The Already Dead

The New Time of Politics, Culture, and IllnessBy ERIC CAZDYN

Duke University Press

Copyright © 2012 Duke University Press
All right reserved.
ISBN: 978-0-8223-5203-7

Contents

Acknowledgments………………………..1Introduction…………………………..13PART 1 The New Chronic………………….99PART 2 The Global Abyss…………………159PART 3 The Already Dead…………………205Notes…………………………………217Selected Bibliography…………………..221

Chapter One

The New Chronic

There are moments in history when time seems to stand still, when the layers and cycles and rhythms snap back into a single instant, stinging us in a way that is not quite painful but undeniably felt, like a rubber band whipping back against our skin. If you can imagine this, then try to imagine its opposite—the stretching of time, the extending, flattening, and rolling thin of time, the dull soreness of a meantime with no end; and if you can imagine this (if not feel it), then you have come very close to understanding how the dominant mode of time works today.

We have entered something like a new chronic mode, a mode of time that cares little for terminality or acuteness. Every level of society is stabilized on an antiretroviral cocktail. Every person is safe, like a diabetic on insulin. A solid remission, yes, but always with the droning threat of relapse—of collapse, if not catastrophe, echoing back to us from a far-off future or from the memory of a distant past. So monotonous and stripped of urgency is this mode of experience that there is little reason to agonize, as long as the pain is managed and the possibility of any future change is repressed. All signs must remain “unremarkable,” as the doctors like to say when the health tests come back negative. These medical metaphors (fairy tales, really) are not accidental, for it is medicine that leads this new mode of time, a mode in which we relate to death like a child to his future—with dreamlike indifference and from a safe distance. But, as we all know (and certainly for those who, in one of those untimely instances, lose their lives in earthquakes, in bombings, and in health emergencies in villages and cities around the globe), the future cannot be put off, crisis and disaster cannot be totally managed, life can never be safe, and we do not all experience time—and certainly not the political effects of time—in the same way.

My point in raising the issue of time and the medical is not to pursue the raw and heartbreaking question of unequal access to, and quality of, health care the world over or to talk about the social causes and uneven effects of disaster. My purpose is to claim that time itself constitutes a privileged path to understanding our present moment. Not just time, but the dominance of a certain mode of time—one that resists viewing the future as anything other than an extension of the present and one that can be tracked in various levels of the present global formation.

Changing medical practices have shifted standard notions of the chronic and the terminal, thus shifting how we manage the present and the future and, indeed, how we think about and feel time. Likewise, within political and cultural theory (and practice) a targeted approach to the present, a certain prescriptive mode that limits itself to targeting individual symptoms, is becoming dominant. Site-specific and occupied by single issues, this “immanent” mode celebrates the guerrilla fighter or performance artist who seems to disappear dreamlike at the very moment of his or her radical act—all in real time and all without an apparent claim to something larger.

The chronic, therefore, is not solely a medical category. It is as much about the psychological and emotional relation to illness as it is about lifesaving medications, as much about economic accumulation and geopolitical relations as it is about the latest definitions of death. It is as much about the possibilities of aesthetic representation as it is about the latest medical-imaging technologies.

But this widening of the chronic does not only lead to a political economic, psychoanalytic, or cultural analysis of medicine. It leads to analogies and shared formal logics among the most disparate aspects of our lived experience. The elaboration of these analogies (the elaboration of the problem of analogy itself ) is central to my argument, for there is an overarching logic of time that jumps from one level to another (medical, cultural, political) and, when highlighted, reveals key insights. But overarching does not mean transhistorical or universal; rather, the current logic of time is specific to the present moment of global capitalism. Indeed, capitalism always exceeds itself; it is not only about capital (not only, that is, about production and exchange, value, labor, class, and consumerism). Capitalism is both the inside and outside of our being, informing even its (capitalism’s) own undoings, its resistances, its alternatives—its unthought and unacted. Capitalism digs its own grave, yes, but not just for the moment of its death; it does so also as a productive act in the present, an act that can, perhaps, teach us something about how life and death, as well as any number of other apparently opposing terms (health and illness, for example), are not always or necessarily chronologically ordered, one term preceding the other like so many days on a calendar.

The idea and desire we call “cure,” and the idea and desire we call “revolution” are inextricably tied to each other, and today both of these categories are in freefall. A productive freefall, no doubt, and one that opens up new progressive possibilities, from life-saving medications to new social movements to the most ingenious aesthetic interventions. But there are crucial limitations as well, limitations that turn on a reluctance to engage the central question of radical change and what this reluctance means for imagining alternative futures and, more important, acting in the present. And this returns us to time, for it is through an attentive engagement with time that we can (however blindingly) see the stakes of our current moment, the medical stakes of the political, the political stakes of the medical, and the cultural stakes of the biopolitical. But we also enter into the singular realm of the human psyche, though perhaps from the back door, and must remember that none of this is elegant, none of these realms fit flush with the other. There is always something missing, always something that cannot be squared. As Chris Marker reminds us in the film Sans Soleil, “Who says time heals all wounds? Time heals everything but wounds.”

To hear time as a keynote today (we have just established it is not a panacea) seems to force us down a philosophical rabbit hole, returning us to ancient brainteasers on the meaning of time or to the various clock technologies, from sundials to obelisks, from the seventeen-year libidinal cycle of the cicada to the beating of our own hearts. And then there is the modern history of theoretical physics, with its tenses and loops, its Möbius twists and infinite branchings all the way to the very end of time in super-string theory and canonical quantum gravity. But this focus on time (as a cutting-edge scientific problem or as one of the key philosophical puzzles persisting at least since St. Augustine) should not divert us from recognizing that something is going on today with time that marks a qualitative shift in how it operates on us, a shift that relates to new and old inquiries into time, surely, but a shift that cannot be reduced to science and philosophy. As already proposed, I name this shift, this dominant operation and experience of time, the new chronic.

Before beginning, however, there is one more thought experiment that I want to suggest: try to imagine what comes after globalization. If you find this difficult, if not impossible, then perhaps it is because imagining what is beyond globalization is like imagining what comes before or after time—a mind-bending exercise, indeed. But this inability to think beyond globalization is precisely one of globalization’s most crucial ideologies. If one were to imagine what comes after globalization, then globalization would cease to exist, for globalization is precisely that category that incorporates and absorbs everything into its realm, especially the very thought of its own end.

One of the more interesting facts about the globalization debate is that almost all historiographical concern has been directed backward, so that locating the origins of globalization becomes the fundamental point of confrontation. Did it begin with the oil crises of the 1970s or the moment of political-economic integration after the Second World War? Should nineteenth-century colonialism or the expansion of fourteenth-century trade routes mark its beginning? When someone enters into the globalization debate they invariably smuggle into their argument an argument about origins. Every argument about globalization, therefore, is a theory of history. But such a theorization is almost always unconscious. Most thinkers directly engage the question of when globalization began or whether or not it has even started, but they rarely considered what opens up or closes down when history is punctuated in such a way. The question of “an end” to globalization is not to reproduce from the other direction this repression, but to reveal how the problems of history and time are at stake, how globalization, like certain manageable conditions, can admit an origin but not a termination point. To name an endpoint to globalization is to simultaneously do away with globalization as we currently understand it. The very category of globalization depends upon the dominance of a certain notion of time, the new chronic.

The new chronic, however, is not an entirely smooth and sealed temporality. It contains a fundamental crack within its formation, a gap that comes between its ideological work and the possibilities of human existence. Here I am reminded of the joke told by Slavoj Zizek about two security officers patrolling a city street after a military coup in Poland. The officers have orders to shoot and kill anyone out on the street after 10:00 pm. It is ten minutes to ten and one of the guards sees a man hurrying along and shoots him dead. The other officer, perplexed and worried, turns to his partner and asks why he shot too soon. “I knew the fellow—he lived far from here and in any case would not be able to reach his home in ten minutes, so to simplify matters, I shot him now.” The new chronic experience of time submits to this very logic, a logic that assumes that everything will remain the same as the present turns into the future. The reality that structures this “now” in time will be the same reality that structures subsequent “nows” (not only does this invoke a classic Aristotelian mode of how time works, but this mode continues to be pressed into political service today, an ideological exercise regime for reducing the imagination). No doubt, and as I will stress throughout my analysis, this reality is provoked by (and provokes) very real fears and vulnerabilities—an existential mode that privileges management over change and holds fast to rigid continuities while walking with only the most tentative and straightest of steps.

Notwithstanding the many progressive aspects of the chronic in the medical, political, and cultural realms, there are many reasons why such a mode is also debilitating and inadequate. In the context of our joke, the curfew could be lifted during the ten minutes before it is ten o’clock, transforming bureaucratically sanctioned efficiency into murder. There could be another coup. The guard could be fired in the meantime. The man could have moved closer to the city center. The point is that when contingency is removed from the present and the unknown (including the potential termination of the present) is eliminated from the future, we have devolved into a military state, one that in order to reproduce itself must shrink the imagination and squeeze dry the experience of time. The following is an exploration of the extent to which this military state is an epistemological and existential state of being (not necessarily an authoritative political structure) and inextricably tied to a dominant mode of time.

The Medical

Today, there is an emerging global culture of cancer in which very few doctors speak of a cure, and in which even the category of remission is starting to lose its value. Rather, the watchwords are now management and preemption. Instead of depending on the total removal of cancer by either cutting, burning, or chemically killing it (procedures that always leave the possibility of relapse), doctors regularly turn to drugs produced to manage cell growth and other procedures (such as stem-cell therapy) designed to preempt the very manifestation of cancer itself. In the trenches where medical researchers and clinicians—and pharmaceutical executives—work, cancer is quickly transforming from something to be cured to something to get along with, to manage with technologically advanced drugs that keep things in check. The war metaphors still exist, but now instead of carpet bombs and nuclear blasts, we have smart bombs and reconnaissance drones.

At the heart of such transformations is the radical expansion of detection technologies. For example, recent experiments with highly sensitive medical imaging systems revealed that a preposterously high number of people in the general population are walking around with certain forms of cancer. Whether or not the diseases will accelerate before their hosts die of something else is difficult to determine. This has generated a certain crisis of meaning for the radiologists employed to read medical images. The older paradigm under which many radiologists were trained to read (with specific interpretive strategies and narrative assumptions) no longer seems to work; it no longer seems to apply to the foreign texts the new technologies are now producing. This is also connected to what has recently been called overdiagnosis.

In the summer of 2008, the U.S. Preventive Services Task Force recommended that doctors stop screening men ages seventy-five and older for prostate cancer. Since these men, on average, will not live longer than ten years, and since prostate cancer progresses slowly, the study determined that more harm than good could come from screening prostate-specific antigen levels. The study effectively argues that prostate cancer is overdiagnosed in 29 to 44 percent of cases. Overdiagnosis occurs when a medical test picks up an illness that will not cause symptoms during the patient’s lifetime. The study goes on to argue: “Because patients with ‘pseudodisease’ receive no benefit from, and may be harmed by, prostate cancer screening and treatment, prostate cancer detection in this population constitutes an important burden.” In this context, “pseudo-disease” does not refer to false positives (when detection technologies incorrectly indicate disease characteristics that do not actually exist), but rather to a disease that is correctly diagnosed, but clinically insignificant. As might be expected, the responses to this study were severe and hostile, most coming from healthy men in their seventies and eighties who were offended by the statistical argument. “Isn’t the whole purpose of futuristic medical care (including new testing and treatment breakthroughs) about beating—and changing—the odds,” those in this demographic seemed to be saying. When cancer might be in all of us and only some of us are unlucky enough to suffer from it (or when cancer and other terminal illnesses are made chronic or are overdiagnosed), then the very categories of health and illness, benign and malignant, cure and relapse, and perhaps even present and future, become permanently confused.

The consequences of such confusion are especially acute if you are an insurance actuary, a health care bureaucrat, or even a future employee of a company relying on medical imaging. In the United States, for example, there is an emerging trend in which insurance companies and employers subject clients and potential employees to medical screenings, the interpretation of which determines their future, a determination based simply on the likelihood of illness, not even on the actual presence of illness. But without a clear-cut category of preexisting illness or of illness itself, how does one determine risk? How does one plan for the future? And on top of this, the usual ways of determining the durability of a therapy through long-term results is radically changed when management (with its rapid modifications and unique-to-patient configurations) is emphasized over a cure. As usual, there is also a certain economics at work in which an emphasis on management serves certain financial interests, usually the interests of global pharmaceutical corporations whose therapies usually require long-term, continual use. An emphasis on prior notions of cure serve other interests, from the interests of those with a stake in traditional medical rituals to those invested in nationally based protocols of medical training and practice. And patients often get caught in the middle.

(Continues…)

Excerpted from The Already Deadby ERIC CAZDYN Copyright © 2012 by Duke University Press. Excerpted by permission of Duke University Press. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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