inverted quarantines, mosquitoes & the common man in delhi

This post has been some time in the making, ever since Raul Pacheco-Vega introduced me to Andrew Szasz’s concept of an ‘inverted quarantine,’ defined further below, and fabulous Manpreet Singh and i started kicking around how the idea applied to our lives in Delhi. This week, a few events, including a desperate effort to stay awake to fend off jetlag, have conspired to help this post come together.

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i’ll start with the idea of a quarantine, since it has such a delightful etymological origin. The phrase comes from the Italian for ’40,’ the number of days a ship needed to stay in the Venetian harbor before its booty or crew came ashore, a practice put in place during the Black Death of the later 1300s. Specifically, the ships subjected to quarantine (or forced isolation) were those returning from plague-stricken countries. The idea, as Szasz elaborates, implies the following set-up: we (Venetians) are mostly in a healthy environment, from which (potentially) diseased individuals need to be kept out. It is a collective (if enforced) action to preserve the health of the environs and, therefore, the people living in it.

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An inverted quarantine is a response to a reversed scenario: an unhealthy environment in which individuals wish to stay healthy. Worse, these individuals have become “fatalistically resigned to it being a dangerous world” (2006). The response is a middle-class or elite response (in general) with two components intended to isolate individuals and their households/immediate environments from harm:

  • An individual response: Despite ‘the environment’ (air & water, in particular) having a generally public good quality, those constructing inverted quarantines are engaged in a response that “is individualistic in both goal and method.”
  • A consumeristic response: A sense that the way to isolate oneself and one’s family from harm requires the purchase of specialized commodities, such as bottled water.

It is the latter point, in particular, that converts a citizen (a political actor) into a consumer, who exercises a certain form of exit (to the market) rather than (political/public) voice, thus functioning as a political anesthesia.

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This idea of building bubbles through consumer purchases has many examples in Delhi, with bottled/canister or water filters as a prime example. The air quality in Delhi has recently taken on a similar, if (deplorably) much less wide-spread, response. If you haven’t been paying attention, the air quality in Delhi is real bad (as in, the worst by measures) and air pollution is real bad in general.

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To illustrate, here is a typical workday morning for me in Delhi, which has only been made more extreme by my recent acquisition of an air quality monitor for my house.

  1. Leave the house with my air filters (n=3) running
  2. Hope that my maid (because… India) doesn’t turn off the filters during the day
  3. Wonder how much electricity I use and therefore pollution I cause running my air filters all the time. Then promptly forget about this.
  4. Wish my maid wouldn’t leave the doors open after she makes breakfast.
  5. Chuckle about how my landlords believe that the air in their small front yard is ‘fresh’ even if the rest of the city is dirty.
  6. Get into an auto-rickshaw (open-side 3-wheeler). auto.jpg
  7. Put on my fancy, Paris-ready vog mask (mine is actually plain black — but).mask
  8. Think about how i should buy masks for my mostly faithful autowalla and then wonder if he would use them (curse my non-existant Hindi).
  9. Arrive at office, where air filters are running most of the time, except during skype calls.

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This is not a perfect bubble but it is certainly an attempt at insulating myself nevertheless: an inverted quarantine that i have tried to construct to protect me at home, at work, and in between. i have tried to make myself part of an air-istocracy.

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And, it is worth noting that there is relatively little political action around air quality. The government has experimented with car-reduction measures but, at least anecdotally, folks were far more interested in whether this reduced their commute time than whether it lowered the particulate matter in their air.

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The idea of an inverted quarantine, as presented by Szasz, rests on both the individual and the consumer response. Given both my research and the current outbreaks of dengue and chikungunya and other viral fevers in Delhi, i have been thinking about mosquitoes and whether the concept applies — both whether mosquitoes constitute the sort of unsafe air/water/land of which Szasz writes and also whether the individual/household response is sufficiently consumeristic to count as an inverted quaratine.

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To be glib, we could lump mosquitoes and the diseases they carry in with ‘bad air’ (literally the origin of ‘malaria’) and solve the first problem.

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And the idea of a consumeristic response to mosquitoes may apply to at least some of the options available. Purchasing a bednet allows me to protect my sleeping space from most night-biting mosquitoes, though we have all had the experience that one always manages to get it. Various sprays, creams, bracelets, coils, plug-ins, and electrified tennis racquets can help to ward off mosquitoes but none of them seem to keep all of them away.

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There are also non-consumer responses to limiting mosquitoes and therefore mosquito-borne diseases in the confines of one’s house and grounds, such as covering or draining standing water, as recommended by the government in posters, including this one from my neighborhood:

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It is not quite clear how to classify these individual / private-good responses to larger public health problems that don’t have a strictly product-based bent within a framework of inverted quarantines — but they are certainly an important type of response in India. A similar idea can be found in the constant cleaning of private spaces but the dirtiness of public spaces (as catalogued in Maximum City, inter alia), the intense faith put in ‘home [prepared] food’ as opposed to dirty and dangerous ‘outside food’ and other ideas that mix real ideas of toxins and pathogens with older ideas of purity and pollution (i believe relating to ideas of protecting oneself from social threat, as Szasz discusses).

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In any case, mosquitoes, unlike air quality, are getting political attention in Delhi — or at least, people are calling out the lack of political action and the over-reliance on promoting individual preventative measures in the face of an outbreak. Mosquitoes are annoying little buggers and can (visibly) get through any inverted quarantines we might construct, so perhaps this call for more public, preventative action is not surprising.

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For my thesis research in Ghana, to better understand the context in which a new malaria treatment program was being introduced, i undertook a media content analysis of how the term ‘malaria’ was deployed and discussed in online newspapers during the relevant time period. Most of the discussion was around specific malaria donations that had come in, reporting of malaria numbers at different state health facilities, or actions that the government had or would soon take around malaria prevention and ‘environmental hygiene.’ One of the presidential candidates being covered during that time was particularly concerned about environmental cleanliness and ‘filth.’

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But a few mentions cast malaria as a disease of common humanity, from which neither rich nor poor could make themselves perfectly safe — an actual or imagined inverted quarantine does not exist (especially against day-biting mosquitoes). It (vulnerability to malaria, mosquitoes) was used as a political symbol of issues that affected all Ghanaians. This idea of malaria and the mosquito as threatening a common humanity — the common man — has a slightly funny resonance with the current political situation in Delhi, where the ruling Aam Aadmi Party (literally, ‘the common man party’) has come under fire for insufficient public health action (rightly or wrongly) in the face of an outbreak of mosquito-borne viral fevers.

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The idea of the non-availability of inverted quarantines in the face of the biting mosquito as a source of political action deserves more attention, as does trying to shake people out of believing that their inverted quarantines against polluted air are sufficient (or indeed, that the air is something from which one requires protection) — ideally stimulating meaningful political action. Just thinking about Delhi, i am not yet convinced that measures need to be both individual and consumeristic to act as a political anesthesia. If the goal is to explain a lack of political action, then more conceptual work is needed. For example, as long as my landlords believe their front yard is fresh/unpolluted because they keep a nice garden (and others at their club start to get worried as well), it is unlikely they will be taking any political action about air pollution. Nevertheless, the idea of an inverted quarantine and how it limits public outrage and civic response seems like a useful concept for studying urban (perhaps in particular?) responses to environmental (and pathogen?) threats, not just in the US, where Szasz focuses, but far beyond.

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To close with a small piece from Szasz’s 2006 presentation paper for the Sustainable Consumption and Society Conference:

Inverted quarantine is a twisted and perverse sort of environmentalism. The person who engages in it clearly recognizes that there is a problem [even if misdiagnosed?], is in fact quite distressed by the problem, and intent on doing something about it. Such a person, however, is deeply pessimistic about real change, unable to imagine that things can actually improve, and therefore fatalistically resigned to it being a dangerous world.

Sounds like a lot of Dilliwallas to me.

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going viral in delhi / is diagnosis a luxury (delhi summer illness 2)

In this post, i continue to try to make research and observational hay out of my own illness in Delhi (starting here). As a quick re-cap, there was a week of severe, arthritic joint pain and weakness, which started to let us slightly right when the rash and fever kicked in. Those were mercifully short-lived but the joint pain has continued for over a month.

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When you shuffle (quite literally since my feet weren’t keen on bending and my hips weren’t into a long stride-length anyway) into a doc’s cabin in Delhi and the first words out of your mouth are ‘joint pain’ and it is dengue and chikungunya season, these are the immediate suspects (also here for news of outbreak). One of the doctors i saw  was happy to diagnose me by sight and actually, actively encouraged me not to bother with the (pcr) bloodtest, since (he was a bit of an overconfident ass and) the test is expensive (about INR 5000 or roughly US$ 75 — definitely out of reach for a lot of patients). An earlier doctor had prescribed a cheaper test, which is more sensitive to the stage of the illness (IgM).

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At this point, i have had the two different chikungunya tests, a dengue test, a malaria test, & a parvovirus b19 test, all of which have come back negative. If malaria had been positive, of course, it would have indicated a very different treatment course than any of the viruses. And it’s good to know if you have dengue rather than a different virus because it is possible you may need a transfusion. But at the patient-level, all the rest of these viruses have a similar ‘treatment’ protocol – fluids, rest & painkillers (plus, as it always seems in Delhi, an antacid to pair with the painkiller).

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There perhaps isn’t much reason, then, to explore which specific virus ails you unless you, like me, find comfort in having a named illness rather than a collection of symptoms that could be named ‘a viral fever.’ (Update 9 Oct 2016: unknown viral fevers in Delhi.)

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And anecdotally, some folks in Delhi seem comfortable just saying that they have ‘a viral’ or ‘a viral fever’  or, intriguingly, that they are going to get tested for dengue to see ‘whether it’s dengue or a viral fever.’ (See also the name of the disease and the work of many anthropologists on this kind of non-specificity vis-a-vis underlying causes.) People also don’t seem a lot of stock in the tests — colleagues and at least one of the doctors i have seen feel like i probably had/have chikungunya, blood work .

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Which raises the question of why i have sought so many different diagnostics (yes, insurance covers it) and why a person might do so more generally. For me, i have both a desire to have a name for my diseases and also a suspicion that a virus doesn’t explain the full story of what has been an extended summer of illnesses rather than a single episode. But for a regular patient paying out-of-pocket, beyond sorting illnesses with different treatment protocols (so, parsing malaria from dengue), being able to pin a particular name to the cause of feeling unwell may not be that important — or, indeed, may be a luxury.

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From a public health perspective, though, lack of clear diagnosis means no numbers to report upward, to understand how illness patterns are changing (including with zika looming on India’s doorstep), when there is a legitimate outbreak, etc. i say that without a complete understanding of how my test results in a private, corporate hospital (some of which were sent to a private path lab in Bombay) make it into any sort of public health statistics at all. The current numbers being reported in Delhi and the surrounds certainly seem too low relative to what doctors off-handedly say they are seeing.

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All of this raises a few questions:

  • During an outbreak, should people satisfied with a diagnosis not based on blood-work (if it looks and walks like chikungunya, it probably is)? Is this sufficiently successful to make up for time and money saved?
  • If diagnosis (sorting between viruses, say) has more public than private benefit (since your treatment won’t change and having ‘a viral fever’ seems satisfactory), should diagnostics be subsidized? How, for whom, etc?
  • Can anyone explain to me whether and how test results from the private sector of clinics and diagnostic centers make it to official numbers? What would need to be done to improve reporting and merging of results into city- or state-wide stats?

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  • Would i be more satisfied with a diagnosis of an unnamed virus in the States? Possibly — it’s certainly happened when down with non-specific ‘flu‘ symptoms that rule out the need to treat with antibiotics. But why am i more comfortable with this?