography on the formation of potential "subjects of access." The diagnostic therapies and expertise required to determine need for treatment are expensive, urban, and largely privatized. Moreover, knowledge about HBV and its possibilities of care circulates in narrow and sparsely distributed channels. Only a tiny minority of persons are effectively "filtered into" care, while issues of access remain largely outside of public debate. I then move onto small-scale efforts, led by rural primary health workers and community associations, to raise awareness of and expand screening for HBV. Those driving information and screening either do not reveal that effective drugs exist or locate these beyond the reach of most of their audiences or patients. Why then do they do it? I examine the logics and effects of their work to identify the forms of inclusion, care, efficacy, and explanation these open up. At the same time, I seek to discern the indirect effects of unequal access to knowledge and resources in the ambivalence, uncertainties, and contradictions that pervade these efforts to inform, diagnose, and advise.

International Health Research and the Emergence of Global Health in the Late Twentieth Century.

An influential policy network emerged from two overlapping developments of the 1970s and 1980s: new research programs focusing on tropical diseases and debates about how to implement the concept of primary health care at the World Health Organization. Participating actors came together in an informal network that, by the late 1980s, expanded advocacy to include the promotion and reorganization of all forms of research that might improve health in the Global South. This goal became associated with a search for new research methods for determining priorities, a quest that reached a peak in the early 1990s when the World Bank entered the picture. The bank brought money, economic analyses, and neoliberal ideology to the research advocacy movement and helped stimulate an upsurge of cost-effective forms of economic thinking in global health (GH) circles. This expanded research network provided some of the conceptual foundations and leadership for several of the most emblematic institutions of the new GH. These included new organizations to bring together and coordinate public and private actors in pursuit of common aims and new forms of economic rationality. The network's advocacy work contributed as well to a massive expansion of GH research at the turn of the century.

INTRODUCTION: SUSTAINING THE LIFE OF THE POLIS.

How are publics of protection and care defined in African cities today? The effects of globalization and neo-liberal policies on urban space are well documented. From London to São Paulo, denationalization, privatization, offshoring and cuts in state expenditure are creating enclaves and exclusions, resulting in fragmented, stratified social geographies (see Caldeira 2000; Ong 2006; Harvey 2006; Murray 2011). 'Networked archipelagoes', islands connected by transnational circulations of capital, displace other spatial relations and imaginaries. Spaces of encompassment, especially, such as 'the nation' or simply 'society' as defined by inclusion within a whole, lose practical value and intellectual purchase as referents of citizenship (Gupta and Ferguson 2002; Ferguson 2005). In African cities, where humanitarian, experimental or market logics dominate the distribution of sanitation and healthcare, this fragmentation is particularly stark (see, for example, Redfield 2006, 2012; Fassin 2007; Bredeloup et al. 2008; Nguyen 2012). Privilege and crisis interrupt older contiguities, delineating spaces and times of exception. The 'public' of health is defined by survival or consumption, obscuring the human as bearer of civic rights and responsibilities, as inhabitants of 'objective' material worlds 'common to all of us' (Arendt 1958: 52). Is it possible, under these conditions, to enact and imagine public health as a project of citizens, animated in civic space?

PHARMACY, MONEY AND PUBLIC HEALTH IN DAKAR.

Pharmacy students at the Cheikh Anta Diop University in Dakar must research and write a thesis to graduate. Thésards who took topics in analytical chemistry and toxicology describe their thesis work as a temporary opportunity to perform 'street-level' public health research that they regard as 'relevant' to the quality of people's lives. Expecting futures in the private commercial sector, thésards regretfully leave the thesis behind. This article explores the parenthetical nature of this moment - its brief openings and more durable closures - as part of the history of ways of being a pharmacist in post-colonial Senegal. The thesis as an interlude in students' biographies, curtailed by narrowed horizons of expectation, evokes other contractions: in the range of professional roles open to Senegalese pharmacists, and in the circuits of public health with which they might engage. For thésards, fieldwork, government work and commercial work entail spatial practices and imaginations; different ways of moving around the city and of tracing urban space that define pharmacists' roles in terms of the modes through which they engage with broader collectivities. Mapping thésards' parenthesis in Dakar is a means of capturing both their urban experience of work and the intertwining spatial, temporal and affective dimensions associated with this work. The past, probable and possible trajectories of pharmacy work are imprinted and imagined in the space of the city as field, market and polis. Pharmacists' prospects and aspirations are caught up in broader shifts in how education, (un)employment and entrepreneurship animate relations of association and exchange in Senegal.

Afin d'obtenir leur diplôme, les étudiants en pharmacie à l'Université Cheikh Anta Diop de Dakar doivent préparer et rédiger une thèse. Parmi les thésards qui ont pris des sujets de thèse en chimique analytique et toxicologie, certain(e)s décrivent ce travail comme opportunité temporaire de faire de la recherche en santé publique "au niveau de la rue," c'est à dire pertinente au bien-être des populations. Anticipant un avenir dans le secteur commercial privé, les thésards regrettent devoir tourner la page sur ce travail au terme de leurs études. Cet article explore la nature parenthétique de la thèse, en tant que moment de brèves ouvertures qui se referment ensuite durablement, et la situe dans l'histoire des manières d'être pharmacien au Sénégal post-colonial. La thèse apparait comme interlude dans la biographie des étudiants, écourtée par le resserement de leurs perspectives d'avenir, evoquant ainsi d'autres contractions: dans l'éventail des rôles professionnels et dans les circuits de santé publiques ouverts aux pharmacien(ne)s sénégalais(es). Le travail de terrain, le travail fonctionnaire et le travail commercial comportent pour les thésards des pratiques et imaginations spatiales ; différentes manières de se déplacer dans la ville et de tracer l'espace urbain, chacune définissant le rôle pharmacien en terme de ses modes d'engagement avec les collectivités. La projection de cette parenthèse sur la carte de Dakar nous donne un moyen de saisir à la fois l'experience urbaine de leur travail de terrain et l'imbrication de ses dimensions spatiales, temporelles et affectives. Les trajectoires passées, probables et possibles du travail pharmacien s'imprègnent et sont imaginées dans l'espace de la ville en tant que terrain, marché et polis. Les perspectives et aspirations des pharmacien(ne)s relèvent de dynamiques historiques plus larges, changeant la manière dont l'éducation, l'emploi (et le chômage) et l'entrepreunariat animent les relations d'association et d'échange au Sénégal.

The rise and fall of the dolorimeter: pain, analgesics, and the management of subjectivity in mid-twentieth-century United States.

This article describes how two experimental technologies, the Hardy-Wolff-Goodell dolorimeter and the clinical trial, were involved in, and transformed by, American analgesic research. Introduced in 1940, the dolorimeter quickly became popular as an analgesic-testing technology. By the early 1950s, however, the main sources of funding for analgesic evaluation had shifted to Henry K. Beecher's clinical trial methodology. To explain both the initial popularity of the dolorimeter and its displacement by the clinical trial, I examine the demands and resources generated by those who participated-as sponsors, investigators, collaborators, or subjects-in analgesic research and evaluation. These actors linked methodological designs to material resources, social interactions, and epistemological values, changing how pain-relieving efficacy both should and could be evaluated. They also mediated the interaction between specific expectations of, and investments in, analgesic evaluation and broader ideas about the reliability of drug evaluation and the subjectivity of pain. My analysis thus connects the changing social and material configuration of analgesic evaluation to the rise of clinical trials as well as increasingly psychological understandings of pain in order to frame the rise and fall of the dolorimeter.