Book commentary, Somatosphere Sept. 2015

Somatosphere | September 21, 2015 Book Forum: Theresa MacPhail’s The Viral Network: A Pathography of the H1N1 Influenza Pandemic Lyle Fearnley Nanyang Technological University Katherine A. Mason Brown University Natalie Porter University of Notre Dame Adia Benton Brown University Carlo Caduff King’s College London Theresa MacPhail Stevens Institute of Technology Edited by Eugene Raikhel University of Chicago In this Book Forum, our commentators respond to Theresa MacPhail's provocative ethnography of influenza research and public health response, The Viral Network: A Pathography of the H1N1 Influenza Epidemic. Lyle Fearnley, Katherine A. Mason, Natalie Porter, Adia Benton, and Carlo Caduff reflect on — among other issues — the place and privileging of the laboratory, the simultaneously limiting and lubricating effects of network connections, the problems with foregrounding expertise over power as an explanatory framework, and the way that experts wield speculation and temporality as tools in the global health arsenal. Theresa MacPhail concludes with a response and meditation on her notion of pathography and the continued mutations of a viral anthropology. Book Forum: The Viral Network: A Pathography of the H1N1 Influenza Pandemic 2 Inside the Viral Network Lyle Fearnley Nanyang Technological University The provocation of Theresa MacPhail’s Viral Network is her concept of Global Public Health as a “superorganism.” MacPhail distances herself from Spencer, Durkheim, and Kroeber’s conceptions of a superorganic Society or Culture autonomous from the biological or psychological (214, note 7). She draws on biologists and theorists of social networks who describe phenomena such as swarms of bees as ‘superorganisms,’ displaying unity and emergent characteristics not present in the individual members. Global Public Health, in her account, acts like a swarm of sorts, gaining capacities for “sense-making, knowledge production, and decision-making” (214, note 7) as the networked relations among its disparate members configure a concerted response to the epidemic event. This is the viral network: a network of expertise and communication that resembles or even mimics the way an influenza virus spreads. “By the end of my fieldwork,” MacPhail writes, “I realized that global public health is as viral as the viruses it tracks, collects, studies, reproduces, manipulates, and helps to contain or eradicate” (211). She argues that the ‘global’ of global health, like a virus, relies on the infection of local host institutions, and “is constituted by information that moves and flows and mutates and self-replicates,” expanding its reach (contagion) through transformations and adaptations (mutation). Far from Kroeber’s attempt to preserve the autonomy of culture from biology, MacPhail emphasizes the formal homologies between biological genes and cultural memes. Amidst these contagious flows and mutating forms, MacPhail locates what she considers the skeleton of the superorganism in the laboratory. In what MacPhail calls the “invisible chapter” of the book, she argues that “even if the lab techniques are often unspoken, they form the backbone of everything scientists know — or want to know — about how influenza viruses act in the world outside the laboratory” (50). In this chapter, MacPhail makes clear that the relationship between her “two main protagonists” (14) is much more than an analogy. Rather, both the influenza virus and Global Public Health are made — one could even say, co-produced — through laboratory practices. The phylogenetic trees that scientists construct to show the genetic relations between influenza viruses, for example, also build the social relations among the scientific experts that constitute Global Public Health. “Nodes in the global public health network are fashioned through work done on the influenza virus,” she writes, “so it should also not be all that surprising if those Somatosphere | September 21, 2015 Book Forum: The Viral Network: A Pathography of the H1N1 Influenza Pandemic 3 same interpersonal and institutional relationships ultimately reflect certain characteristics of the phylogenetic trees crafted through the process of sequencing, analyzing, and sharing genetic information” (22). Historically, the laboratory has been pivotal to the very idea of a global influenza pandemic, particularly through the World Health Organization’s Global Influenza Surveillance Network (GISN), which has provided the standards and protocols for observing the spread of influenza around the world. But MacPhail, like many of her predecessors in science studies, extends this historical role of laboratories into a general model of the production of scientific knowledge. Karl Marx wrote that political economy, “which first emerged as an independent science during the period of manufacture,” mistakenly analyzed the social division of labor in terms of the division found in manufacture, as if society were a massive factory (Capital Vol. 1, 486). For MacPhail, the laboratory is what the factory was for political economy: not only an important site in the field of global health, but also the vantage from which the vital structure and function of the entire superorganism can be observed. But what if our anthropological models of scientific knowledge production no longer treated the laboratory as the essential organ of science, as if laboratories were the vertebrae that hold up the entire body of knowledge? This would mean not only following experts out of the laboratory, but also investigating how knowledge about influenza is made beyond expert domains (such as among Buddhist practitioners in Hong Kong or poultry farmers in China). MacPhail provides a few hints of these outsides, particularly in her ethnographic accounts of influenza research in Hong Kong. But ultimately the superorganism incorporates these outsides, reducing them to heretics that only confirm the fundamental doxa of flu research: “The heretics and the orthodox might disagree on the meaning of influenza research, but they agree on the importance of the research itself” (182) — and by research MacPhail means sequencing viruses in the laboratory (see 191; 197). MacPhail’s concept of global health as a superorganism ultimately reaffirms the particular view of influenza, and the world, availed from the inside of the viral network. But if we leave the laboratory, and look back on its walls from the outside, we see that the superorganism, despite its global claims, remains confined within a rather limited space. Lyle Fearnley is a Postdoctoral Fellow in the Humanities, Science and Society Cluster at Nanyang Technological University, Singapore. He has recently published an essay in Cultural Anthropology entitled “Wild Goose Chase: The Displacement of Influenza Research in the Fields of Poyang Lake, China,” and is co-editor (with Anthony Stavrianakis and Gaymon Bennett) of Science, Reason, Modernity: Readings for an Anthropology of the Contemporary (Fordham University Press, 2015). Read this piece online at: http://somatosphere.net/forumpost/inside-the-viral-network Somatosphere | September 21, 2015 Book Forum: The Viral Network: A Pathography of the H1N1 Influenza Pandemic 4 Katherine A. Mason Brown University Lurking beneath the metaphor of viral contagion in The Viral Network is an aspect of the viral experience so fundamental as to be absent from much of the explicit discussion in the book: the power to inflict suffering, and to do so differentially. The viral represents connectivity, to be sure, but it also represents the pain and suffering that that connectivity can create. Perhaps more to the point in the context of MacPhail’s discussion, not all nodes in the network are equal either in their ability to create or ease suffering, or in their likelihood of being made to endure it. To extend one of the book’s more evocative metaphors, the ‘superorganism’ of global health has a brain (the center) that exercises profound control over other organs (the periphery). This is a book on expertise, so it is perhaps not the place to delve deeply into the highly unequal global suffering and equally unequal fear of suffering that drives so much of the discursive power of viral pandemics — except perhaps to note that the very real specter of death surely partners with what the author terms “strategic uncertainty” in driving the cycle of funding, research, and fear that keeps the engine of pandemic preparedness chugging along. That the outsized fears of contagion on the part of some of the wealthiest places on Earth — a category into which one could place Hong Kong, despite its postcolonial status — match up poorly with the actual distribution of suffering caused by viral outbreaks is now an aphorism among social scientists studying global health. The recent Ebola outbreak and its concentration in some of the poorest parts of the world provides only one recent illustration of how viruses spread in ways that are so far from the vision of “pandemic humanity” that MacPhail describes at the end of her book as to make this vision tragically comedic. The steep slopes of global geopolitical power almost always track viral suffering and death more closely and accurately than any epidemiological model. Epidemiologists know this well — and yet they keep building their models, trying to keep deadly viruses, as WHO has often articulated it, “at their source.” The always unspoken addendum being, “in the poor places that are going to suffer anyway.” This is what SARS and avian flu wrought: a fantastical notion of a just world unified against a common enemy, against the background of a grossly unequal burden of existing and potential suffering. And yet the flip side of differential suffering and power is that those “experts” residing in the less powerful nodes of the global viral network are left to implement this impossible vision with little power to shape what the vision should or could be. MacPhail points out that in Hong Kong public health scientists were “global partners” who nonetheless had a highly delimited ability Somatosphere | September 21, 2015 Book Forum: The Viral Network: A Pathography of the H1N1 Influenza Pandemic 5 to shape global best practices. Pandemic control protocols continued to be made by and for Western nations, particularly the U.S., with junior partners subject to criticism if and when they went down their own paths in attempting to achieve the goals outlined in official preparedness plans. As I have described previously in my own work (Mason 2010), Chinese public health professionals on the other side of the border from Hong Kong drew upon their own experiences with the SARS epidemic to design and implement harsh H1N1 control measures like the ones MacPhail describes. Such measures included mass fever checks, border quarantines, and involuntary collection of bodily fluids. My interlocutors’ decision to draw upon China’s authoritarian powers to attempt to control an uncontrollable virus was motivated by a sense of professional striving as well as by a belief that disease control with Chinese characteristics could and should be a more perfect version of global preparedness. Without the bothersome problems of democracy and human rights claims, Chinese public health professionals felt they could do what needed to be done — thus fulfilling the “temporary authoritarianism” fantasies of MacPhail’s informants. They thought, perhaps naively, that strict quarantine and isolation procedures would reward them with upward mobility within the global public health superorganism. The backlash they instead felt highlighted for them the global hierarchies of power. They were “partners,” yes, but until they did things the “Western” way, they would only ever be junior partners at best. Their power over their own people was, from their perspectives, no match for the power that U.S.-dominated science continued to have over them and their aspirations. Katherine A. Mason is Assistant Professor of Anthropology at Brown University and a Robert Wood Johnson Foundation Health and Society Scholar at Columbia University. She is the author of After SARS: The Rebirth of Public Health in a Chinese ‘City of Immigrants’ (Stanford, in press). Read this piece online at: http://somatosphere.net/forumpost/mason_comments Somatosphere | September 21, 2015 Book Forum: The Viral Network: A Pathography of the H1N1 Influenza Pandemic 6 Pathways to Expertise Natalie Porter University of Notre Dame One of the first lessons I learned in graduate school was how to characterize an ethnography in a single phrase or sentence. These characterizations followed a predictable pattern: X is a book about Y in Z — witchcraft in the Sudan, adolescence in Samoa, AIDS in Haiti — as if the phenomenon, its place, and its people could be captured and packaged in a tidy phrase. Some books, however, defy this pattern and challenge the conventions of ethnography itself. The Viral Network is not about H1N1 in Hong Kong, even though Theresa MacPhail spends much of her time exploring the 2009 outbreak from the vantage point of microbiologists and epidemiologists in this metropolis. Reasoning that the global and virtual nature of pandemics challenges traditional narratives and methods of ethnographic analysis, MacPhail proposes a pathography: a metanarrative of the H1N1 pandemic over multiple sites and timeframes. Like viruses themselves, the subject of MacPhail’s pathography is more nebulous and mutable than those encountered in traditional ethnography. This ambitious book tackles global public health and “pandemic humanity” as “superorganic subjects that become infected with influenza.” What’s exciting about the pathographic approach is that it unapologetically reconfigures conventional anchors of anthropological analysis. The text traces a quasi-sentient network of individuals, institutions, and things entangled in webs of knowledge and information sharing. Like viruses, the actors in this web do not really exist on their own, nor are they situated in any one place or time; rather they emerge, interact, mutate, and communicate at different sites and moments in the the ever-expanding network. Crucially, the viral network’s limitless growth potential offers a prompt to further expand the field of experts in global disease crises. Though this is not a book about affected communities, I am curious about how their expertise figures into the viral network, for what they know about H1N1 matters to the metanarrative. Such communities are at least partially responsible for the epistemological rupture between virologists and epidemiologists that MacPhail deftly describes throughout the book. Just as epidemiologists in Hong Kong strategically deployed “local knowledge” to assess sequence data and negotiate H1N1 standards, I have observed that those confronting H5N1 in Vietnam make claims about the knowledge and attitudes of “at risk” communities in order to define actionable information. They also package this information in ways Somatosphere | September 21, 2015 Book Forum: The Viral Network: A Pathography of the H1N1 Influenza Pandemic 7 that conform to donor requirements and governmental agendas. Adding threads to the web, we can ask specific questions about how patients, farmers, funders, and state leaders also transmit information in the viral network, whether directly or through scientists’ discourses. MacPhail provides glimpses of such alternative knowledge bearers, particularly in her conversations with Dr. Leung, whose heretical stance on H1N1 stems from his relationships to poultry farmers. Knowing that farmers entrust virus samples to him, Leung foregrounds his responsibility to their livelihoods as he generates information from those samples. Quality is only one concern in the uneven world of influenza sample and information sharing. At stake here are the livelihoods of some of the worlds’ poorest populations, as well as the geopolitical status of states in a global health arena that, though charged with moral directives to freely exchange materials and information, at times seems anything but free. I thus take MacPhail’s insightful analysis as a provocation to bring more entities and values into narratives of scientific production and practice. Viral anthropology can and should spin its web in many directions, capturing more and more sources of expertise in pandemic crises, and remembering that any individual or institution’s commitment to generating and sharing “good” information is always situated alongside other commitments. As MacPhail shows, webs form connections, but they are also sticky. Admittedly, such a provocation focuses attention on more traditional ethnographic subjects at a time when MacPhail’s innovations are both welcome and necessary. Still, the incorporation of patients, farmers, funders, and statemakers into pathography could reveal that they are not only subjects of viral infection or scientific intervention, but also active in the production of scientific knowledge and value. Expanding the field of experts could reconfigure the pathways, and directions, of pandemic expertise. Natalie Porter is Assistant Professor of Anthropology at the University of Notre Dame. She has published articles in American Ethnologist, Social Science and Medicine, BioSocieties, and Public Culture on global health interventions for zoonoses. She is currently completing a book length ethnography on the global exchange of materials and information in pandemic flu control, with a particular focus on Vietnam. Read this piece online at: http://somatosphere.net/forumpost/pathways-to-expertise Somatosphere | September 21, 2015 Book Forum: The Viral Network: A Pathography of the H1N1 Influenza Pandemic 8 On the Uses of Time Adia Benton Brown University In The Viral Network, MacPhail tells her readers that “one cannot talk about biology without recourse to geography” (77). She also makes the case — albeit less pointedly — that one cannot talk about geography or biology without recourse to time and temporality. This connection comes into focus in MacPhail’s account of Hong Kong as a post-colonial space (itself a spatiotemporal descriptor), as a setting for collectively-imagined influenza origins, and as a site where distinct public health cultures intermingle and expertise is forged. Notably, MacPhail demonstrates how “stories we create about pandemics…loop back and forth in time and space and weave fears about death and disease into the fabric of our daily uncertainties” (131). Earlier influenza outbreaks occurring in 1918 and 1997 (and 2003 and 2005), she argues, form the basis for planning for present and future H1N1 outbreaks. Person, place and time are the building blocks — the elementary structures, if you will — of descriptive epidemiology. The spaces of post-colonial global health expertise and knowledge are produced through what Johannes Fabian has called the ‘uses of time.’ This means that if one is tracking the various kinds of epidemic narratives “thickening” in time and space, as MacPhail does quite fluidly in her book, one cannot simply configure her analyses in terms of past, present and future. Rather, accounting for temporality in ethnographic studies of epidemics also means engaging in deep study of timing, sequencing, tempo, and synchronization, among other things. MacPhail begins to sketch some of these dimensions in her ethnographic accounts of the tempo of everyday laboratory work, the sequencing, timing and duration of public health agency operations, and the improvisational aspects of ‘evidence-based’ decision-making. I will briefly address the latter two. In chapter three, MacPhail recounts a debate among officials in the U.S., Europe and Hong Kong on the effectiveness of quarantine. She notes that Hong Kong public health authorities agreed with American and European experts about quarantine’s inability to stop transmission. But they disagreed with them on whether the epidemic could be sufficiently slowed for the purpose of planning or minimizing its potential effects (99). Delay as a part of a calculated strategy for addressing an epidemic flu outbreak, then, is a way that difference — manifest in ideology and practice — is produced as a function of time. In this way, the uses of time not only become techniques or tools of power (as others have convincingly argued), or another way in which Somatosphere | September 21, 2015 Book Forum: The Viral Network: A Pathography of the H1N1 Influenza Pandemic 9 references to the past bear on present decisions about the future, but also the means through which effective action, of taming chance, is articulated and understood by different actors. In chapter four, MacPhail examines how public health experts strategically deployed uncertainty to justify future and continued knowledge production about influenza. The management of risk through these strategic deployments, to borrow loosely from MacPhail’s analogy to the sirens’ song, resembles musical improvisation — rhythm, tempo and key are preserved, a theme is repeated, but at points, the melody changes at the will of the performer. Yet the song never ends, if we are to take seriously MacPhail’s suggestion that the expert narratives about uncertainty are consistently open-ended. What we know about flu is, therefore, circumscribed by loose conventions of composition in the form of predictable uncertainty. In light of these very brief meditations on this book, my question, then, is this: how might an even more thickened conception of time and temporality — beyond loops of past-present-future — open up how expertise and knowledge about pandemic flu is produced and circulated, how viral networks constitute themselves? Adia Benton is Assistant Professor of Anthropology at Brown University. Her research and teaching focus on ideologies, cultural practices, and political economy of global health. Her new book, HIV Exceptionalism: Development through Disease in Sierra Leone, is an ethnographic account of how HIV exceptionalism — the idea that HIV/AIDS is an exceptional disease requiring an exceptional response — shapes local institutions, cultural and political idioms of development and the lived experiences of HIV-positive individuals. Read this piece online at: http://somatosphere.net/forumpost/on-the-uses-of-time Somatosphere | September 21, 2015 Book Forum: The Viral Network: A Pathography of the H1N1 Influenza Pandemic 10 The Mimetic Moment Carlo Caduff King’s College London How can we write about experts without reducing expertise to the limits of reason alone? To understand expertise we need to understand its excess. On September 11, 2014 (a date with more than one meaning), public health expert Michael Osterholm from the University of Minnesota shared a secret with the readers of the New York Times. According to the prominent public health professional, experts are “loath to discuss openly but are definitely considering in private” that the Ebola virus could mutate and change and spread through the air. This, then, was the secret to be shared with the public: that Ebola could turn into a kind of flu, a germ spreading through the atmosphere with the speed of a plane and the power of a storm. Theresa MacPhail’s pathography of pandemic influenza demonstrates how, in the world of expertise, infectious disease is always in the future. The worst is always to come. This displacement of disease into the future is grounded in an understanding of the virus. The virus always exceeds itself; it cannot keep itself to itself. It is constantly mutating and recombining, making itself different from itself. Thus, the virus as a figure of potentiality operates as an objectification of the future in the world of expertise. It serves as a powerful source of discursive production, allowing experts to enter the universe of the unverifiable. Osterholm’s vision of a virus that can transmit rapidly through the air and infect millions of people with Ebola: was it just a fiction, another figment from the expert’s savage mind? Or was it, on the contrary, more than mere speculation? A prophetic revelation of a coming plague? To prepare for the future, experts count on the power of fiction. The promise of such fiction is to contain the force erupting from the mutant nature of the virus. Experts spectralize the virus to convey its essence, capture its spirit. What needs to be theorized in this production of spectrality as reflection of reality is the relationship between reason and its object. As Hegel once noted, “true scientific knowledge…demands abandonment to the very life of the object.” Somatosphere | September 21, 2015 Book Forum: The Viral Network: A Pathography of the H1N1 Influenza Pandemic 11 Carlo Caduff is Lecturer in the Department of Social Science, Health & Medicine at King’s College London. He is the author of “On the Verge of Death: Visions of Biological Vulnerability” (in Annual Review of Anthropology) and “Pandemic Prophecy, Or, How to Have Faith in Reason” (in Current Anthropology). The title of his forthcoming book is: The Pandemic Perhaps. Dramatic Events in a Public Culture of Danger (University of California Press). He is a Visiting Lecturer at the Graduate Institute in Geneva and co-organizer of the Wenner-Gren symposium “New Media, New Publics?” Read this piece online at: http://somatosphere.net/forumpost/the-mimetic-moment Somatosphere | September 21, 2015 Book Forum: The Viral Network: A Pathography of the H1N1 Influenza Pandemic 12 Secondary Infections Theresa MacPhail Stevens Institute of Technology When I first began my fieldwork, and began the process of grappling with influenza viruses and the various experts who study and track them, I lamented the difficulties of doing research on global phenomena. The 2009 H1N1 pandemic not only mutated faster than I could write about it, but the boundaries of my subject matter were notoriously difficult to delineate. Where did one go to study a pandemic? When did it begin or end? And how could I possible incorporate everything I observed or experienced into a cohesive ethnographic narrative? In the end, I decided that the virus was the key to unlocking the puzzle of how to study pandemics. All I had to do was let it mutate my thinking and writing and research methods. The Viral Networkwas the result. Happily, the insightful and provocative comments collected here have further infected my thinking. Reading through these careful reviews from some of my favorite scholars and colleagues has led me to see my original project and its scope, its successes and failures, from a few new vantage points. And for that, I’m grateful both to them and to Somatosphere for inviting me to take part in the book forum. To begin, Lyle Fearnley is absolutely right to suggest that perhaps we focus too much on the laboratory. My own work bridges the fields of anthropology and science & technology studies (STS) and it is difficult, after over a decade of delving into STS and the history and philosophy of science, not to be contaminated by the concept of the lab. Fearnley compares this lab mania with the factory obsession of Marxist political economy. The comparison is an apt one. He provocatively asks, “But what if our anthropological models of scientific knowledge production no longer treated the laboratory as the essential organ of science, as if laboratories were the vertebrae that hold up the entire body of knowledge?” What if? For a start, I’m not sure that one can ever fully ignore the lab — especially since “the lab” has now become a metaphor for any space in which science is practiced. After all, where isn’t the lab these days? Fearnley suggests that, ultimately, the superorganism of Global Public Health is confined to the space of the laboratory. I don’t think that’s true. I spent a bit of time in the actual, physical space of a virology lab, but quite a bit more time outside of it. Yet where ever I went — U.S. CDC meeting rooms, conferences, fresh chicken stalls, public health offices — there it was. I was never fully outside of the lab. But I do agree with Fearnley in that global health does best — or is Somatosphere | September 21, 2015 Book Forum: The Viral Network: A Pathography of the H1N1 Influenza Pandemic 13 healthiest in terms of its capacity to function — inside the institutional spaces from which it emerges and reemerges during times of international health crises. And one of those spaces is, and will continue to be, the laboratory. And yet, why should the lab — by which I mean the products of the lab, lab thinking, or the concept of the lab — travel so well throughout the viral network of global health? Natalie Porter reminds us that a network is, at its core, an informational and material web. Knowledge about viruses travels along sticky trails already carved out by the viruses themselves. The flu virus, at least in part, spins its own webs. In many ways, the lab is the virus’s workshop as much as it is the virologist’s. It’s the constant interaction of people, places, and viruses that produces the silk threads of the web in the first place. The resultant viral network is, as Porter argues, very sticky. Porter writes, “Like viruses, the actors in this web do not really exist on their own, nor are they situated in any one place or time; rather they emerge, interact, mutate, and communicate at different sites and moments in the ever-expanding network.” People and things and ideas can, and often do, get trapped in tacky threads of knowledge and expertise and their movement is both aided and limited, to be sure. But what are the limits of the viral network? Does everything become caught up in this gummy web of viral expertise? And what about the very real dangers of the flu to the communities most at risk (rural farmers, chicken stall workers, etc.)? Katherine Mason’s review astutely points to one of the limits of my ethnographic research and the book itself. Porter wonders about “the affected communities” and “how their expertise figures into the viral network.” She argues convincingly that the narratives produced by the superorganism of global health completely co-opt or drown out the voices of the disenfranchised — people who are at the mercy of the institutional structures that global health is supported by and undergirds. Echoing Mason, Porter writes that we can and should “ask specific questions about how patients, farmers, funders, and state leaders also transmit information in the viral network, whether directly or through scientists’ discourses.” I take seriously Mason’s critique that the viral isn’t just about global networking or connection, but “also represents the pain and suffering that that connectivity can create.” In a provocative continuation of my own usage of the superorganism, Mason writes that “the ‘superorganism’ of global health has a brain (the center) that exercises profound control over other organs (the periphery).” In other words, not all actors or experts are alike — some experts are more subject to the strict hierarchies of the global network itself. This is no doubt very true and very troubling. Mason suggests that the concept of pandemic humanity that global health helps to construct is a dangerous pipe dream. Death is very real; it’s not just a narrative that relies upon ungrounded fears of a once or future pandemic. The problem is, as Mason points out, that death does not come for everyone equally. It is more likely to affect those living in the most dire situations — as is seen in the continuing Ebola outbreak (or the continuing cholera outbreak in Haiti for that matter). Mason effectively argues that tracking power would work just as well as tracking viruses in terms of epidemiological forecasting. Epidemiological models, as she suggests, Somatosphere | September 21, 2015 Book Forum: The Viral Network: A Pathography of the H1N1 Influenza Pandemic 14 simply mirror what we already know: that the “global” poor will die faster and in greater numbers than the “Western” rich. Since the book’s publication, and throughout the Ebola epidemic, I’ve been thinking a lot more about how expertise is created and then functions within global health and how “local knowledge” factors into policy planning and decisions. One of global health’s biggest problems centers around the issue of “culture.” Medical anthropology has largely infiltrated public health in so far as epidemiologists and other experts working in places like the WHO and MSF understand that they need to be aware of and take “local cultures” into consideration. They also understand that local knowledge is important to a successful global health response. However, “global” health is a patchwork of “national” and “local” actors anyway. All experts, without exception, come into any outbreak situation carrying their own institutional “cultures” with them. Epidemiology isn’t practiced alike everywhere — even though the terms, protocols, and “facts” are all the same. Knowledge about what to do and what to prioritize are different between, say, the U.S. CDC and the European CDC. It’s not just the disenfranchised voices that are being lost, co-opted, or misinterpreted. In the cacophony that is global health in a crisis, whose voices should matter the most? To trouble this even further, Carlo Caduff suggests that the problem may originate in equating expertise with reason, as if rationality were the only true path to knowledge. Expertise, Caduff argues, is always about the future — you need expertise to predict events, not necessarily to tell you about what already happened. Or rather, those working in global health only care about what happened if it is useful in the present moment in relationship to deciding upon a future course of action. Global health knows in order to plan to do. In this way, global health is truly viral. As Caduff points out, the virus is excess; it cannot be contained or predicted. Thus global health is doomed to be as ever-shifting and incapable of understanding itself as a virus is. And this is to say nothing of its capacity to accurately predict the course of future viruses. (Unless, like Mason suggests, global analysts simply do away with their models and pay more attention to the real-time movements of poverty and the dynamics of economic and political power.) Experts, in Caduff’s view, traffic in pure fiction. They have to — since the future is always fictive. Adia Benton’s response also asks us to think about time in epidemiology, but in terms of its uses. She suggests that “accounting for temporality in ethnographic studies of epidemics also means engaging in deep study of timing, sequencing, tempo, and synchronization, among other things.” Timing is, as Benton argues, a tool of power. Indeed, in my time observing global health is action, timing can be not just an enemy (in terms of the speed of response and lives saved), but a weapon. A delay in sending requested information or performing an action might signal resistance or act as a way to renegotiate the power dynamics at play; a speeding up might be a response to a delay and indicate that the message was heard. Benton asks us, echoing but going beyond Fabian, “how might an even more thickened conception of time and temporality — beyond loops of past-presentfuture — open up how expertise and knowledge about pandemic flu is produced and circulated, how viral networks constitute themselves?” It seems to me that this question is in concert with Caduff’s reflections on the future-oriented focus of expertise. I meant pathography to be a method Somatosphere | September 21, 2015 Book Forum: The Viral Network: A Pathography of the H1N1 Influenza Pandemic 15 capable of doing this work, of attending to time and space and power, and I hope that it will be useful to scholars doing similar work on global events. In the end, what this exercise in responding to these thoughtful reviews has really shown me is that the idea of viral anthropology is already a concrete reality. The ideas and critiques here have already begun their mutations and recombinations. Their transformative effects will be hidden, but no doubt traceable, in everything I write on global health far into the still-fictive future. Theresa MacPhail is a writer, journalist, and medical anthropologist. She is an assistant professor at Stevens Institute of Technology, where she teaches classes in science & technology studies, medical anthropology, and global health. Read this piece online at: http://somatosphere.net/forumpost/secondary-infections Somatosphere | September 21, 2015