by Britt Halvorson, Colby College

Recent writing about temporality in global capital flows has focused on financial instruments like derivatives and securities, which prioritize a forward orientation to time (Maurer 2010, Miyazaki 2003). It could be argued, however, that people can engender different socialities and orientations to time through a number of other economic forms, as well, ranging from charitable donations of medical supplies to discarded clothing. Most castoffs, including e-waste, medical discards, and building materials, are economic forms holding latent exchange value. Cultural actors can generate, seize, and channel this value in myriad ways, using waste economies to further various projects of social reproduction. Yet the mechanisms by which these value-generating activities enable people to place themselves in time, or further specific orientations to a future or past, are less well understood. Drawing from long-term ethnographic research on a 25-year-old medical aid program linking the U.S. and Madagascar, I use this brief essay to trace how Malagasy and American participants engender different orientations to time through their work with discards, as they transform both discards’ value and the social relations surrounding them.

My research has focused on two Christian aid agencies, Malagasy Partnership (est. 1980) and International Health Mission (est. 1987), established by Malagasy physicians, former American missionaries to Madagascar, and their supporters in Minneapolis/St. Paul.[1] Both faith-based agencies procure biomedical discards from U.S. hospitals and disburse them to the nine hospitals and 39 dispensaries of the island-wide Malagasy Lutheran health department or SALFA (Sampan’asa Loterana Momba Ny Fahasalamana), an arm of the Malagasy Lutheran Church. The Minnesotan organizations collect donations of primarily unused but “recovered” medical supplies, such as catheters, IV needles, respiratory tubing, and blood pressure pumps, which have been cast off by U.S. hospitals due to planned obsolescence or insurance regulations (specifically, patient/clinician “risk”). The NGOs’ volunteer workforces, which range from approximately 150 Euro-American, middle-class retirees at IHM to fifteen volunteers at Malagasy Partnership, sift through these aggregate donations and carefully separate “useful” from “junk” materials, further categorizing items by biomedical procedure (e.g., respiratory, orthopedic). In this view, certain medical discards, such as spare machine parts, surgical sutures of material or size appropriate for only very specialized procedures or equipment without a convertible power source, have non-malleable “junk” qualities that effuse the negative moral and ethical values of non-usefulness. Some aid workers even draw direct connections between the circulation of “junk” aid and human sinfulness. Aid workers’ labor with medical discards thus operates as a cultural practice in which to reconfirm one’s commitment to God through the sorting and selection of useful things. Collectively, American aid workers socially characterize the discards as useful gifts and clinical tools, muting their exchange value and role in global medical commerce (see Halvorson 2012).

Figure 1. An IHM volunteer whom I call Harriet, and with whom I regularly worked, sorting medical donations; at the time of my fieldwork in 2005-2006, Harriet, a retired missionary nurse, had spent 16 years volunteering at the agency. She passed away in 2010.

Figure 1. An IHM volunteer whom I call Harriet, and with whom I regularly worked, sorting medical donations; at the time of my fieldwork in 2005-2006, Harriet, a retired missionary nurse, had spent 16 years volunteering at the agency. She passed away in 2010.

These practices attempt to reconstitute the moral value of discards in a Christian ritual framework and, thereby, remake social relations with brethren in Madagascar and elsewhere. American NGO workers, above all else, place emphasis on the value of relations through things. This work is done, however, through things that bear limits to how much they can be remade. Discards are things with pasts, and their pastness can overwhelm what else they are or can be. Medical materials sometimes carry observable stamps of their previous institutional life, such as hospital insignia, signs of wear or, more rarely, bodily imprints. Additionally, the heterogeneity of medical discards is a continual reminder of the materials’ diverse itineraries through the hospital system and their previous status as institutional cast-offs. The IHM operations manager, Mark, bristled once in my presence at the idea, suggested by a journalist for a local religious newspaper, that IHM “recycles” medical materials; he pointed out that many donated supplies have never been used in U.S. hospitals. I suggest Mark disagreed with this characterization not because he does not support recycling but rather because the term directly acknowledges a thing’s previous life and, thereby, minimizes the NGOs’ ethical work to make discards into useful aid. Downplaying the discards’ previous lives is a way of attempting to make them anew, pressing these institutional “end products” into a new future (cf. Hawkins and Muecke 2003:xiv). In striking ways, this work reverberates with broader American efforts to remake relations with Malagasy brethren. Medical aid work can be positioned within more widespread efforts in American Lutheran (ELCA) circles in Minneapolis to break from socially recognized aspects of cultural and religious imperialism during the colonial period, specifically the inequitable religious authority and racial ideologies pervading early-mid 20th century American foreign mission work. Transforming medical discards into medical relief is a cultural activity that serves among Americans as an “instrument of historical reinscription” (Yaeger 2003:109), but is continually limited by the traces discards bear to their previous lives.

Through my research with SALFA headquarters in Antananarivo, I came to understand Malagasy acceptance of such heterogeneous materials as an act of value generation in itself, an actively chosen move to create ties irrespective of something’s individual use-value or exchange-value. This transaction hinges not so much on value in things but rather the future potential of the ties themselves. One of the largest not-for-profit systems of its kind in the world, SALFA coordinates both medical donations and equipment from foreign donors like the two U.S. NGOs and purchases some pharmaceuticals and supplies, tacking on a “service fee” for these items to each of its forty-eight member clinics. When multiplied to account for the thousands of individual relief items that SALFA receives annually, this small amount, which could be as low as 1,500 Malagasy francs or USD$0.11 for a single suture (otherwise US$2-4), helps fund the central operation. Like many medical clinics in Sub-Saharan Africa operating under the conditions of structural adjustment reforms, SALFA has built a thick web of contacts so that, should a grant end or funding priorities change, SALFA and its member clinics will not be left without support. SALFA currently partners with no less than thirty-three technical and financial donors, including Médecin du Monde, Global Fund, United Nations Population Fund and USAID.

SALFA clinicians and administrators pour considerable effort into maintaining relations with donors not merely for the medical materials or financial security they bring in the present but for their potential future contributions. Though they frequently expressed gratefulness for their partnership with the American NGOs, SALFA administrators often characterized their 25-year aid relationship not necessarily in terms of the valuable things it had produced but rather for what it could produce. For instance, the SALFA financial administrator Clement, Dr. Andry and another SALFA informant Mr. Rajoanary all separately observed that, while considerable American supplies donated since the late 1980s were clinically and economically useful for SALFA, sea containers often included things that could not be used – or at least not immediately – requiring a storage facility in Antananarivo. The storage facility itself underscores this view of the American medical discards’ “stored” or contingent value. Even if some supplies were found later to be discards by Malagasy clinicians, the potential for support provided through ties with the American NGOs imbued the transaction with value. In short, while discards’ individual clinical value is often uncertain, SALFA workers have strategically organized value in their contingent worth, as the act of receiving and holding them retains a connection with the American NGOs.[2]

Figure 2. The SALFA storage facility on the outskirts of Antananarivo, composed of decommissioned shipping containers and known to Minneapolis volunteers as “container city.” Photo by the author.

Figure 2. The SALFA storage facility on the outskirts of Antananarivo, composed of decommissioned shipping containers and known to Minneapolis volunteers as “container city.” Photo by the author.

Figure 3. Inside one of the storage facility’s sea containers reside labeled bags of povidone iodine solution, used to prevent infection in wounds and to prepare the skin for a surgical procedure. Photo by the author.

Figure 3. Inside one of the storage facility’s sea containers reside labeled bags of povidone iodine solution, used to prevent infection in wounds and to prepare the skin for a surgical procedure. Photo by the author.

By accepting the discards, Malagasy Lutherans contribute to a broader set of medical commerce transactions. They enable U.S. hospitals to revalue medical discards as “charitable donations” and, perhaps above all, absorb “risk” deemed undesirable for U.S. medicine. Malagasy Partnership and IHM not only export medical goods but export risk, a social “bad” (Hayden 2004). Medical supplies become castoffs mostly because of the U.S. medical insurance regime that associates manufacturer expiration dates or opened packaging, even when medical supplies remain unused, with increased epidemiological and financial risk for U.S. patients and practitioners.[3] This uneven global distribution of risk maintains a two-tier global medicine that upholds a form of “cosmopolitan” medicine in the U.S. and its legal regime (DelVecchio Good 2001:396), in which risk is an object of active reduction, while tacitly characterizing Malagasy medicine as an inherently “risky” proposition or practice in which patient risk is normalized. Together, the geographically dispersed medical commerce transactions I have described create a global topography of medicine characterized by unequal access to medical resources, even as the aid program seeks to address such inequalities (cf. Povinelli 2006). But part of what I have suggested here is that, as with American aid workers, the value of these transactions can be understood in other ways from Malagasy points of view, that is, not merely through the dominant market or biosocial perspective.

Figure 4. A donated baby scale in the well-baby clinic at Ambohibao Lutheran Hospital, Madagascar. Photo by the author.

Figure 4. A donated baby scale in the well-baby clinic at Ambohibao Lutheran Hospital, Madagascar. Photo by the author.

Examining the circulation of medical discards between the U.S. and Madagascar unveils a revealing set of contrasts in how discards are valued and positioned amid broader projects of social reproduction. Many of my Malagasy informants like Mr. Rajaonary were well-versed in the workings of global medical commerce, noting they often ended up with what U.S. hospitals decided to dispose; they received things deemed technologically “past” for U.S. clinics but not presumed so for Malagasy hospitals. Yet, it is noteworthy that, rather than frame their work through the materials’ discard status, the Malagasy aid workers in my research consistently positioned the discards as a sometimes valuable commodity chain, situated in a potentially much more valuable foreign partnership. We could interpret this as both an active valuation of donor ties and a casual refusal of the notion that SALFA should find central value for its medical operation in someone else’s cast-offs. It is a cultural space in which Malagasy make visible their long-running awareness that the medical relief is not necessarily geared to Malagasy clinical needs but came about through a complex system of global commerce in which they and their American brethren play specific roles.

In conclusion, Americans and Malagasy take medical cast-offs through what John Frow (2004:35) calls “multiple regimes of value,” as their gift status, religious value, clinical usefulness, and market value are differently emphasized and muted. In this process, the transformative potential of discards fuels wider, ongoing Malagasy and American work of “reorganizing social values” (Hawkins and Muecke 2003:x) through foreign ties. My account has endeavored to capture how aid workers themselves negotiate what Jane Guyer (2004) calls “asymmetrical value conversions” in which there is a gap of commensurability or equivalence, sometimes sparked by the commingling of multiple valuation scales. Value itself emerges in these activities as inextricably temporal. To better appreciate the spaces of cultural and political maneuver people create in global waste economies, as well as the often subtle critiques waged in delicate aid relationships, we need to tend to how people differently harness discards’ value within the limits imposed by their form; value is not only an emergent or immediate property of discarded things but materializes in the way it can be created anew, stored, stretched or slowed across diverse time scales, thereby advancing specific moral and political aims. This kind of creative work speaks to the realities of medical relief programs, in which people must make the most of conflicts of value, perhaps particularly as they deal in discards.

Footnotes:

[1] The agency I call Malagasy Partnership closed down toward the end of the political crisis that unfolded in Madagascar between 2009 and 2013. IHM has since absorbed most of its programs. Here, I draw from over two years of ethnographic research I conducted with both agencies before Malagasy Partnership closed.

[2] I am grateful to Debbora Battaglia for her engaging comments on this subject.

[3] The NGOs also receive supplies and equipment due to planned obsolescence; biomedical innovation, such as when a new or newly reworked procedure demands different supplies; or when a new product vendor has been chosen for a particular type of supply, making the previous supplies in stock superfluous. Many factors must be taken into account when assessing a particular medical supply’s “safety” for patients. However, medical doctors who run a similar medical recovery program at Yale-New Haven Hospital in Connecticut, called REMEDY, have noted that many of their program’s recovered surgical supplies have been discarded more because of the “legal and political climate” surrounding U.S. medicine than because of their inability to be used for “safe, effective patient care” (Rosenblatt and Silverman 1992:1442).

Britt Halvorson is a cultural anthropologist whose research engages issues that cross-cut the anthropology of religion, discard studies, medical commerce, and the colonial legacy. Her current research focuses on the cultural politics of aid relationships between churches in the U.S. and Sub-Saharan Africa, particularly those that involve the global circulation of medical discards. She is in the Anthropology Department at Colby College in Maine.

This post is part of a series on Emergent Socialities of Waste that includes:
Dumpsters, difference, and illiberal embodiment by David Boarder Giles
The Value of Time and the  Temporality of Value in Socialities of Waste by Britt Halvorson
The Time of Landfills by Joshua Reno
Trading on Obsolescence on the Streets of Hong Kong by Trang X. Ta

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