Why Nation States and Journalists Cant Teach People To Be Healthy - BRIGGS

Why Nation-States and Journalists Can't Teach People to Be Healthy: Power and Pragmatic
Miscalculation in Public Discourses on Health

Author(s): Charles L. Briggs
Source: Medical Anthropology Quarterly, New Series, Vol. 17, No. 3 (Sep., 2003), pp. 287-321
Published by: Wiley on behalf of the American Anthropological Association
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CHARLESL. BRIGGS
Department of Ethnic Studies
University of California, San Diego
Why Nation-Statesand Journalists Can't Teach

People to Be Healthy: Power and Pragmatic
Miscalculation in Public Discourses on Health
For Feliciana
This article analyzes how Venezuelan public health officials collaborated
with journalists in producing information about cholera in JanuaryDecember 1991. It uses Michael Warner's (2002) observation that such
public discourse involves a contradiction: it must project the image of
reaching an actually existing public at the same time that it creates multiple
publics as it circulates. The analysis explores the language ideologies
that hide complex sets of practices, networks, and material conditions
that shape how public discourses circulate. At the same time that epidemiologists targeted poor barrio residents, street vendors offood and drink,
and indigenous people as being "at high risk," health education messages
pictured women in well-equipped kitchens demonstrating cholera prevention
measures. The gap between these ideal audiences and the discrepant publics
created by their circulation limited the effectiveness of prevention efforts
and created a substantial chasm between public health institutions and the
publics they sought to reach. [public discourse, epidemics, health education,
social inequality, Latin America]
ow should we understand the concept of "public" that is embedded in notions of "public health"? Although care is often taken to define the concept
of "health," "public" seems to be relegated more frequently to commonsense understandings. It is contrasted, of course, with individual, thereby distinguishing clinical medicine from public health. It is often equated with "society" in
general, or all of the people who live in a particular political unit.' This range of
meanings seems to emerge from a central narrative that informs discussions of public health-the idea that 19th-century epidemics of infectious diseases induced
North American and European nations to undertake a sanitary revolution. According
to this account, these countries were spared from epidemics of cholera and other
epidemic diseases that continued to plague other regions by a new type of relationship
Association.
MedicalAnthropology
Quarterly17(3):287-321.Copyright? 2003,AmericanAnthropological
287

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between states and citizens. As Charles Rosenberg(1962) and other researchers

have articulated,the nation-statecame to define the taskof protectingthe healthof
citizens as one of its basic functions,andpermanentinstitutionswere establishedto
providetechnologiesand infrastructuresfor environmentalsanitationand for conductingdisease surveillanceandcontrol.The narrativealso suggeststhatthe public
acceptedresponsibilityfor adoptinghygienic practices,orderingdomestic spaces,
and abdicatingauthorityover disease preventionand treatmentto health professionals.
As a numberof writerssuggest,the stateassumedtherightandthedutyto bring
members of racialized and immigrant communities-who were seen as being
ignorantof or rejectinghygiene andinstitutionalmedicine-under the scope of this
revolution(see Kraut1994;Rosenberg1962;Shah2001). The statethusclaimed primary responsibilityfor producingwhat I have referredto as sanitary citizens (see
Briggs with Mantini-Briggs2003), individuals who (1) conceive of the body,
health,and diseasein termsof medicalepistemologies;(2) adopthygienicpractices
for discipliningtheirown bodies and interactingwith others;(3) and recognizethe
monopoly of the medical profession in defining modes of disease preventionand
treatment.Otherindividualsbecamewhat I referto as unsanitarysubjects-persons
who were expectedto have failed to internalizemedicalizedepistemologies,bodily
practices, and deferralto health professionals.Their bodies and domestic spaces
were subjectto whatJaberF. GubriumandJamesA. Holstein(1997) referto as deprivatization,such that the state could inspect their homes at will and attemptto
transformbodily, culinary,child-care,and otherpractices.In visits to theirhomes,
public health nurses identifiedhealth as a key dimension of the process of transformingimmigrantsinto citizens.
Once the germ theory of disease began to gain acceptabilityamong public
healthprofessionals,JudithWalzerLeavitt (1996) suggests thatthe stateincarceratedMaryMallon ("TyphoidMary")for morethanthreedecadesas a meansof impressingon the public the obligationsof citizens in the new biomedicalorder.The
sanitaryrevolutionthus placedpublic healthat the centerof how the stateandcitizenship came to be defined at the same time thatit imaginedthe public as divided
into distinct types of individualsand groups on the groundsof health. P. Stanley
Yoder (1997) has suggestedthatwhen healtheducationforms partof international
health programs,the constructionof populationsas respondingto culturalnorms
thatimpede the assimilationof scientific knowledge can be extendedto entire societies.
L. W. Green(1999) tracesthe shift in attemptsby the stateto educatethe public in healthfollowing WorldWarII. He suggests that as biomedicaltechnologies
became the focus, health educationcame to be seen as a means of enhancingthe
public's knowledge and use of medical resources,therebyproducinggood consumersof health services. Beginning in 1974, however, a new emphasison health
promotionpartiallyshifted the centerof attentionfrom the needs of public health
institutionsto those of populations.Enhancingcommunityparticipationin public
health has become an increasinglyimportantfocus (see Minklerand Wallerstein
2003). It is often suggested, however, that this is one of the main areasin which
both states and publics have failed. In its influentialThe Futureof Public Health,
for example,the Instituteof Medicine suggests that"thisnationhas lost sight of its
public health goals and has allowed the system of public health activities to fall

POWER AND PRAGMATIC MISCALCULATION IN PUBLIC DISCOURSES ON HEALTH
289
into disarray"(1988:1). Suggestingthat "thecontentof public values and popular

opinions"forms one of the two majorfactorsthatshapethe way thatpublic health
issues areaddressedandthe success of such efforts,the reportarguesthatthe problem lies not only in the need for more health-relatedknowledge on the part of
membersof thepublicbutalso in how theyhavelosttrustin publichealthinstitutions.
One institutionthat is often cited in explaining public perceptionsof health
and health institutions is the media. As Simon Chapmanand Deborah Lupton
(1994:25) observe, surveys often suggest that the media provides most people's
major source of informationabout health. Nevertheless, Green (1999) suggests
thatthe penchantof reportersfor portrayingmedicine andpublichealthnegatively
has fostereda skepticalattitudeon the partof manymembersof the public.Writers
such as Eva Benelli (2003) arguethatjournalistsoften pay undue attentionto unproven medical claims, thereby creating public pressureto shape public health
policies and expendituresin problematicways. In a study of radio programsthat
promotenaturalmedicinesin Ecuador,Ann Miles (1998) points out thatthe media
can actuallyincreaseacceptanceof consumerismand scientific authorityunderthe
guise of urgingresistanceto biomedicalpractices.Healthofficials (like otherpublic figures) often complain in privatethatjournalistsdistorttheir words, subject
them to unfaircriticism,andfail to reportwhat is trulyimportant.2In an articlethat
appearedin Public Health Reports,renownedscience and health reporterLaurie
Garrettrespondsto criticismsthatreportersincreasepublic panic, impedemedical
responses by rushingto the scene of emergencies, and politicize health issuesthatis, that"themedia areeitherenemies or troublesomefools thatneedto be coddledintodispersinghelpfulinformationagainstits betterwisdom"(2001:88). She argues, instead, for a relationshipof mutualrespect between public health officials
andreporters.
Nevertheless,neitherthe notion of ignorant,ambitious,careless, or skeptical
journalistsnordisrespectfulandparanoidhealthprofessionalsprovideeven the rudimentsof a frameworkthatcan be used in explaininghow informationcirculates
between biomedicalinstitutions,the media, and public audiencesor the problems
thatemerge from this relationship.My focus in this articleis precisely on the way
that received models of this process systematicallymisconstruethese discursive
interactions.Languageideologies that constructhow health professionalstalk to
reportersand how journalistspass messages along to the public fail to capturethe
statusof this informationas public discourse,as words and images directednot at
circumscribed,copresentaudiencesbut at strangers.3I drawon a recent articleby
Michael Warner(2002) that develops a sophisticatedunderstandingof the complex and contradictorycharacterof public discourse: althoughits producerssee
themselves as speakingto "thepublic,"a defined and knowablepopulation,audiences for public discourseareproducedby the circulationandreceptionof the discourseandthe materialunderpinningsthatshapethese practices.
This contradictionbetweenmodels andprocesses of discoursecreatesimportant obstacles to the circulationof health-relatedmessages as they move between
public health institutions,the media, and publics, often leading to the failure of
programsthat attemptto build public awareness of prevention, screening, and
treatmenteffortsandeven at times to widespreadskepticismin some social sectors
of all governmenthealth messages. Note that these debates about the role of the
media in circulatinghealth-relatedinformationdeal primarilywith questions of

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content-the extent to which media reportsaccuratelyconvey biomedicalknowledge and describeextant health conditions. My interesthere is both with content
and with process-the routesof circulationand the way thatpublichealthauthorities and reportersoften build models thatprojecthow messages oughtto circulate
andembedtheseprojectionsinto health-relatedinformationitself.
Taking up questions of how public discourses are produced,circulated,and
received opens up new vantagepoints on an issue that has received a greatdeal of
discussion of late, thatof healthinequities.Worksby such scholarsas Paul Farmer
(1992, 1999, 2003), Jim Yong Kim et al. (2000), Vicente Navarro(1998), and
RichardG. Wilkinson (1996) point to the role of social inequalityin shapingthe
distributionof morbidity and mortality within and between populations.What
Farmer(1992) refersto as "geographiesof blame,"characterizationsthatblame ill
health on individual and collective behavior and cognition, can draw attention
away from questionsof access to health services and institutionalracism.The Instituteof Medicinepublisheda massive reportthatarguesthatracializedminorities
in the United States-particularly African Americansand Latinos-receive inferior treatmentas comparedwith Whites for a wide range of diseases, even when
controllingfor such factors as socioeconomic status and type of healthinsurance
(Smedley et al. 2002).
Tracingthe way thatpublic discoursesabouthealtharegenerated,circulated,
and received goes beyond simply producinganothermeans of showing how such
inequalitiesarejustified. It also suggests thatmultiplepublics arecreated by these
discourses,therebymakingideas aboutpopulations"atrisk"and health inequalities seem natural.In the "mediatedsocieties"in which we live (see MartinBarbero
1987), thatis, whereour notions of ourselves and even of society itself are shaped
by media representations,deconstructingcommonsenseunderstandingsof public
discoursesof healthcan betterequipus to rethink"thepublic"in publichealth.
My focus is on a 1991 programaimed at preventinga cholera epidemic in
Venezuela.I drawon materialscollected in the course of severalyears of research
conductedcollaborativelywith ClaraMantini-Briggs,M.D. (see Briggs with Mantini-Briggs2003). Much of the focus of the largerstudywas on a rainforestareain
easternVenezuela in which some five hundredpeople categorized as indigenas
(indigenous people) died from cholera in 1992-93. Hundredsof hours of interviews were conductedin this area, nearbycities, Caracas,and other urbanareas,
and with public healthinstitutionsin the United States,Geneva (WHO),and elsewhere. This article analyzes a corpus of 221 articles that appearedin national
newspapersstartingin early February1991 when the first cases were reportedin
Peruandthe time thatcholerawas reportedin the Venezuelaby the press (December 4, 1991). Sourcesalso includeinterviewswith publichealthofficials andhealth
educationand promotionspecialists,journalists,politicians,and membersof various publics regardingofficial statements,health education,press coverage, and
publicreception.
The Circulation of Public Discourses
Researchon the circulationof health-relatedinformationmustcontendwith a
numberof complexities.These efforts areordinarilygeneratedin institutionalcontexts, andthey aremost frequentlyassociatedwith the state.How exactly does the

POWERAND PRAGMATIC
MISCALCULATION
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state place material into public circulation? What are the dynamics that shape such
information'sshifting relationshipto the state in the course of its discursivelife?

This process depends on what Louis Althusser(1971) termed interpellation.His
celebratedexampleis of a policemancalling out: "Hey,you!" Insofaras we recognize ourselvesas the personaddressedby this statementandturnaround,we areinterpellated as the subject of state discourse. Information disseminated as a means
of preventing infectious diseases entails the interpellation of members of popula-
tions deemed to be "atrisk,"such thatthey interpretthe discourseas being about

them. How do health-relatedmessages interpellatetheiraudiences?Whatleads to
interpellativemisfires?
Recent work on social suffering (see Kleinmanet al. 1997) has emphasized
the social and political-economic effects of differentways of representingthe experience of illness. The mannerin which victims, villains, and heroes are narratively constructedgrantspolitical agency to some and silences or subordinatesothers. As these representationsbecome public discourse,the pragmaticeffects of the
social images and attributions of agency they contain operate differently than, for
example, in doctor-patientinteractions.Their producerscannot determinein advance the precise natureof this public, how informationwill reachit, how the discourse will continueto circulate(if it indeed does), and the multiple ways that it
will be received.Even authoritativemessages arethus subjectto a complex process
that cannot be known in advance-no matterhow much money and time are devoted to attemptsto determineroutesof circulationand modes of reception.How,
then, is the public that is entailed in the notion of public health constituted,and
how does this process affect the power of elites to circulaterepresentationsof social sufferingandto controltheirpoliticaleffects?
In developing a frameworkfor the analysis of public discourse, Michael
Warnersuggests that "the pragmaticsof public discourse must be systematically
blocked from view" (2002:84).4Warnerreveals how the productionof public discourse revolves arounda numberof fundamentalcontradictions.To become public, a discoursemust addressa public as a collection of "alreadyexisting real persons" (2002:82) with some known, specifiable commonalities, and its success
depends on the interpellationof the discourse by persons who recognize themselves not simply as individualreceiversbut as membersof a collectivity thatis addressed by the discourse. Because this public is projectedas being known in advance, the problem for the discourse producer can be construed as "getting
people's attention,"impartingknowledge to them, and persuadingthem to change
theirattitudesandbehavior.
Nevertheless,public discoursesare,in Warner's terms,self-creatingandselforganizing-the public is actuallycreatedthroughthe circulationof discourse as
people hear, see, or read it and then engage it in some sort of way. Public health
authorities,even when they hire advertisingfirms or give press briefings, cannot
accuratelypredictwho will comprisethe public for a given programor how it will
be constituted-such as through interest, disinterest, ridicule, or protest. This
"autotelic"(Warner2002:51)processof reificationis not accidentalbutconstitutive:
the productionof public discourse projectsan imaginarypublic that only comes
into being as a communicativeentityonce the discoursecirculates.Nevertheless,it
must be imaginedas real in the course of both productionandreception-"people
do not commonlyrecognizethemselvesas virtualprojections"(Warner2002:82).

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This "imaginary"quality raises a second constitutivecontradiction.Like a

Hollywood studiothatattemptsto maximizemovie sales, publicdiscoursesengage
to varying degrees in a process of totalizationor universalization,purportedly
reachingout to all possible readers,listeners,or viewers. Althoughthey may be directed to specific "groups"or "populations,"such as "women,""smokers,"or
"youth,"publichealthdiscoursediffersfroma presentationin a school gymnasium
by virtue of its addressto strangers,to individualswho become partof the public
by virtueof theirreceptionof the messages. Nevertheless,Warnernotes, "thereis
no speech or performanceaddressedto a public that does not try to specify in advance, in countless highly condensed ways, the lifeworld of its circulation"
(2002:82). This is not to say, however, thatpublics are simply broughtinto being
by the insertionof images of imaginarypublics.Warnergoes on to suggestthatthis
process is shapedby "materiallimits-the means of productionand distribution,
the physical textual objects themselves, the social conditionsof access to themandby internalones, includingthe need to presupposeformsof intelligibilityalready
in place, as well as the social closure entailedby an genre, idiolect, style, address,
and so forth"(2002:54-55).
All public discoursesareby definitionexclusionary,becausefeaturesof their
content, discursive organization,mode of transmission,and so forth, restrictthe
rangeof people who are likely to come in contactwith and interpellatethem. One
crucialdimensionof the contradictionlies in hiding its relationshipto capital.Althoughpublic discoursepretendsto travelwhereverit needs to go to reachthe public, it is really a commodityin a market,therebysubjectto constraintson production costs, access to media, and the political economy of reception (particularly
access to communicativetechnologies, media, electricity, dominant languages,
and formaleducation).Here we can build productivelyon Warner'sinsights-and
avoid the mistakensense thatthese discoursesarefree floating-by examiningthe
institutionalsettingsin which health-relatedmessages areproducedandcirculated
as well as the forms of symbolic capital(Bourdieu1991) requiredto participatein
this processin particularways.
Finally, Warner(2002:69) suggests that a peculiarfeatureof moder public
discourse is its need to representthe paths throughwhich it intends to circulate.
Definitions of social groups and theirrelationshipto the state and otherprojected
groupsis reformulatedin the complex process throughwhich messages are generated in institutionsand picked up by the media as well as the likelihood that particular groups will receive these messages, understandtheir contents, assimilate
them behaviorally, and succeed in preventingthe disease. Differences between
populationsin termsof theirrelationshipto the circulationof health-relatedinformation can be crucial determinantsof their citizenship status-at the same time
thatit shapesunderstandingsof the stateand statepower.
Recent work in linguistic anthropology on language ideologies-beliefs
about the natureof communicativeprocesses and the people and technologies on
which they rely (see Kroskrity2000; Schieffelin et al. 1998)-provide interesting
perspectiveson these questions.Stacy Leigh Pigg (2001) has shown how language
ideologies shape what people think they can say in English versus Nepali about
AIDS and sex, therebycreatinghierarchiesof texts andforms of knowledge.Here,
I suggest that the language ideologies that commonly guide state-media-public
dialogues abouthealth oversimplifythe processes throughwhich public discourse

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is produced,circulated,and is received. Linguistic anthropologistshave also focused on questions of the circulationor recontextualizationof texts and the intertextualrelationshipthis processcreates.
Influencedby M. M. Bakhtin(1981) and PierreBourdieu(1991), CharlesL.
Briggs andRichardBauman(1992) suggest that,at the same time thatintertextuality and recontextualizationconstitutecentralmeans of creatingsocial power and
control,they remainopen to subversiondue to a fundamentaldialectic in the way
they connect discoursesand contexts (see also Silversteinand Urban 1996). Participantscan eitherprivilegethe intertextuallinksbetween successive contexts,the
degree to which the content is deemed to remainstable as it circulates,or the intertextualgaps, the differencesthat are seen as having emerged as informationis
recontextualized.Questions of capital-material and symbolic-shape this process in multiple ways, including rights to insert discourse into public arenas, to
deem some accounts authoritativeand subordinateor exclude others, and to use
particularrepresentationsof healthin locatingthe populationsthatthey interpellate
(or fail to interpellate)in political-economic terms.My analysis suggests thathegemony shapesand limits-but does not mechanicallydetermine-how this process takes place. It thus provides us with a fascinatingwindow on both the nature
andthe limits of the power thatthe stateandmediaexerton publics.
The Daily Dance of Journalists and Public Health Officials
Cholerabecame a subjectof global public discoursethrougha series of InternationalSanitaryConferencesheld between 1851 and 1938. In the Americas,the
Pan AmericanSanitaryCode of 1924 requirednationalhealthauthoritiesto notify
both the PanAmericanHealthOrganization(PAHO)andneighboringcountriesof
the existence of cases of "regulated"or "controlled"diseases, cholera,yellow fever, plague, and small pox. Starting in 1946, the World Health Organization
(WHO) became the global clearinghousefor epidemiologicalstatistics,which are
circulatedworldwidein WHO's WeeklyEpidemiologicalRecord.
Venezuela officially adopted these reporting requirementsin 1939 in its
"Rules Governing Obligatorily Reported Diseases." The same legislation that
committedthe countryto turninginformationregarding"regulateddiseases"into
global public discourse also set up an official regime for controllingthe national
productionandcirculationof informationaboutthem:"All datathatofficials of the
[Ministryof] Healthobtainregardingobligatorilyreporteddiseases areby theirnatureprivate, [and]officials who reveal them are subjectto" eitherfines or imprisonment(MSAS 1967:454), a strongwarningregardingunauthorizeddisclosures.
The first cases of cholerain South Americain the 20th centurywere reported
in Peruin late January1991. Peruvianhealthauthoritiesreported322,562 cholera
cases and 2,909 deathsin 1991, and epidemicsbegin in Colombiaand Ecuadorin
MarchandBrazilin April.In all, 391,220 cases and4,002 deathswere reportedfor
1991 in the Americas (WHO 1993). Venezuelanpublic health authoritiesdid not
announceany cases in the countryuntil November 29, and they only reported15
cases and 2 deaths in 1991. The official tally for 1992 was 2,842 cases and 68
deaths(WHO 1993); becauseonly laboratoryconfirmedcases were reportedto the
World Health Organization,these figures do not representthe full scope of the
Venezuelanepidemic(see Briggs with Mantini-Briggs2003).

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Long before it announcedthe first cholera cases, efforts by the Ministryof

Health and Social Assistance (MSAS)5to promotethe flow of informationabout
cholera was coupled with deep concern with its regulation.MSAS (1991a) published an organizationalchart that modeled a hierarchicalflow of information
aboutcholeracases from hospitals,clinics, and otherfacilities to districtepidemiologists and thence to regional and nationalepidemiologists. The chartmakes it
clear that only the minister of health and the directorof the National Office of
Epidemiologyhave the rightto disclose informationaboutcholerato otherstateoffices or to partiesoutside the government,includingthe press. These officials, respectively Pedro Paez Camargoand Lufs Echezuria,were thus designatedas the
sole official spokespersonson cholera.These laws and guidelines referto the circulation of informationduring epidemics. Nevertheless, they conferredon high
MSAS officials a virtualmonopoly over the productionof authoritativeinformation about cholera from Februaryuntil early December of 1991-that is, before
any cases were reported.
Startingin early February,articles were published almost daily in the two
benchmarknewspapers,El Nacional and El Universal, and they appearedfrequently in nationaltabloids, the regional press, and television and radio news reports. Internationalnews services, including Agencia EFE, Associated Press, the
New YorkTimes News Service, Reuters, and United Press International,carried
storieson the LatinAmericancholeraepidemicthatwere pickedup by Venezuelan
papers.Largerdailies soon assigned theirown reporters.El Nacional was particularly strongin its reportingof public health,medical, and scientific issues. In early
1991, it boastednearlya dozen reporterswho specializedin this area,all of whom
had been trainedby AristidesBastidasin a programthatcombinedundergraduate
studyin journalismat the UniversidadCentralde Venezuelawith a lengthyinternship at El Nacional.
Interviewswith these scientificreporterssuggest thatthey did not define their
role in the disseminationof informationabouthealthissues in oppositionto thatof
medical and public health professionals-they rathersaw themselves as forming
partof the scientific/medicalcommunity.IsabelMachado,6who workedfor El Nacional for morethan20 years,pointedto the degreeto which thesejournalistsidentified themselves with health professionals:"We were almost like unauthorized
physicians(medicospiratas), becausepeople thoughtthatwe knew;they askedus,
when something was botheringthem, and we had to say that we didn't know!"
(personalcommunication).El Nacional reporterRoberto Guzmandescribedthe
beginningof the choleraepidemicin these terms:"Itsurprisedus-we were practically defenseless againstan attackfrom this disease (mal), which is a plague"(personal communication).These reportersfrequentlyused the first person plural,as
Guzmanuses it here, in constructinga "we"thatincludedboth public healthprofessionalsand scientificreporters.Journalistsprojectedthe sense thatleadingpublic
healthofficialssimilarlyviewedthemas membersof the sameteam.Machadonoted:
Theyreallyhelpedus outa lot, theygaveus thebulletins,we calledthemevery
day.I hadthecell phonenumberof theministerof health,I'dcall,"Look,what's
We hadaccessto everybody.... We hadtheadnew,hasanythinghappened?"
vantagethatthey knewus already,we weren'tjust anybodywho was calling
them.[personal
communication]

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Referring to a more recent epidemic, that of dengue fever, she defined the role of
scientific reporters:
Our function as reportersis to educate, that is, indirectlywe are educating the
population.Because when you keep insisting about dengue-"don't leave open
containersof water,"findingan angle to makeit newsworthy,andyou keep insisting, you arereally educating.... Our [work]was a grainof sandin the middleof
all this. [personalcommunication]
By emphasizing the need to find new information that would make each cholera
story interesting and newsworthy, "as much for the reporter as for the public"
(Guzman, personal communication), this statement opens up one dimension in
which reporters placed themselves alongside "the public" rather than health professionals. (See Chapman and Lupton 1994 on how this concern with newsworthiness
shapes health coverage.)
Public health officials had a rather different view of reporters. Although they
sometimes described the press as playing an important role in transmitting information to the public, in private they expressed a combination of fear and distrust.
Journalists, they claimed, were most interested in finding fault with MSAS efforts,
and successes generally were not reported. The press was often characterized as a
weak mediating link that included uninformed, gullible, and sometimes unscrupulously self-serving individuals who often distorted the words of health professionals and passed on misinformation. Such accusations sometimes emerged in public.
On May 17, 1991, for example, Paez Camargo asserted that a mayor "alarmed by
the health problems in his jurisdiction and in order to draw the attention of the
authorities, turned some reporters from the region into innocent dupes" who transmitted false reports of cholera cases (El Nacional 1991c). Even when they were
credited with being helpful and getting the story right, public health officials contrastively constructed journalists as standing outside the health arena.
Reporters played a key role in turning official statements into public discourse. As Stuart Hall points out, professional concern with separating "fact" from
"opinion" or "rumor," obtaining objective and authoritative sources, and generating stories rapidly to meet deadlines all lead journalists to depend heavily on institutions, which generate news on a regular basis (Hall et al. 1978). Guzman,
Machado, and their colleagues left their offices each day at about ten in the morning and had to be back by two or three in the afternoon with sufficient material to
be able to write two or three articles and submit them to their editor by 6:00 p.m.
Public health institutions based their claim to constitute the primary sources
of authoritative information not simply on the medicalization of infectious diseases but on their special relationship to PAHO and WHO (and thus transnational
health authorities, institutions, and discourses) and the national legislation that
spelled out their control over the production and circulation of public information
about public health. Because the government employed most epidemiologists and
controlled the production of health statistics, the central role of epidemiology in
creating authoritative cholera stories-and the power of social statistics in sparking popular imaginings-rendered this symbiosis between reporters and institutions especially pronounced.
Moreover, the journalists who covered cholera regularly saw themselves as
specialists in scientific matters and they accordingly privileged medicalized views

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of health.Both in theirdesirefor readysourcesof informationandtheirown scientific ideologies, reportersgreatlyaugmentedthe ability of high public healthofficials to constructthemselvesas the sole legitimatesourceof authoritativeinformation about cholera. Paez Camargo and Echezuriathus became what Hall et al.
(1978) referto as the "primarydefiners"of the cholerastory.They shapedthe language thatwould be used in producingcholeranarratives,they proposedthe metaphorsthatwould shapeperceptionsof the disease, andthey decidedwho would become charactersin the storyandwhat sortsof roles they would play.
Reportersexplicitly placed public health officials in this role when contrasting theirstatementswith extraofficalaccountsof choleracases. El Mundopublished a United Press Internationalstory in which the Panamanianministerof health
declaredthat "if every Panamanian... startsto give information,we're going to
have anarchyhere, and in the end you [reporters]won't know, nor will international organizationsknow whom to believe" (United Press International1991).
Here, an official not only discreditsa single rumorbut attemptsto banishalternative sources of the productionof discourseaboutcholerafrom the public domain.
When clinicians,communityleaders,or othersprovidedinformation,reportersimmediatelycalled Paez Camargo(or a regionalhealthofficial, if the reportwas from
"the interior")in order "to confirm it." Ratherthan emphasizingthe intertextual
links between official and alternativecontributions,journalistsstressedthe gaps,
makingcompetingsourcesof informationseem maximallyfarapart-rumors versus scientific proof. Scientific reportersthus played a crucialrole in medicalizing
public discourseabouthealth.
WHO cholera guidelines state that "when cholera is newly suspectedin an
area,the InternationalHealthRegulationsrequirethatthe diagnosisshouldbe confirmed by laboratoryinvestigations as soon as possible" (1992:1). To invoke
Bruno Latour's (1988) term, such stipulationsturn microbiologicallaboratories
into obligatorypassage points in the productionof biomedicalknowledge. Once
MSAS refurbisheda laboratoryin the NationalInstituteof Hygiene (INH) to process cholerasamples,its directordeclaredthat"itis up to the INH, with the support
of its investigations,to say: 'cholerahas begun' " (Diaz Hung 1991a). In her article, reporterVeronica Diaz Hung turnedMSAS's representationof how cholera
discourseought to circulateinto "news"and ratifiedits claim to determinewhich
information was authoritativeand which should be expelled from the public
sphere.Herewe see one of the key characteristicsof public discoursein operation:
at the same time thatreporterstreatedthe circulationof biomedicalinformationas
newsworthy,they covered up theirown and theireditors' roles as the gatekeepers
who turnedstatementsutteredby officials over the telephoneor to small groupsof
reportersinto public discourse-and excludedothertypes of informationandother
classes of speakers.
Tying Cholera to Poverty, Street Vendors, and Indigenas
As they imagined the course of a cholera epidemic in Venezuela, public
healthofficials andreportersprojectedthreepopulationsas being "athigh risk"for
cholera.First, los pobres (the poor) were designatedas a key populationin which
choleracases would be concentrated.Eitherthe poor or "residentsof marginalbarrios" appearedin 55 of the articlesin the sample,often as the mainfocus. Minister

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Figure 1
Hillside barrio in Caracas, contrasted with middle-class apartment buildings. Photo
(Frasso) courtesy of El Nacional archives.
Paez Camargosuggested that "cholerais an undemocraticdisease because it affects a very specific part of the population in which hygienic variables are extremelymarked"(Bracamonte1991). Povertywas thus constructednot simply in
economic but in behavioralterms. Reportersimmediatelypicked up on this connection and expandedit. MarleneRizk (199 la) suggestedthatcholerawas associated with "a grave deteriorationof environment,housing, and culturethathas become more accentuatedwith the crisis of recentyears."
Discussions of povertyand cholerain the press focused particularlyon urban
cerros (poor hillside communities) or barrios marginales. The juxtapositionof
barrioswith marginalityconveyed a sense of people who standoutsidedemocratic
politics, the formaleconomy, the law, education,and morality.In pinpointing"the
poor"as being at high risk for cholera,public health officials and reportersthrust
cholerainto the middleof the rapidrise of social inequalityin the country.The percentage of the populationliving in povertyis estimatedto have increasedfrom 24
percentin 1981 to 59.2 percentin 1990 (Marquezet al. 1993:146, 155). These articles were often accompaniedby photographsof barrioneighborhoods,children
playing in the street(nakedtoddlersprovidinga commonmotif), people bathingin
open spaces, and areas clutteredwith garbageand/orrubble.The photographreproducedin Figure 1, for example, creates a strikingvisual contrastbetween the
hillside barriodwellings and, behind, the middle-classapartmentbuildings,complete with giantsatellitedishes.

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'7,
'
A;
l! '
'.!
,
'i
I-
Figure2
Chicero,sellerof ricebeverage,Caracas.Photo(LuigiScotto)courtesyof El Nacional
archives.
Second, some of the most stridentcriticism was directedtoward streetvendors who sold hot dogs andhamburgers,homemadecandy, drinks,fruit,etc.; they
appearedin 33 of the articles.Trying to convince the public not to buy food from
these vendorsfiguredcentrallyin both healtheducationandmediaefforts.Reporters used strongnegative imagery in suggesting that streetvendors were breaking
not only sanitarycodes by using contaminatedwater and unhygienicpracticesin
preparingtheir fare but also moral strictures.AsdrubalBarrios(1991b) describes
one Caracasscene: "this reality beats plainly in dark alleyways where [people]
play with the health of citizens in the domainof foodstuffsand also in the domain
of pleasures,convertingone of these comers into a pimping stripwhere ladies of
the night catchthe innocent."
When their customers continued to purchase these foods and beverages,
spokespersonsandreportersalso focused on the alleged ignorance,abasement,and
willfulness of the customers.Photographsoften featuredlong lines of carts, chaotic throngs of customers, and foodstuffs exposed in open spaces. The chicero
(vendor of a homebrewed rice beverage) featuredin Figure 2, for example, is
shown crouchingover a plastic or metal bowl that is placed directly on the sidewalk, next to his rustic,hand-decoratedcart.The framingof the photograph,with
customersbounded in front by a dilapidatedsection of sidewalk and in back by
hurriedpassersby,along with the indiscretepose in which the chicero is caught,
seems to add irrefutablevisual confirmationto the interpretivemessage presented
by reportersandpublichealthofficials.

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Figure 3
Indigena woman from Zulia State with child in clinic. Photo (Jesus Castillo) courtesy
of El Nacional archives.
Third,indigenas also became potentialbearersof the disease.7Appearingin

26 articles in the sample, indigenas figured especially prominentlyin the media
once the first cholera fatality in Venezuela was deemed to be an indigena. The
strongmoraltone used for the poor and streetvendorswas juxtaposedwith the language of culture in suggesting why indigenas were particularly at high risk for
cholera."Indigenaculture"was constructedas the antithesisof "thenationalsociety."Indigenaswere associatedwith vernacularhealingpractices-and thus as being ignorantof andrejectingbiomedicine-and portrayedas being unhygienic,nomadic, andunconcernedwith the healthof theirfamilies (see Briggs with MantiniBriggs 2003).
When he was pressuredto close the borderwith Colombia, Paez Camargo
counteredthat "Closing the border is an idea that makes no sense, because the
Guayuindigenousethnic group,which is the one thathas been affectedby the disease, is geographicallyand culturallya single entity, which feels the same in Colombia as in Venezuela and has no concept of physical border"(Zambrano1991).
Any residentwho did not recognize the importanceof the Venezuela-Colombia
borderwas not a participantin the political life of the nationand could make only
weak claims to substantivecitizenship.Paez Camargomade the statementduring
an epoch in which indigenaswere pressingfor recognitionof theirpolitical,territorial,andhumanrightsin the courseof "500 Yearsof Resistance"actionscountering
the "ColumbianQuincentennary."This construction,made in a press conference
by a cabinet-level official, seems to imply that political parties and government

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institutionsneed not respondto such demandsfor political representationbecause

indigenas had excluded themselvesfrom the political process. These sorts of generalizations were extended once cholera cases appeared in this region. Paez
Camargodeclared,for example, that "it is very difficult to work with this population, because it is itinerant,and its distinctculturemakespeople fear the measures
taken by our physicians"(Linares 1991). In photographs,indigenas were commonly portrayedin poor ruralsettings,paddlingcanoes, and doing artsand crafts.
Figure 3 actually appearedjust after the first case was reported.It pictures an
indigenawomanfromZuliaStateandherchild.
In all three cases, these powerful visual images naturalizedconnectionsbetween the disease and these populationsin several ways. First,the frequentjuxtaposition of articleson the "threat"of cholerawith photographsof the threepopulations (83 in all) createda visual image that got attachedto widespreadfear of the
disease. Cholerajust seemed to be naturallyassociatedwith these groups.Second,
barrio residents, street vendors, and indfgenas were not pictured cleaning their
neighborhoods,stockpilinganti-choleramaterials,or giving anti-choleratalks but
ratheras mergingwith the scenes of urbandecay thatsurroundedthem.Healthprofessionals, on the other hand, were not only well dressed and picturedin orderly
and sanitizedenvironments,but shown actively working to preventan epidemic.
Figure 3 embodies this contrastin a single photograph.While the professionalis
caught in an active pose, seemingly trying to reach out and help the child, the
woman staresoff into the distance,not moving and seemingly unmoved,thereby
visually conveying the stereotypesof the passive indigena who lacks agency and
the will and ability to help herself or her child. Photographsappearingin newspapers, along with similarimages on television broadcasts,thus helpedcreatea cholera "geographyof blame"(Farmer1992), reify it as a directreflectionof social reality, and imbue it with strongaffective significance.These powerfulimages were
used in creatinga coherentstorythatexplainedthe courseof a choleraepidemicin
Venezuela,all beforethe firstcases were reportedin the country.8
The Health Education Program
Startingin February1991, responsibilityfor organizing a health education
and promotionprogramdesigned to inform "thepublic"aboutcholeraand inducing it to take steps aimed at preventingan epidemic was located in two MSAS offices. First, the Division of Social Health Promotionof the CommunicableDiseases Programwas chargedmainly with creatingthe manualsthatwould be used in
traininghealth professionalsand other personnelin cholerapreventionand treatment and with working directly with communityrepresentativesand membersof
the public.The teamconsistedof individualswith undergraduate
trainingin the social sciences and educationand one journalist;they were all supervisedby an epidemiologist. They took manualsproducedby WHO and PAHO on the controlof
infectious diseases, communityparticipation,and cholera preventionand turned
them into booklets producedfor health professionalsand manualsto be used in
trainingcommunityrepresentativesandemployees in otherinstitutions.
A Module of Cholera Instruction(MSAS 1991d), publishedin March 1991,
was preparedfor use in workshopsdesignedto transformindividualswho were not
health professionals into disseminatorsof cholera prevention information.The

301
topics discussed include the history of cholera, Vibriocholerae, the statusof humans and theirexcretionsas cholerareservoirs,clinical symptoms,treatment,prevention, environmentalhygiene, and how to involve communitymembersin prevention programs.The popularaudienceprojectedfor the text is markednot only
by the nontechnicallanguageand the statedgoal of providing"basicinformation"
but also by drawingsthatturn Vibriocholerae into little bacterialmonsters,complete with hair, eyes, hands, andjagged teeth. Two booklets, a Manual of Norms
and Proceduresfor the Preventionand Managementof Diarrheal Diseases and
Cholera (MSAS 1991b) and EnvironmentalSanitationMeasuresfor Preventing
Cholera (MSAS 1991c), both released in May, were designed for distributionto
physicians and other health professionals. They used a specialized lexicon, and
they lacked anthropomorphic
drawingsof Vibriocholerae. One of the goals of the
Manualof Normswas to "extendthroughall of the areasof PublicHealththe unification of basic, currentknowledge and strategies to pursue in the fight against
choleraandall diarrhealdiseases"(MSAS 1991b:1).
These three publicationsseemed to become importantsymbolic capital for
the professionalswho securedthem, indicatingtheir access to MSAS centraloffices; furtherdistributionwas thus impededby the desireon the partof individuals
to hold onto theirsymbolic value. Once cases were reportedin Venezuela,the Division of Social HealthPromotion,in collaborationwith PAHO, initiatedprojects
in Delta Amacuroand Zulia States. The researchthat they conductedunderthese
auspicesconsistedprimarilyof focus groupswith publichealthofficials thataimed
at eliciting ideas and evaluatingstrategies.They also worked alongside epidemiologists in teaching cholera prevention techniques to residents, particularlyin
Zulia.
Second, the Office of Public Relations was chargedwith createdpamphlets
and postersfor mass distributionand getting cholerapreventionmaterialsinto the
mass media. Their staff consisted primarilyof persons trainedas journalistsand
graphic designers. Newspapers presentedpreventioninformationwithin articles
and as separatesections (often intendedto be cut out and pastedon walls), such as
the following publicationof WHO's "goldenrules"for choleraprevention:
Measuresfor Avoiding Cholera:
Wash vegetableswith waterandvinegarfor half an hour.
Cook fish andseafood well.
Avoid foods purchasedfrom streetvendors[comidas ambulantes].
Wash fruitbefore eating.
Boil drinkingwaterten minutesor freeze filteredor bottledwater.
Also wash kitchenutensilswith boiled water.
Wash handswith soap and waterbefore preparingfood, serving children,[and]
aftergoing to the bathroom,takingcareof someonewho is ill, or cleaningup after
children.
* Combatflies; since they come to reston feces andcontaminatedwater,[they]become vehicles of transmission.Use insecticides,anddeposittrashin plasticbags
andkeep them shut.
* Use bathroomsandlatrines.
?
?
?
?
?
?
?

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* Preparepowdered milk with boiled water or drink pasteurizedmilk. [El Nacional 1991d]
Radio and television stations also presentedhealth education informationon a
regularbasis. These succinctrecommendationswere decontextualizedanddehistoricized, appearingto applyequallyto everyoneandto bearno directrelationshipto
currentevents. Once the first official case was reportedby MSAS on December3,
1991, both of these offices stepped up the pace. Posters were placed in public
spaces, and workerspassed out pamphletson the streetand in bus terminalsand
clinics. The Christmas,New Year's, and Holy Week holidays were the focus of
particularconcerndue to fear thatthe massive numberof people travelingduring
those times would spreadcholerathroughoutthe country.
Reporters,public health officials, and politicians deemed the stakes for the
healtheducationprogramto be high. They underlinedthe centralityof "individual
responsibility"(see Gonzalez 1991a). A regional official declared,"it won't help
at all if we healthauthoritiesmakethe effortto fight againstthe disease if the community doesn't supportus by paying attentionto the recommendations"(Azocar
1991). Diaz Hung (1991b) quotes Milagros Polanco as saying that "if the people
fail to follow the basic hygienic norms,everythingwill be lost." Politiciansarticulated the importanceof health educationthroughthe language of citizenshipand
civic participation.Caracasofficials attemptedto mobilize "the community"by
settingup "anti-choleracommandos"consistingof a local official, a physician,and
five neighborhoodleaders for each parishin orderto "makeeach citizen into an
ally"(Gonzalez 1991b).A memberof Congresssuggestedthat
eachcitizenmusttransform
himselfinto a guardian[fiscal] of his own home,
andcommunity,
to demandcompliancewiththe
placeof studyor employment,
rulesthathavebeenissued;andwhenwe canmakesurethatourneighborprotects
himselfadequately,
we areprotecting
ourselvesas well.[RiveroG. 1991:4]
Messages presentedas partof the health educationprogramthus embodied what
has been observedto be a generalfeatureof the public service announcementtype.
They tend to "supporta politicallyconservativepredispositionto bracketoff questions aboutthe structureof society-about the distributionof wealthandpower,for
example-and to concentrateinsteadon questionsaboutthe behaviorof individuals withinthat(apparentlyfixed) structure"(Tesh 1988).
To whom was the healtheducation"campaign"directed?This questionmay
seem silly at firstglance. The use of the mass mediaandthe placementof postersin
public spaces would seem to target all Venezuelans. Constantinvocations of la
gente (the people), la comunidadvenezolana (the Venezuelancommunity),elpais
en general (the countryin general),and la mayoriade los venezolanos(the majority of Venezuelans)constructedthe targetaudienceexplicitly and seemed to project the actualrangeof disseminationof the healtheducationinformationmaterial.
Nevertheless,let us recallWarer's (2002) suggestionthatone of the contradictions
thatspringsfromideologicalconstructionsof publicdiscourseinvolvesa discrepancy
betweenclaims to be addressingeveryone andthe embeddingof implicitmessages
thatdefine an implied audience.This contradictionwas most apparentin televised
messages that showed well-dressed women demonstratinghygienic measuresin
well-equipped,middle-classkitchens.MSAS cholerapreventionpamphletssimilarly

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often projected images of middle-class, light-skinned,nuclear families. In one

case, a woman dressedin such a fashion as to markher as Wayuu(indigena from
Zulia) was shown demonstratingcholerapreventiontechniquesin a modem, wellequippedkitchen-even thoughpoliticians,public healthofficials, andjournalists
had characterized"theWayuu"as being poor and premoder. The pamphletwas
designed for distributionamong indigenas who lived in Zulia and surrounding
states.9
Even basic, widely disseminated,and most highly decontextualizedinformation, such the Golden Rules and otherbasic preventionguidelines, seemed to presupposethe inclusion of vegetables, fish and seafood, fruit,and powderedmilk in
diets and sufficientfundsto be able to purchasesoap, pesticides,plasticbags, vinegar to wash vegetables, and gas to boil water for consumptionand for washing
utensils.Manyhomes not only lackedfreezersbutbathrooms,latrines,andrunning
water. The nearly40 percentof the laborforce engaged in the informaleconomy
spent substantialpartsof their day on the street;telling them to avoid foods purchased from streetvendorsmight seem like asking these individualsto go hungry
(not to mentionthreateningto deprivethe membersof a substantialsectorof the informal economy of their primarysource of income). The media campaign thus
seemed oblivious to the economic constraintsthatrenderedthe implementationof
such proceduresdifficultor impossiblefor the majorityof Venezuelans.
The health educationprogramwas thus structuredby a fatal contradiction.
The epidemiologicalmessage suggestedthatif you arepoor, a streetvendoror one
of their customers,or an indigena you are "athigh-risk"to get cholera.If you are
middle- or upperclass andnot raciallymarked,you arevery unlikelyto get the disease. The primaryaudience for health education,as defined by the middle-class
images in many of the messages and seeming economic prerequisitesfor enacting
the preventionguidelines,was unlikely to interpellatethis information,becauseits
membersdo not considerthemselvesto be dirtyor ignorantandthey had been told
thatthey were not likely to get cholera.
Severalobstaclesthwartedpeople who fit the high-riskprofile from interpellating the message. First,they could not recognize themselvesin the healtheducation discourse-they were not projectedas partof its public.Second, to interpellate
oneself as in need of cholerahealtheducationwas to acceptan image of oneself as
premodem,dirty,ignorant,superstitious,impoverished,and a threatto the health
of the body politic. Accepting a denigratingimage of oneself is a high price to pay
for getting information!Third,the explicit message thatno intertextualgaps were
acceptablebetween statediscoursesand public responseswas contradictedby this
tremendousgap between "news"and "pedagogy,"a hiatusthat assumedquite differentforms andproportionsfor the middle class, on the one hand,andpeople projected as being poor, streetvendors,or indigenas,on the other.
The surveillanceconductedin poor and indfgenacommunitiesand of street
vendors was used in measuringthe success or failure of health educationefforts.
Just as epidemiologists visited poor neighborhoods,streetvendors, and indigena
communitiesto assess conditions,Guzmandescribeshow reportersbecame amateurepidemiologists:
We arrivedat poorhomes(ranchos),at unhealthydwellings,andwe askedthe
womenhowtheywerestoringwater,underwhatconditions,
thecharacteristics
of

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thedwellings.... A poorhomecanbe a perfectculture[inthebiologicalsense]

for cholera wreakinghavoc. So we went and asked the women, the housewives,
we lookedat thechildren,we tookphotosof thelittlenakedchildren,withtheir

belliesswollenby symptomsof malnutrition.
communication]
[personal
VeterancholerareporterMarleneRizk drew on such observationsin assessresultsof healtheducationefforts:"None of these measuresis being comthe
ing
plied with, and it only takes a trip throughthe center of the city [Caracas]where
every day the numberof streetvendorsincreasesor a visit to any barrio,wherethe
minimumhygienic conditionsaremissing"(1991c). Reportersand officials do not
seem to have visited middle-class or wealthy homes or to have inspected restaurantsin well-to-do neighborhoodsbefore decidingthatthe programhadfailed.
This structural process of misrecognition (see Taylor 1994) effectively prevented all parties from interpellating these messages, from believing that they were
directed at them and that they meshed with their own perceived social locations
and identities.The healtheducationprogramthusconstituteda classic Batesonian
double-bindin which the overt message is contradictedand overriddenby an implicit metamessage(Batesonet al. 1972).
Resisting Unsanitary Subjecthood
Medical anthropologistshave argued that we should not assume that state
power or processes of medicalizationturns patients and publics into dupes who
passively accept dominantconstructions.Studies of women's responsesto reproductive technologies, for instance, suggest thatpeople respondin complex, pragmatic, sometimes contradictory,and often unpredictableways to hegemonic ideologies and practices (see Ginsburg and Rapp 1995; Lock and Kaufert 1998).
Accordingly, if my analysis were to end here, therebygiving the impressionthat
publics simply acceptedthe contentof choleradiscourseandthe hegemonicmodel
of its circulation,I would leave out crucialelementsof the story.
Justas the statewas using cholerato shapean image of the poor, popularsectorsused the disease to shapepublic opinionof the state.Stepped-uprepressionafter the February27, 1989 popularinsurrectionaugmentedthe uncertaintyof life in
poor neighborhoods.The coup attempt organized by Lt. Colonel Hugo Frias
Chavez on February 4, 1992 may have failed, but it created a more visible space for
debatingthe role of the governmentand evaluatingits policies. Popularmistrust

contributedto the tendencyto regardcholeraas a smokescreen(cortina de humo)
conjuredup to keep people from thinkingaboutthe crisis and criticizingthe government.10
The location of some specific sites of resistanceare interesting.When Caracas officials urgedcommunityrepresentativesto join themin establishingan "antic6lera commando,"some readthese attemptsto enhancecommunityparticipation
as an attemptto place the government'shealthobligationson the public:
Theneighbors
hasbeenfocusedin sucha
complainthattheanti-cholera
campaign
forallof thisis thecommoncitiwaythatit appearsas if theonlyoneresponsible
zen. "Doesn'tthegovernment
alsohaveresponsibilities
to assume,suchas supwithdrinking
plyinghospitals,cleaningthestreams,andprovidingthepopulation
water?"[Gonzalez 1991b]

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Second, some communitiesseem to have felt thatsurveillanceandcontrolwere directednot at cholerabut at them, andthey sometimesactively resisted.Publicofficials complained, for example, that Wayuu communities "armthemselves and
confronthealthcommissions"(Montesde Oca 1992).
One of the most pervasive and visible sites of resistance lay with our old
friends, the street vendors. Unable to get their responses into the public sphere,
they largely voted with theirfeet-they continuedto sell theirproductseven in the
face of criticismand prohibition.The sale and consumptionof food and drinkon
the streetgrew markedlyin the 1980s and 1990s. In the face of massive underemployment, unemployment, and steep price increases, many workers had been
driven out of the formal economy and into the ranksof vendors, whereas others
used sales to supplementwages. Datanalisis, an economic consulting firm, estimated that 39 percent of the populationworked in the informal sector in 1992.
Many of their customersfaced longer work schedules, longer commutes, and/or
the need to work more thanone job. For them, cheap food purchasedon the street
helped meet both temporaland economic constraints.Criticismby reportersand
public healthofficials of vendorsand theircustomerscut "formal"capitalism,globalization,andgovernmentpolicies out of the picture.
In makinga fetish of the vendors' transactions,the healtheducationprogram
transformeda pervasive social and political-economic effect of globalizationinto
the cause of increases in infectious diseases. But these conditions were partof a
process thathas engulfedmany LatinAmericancities in a structuralchaos so deep
that the state could no longer effectively claim the ability to maintainorder (see
GarciaCanclini 1989). This inversion of cause and effect, the transformationof
global structuralprocesses into faulty individual decisions, and the adoption of
medical profiling procedureswere accomplishedby cholera discourses even before Vibriocholerae appearedin Venezuela. MSAS seemed to be completely out
of touch.
This sense of misrecognitiondiscreditedMSAS in the eyes of many. An El
Nacional poll conductedin April 1991 found that only 1 percentof respondents
thoughtthat hospitals were "well prepared"for an epidemic, 27 percentbelieved
that hospitals were "somewhatprepared,"and 72 percentthoughtthat they were
"notpreparedat all" (El Nacional 199 lb). A July El Nacional poll reportedthat50
percentof respondentsbelieved thatcholera"hadindeed come to Venezuela,"but
thatMSAS was "hidingthe cases." Only 36 percentstatedthatMSAS was telling
the truth,while 14 percentsaid they didn't know (Rizk 1991b). A newspaperpoll
conductedin February1991 suggestedthat65 percent"saidthatthey do NOT believe that the authoritieswill do everything necessary for preventionof the disease." The data revealed a strikinggender gap: women outnumberedmen more
thantwo to one amongthe ranksof skepticalrespondents,while nearlyeight times
as manymen believed thatMSAS effortswere sufficient(El Nacional 199la).
Reporterssometimes framedcriticismsof MSAS and its top officials in their
own voices. El Nuevo Pals captioned a photographof a broadly smiling MSAS
ministeras follows:
leavesthe[Presidential]
Palacewearinghis bestsmile,in spite
[RafaelOrihuela]
of the resurgenceof infectiousdiseases,suchas dengue,malaria,andcholera,
lackof attention
onthepartof thegovernment
of President
generated
bythecomplete

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in
Pereztohealthissues(theIMF[International
Fund]is onlyinterested
Monetary
[Gonzalez1992]
paymentof thedebtandhandingoverstateindustries).
The richly parodic article accompanying the photographcountered Orihuela's contentionthat "Venezuelacan relax"because the governmenthad controlledthe outbreakof choleraby assertingthat"newoutbreaksof malariaanddengue, newly rebornThirdWorld diseases, along with cholera"presentedclear and
presentdangers.Photographerssometimescontributedto these critiques.A photographby Eresto Morgadojuxtaposedpiles of trashandfilthy waste waterin association with a huge sign thatmarksthe scene as a projectof the Caracascity government.11Here, images that the state imbued with moral and political meanings
seemed to get turnedback on the state.Subversivereadingsalso emergedin television comedy programsthatparodiedofficial statements.
It would, however,be unwise to exaggeratethe extentof this reportorialresistance. Journalistsdid not challenge MSAS officials' statusas the primarydefiners
of choleradiscourse,nordid they elevate critiquesof public discourseabouthealth
and the social spaces in which they were generatedto the level of equally valid
sites for the productionof cholerainformation,shift the basic termsof theirstories,
or challenge dominantequationsbetween cholera and social inequality.Critical
public voices were subordinatedin termsof the relativefrequencywith which they
spoke (much less than MSAS officials), their placementin articles (generallytoward the end), and the types of discursive acts they were permittedto perform
(such as criticizing MSAS proposals ratherthan offering their own), a common
way that inequalitystructuresmedia discourse (see van Dijk 1991). In short,the
media left the hegemonicmodel for circulationof medicalandpublic healthinformationandits authorityintact.
Nor did these criticisms result in a shift in the way that agency was constructedin choleranews: when reportingthe "news"aboutcholera,reporterscast
both Vibriocholerae andMSAS officials as agents,as the forces thateithercaused
or could cause things to happen,while the public-and particularlythe poor and
indigenas-were constructedas patients (here in the grammaticalsense of the
term),therebyreplicatinganothergeneralfeatureof discoursesof social inequality
(see van Dijk 1989).12 Hereinlies anotherbasic contradictionof the healtheducation program.Having alreadyestablishedthatthe poor, indigenas, and streetvendors lacked agency and, therefore,could not change in ways that would enable
themto get out of cholera'sway, the healtheducationprogramrequiredthemto do
just that. While the press may have occasionally relayed voices that pointed out
this contradiction,it did not fundamentallyrevise its picture of passive unsanitary subjects.
In short,these criticismsdid not dislodge reportersfromtheirrole in elevating
high MSAS officials to the status of the primarydefiners of cholera discourse.
Rather,circulatingcriticismshelpedconstructthejournalists'roleas thatof objective,
neutralcollectors of facts. They could seem to align themselves with the people,
therebyclaiming the rightto ventriloquizethe reactionof the public to MSAS discourse, andconfirmtheirrole as the public's watchdog,as doing the work of critically assessing the truthand value of official statements.Oddly, one importantfocus of popularcriticismof the circulationof public discourseon choleraseems to
have been overlookedby journalists-how people resistedmedia representations

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and the power of the media to legitimize MSAS's authority.Reportingpopular

criticismsof MSAS can thusbe seen as a strategyof dissimulation,as playingtheir
part in keeping the pragmaticsof public discourse-particularly the press's own
practices-"systematically blockedfrom view" (Warner2002:84).
How Public Discourses Circulate: Idealized Links and Pragmatic Gaps
The public health officials and scientific reporterswe interviewed largely
sharedan ideological constructionof how publicdiscourseaboutcholerashouldbe
produced and circulated.Authoritativeinformationabout the disease emanated
from privileged sectors of MSAS, particularlythe National Office of Epidemiology and the INH nationalreference laboratory,and the internationalinstitutions
thatshapehealthpolicies andpractices,PAHO andWHO.
This informationthen moved throughthreecircuits.First,healthprofessionals, particularlythose employed by MSAS, received technical informationfrom
manuals,the Boletln EpidemiologicoSemanal (WeeklyEpidemiologicalRecord),
circulars, and the like. Second, the Division of Social Health Promotion then
passed along nontechnicalinformation,such as the Moduleof CholeraInstruction,
posters,and brochures,to employees in otherinstitutions,communityleaders,and
other persons who are not health professionals. Some of this informationalso
found its way to "thepublic"via the media. Finally, statementsby the ministerof
health and the directorof the National Office of Epidemiology, as articulatedin
press conferences and telephone calls, were relayed as news by reportersto their
audiences.Both journalistsand public health officials point to how this information should be received-it should be comprehended,assimilated into ways of
thinkingabouthygiene, food procurementand preparation,the environment,and
so forth, relayed to family members,coworkers,and neighbors,and embodied in
action.
When it operatescorrectly,this process should be characterizedby intertextual links alone-no gaps should appear.Such transformationsas lexical register
shifts from scientific terms to a nontechnicalvocabulary,transitionsbetween or
beyond institutions,changes of communicativechannel,context, and participants
should not creategaps, because continuitywas defined in termsof the stabilityof
semanticcontent. Gaps in these circuits were problematic,reflecting either ignorance (an inability to recontextualizethis information)or willful resistanceto an
educationalprocess on which the healthof the nationand its citizens depends.Because both media coverage and public healthinformationwas aimed at the public
andthereforeaccessibleto everyone,the failureof individualsto gain this information and use it in preventingcholera-breaks in the transmissioncircuit-were
theirown fault.
This languageideology systematicallyblocks from view the way thatthe idealized process of discourseproductionand circulationitself createda vast network
of gaps and communicativebarriers,along with the materialand symbolic inequalitiesto which it was tied. Thus, the image of a horizontal,unidirectionalflow
of informationmasked the creationof quite vertical structuresof knowledge and
statusin a numberof ways:
First,the temporalityof circulationof public discourseis crucial,in thatpeople gain access to messages at differenttimes andaccordinglyuse themin claiming

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differentsocial positions.(The concernwith "beingin the loop"pointsto the desire

for enhancingone's own relationshipto the temporalityof circulation.)Epidemiologists and INH microbiologists enjoyed temporal priority over other MSAS
health professionals, who, in turn, supersededreporters;the informationfinally
reachedtheir audiences and persons with whom viewers and readersconversed.
Health promotion specialists similarly trained community leaders who then, in
turn,educatedtheirneighbors.This image of circulationturnstime into social hierarchies.
Second, as Pigg (2001) points out for HIV/AIDS education in Nepal, the
rankingof texts in termsof theirprovenience(in Genevaor WashingtonversusCaracas), lexical register, and degree of detail project a hierarchicalview of audiences, creatinggradationsof knowledge and capacitiesfor assimilatinghealth-relatedinformation.
Third,a person's own social standingwas markedby the personfrom whom
he or she received information(the ministerof health versus a reporterversus a
health promotion worker versus a community representative).The fartheryou
were located down the discursive chain, the less authorityand agency you were
projected as enjoying. Some people can produce cholera discourse and sort
authoritativefrom illegitimateinformation;others (e.g., clinicians)can transmitit
with authority.Still others(such as communityleaders)can only transmita popular understandingof it.13Otherscan only embody the informationin theirbehavior
andtransmitit withintheirimmediatesocial environments.
Fourth,recipientswere projectedas ratifiedhearerson the basis of constructions of implied audiences,reducingothersto the statusof ideologically excluded
overhearers.At the same time thatCamachoinsisted, with referenceto her scientific reporterpeers, that "we always sharethe idea that we are writing for everyone," she clearlyspecifiedthatthe readersof El Nacional were primarily"students,
teachers,professors,professionals"(personalcommunication).Nonprofessionals
and persons with limited educationalopportunitiesdid not figure among her implied readers.As I have suggested above, pronounsand other discourse features
projectedthe three"athigh risk"groupsas being thirdpartieswho were referredto
but not addressedby El Nacional stories.
Locations within this projected process of discourse circulationwere also
graphicallyprojectedin the accompanyingphotographs.Healthprofessionalswere
pictured precisely in their roles in actively circulating discourse about cholera
and/or effecting materialpreparations-processing laboratorysamples, stockpilanddomesticspaces,andthe like.
ing resources,examiningsanitaryinfrastructures
They seemedto formpartof the very event of circulationas they look at the camera
or fit into the bodily frame of the meeting, tour, or other performanceof cholera
prevention.Barrioresidents,indigenas, and street vendors seem to have been always caughtin the act. Ratherthan staringinto the cameraor focusing on prevention activities,they seemed to embody its antithesis-bathing in the open, playing
next to piles of garbage, serving food in spaces surroundedby crowds, cars, and
urbandecay, orjust living in the wrong partof the city. They were entirelyout of
the loop, not only failing to play any active role in circulatingcholeraprevention
discourse but seeming to be entirely unawareof or resistantto it. The projected
readersof El Nacional (with the exceptionof healthprofessionals)were strikingly
absent, seldom appearing in these photographs. Because they were reading

POWERAND PRAGMATIC
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authoritativeinformationabout cholera as conveyed by authorizedscientific reporters, their role in acquiringinformationregardingcholera preventionwould

seem to have gone withoutsaying (or ratherphotographing).
This fragmentationprocessdoes not emerge simply from these projectionsof
where differentplayersare expected to fit into the process. Officials and reporters
also commentedexplicitly on the degree to which participantswere performing
theirpartsadequately.Recall Paez Camargo'scriticismof reporterswho had been
turnedinto "innocentdupes"by a politicianconcoctingcholeracases; he implicitly
suggests that they behave properlywhen taking only official statementsas news
sources.Reporterssometimesreturnedthe favor by criticizingMSAS officials for
failing to provide useful, accurate,and timely informationabout cholera,as in El
Nuevo Pais's parodic characterizationof Minister Orihuela's smile. Reporters
more commonly ratifiedthe position of public healthofficials as not only being in
the loop but ensuringits properoperation;Diaz Hung (199 la) thus suggestedthat
"Thefalse alarmthatcholerahas arrivedhas circulatedseveraltimes. A few hours
later, you hear the ministerof [M]SAS, Pedro Paez Camargo,disprovingthe rumor."
Assessments also focused on differencesassociatedwith the degree to which
these imaginedhierarchicalnodes were reflectingcholerapreventiondiscoursebehaviorally.Both MSAS officials and reportersvisited barriosand indigena communities and inspected their homes and neighborhoodsjust as they observedthe
street vendors' carts. Rizk's (1991c) indictment:"None of these measures"has
been transposedinto action by streetvendorsor barrioresidents.Here again, middle-class readersremain invisible-neither epidemiologists nor reportersvisited
their homes, workplaces,or neighborhoodsto see if their behaviorreflected the
preventionguidelines.Interestingly,Camachotold me thatit was easy to interview
members of the working class and gain access to their homes, but middle-class
residentswould seldom even consent to be interviewedaboutcholeraor otherepidemic diseases. She did not mention attemptingany inspections there. The state
andthe mediamade little effortto deprivatizethe lives of the middle class through
healthsurveillance,andit does not appearthatit would have been easy to do so.
Now we come back to Warner.Public discourseaboutcholeradid not simply
reachthe publicbut definedfour differentpublics:barrioresidents,streetvendors,
indigenas, and sanitarycitizens of the middle class. These "groups"were not defined by cholera or its epidemiological trace-no cases had yet been reportedin
Venezuela.They were definednot only throughthe referentialcontentof these discourses,the descriptionsof theirbeliefs, habits,environmentalconditions,etc., but
also by the place thatthey were assignedin this idealizedcirculationof public discourse. These four publics were defined in contrastto both health professionals
and reporters.(The journalistsplaced themselves within the public health "we,"
whereasofficials positionedthemmuchcloser to "thepublic.")
These gaps underminedthe idealizedimage of discoursecirculationas well as
its pragmaticenactment.Located at the very end of a discursive chain that also
formeda social hierarchy-and portrayedas lacking the cognitive, attitudinal,and
materialprerequisitesfor successfullybringingthe circuitto completion-it would
seem thatpeople cast in the cholera story as barrioresidents,indigenas,and street
vendors were expected to fail. Calls for fostering communityparticipationwere
thus issued in bad faith. And if preventinga cholera epidemic was deemed to be

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contingenton gettingthese threesectorsto embodypublicdiscourseaboutcholera,

then the "campaign"as a whole appearsto have been designed in such a way that
its outcomewould be, at best, uncertain.
Unnamed, unstigmatized,and interpellatedas the designated audience for
denigratingdepictionsof the otherthreepublics, sanitarycitizens seldom seemed
to challenge the way they were positioned in this projectedprocess. Many of the
people who got thrustinto the barrioresident,streetvendor,and indigenaslots, on
the otherhand, sought to redefinethe way thatthey were interpellatedby cholera
publicdiscourse.Manyindividualsdefinedtheirpositionby rejectingaspectsof its
content, from its more blatantlystigmatizingsocial featuresto even the idea that
cholera-qua disease-existed at all. Many people challengedthe regime of truth
thatcast MSAS as the locus of productionof knowledge and theirown relegation
to a passive anddependentrole.
But it is clearthatmanyindividualsreconfiguredthe referentialfield in which
cholera signifiers were located, using images of the disease as means of evoking
corruption,the indifferenceof stateofficials to theirneeds, the failureof stateinstitutions to provide adequateservices, and the lack of adequatejobs and housing.
They thereby subversivelycast themselves as producersof cholera discourse, as
people who could see what was really going on. At the same time, this transgressive mode of interpellationshifted not just ideas abouthow choleradiscoursecirculated but its very political definition. Discourse became less a referentialand
cognitive process of the coding and decoding of free-floatingsignifiers (presumably tied to "real"referents)than a set of practicesthatwere groundedin material
reality, such as access to food, runningwater,sewage facilities, adequatehousing,
and healthcare. Ratherthanchallenge the constitutionof multiplepublics or their
inclusion in a particularsector, most individualswho talkedback to public health
officials seemedto challengethe dominantmodel as to how publicdiscourseought
to circulateand how a seemingly linear,horizontalprocess createddiscontinuous,
hierarchicallyarrangedcategories of knowledge and knowers. Kitzinger (1998)
suggests thateven when audiencesare skepticalof mediacoverage (andthus of reporters'ssources),the mediamay still constitutethe primarysourceof information
about an issue. Nevertheless,this case suggests that the force of subversivereadings also springs from people's ability to question hegemonic projectionsof the
routes of circulationof public discourses and/orhow they are positioned within
them.
Evidencefrom otherSouthAmericancountriesregardingresistanceto official
discoursesaboutcholerasuggeststhatthe Venezuelanexperienceis hardlyunique.
Marilyn Nations and ChristinaMonte (1996) document the highly stigmatizing
natureof the anti-choleradiscourseproducedby the Brazilianstateand how it led
to widespreadrejection of health education recommendations.Rudi ColloredoMansfeld (1998) suggests thateven as indigenousresidentsof Otavaloin Ecuador
were gainingeconomicallyon theirneighborsthroughtransnationalsales of handcrafts and culture,an outbreakof choleraled to their depictionas "dirtyIndians"
who would naturallybe "at risk" for the disease. Marcos Cueto (1997) suggests
that poor Peruvianschallengedstigmatizingimages by placing cholerain a much
wider geopoliticalframe.And this sort of relationshipbetween states,classes, and
cholera is hardlyconfined to Latin America or the late twentiethcentury.Morris
(1976:95) suggests with respect to the 1832 choleraepidemic in Englandthatthe

311
middle and upperclasses reactedstrenuouslyto what they saw as a threatto their

privileges. Contrastively,"from a working-class viewpoint this reaction was a
threat to their normal life and legitimate rights far more serious than anything
promisedby choleraitself"(see also Delaporte1986; Evans 1987).
Conclusion
Thus, problemswith public discourseson healthcannotsimply be blamedon
ignorantor manipulativejournalistsor on paranoidand disrespectfulpublic health
officials. In the example I have described,these partieswere largely in agreement
regardingan ideological view of how health-relatedinformationis producedand
how it circulates.Health professionalsoften get angry over reporters'penchants
for extractingwords from institutionalcontexts and placing them in new textual
settings,leading to such chargesas "I've been misquoted"or "Youtook my words
out of context."
The pointis thatfragmentingdiscourseis parfor the course-the way it circulates throughcomplex arraysof institutionaland noninstitutionalsettings, registers, genres, channels,and participants;moreover,healthprofessionalsarejust as
guilty in this regard.Theirrecontextualizationsare legitimizedby the ideology of
referentialstability.In Latour's(1988) terms,they claim to have createdimmutable mobiles, packets of informationthatcan travel aroundwithoutchangingtheir
meaning as they move from Washingtonto Caracasand are recontextualizedin a
variety of manuals, posters, pamphlets, press briefings, and public service announcements.
As GeoffreyC. Bowker and SusanLeigh Star(1999) argue,even such seemingly water-tightentities as diagnostic categories carrythe history of the institutional sites they have visited within them, no matterhow much they may seem to
be imperviousto recontextualization.The way that these juxtapositionsof microbiological, clinical, and social informationthat emerge in cholera manuals,pamphlets, and press briefingsareinterpretedandthe social effects thatthey createare
highly sensitive to changes of context, channel, genre, and personnel.Claims by
health professionals that it is only reporterswho fragment information about
health-even as they turnprojectionsof horizontaland lineartransmissioninto a
wealthof hierarchicallyorderedsocial categories-seem, shall we say, naive.
Let us returnhereto the issues with which I beganthis article:healthinequalities, the need for greaterpublic involvement in public health, and the distinction
between sanitarycitizens and unsanitarysubjects. Startingin the nineteenthcentury, states that claimed the mantle of modernity also claimed the right to use
health as one of the key bases for creating normativedefinitions of citizenship.
Since thattime, statediscoursesabouthealthhave differentiallyinterpellatedpeople on the basis of theirperceivedrelationshipto hygiene, medicalknowledge,and
ways of preventingand treatingdiseases. Publichealthhas thus involved, since its
moder inception,ways of addressing"thepublic"that create a range of publics.
Healthdiscoursehas thus played a crucialrole in defining and naturalizingsocial
inequality.Recentwork in medicalanthropology,the historyof medicineandpublic health,medical sociology, science studies,and otherfields has helped us grasp
the many ways that differential access to biomedical technologies and clinical
practices and the circulation of stigmatizing images expands social inequality,

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often with fatal effects. At least in the presentcase, models of the mannerin which
health-relatedinformationis producedand circulatesand attemptsto controlthis
processprovidea meansof creatingandnaturalizingsocial inequalities.
Latour(1993) arguesthatpurifyingand hybridizingpracticesimplicitly connect science and society at the same time that they explicitly pretendto separate
them. This distinctioncan help us grasp the problemat hand. The more officials
and reporterssuggest that one's location in the circulationof health discourse is
contingenton individualdifferences in knowledge and acceptanceof biomedical
knowledge, the more these circuits get intertwinedwith materialinequalitiesand
stigmatizingimages. Drawingon visual culturalstudies(see Burgin 1996; Sturken
andCartwright2001), I arguethatphotographsplace particularlocationsin projections of discursive circulation,stigmatizingimages, and materialinequalitiestogetherin the sameframe.How you get placedvis-a-visimaginedpublicsandimplied
readers-and thereforehow your speech and behaviorare read in relationshipto
diseases-turns out to both shape and be shapedby your access to sanitaryinfrastructuresandhealthcare.
My analysis suggests thatthe dominantideology regardingthe circulationof
public discourses, at least when applied to public health, furtherunderminesthe
healthof the most medically underservedpopulations.But does it really serve the
state-or at least public health professionals who are working to address these
problems?Recall the rising emphasis on health promotion,the Instituteof Medicine's (1988) call for more public involvement in health, and the growing influence of policies thataccordsubstantialweight to communityparticipationin health
programs(see Minklerand Wallerstein2003). If, as MartinBarbero(1987) suggests, our perceptionsof self, society, and the state are fundamentallymediated,
then public discoursesabouthealth shapebasic conditionsof possibility for fashioning new state-publicrelationswith regardto health.
Insofaras the ideologies, pragmatics,andmaterialrelationsthatshapethe circulation of health-relatedinformationcreate chasms between health institutions
and publics-and between people perceived as sanitarycitizens and unsanitary
subjects-getting communitiesto collaboratewith public health institutionsand
clinicians will be an uphillbattle.Effortsby progressivepractitionersto creatively
seek ways of fosteringhorizontalcollaborationsthatpromotecommunityinvolvement are hinderedwhen the airwaves and newspapersproject discursive hierarchies thatdistancepublic healthprofessionalsandcliniciansfrompublics,particularlywhen they place the very participantsin projectstargetedat disease-burdened
communitiesat the end of circuitsof informationandpower.Whenthe stateextols
the virtuesof citizen involvementin healthandthen createsdiscursivechasmsthat
effectively makesit impossibleto shapepublic discoursesabouthealthandeven to
be creditedwith understandingthem, distrustof public health institutionswould
seem to be a foregone result. In an era in which social inequality is expanding
unrelentinglyand healthinequitiesare far from disappearing,this contradictionis
fatalfor bothunderservedcommunitiesandpublichealthinstitutionsalike.
It would be presumptuousto purportto provide a formula for confronting
these problemson the basis of a single study. Not all diseases are reportedin the
same way, not all healthprofessionalsand reporterssharethe same languageideologies, andthese connectionsdo not have the samepoliticalandmedicaleffects in
all partsof theplanet.Indeed,we needa greatdealof comparativeresearchto establish

313
the broaderparametersof these processes. But I do thinkit possible to offer some

tentativesuggestions.
First, as Warer's (2002) articlesuggests, Venezuelanpublic health officials
are not the only ones whose attemptsto place informationinto public circulation
are guided by a rathernaive idea as to how this process works.Models of horizontal, linear, and unidirectionalflows of informationlegitimize implicit hierarchical
structuresfarbeyondthe country'sborders(see Patton1996).
Second, hierarchiesof biomedicalknowledgedo not lend themselvesto identifying who is most capableof decipheringthe complex pragmaticsof public discourses abouthealth. More accuratelyanticipatingthe social effects of health-related public discourses requiresthe involvement of people who understandhow
discourse circulates in all phases of the design and implementationprocess, not
simply in decidinghow bookletsor pressreleasesareworded.
Third, this is an area in which community-basedparticipatoryresearch is
sorely needed. It may seem bizarreto suggest that members of the most underserved communitiesshouldhelp shapehow high officials presentpublic information about health. Nevertheless, such involvement is not only crucial for rooting
out stigmatizingimages but also for uprootingthe hierarchicalrelationscreatedby
placing the people who face the worst healthconditionsas the final link on a projected informationchain. Why not include people who are "experts"in reading
how informationis interpellatedwithin their own communities?In doing so, we
might learn a lot more about the full range of publics that emerge as discourse
about health circulates. Nevertheless, inviting popular participationin shaping
how health-relatedpublic discourseis disseminatedshould form partof efforts to
breakthe hold of hegemonic models andpractices-not to make them more effective.
The state tries to speak to the people about other topics, such as democratic
practices, drugs, ecology, education, and crime. In the United States and other
countriesin which neoconservativemovementshave gained ascendancy,the perceived failureof liberalprogramsaimed at inspiringpublics to act in ways thatthe
statedeems to be rationalhave providedneoconservativecritics with argumentsto
eliminateservices for the growing ranksof the poor-or to make them more inaccessible and punitive.Creatingdiscursiveblueprintsthat lead to such failures,or,
more precisely, to the perceptionthat they have failed, contributesnot simply to
preservingthe "kinder,gentler"hegemony of the welfare statebut to regimes that
eliminaterestrictionson economic exploitationandenact"race-blind"policies that
suppresspublic challengesto discrimination.If healthhas been crucialfor shaping
notions of citizenship,publics, and the state for nearly two centuries,health specialists can play a key role in challenging these attemptsto rationalizenew inequalities.
This case sheds new light on a problemthathas generateda greatdeal of research and theorizing in anthropology in recent years, how states generate
hegemonic discourses,theirpolitical economic effects, and possibilities for resisting them. Along with medical historians,sociologists, and specialists in women's
and culturalstudies,medical anthropologistshave challengedthe modernistseparationof science and society (see Latour1993) in demonstratinghow states,transnationalcorporations,and internationalagencies shape constructionsof diseased
and healthy bodies (e.g., see Briggs with Mantini-Briggs 2003; Cohen 1998;

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Lindenbaum1998; Martin1987, 1994; Pigg 2001; Rapp 1999). Scholarshave also

demonstratedhow medicalideologies andpracticesbothreflectandshapepolitical
economies and structurerelationsof inequality(see Das 1995; Farmer1992, 1999,
2003; Kim et al. 2000; Nichter 1987; Scheper-Hughes1992).
The present case points to a dimension of these processes that is not adequately revealed eitherby sensitive analyses of how images located in health-related discourseslegitimize power relationsand forms of inequalityor by illuminations of the broaderpolitical-economic and historicalfactors that shape diseases
and theirsocial effects. When medicalizedconstructionsbecome public discourse,
grasping their social, cultural, political, and medical consequences also entails
analysis of the political economy of the complex pragmaticsentailedin theirproduction, circulation,and reception.Following Warer, I have arguedthat neither
the images themselvesnorthe broadercontextsin which they circulateprovideaccurateindicatorsof how they will be read or how they will affect peoples' lives.
Such analysis is a key prerequisiteto understandinghow states create power
throughdiscourseas well as how people resistthem.
I would thus urge a new focus of concern for medical anthropologistswho
seek to understanddiscoursesof health and disease and their political-economic
underpinningsand effects. Developing this desideratumwill be most fruitful if
medical and linguistic anthropologistsengage more widely in dialogue-and if
trainingin medical anthropologyincludesgroundingin discourseprocesses.There
is a doublemotivationfor developinga politicaleconomy of the complex pragmatics of health-relateddiscourses.This sort of analysis can help us understandhow
the state and media create dominantconceptionsof health,disease, and the body
and some of the ways they areresisted.But it can also assist us in identifyingways
in which we areinfluencedby hegemonicformulations.Insofaras anthropologists,
medicalor otherwise,themselvesrely on simplistic,linearmodels of discourse,we
runthe risk of helping the stateand otherdominantinstitutionsconceal the effects
of dominantdiscourses-and strategiesfor challengingthem-from view.
NOTES
This articlehas benefitedfromexcellentcriticismprovidedby

Acknowledgments.
three reviewers for Medical AnthropologyQuarterly,fellow members of the Health and

Race Group at the University of California,San Diego (Hector Carrillo,Steven Epstein,
Natalia Molina, Lisa Sun-Hee Park, David Naguib Pellow, and Nayan Shah), Vincanne
Adams, and audiences at the Instituto de Altos Estudios en Salud Piblica "Amoldo
Gabald6n"(Maracay,Venezuela), the Departmentof Anthropology of the Universidad
Aut6noma Metropolitana-Iztapalapa (Mexico City), the Escuela Nacional de Salud
Piblica (Habana,Cuba), and the Facultyof Medicine, Universidadde la Cuenca (Cuenca,
Ecuador).Employees of the (then) Ministryof Health and Social Assistance,journalists,
politicians,and many othersgave generouslyof theirtime in documentingthe choleraprevention program.Maria AlejandraRomero helped compile the newspapersample, Jansi
L6pez assistedin quantifyingtheirthematicfoci, andEstrellaMantiniandLicet Villanueva
transcribedthe interviews. Financial supportfor the overall project was provided by the
JohnSimonGuggenheim
MemorialFoundation,
theNationalScienceFoundation,
theSocial ScienceResearchCouncil,theNationalEndowment
fortheHumanities,
theWennerGrenFoundationfor Anthropological
Research,Inc., and the AcademicSenateof the
Universityof California,San Diego. ClaraMantini-Briggs,MD, served as my collaborator
in the overallresearchprojectandenrichedthis articlewith her ideas andcriticisms.

315
may be addressedto the authorat the Centerfor Iberianand LatinAmerican

Correspondence
Studies,Universityof California,San Diego, 9500 GilmanDrive, La Jolla,CA 92093-0528.
1. In TheFutureof Public Health, the Instituteof Medicinesuggests,for example,that
"Publichealthis whatwe, as a society, do collectively to assurethe conditionsin which people can be healthy"(1988:1).
2. With regardto mediacoverage of healthissues, also see Arkin 1990, Chapmanand
Lupton 1994, Convissoret al. 1990, DorfmanandWallack 1993, Joffe and Haarhoff2002,
Leask and Chapman2002, Milleret al. 1998, U.S. Departmentof Healthand HumanServices 1991, andWallack 1989.
3. To be sure,collaborationsbetweenpublic healthprofessionalsand advertisingspecialists are of tremendousimportance(see, e.g., Lyles 2002). I do not treatthem here because they did not enterinto the anti-choleraprogramthatI analyze.
4. Warer's essay is, of course, part of a much largerdiscussion of public spheres,
public cultures,and "counterpublics"(see Fraser1992). For examples, see Calhoun(1992)
and GaonkarandLee (2002).
5. Theinstitutionhasnow beenrenamedtheMinistryof HealthandSocialDevelopment.
6. Like all othernamesof personsinterviewedin connectionwith this study,this name
is fictional.
7. I place the term indigenain italics throughoutthis articlein orderto indicatethatit
does not refer to a bounded,discrete social group. Dividing Venezuelansinto discreteand
nonoverlapping"indigenous"and"nonindigenous"categoriesis less a reflectionof a pervasive andelementarysocial differencethana tool for imposingracialcategoriesandthe forms
of social inequalitythatgo with them.
8. Comer et al. (1990) arguethat readersprocess visual images differentlyfrom text.
Imageshold a "positioningpower"thatgeneratesaffective responsesthataremoreresistant
to reflectionanddeconstruction.
9. This informationis drawnfrom a 2003 interview that ClaraMantini-Briggsconductedwith a memberof the formerDivision of Social HealthPromotionteam.
10. Both this phraseand the notion of un invento(a lie) emergedrepeatedlyin public
health officials' accounts of their attemptsto measurepublic views of a possible an epidemic. Ourinterviewssuggest thatsome membersof the workingclass continuedto believe
thatthe choleraepidemicwas a fiction concoctedby the governmentto drawattentionaway
from its own problemslong aftercases were reportedin Venezuela.
11. This photographappearedin El Nacional on September29, 1992. Althoughit thus
falls outside of the storiesthatappearedpriorto the time thatthe first cases were reportedin
Venezuela, other photographsthat similarlycriticize the governmentappearedduringthe
periodof the sample(Februaryto earlyDecember 1991).
12. Rosenberg(1989:5) arguesthat the attributionof agency to diseases is common:
"Once articulatedand accepted,disease entities became 'actors' in a complex social situation."Also see Tomes 2000.
13. The contestedpositioning of reportershere is interesting.Althoughthey claimed
the abilityto transmithealthinformationmoretechnicallyandauthoritatively
than"thepublic,"
health officials lumpedthem togetherwith othernonprofessionals.But reportersclaimed a
mode of discursiveagency thatno other actorspossessed-the ability to draw on multiple
sourcesanddiscoverhow to makeinformationnewsworthy.
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Why Nation States and Journalists Cant Teach People To Be Healthy - BRIGGS

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Why Nation-States and Journalists Can't Teach People to Be Healthy: Power and Pragmatic

Miscalculation in Public Discourses on Health

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