The tyranny of the gift: sacrificial violence in living donor transplants.

Medical anthropology can bring to living donor transplant useful insights on the nature of gifting, family obligations, reciprocity and invisible sacrifice. Whereas, ethical reflections and debates on the marketing of tissues and organs, especially sales by living strangers, have proliferated to the point of saturation, the larger issue of the ethics of "altruistic" donation by and among family members is more rarely the focus of bio-ethical scrutiny and discussion today, though of course it was much debated in the early decades of kidney transplant. As the proportion of living over deceased donors (especially of kidneys) has increased markedly in the past decade, the time is ripe to revisit the topic, which I shall do via three vignettes, all of them informed by my 10 years as founding Director of Organs Watch, an independent, university-based, anthropological and ethnographic field-research and medical human rights project. Whereas living-related (altruistic) and living-unrelated (commercial) donation are often treated as very different phenomena, I will illustrate what social elements are shared. In both instances, paid kidney sellers and related donors, are often responding to family pressures and to a call to "sacrifice".

The Global Traffic in Human Organs1.

Inspired by Sweetness and Power, in which Sidney Mintz traces the colonial and mercantilist routes of enslaving tastes and artificial needs, this paper maps a late-20th-century global trade in bodies, body parts, desires, and invented scarcities. Organ transplant takes place today in a transnational space with surgeons, patients, organ donors, recipients, brokers, and intermediaries-some with criminal connections-following new paths of capital and technology in the global economy. The stakes are high, for the technologies and practices of transplant surgery have demonstrated their power to reconceptualize the human body and the relations of body parts to the whole and to the person and of people and bodies to each other. The phenomenal spread of these technologies and the artificial needs, scarcities, and new commodities (i.e., fresh organs) that they inspire-especially within the context of a triumphant neoliberalism-raise many issues central to anthropology's concern with global dominations and local resistances, including the reordering of relations between individual bodies and the state, between gifts and commodities, between fact and rumor, and between medicine and magic in postmodernity.

AIDS, public health, and human rights in Cuba.

PIP: Only Cuba has met the problem of AIDS with a traditional public health approach, which includes routine testing, contact tracing, partner notification, close medical surveillance, and partial isolation of infected individuals. The social behavior of Cubans (an absence of iv drug use, hostility toward homosexuals, and sexual puritanism) as well as access to abortion have contributed to the low incidence of the disease. Puerto Rico, with one-third the population of Cuba, has more than 8000 cases of AIDS, whereas Cuba has 927 cases of HIV seropositivity (as of May 31, 1993) and 187 cases of AIDS. Cuba acted promptly and decisively to control the epidemic, banning the importation of blood products in 1983 and administering the first of 12 million HIV tests in 1985. Whereas health screening is a familiar activity for Cubans, the isolation of HIV seropositive individuals in the Santiago fe las Vegas sanatorium was new. What began as a military-style hospital for HIV-infected soldiers returning from Africa was quickly transformed into a community which grants "leaves" to trustworthy residents who have completed a 6-month probationary period. Residents receive their old salaries whether or not they are working and are offered a choice of treatment regimens. As of July 1993, trustworthy residents can return home to live. If Cuba could have contained AIDS through a public educational campaign (and it has the infrastructure to have done so), then the human rights of the confined individuals were violated beyond restitution. International criticism of Cuba centers on this and largely ignores the equally troubling fact that abortions are universally recommended in HIV-positive women. In the parts of the world where AIDS has been regarded as primarily a human rights challenge instead of a public health crisis and preventive actions were dictated by a fear of further stigmatizing certain groups, personal freedoms have been protected, but many lives have been lost.^ieng

Difference and danger: the cultural dynamics of childhood stigma, rejection, and rescue.

This paper presents a brief overview of some cultural, ecologic, and demographic influences on the treatment and maltreatment of infants and children with congenital anomalies. Based on research on the selective neglect of infants leading to death in parts of the developing world, it is suggested that such practices be viewed as "ethno-eugenic" survivalist strategies altogether distinct from malicious child abuse and neglect in the modern, industrialized world. Caution with respect to heroic (and not so heroic) medical interventions and "child saving" in the contexts of both developing and modern societies is stressed.

Three propositions for a critically applied medical anthropology.

This paper initiates a discussion of some viable approaches to a critically applied as opposed to a clinically applied medical anthropology. The old question of the role of the intellectual man or woman is at the heart of this enquiry. Analogies are drawn between the current relations of anthropology to medicine and the history of anthropology's relations to European colonialism. The dilemmas of the clinically applied anthropologists 'double agent' role is discussed and alternatives offered in the form of three separate and to some extent contradictory projects, each of which, however, demands that the anthropologists cut loose his or her moorings from conventional biomedical premises and epistemologies. Ours must be an anthropology of affliction and not simply an anthropology of medicine. Praxis must not be left in the hands of those who would only represent the best interests of biomedical hegemony.

'Mental' in 'Southie': individual, family, and community responses to psychosis in South Boston.

The deinstitutionalization of psychiatric patients is a deeply cultural as well as political task. It entails the sharing of responsibility for human distress with family and community. Consequently, the locus of social control has also shifted from psychiatric and medical expertise to community and legal institutions. Diagnosis and treatment models must be more compatible with lay explanatory models. This paper explores the various meanings of "going 'mental"' and "being 'mental"' in the white, working class, ethnic neighborhood of South Boston. The data are extracted from a study of the impact of deinstitutionalization on a cohort of middle-aged, psychiatric patients discharged from Boston State Hospital in the attempt to return them to community living. Individual, family, and community responses to, and interpretations of, the symptoms of mental distress are discussed. The study indicates that even seriously disturbed individuals are sensitive to cultural meanings and social cues regarding the perception, expression, and content of psychiatric episodes. While madness invariably disenfranchises, it does not necessarily deculturate the individual.

Breaking the circuit of social control: lessons in public psychiatry from Italy and Franco Basaglia.

Much public discourse in the United States and in Canada acknowledges the dismal failure of the policy to 'deinstitutionalize' mental patients and to return them to some semblance of community living. The American Psychiatric Association has recently called for a reassessment of institutional alternatives--a call for a return to the asylum--in response to the needs of the new population of so-called homeless mentally ill. Here we contrast the failures of North American deinstitutionalization with the relative successes achieved in those regions of Italy where deinstitutionalization was grounded in a grassroots alternative psychiatry movement and professional and political coalition, Psichiatria Democratica. Democratic psychiatry challenged both the medical and the legal justifications for the segregative control of the 'mentally ill': madness as disease, and the constant over-prediction of the dangerousness of the mental patient. In addition, the movement challenged traditional cultural stereotypes about the meanings of madness, and was successful in gaining broad-based community support from political parties, labor unions, student groups, and artist collectives that were enlisted in the task of reintegrating the ex-mental patient. The Italian experiment, although flawed and riddled with its own inconsistencies and contradictions, offers evidence that deinstitutionalization can work without recreating in the community setting the same exclusionary logic that was the foundation of the asylum system.

Infant mortality and infant care: cultural and economic constraints on nurturing in northeast Brazil.

The Brazilian 'Economic Miracle' has had an adverse effect on infant and childhood mortality which has been steadily rising throughout Brazil since the late 1960s. An analysis of the reproductive histories of 72 marginally employed residents of a Northeast Brazilian rural shantytown explores the economic and cultural context that inhibits these mother's abilities to rear healthy, living children and which forces them to devise 'ethnoeugenic' childrearing strategies that prejudice the life chances of those offspring judged 'less fit' for survival under the pernicious conditions of life on the Alto. it is suggested that the selective neglect of children is a direct consequence of the selective neglect of their mothers who have been excluded from participating in the national economy. The links between economic exploitation and maternal deprivation are further discussed with reference to the social causes of the 'insufficient breastmilk syndrome' and the commercial powdered milk dependency of these women.

Curanderismo in Taos County, New Mexico--a possible case of anthropological romanticism?

Interviews with 25 Spanish-Americans of Taos County, New Mexico, indicate that time and acculturation have greatly eroded the belief in and practice of curanderismo, the traditional folk medical system of the Southwest. Curanderismo in northern New Mexico today has moved from being a primary and important source of medical care to one used alternatively and very occasionally in cases of pediatric disorders, chronic illnesses and pain, and for those maladies still classified according to the traditional folk beliefs.