Bourgeoning technological advances in biomedicine profoundly animate modern biopolitical understandings of risk and protection and related ways of knowing, offering, and seeking care. But what might it mean to embody protection by means of suspicion toward these very medicotechnological deployments of care? What can suspicion toward biomedical and technological forms of care teach us about histories of risk, medicine, and the imperative to care in the postcolonial world? This article wrestles with these questions. Drawing on ethnographic fieldwork in Barbados between 2015 and 2018, it embraces care’s historically antithetical meanings to examine the caring work of the human papillomavirus (HPV) vaccine and Afro-Barbadians’ hesitancy toward it. Looking closer at care, the impetus to care, and the consequences of refusing that care, it gestures toward the risks and potentialities of not-doing and the affective feelings of suspicion that exist for Afro-Barbadian parents who have refused the care of the HPV vaccine for their adolescent children amid an epidemic of cervical cancer in the developing world.
This article embraces care’s historically antithetical meanings as it examines the caring work of human papillomavirus (HPV) vaccination delivery and suspicion toward it in contemporary Barbados. Looking closer at care, the impetus to care, and the consequences of refusing that care, it wrestles with the (risks of) not-doing and the affective feelings of suspicion that exist for Afro-Barbadian parents who might refuse the care of the HPV vaccine for their adolescent children amid an epidemic of cervical cancer in the developing world. How might the rationale, or perceived rationale, behind care affect the ways that care is both offered and received? What can suspicion toward biomedical and technological forms of care teach us about histories of risk, biotechnologies, and the imperative to care in the postcolonial world? What might it mean to embody protection by means of suspicion toward these very medicotechnological deployments of care and risk? What are the stakes of affective attachments that refuse this care? I offer these as framing questions to contextualize the following discussion on Afro-Barbadian parents’ suspicion around the HPV vaccine in postcolonial Barbados.
Before exploring parents’ suspicions, this piece begins with a technological history of the HPV vaccine and the socioeconomic context in which it was introduced in Barbados in 2014. I then provide a brief genealogical overview of the language of risk and the use of statistical risk assessment in the history of health care to map how risk logics and the bio-logic of biopower have contentiously coincided around the technology of vaccines and the care they espouse to provide. Highlighting the manifold politics of Black female sexuality, medical imperialism, care, and protection that inhere within Afro-Barbadian parents’ claims to suspicion around the HPV vaccine, I then offer a reconsideration of what it means to both care and be suspicious of (the care from) this vaccine in a place such as Barbados and amid popular understandings of vaccination refusal in the western world.
The HPV Vaccine in Barbados
With over one hundred different strains, HPV is a species-specific DNA virus and the most common sexually transmitted disease worldwide. While most HPV infections are asymptomatic and clear without treatment, persistent infection with high-risk strains of HPV can develop into precancerous lesions, cervical cancer, head and neck cancers, and genital cancers.1 The Caribbean is currently among the top four highest subregions in the world with respect to the incidence of cervical cancer and has the highest burden of HPV in the Americas.2 In Barbados specifically, cervical cancer is the second most common female cancer in women fifteen to forty-four years of age, and it is estimated that forty-four new cervical cancer cases are diagnosed annually in a population of less than three hundred thousand persons.3
As a medical technology invested in protecting against HPV and its associated diseases, the HPV vaccine Gardasil is both a profit-making and a risk-managing device. At US$150 per shot, it provides a lucrative market for the pharmaceutical company Merck while also representing a scientific breakthrough as one of the first-to-be-developed preventive cancer vaccines.4 Often referred to as the cervical cancer vaccine, it is most popularly advertised as providing protection for young women against HPV and the risks of cervical cancer posed by the virus. But because HPV is a sexually transmitted disease, the vaccine further participates in an economy of biopolitical surveillance concerned with caring for and managing the risks of sex itself and thus should also be understood to prevent disease while constituting markets of risk and risk management and the surveillance of those to whom this risk attaches. In the context of Barbados, as articulated to me by Afro-Barbadian parents, nurses, and teenagers alike, these risks appear to attach disproportionately to Black adolescent girls’ bodies and their sexuality.
Through the combined efforts of pharmaceutical organizations, international public health organizations, philanthropic agencies, and the Barbadian government, the HPV vaccine was introduced in Barbados as part of a national vaccination program in January 2014 for girls ten to twelve years old.5 According to senior medical officers at the Barbadian Ministry of Health, dismal uptake rates of just below 20 percent at the end of 2014 alongside growing public commentary and concern over the vaccine quickly indicated the prevalence of HPV vaccine hesitancy across the island. In Barbados, both within and outside the biomedical community, much speculation has since existed around the reasons for parents’ hesitancy, from theories about parents’ ignorance, miseducation, and/or distrust in science to the widespread belief that it is a pervasive cultural concern around respectability, premature adolescent (female) sex, and the immunization’s relationship to sex that dissuades many from accepting it for their children, and specifically for their daughters. Rather than seeking to determine the underlying factors behind Barbadian parents’ hesitancy toward the HPV vaccine, the research from which this article derives sought to understand how Barbadians expressed their ambivalence toward the vaccine. This brought insight into some of the histories that comprised parents’ concerns and emphasized the affective nature of suspicion, that is, less an active form of resistance and more an embodied response to the vaccine and its complex entanglements within global biomedical, pharmaceutical, and state assemblages.6
Suspicion that surrounds the HPV vaccine and its administration in Barbados, I argue, converges on the entangled factors of care, profit, science, Black female sexuality, and risk. Conjoined through colonial and postcolonial biopolitical techniques and technologies, these are factors that, in the colonial history of the Caribbean, have long warranted suspicion. Contextualizing Barbadian parents’ suspicion toward the HPV vaccine and its administration thus requires an understanding of how these fraught politics of risk, care, and biotechnologies like vaccines have come into being in coconstitutive ways that underlie the capitalist economy within which the HPV vaccine and the caring work of HPV vaccine delivery exist today.
A Brief History of Risk, Care, and Vaccination
In the 1980s, sociologist Ulrich Beck famously coined the term risk society to refer to the widespread social preoccupation with and intensive management of risk across industrial societies.7 As a modern concept, risk refers to “calculating the incalculable, colonizing the future,” in which danger and peril are associated less with demons, nature, and gods and more with “unnatural, human-made, manufactured uncertainties and hazards.”8 The history of risk, however, precedes these contemporary understandings, originating within the financial realm of transnational maritime insurance and commercialism. Within seventeenth-and eighteenth-century maritime history (and, indeed, maritime slavery), risk referred to a material and corporeal “financial instrument for coping with the mere possibility of peril, hazard or danger.”9 To cope with the natural “perils of the seas” and/or an “act of God,” colonial merchants would purchase financial compensation or insurance on their risks (including human risks of the enslaved) in an effort to manage the uncertainties of their futures.10
As the concept of risk became popularized in the English language from the late eighteenth century (coinciding with rise of capitalism), so too did understandings of risk as something at once material, extreme, immaterial, and in need of quantification and management. Across Europe and the United States, risk management mushroomed in the form of new financial institutions, stock markets, savings accountants, and insurance companies, the latter of which eventually began adopting statistical approaches to mathematically predict chronic disease susceptibilities of prospective policyholders.11 During this time, risk discourse and theorization also entered into the arena of medicine, with statistical aggregations increasingly being used to scientifically and mathematically quantify uncertainty around disease transmission. By the 1830s, statistics had entered squarely into the field of public health, drawn upon for its ability to evaluate and diagnose the efficacy of medical treatment and, for the first time in modern history, to enable doctors, hygienists, and medical administrators to transcend a long-standing reliance on individual cases to attend to those of the population deemed most at risk. Moreover, statistics enabled doctors to quantify, calculate, and control probabilities around diseases and to advise on the impact of social and environmental factors and sanitation measures.12
By the nineteenth century, risk assessment was also prevalent within the realm of biomedicine, where it was used to evaluate the potential dangers of new medical innovations that themselves have always spawned their own risks, questions about efficacy, and social understandings of how these risks might be mitigated.13 Medical historians have detailed how these multiple configurations of risk, probability, and care and competing beliefs about a progressive modernity illustratively converged across class around interventions such as the selective use of anesthesia in Europe in the 1840s, the contraceptive pill, and vaccines—disputes over which can be traced as far back as eighteenth-century debates over smallpox inoculation in England.14 Indeed, while public health concerns around vaccination refusal have heightened within the past decade, especially with regard to the resurgence of vaccine-preventable communicable diseases in North America and Europe, as Nik Brown incisively notes, “vaccination [was] from its very incipient opening moments . . . inherently a precarious political affair underpinning a new biopolitics of population vitality, statehood and colonialism.”15 In addition to early European concerns around smallpox variolation, skepticism over the clinical evidence for the bacille Calmette-Guerin (BCG) tuberculosis vaccine in France and Germany and related concerns around the role that public BCG vaccination campaigns in the 1950s and 1960s British Caribbean played in reinvigorating the British Empire exemplify the continued tenuous history of vaccination through the twentieth century.16 Across these examples, the rights of scientists, medical professionals, and/or states to subject individuals to the risks of vaccination is rationalized by diminishing risk at the level of the population, and the construction of social risk factors and “at-risk” groups is drawn on to justify the then unknown risk of vaccines.17
Central to these aforementioned logics of risk reduction is the bio-logic of biopower, described by Foucault as the power over life. Vaccines, like other reproductive technologies, act simultaneously on biopower’s two poles, in that the anatomopolitics, or the disciplining and objectifying of individual bodies, is articulated alongside the biopolitical collective regulation of populations.18 Public resistance to vaccination emphasizes both the complexity this entwined anatomo-bio-politics presents to the public and the often disconcerting affect embedded within its disciplinary regulation. Indeed, though the utilitarian and population-based public health rationale for vaccination is publicized to both reduce individual risk (even if entailing greater immediate risk) and induce herd immunity (which ultimately reduces individual risk), scientific statements and biopolitical public health policies around vaccination are not neutral, “embody[ing] and at the same time, often obscur[ing] underlying moral values and implicit political decisions.”19 To be sure, as contemporary biopower manifests increasingly through imperatives toward neoliberal self-government, individual choice, freedom, and encouragement to accept biotechnologies like vaccination as a means of caring for oneself and others, there is an increasing slippage between expert scientific, state, and industry knowledge about risk and the moral regulation of health and its relationship to such factors as race, gender, and sexuality.20
That public opposition to population-based risk assessment, medical technologies like vaccines, and a preference for individualized knowledge and care for oneself is a growing problem for modern medicine further points to this ambivalent relationship among risk, morality, and care as they converge in the practice of vaccination. Like all (bio)technologies, vaccines are pharmakons, fundamentally and irreducibly ambivalent—poison, remedy, or both—and often scapegoats for a plethora of societal problems, values, and understandings about health, morality, risk, responsibility, and care.21 Insofar as public health discourses surrounding vaccination are often oriented toward a scientific logic of risk reduction as the basis for medical intervention, they effectively obscure these tensions between risk and care. In so doing, they overlook the fundamental ambivalence of technologies like vaccines that are inherent within claims to/of care. Like pharmakons, the word care similarly exhibits antithetical meanings of “suffering, sorrow, grief, trouble,” and efforts to protect/ preserve from or assuage these troubles.22 Such ambivalences within and between care and risk are amplified within contemporary biopolitical public health campaigns in favor of the HPV vaccine that further articulate the population-risk logic of vaccination with that of sexuality, morality, and gender.23 In the context of Canada, scholars Erin Connell and Alan Hunt point to an increasing “interconnection between moral discourse and risk discourse” through which accepting the scientific, public health, and pharmaceutical risk-managing strategy/technology of the HPV vaccine becomes doubly tasked a moral imperative to intervene in the sexuality of young females (in particular) to whom the vaccine was initially marketed to prevent cervical cancer.24 These confluences take on especial significance in the context of postcolonial Barbados, within whose history risk logics and medical logics have notoriously coincided within colonial biopolitics and the surveillance and control of Black female sexuality from the period of slavery across the British Caribbean.
Risk, Hesitancy, and Biopolitical Care in Barbados
As sociologist Mimi Sheller argues, to comprehensively analyze prac-tices of citizenship, self-determination, and politics within the posteman-cipation Caribbean, one must trace the “political ‘mechanisms of life’: sex, pregnancy, births, longevity, health,” all of which were central to the colonial project.25 As the predominant colonial tools of classification and spatial governance throughout the colonial period and into the post-emancipation period in the British Caribbean, biopolitical initiatives and medicoscientific conceptualizations of racial difference were strategically employed to monitor enslaved peoples’ (and especially enslaved women’s) health risks so as to maximize their speculative value as laborers and human commodities.26
In places like Barbados, “scientifically” racist ideologies of Black people as a socially inferior, immoral species were simultaneously drawn upon by merchant-planters and other white elites as a rationale to withhold and conserve the state’s economic, welfare, and biopolitical resources for those deemed worthier of care.27 Subsequently, whether it was short-lived infant pronatalist campaigns designed to foster optimal conditions for the reproduction of a Black labor supply, contagious disease hospitals deemed necessary to physically and morally regulate promiscuous Afro-Barbadian women’s immoral souls and diseased bodies, attempts to examine and study Black women’s reproductive labor and heterosexual comportment in the post-WWII period, or birth control campaigns of the 1950s aimed at encouraging their sexual control as a mark of self-governance and civility, biopolitical campaigns in Barbados and across the wider anglophone Caribbean have historically remained entangled with and predicated on this ambivalent relationship between the surveillance and care of Black women and their risky bodies, their reproductive systems, and their sexual activity.28 These tactics and campaigns were executed and managed through technologies of surveillance, which were at once biopolitical and necropolitical—focused on caring for, optimizing, and controlling the risks of/posed to Black female life, through coercive and often violent, life-threatening measures, and for the purposes of labor. The sustained economic calculus, capitalistic motivations, and rationales for care that undergird these differentially constituted risks and the resultant biopo-litical moves enacted in response to them are noteworthy markers of the historically ambivalent manifestation of care and its enmeshment within the bio-logic of slavery’s sordid systems.
In postemancipation Barbados, local white elites and professionals who comprised the colonial legislature, as well as British-trained Barbadian doctors who worked alongside philanthropists and colonial officers, dispersed regulations for biomedical care and implemented policies that would save, civilize, and/or reproductively control those perceived to threaten and impede the nation’s health and wealth.29 As the case of Barbados makes clear, these frequently injurious biopolitical projects of “care” that centered on Black female sexuality have also been entwined with conflictual class, economic, and political dynamics that undoubtedly implicate but often transgress race. In addition to white elite suspicions around hyperfecundity and hypersexuality, for example, a different but related set of suspicions around race and sexuality became apparent for the rising Black middle class hoping to assume their place as nationalist leaders in the preindependence period.30 Here it was specifically the working-class Black woman’s sexuality that was in need of regulation into civility and respectability by educated middle-class Black men and women in the name of nation building.31 By the turn of the twenty-first century, like many other societies, Barbados was facing rapid globalization reflected in the increased commercialization, foreign investment, and technological development within many sectors, including public health.
The 2014 introduction of the HPV vaccine campaign in Barbados reflects one of many biopolitical endeavors historically produced and organized across these aforementioned racialized, gendered, and classed lines, public health discourses of risk reduction and care, and shifting socioeconomic state-industry alliances. As previously noted, HPV vaccination delivery in Barbados was made possible through an assemblage that includes a network of state resources, international public health organizations, and pharmaceutical and philanthropic agencies. These include the Barbadian Ministry of Health, the World Health Organization, the Pan American Health Organization, pharmaceutical company Merck, and the Barbados Cancer Society, which have undertaken various efforts to reduce the high cost of the vaccine, build Barbados’s infrastructure to deliver the vaccine, and drive advocacy campaigns that make possible new promissory ideals of what it means to be protected from the sexually transmitted diseases of HPV and its associated cancers. Indeed, the very existence of the HPV vaccine in Barbados and elsewhere remakes the idea of risk (and what it means to be risk-free) into a form of capital, creating new markets for private companies to profit from. Although the vaccine is heavily subsidized by this nexus of state, nongovernmental, and humanitarian organizations, that Gardasil is the most expensive childhood vaccine to have ever been marketed worldwide makes the biocapitalistic motivations of the pharmaceutical company perhaps impossible to disentangle from the medical advances that its vaccine promises.32 In the wake of these fraught convergences among history, surveillance, care, capitalism, racialization, and risk, it is vital that we question accounts that conflate Afro-Barbadians’ suspicion toward the HPV vaccine with a uniform and uninformed refusal of care at the expense of this deeply informative history. As I argue elsewhere, it is through the language of suspicion that Barbadian parents articulate their contentious feelings toward the HPV vaccine, less as a form of resistance toward care and instead as a palimpsestic feeling, one that is sustained cross-temporally and transnationally across citizens, colonial and postcolonial biopolitical projects, and the often invasive technologies and techniques these projects entail.33
This ambivalence toward particular vaccines, or “vaccine hesitancy,” as it is commonly referred to within the medical community, is defined by the World Health Organization as the delay in acceptance or complete refusal of vaccines in the context of available immunization services.34 While biomedical literature has acknowledged the complexity of this phenomenon and its varying sociocultural, religious, political, and interpersonal constitutive factors, claims to scientific ignorance continue to headline many discussions of vaccine hesitancy across popular science books, medical news forums, and newspaper editorials in North America and the United Kingdom, driving a narrative that often conflates antivac-cination, hesitancy, and refusal and frames these phenomena as collective consequences of mis/uninformed, fearful citizens, and public naivete.35 But antivaccine sentiment ought to be differentiated from vaccine hesitancy, which, as social science research has consistently shown, is context specific and more capaciously encapsulates a range of emotions and decisions, from acceptance amid uncertainty to ambivalence and complete refusal.36 While vaccine hesitancy might entangle with antivaccine sentiment for some citizens in specific locales, it is not, as a phenomenon, subsumable to it. To suggest so overlooks hesitancy’s multiple constitutive factors, risks failing to address them (and thus the biomedical problem that is hesitancy within public health efforts to increase vaccine compliance), and, for my interests in this article, misconstrues hesitancy as but an ignorant refusal of biomedical care.
Rather than reinforcing the assumption that vaccine hesitancy amounts to a blanket refusal of care, my interviews with Afro-Barbadian parents about their suspicion toward the HPV vaccine offer a different starting point from which to think about vaccination, risk, care, and their political predicaments. These parents did not simply detail their differential understandings of risk around vaccination but invoked the aforementioned historicity of the intersections of risk, care, and capitalism, their centrality to the colonial project, and their residues within a landscape of neoliberalism and biocapitalism in postcolonial Barbados.37 For many Afro-Barbadians, the tropes of hypersexuality and attempts to morally regulate the Black female body and Black women’s sexual activity that were perceived to accompany the vaccine’s promotion were further cause for suspicion. These historical intersections both called the state’s “care” via vaccination into question and were central to the formation of new risk logics rooted in understandings of the past and skepticism over the motives, efficacy, and value of the vaccine for Afro-Barbadian young women.
Looking Closer: Suspicion as Radical (Care)
Pamela A. is an Afro-Barbadian writer/poet and mother of two children for whom she refused the HPV vaccine.38 In response to my questioning whether she was at all concerned about the vaccine’s association with sex, she framed her suspicions around the vaccine’s side effects.
The main [thing] that I’m really concerned about is the side effects and I don’t see the reason . . . and nobody haven’t convinced me yet why it is relevant to give a ten-year-old, eleven-year-old, twelve-year-old the human papillomavirus vaccine . . . putting that in her system at such a young age. . . . It’s not there now, and I don’t know if in the future if it would affect her body when she gets to be an adult.
Because they were saying, I guess what [the nurses] was saying was that, umm, if the child is promiscuous too, then it’s important . . . and that’s the thing that have me, this idea of the girls as promiscuous. If you raise your daughter . . . yes you can’t, you can’t predict the future, but if you’re raising your child to have morals and standards and stuff like that, then I don’t know if my daughter needs this right away. But yes, I know there is a high prevalence of sexual activities in secondary schools now too. So . . . well . . . I just don’t think that is up to me to put that HPV in her system when it’s not there now.
David C., a forty-nine-year-old Black Barbadian, schoolteacher, and father of two, also refused the vaccine for his daughter Daphne. David’s articulations of his suspicions extend those expressed by Pamela. Though he acknowledged the potential benefits of the vaccine in light of the prevalence of cervical cancer in places such as Barbados, he framed his ambivalence toward the vaccine in terms of suspicions toward the multinational pharmaceutical industry behind its manufacturing, noting, “At US$450 for the complete vaccine, Big Pharma making a lot of money off this thing. . . . It’s not that we never administer drugs to our children, but this particular one though, nah; 200 million vaccines, $150 USD per shot. . . . Big Pharma is making a lot of money out of this thing!” Like Pamela, David was wary that the marketing of a vaccine—one that protects against a sexually transmitted disease—to Black Barbadians such as his daughter evoked disturbing colonial pasts. A self-proclaimed Pan-Africanist, he referenced the long history of racial science and medicine under transatlantic slavery and the influence that such ideologies as Black female hyper-sexuality held in advancing biopolitical intervention and surveillance upon Afro-Caribbean women’s bodies. David was particularly worried, he said, that those promoting the immunization were motivated by a belief that Black women in the Caribbean were “highly sexed” and in need of the salvation, protection, and intervention that this vaccine might afford in regulating the risks of said behavior. Such ideologies and their sordid pasts informed many Afro-Barbadian parents’ suspicion, a suspicion that circulates, pulses, and resides in their bodies as an affective intensity—a historical and lived reality that has everything to do with care.40
Knitting together legacies of the colonial management of Black female sexuality and suspicions as/and desires to protect their children from these pasts, these and other Afro-Barbadian parents with whom I spoke challenge an understanding of vaccine hesitancy as mere scientific ignorance, mistrust, the antithesis of care, or combinations thereof. Instead, their suspicions at once trouble care’s ethics and political commitments and inform and embrace different ethics of care, sometimes manifesting as vaccination refusal. For others, suspicion informed ambivalence and delay in HPV vaccine acceptance, an “in the meantime” politics necessary to ask questions about the Barbadian state, its public health priorities, and the inconsistencies evident within its doing-as-caring paradigm.41 For such parents, the Barbadian state sat at the interstices of their felt suspicions surrounding the vaccine, its intervention upon adolescents’ sexual health, and its enmeshment in neoliberal global circuits of techno-science, ethics, economics, and pharmaceutical exchange.
Selena A., an Afro-Barbadian mother whom I interviewed, was one such parent. Connecting her suspicion toward the HPV vaccine with what she perceived to be the government’s strategic and misaligned priorities when it came to the sexual health of Barbadians, Selena questioned the exuberant promotion of the vaccine alongside government mandates that restrict adolescents from accessing sexual and reproductive health technologies like contraceptive pills in Barbados without parental consent. Though the age of consent for sexual activity in Barbados is sixteen, adolescents below the age of eighteen are unable to access such sexual health services and treatment without parental consent because they are considered minors under the Barbadian Minors Act.42 While there is no concrete legislation preventing adolescents from accessing these services per se, female adolescents in particular are unable to secure birth control pills or information on other contraceptives, safe sex, and sexually transmitted diseases in government clinics or pharmacies unless they have their parents’ support and accompaniment.
As Selena made clear, despite there being no specific legal mandate in place, the state’s nebulous categorization of adolescents between the ages of sixteen and eighteen holds control over their sexual intimacy, rights, and risks. Regardless of whether it is effective in doing so, the Barbadian state restricts both adolescent intimacy and adolescents’ independent access to prescribed contraceptives for safe sex. Referencing this disparity in the law as a basis to question the appropriateness of the vaccine, Selena asked why ten-and eleven-year-old children were being offered the HPV vaccine by the government when under its same rule they weren’t able to access contraceptive pills until they are eighteen years old. Frustrated, she asked, “What are the government’s real priorities when it comes to adolescent sex and sexual health? Why the restrictions around sexual health in some areas, and the forceful promotion of other technologies like the vaccine to preteens?” As noted by Darcy B., another mother who described herself as still undecided about the vaccine, the government’s stated goal to save lives occurs alongside what she perceived to be efforts to fulfill economic allegiances and partnerships with multinational pharmaceutical companies like Merck and the biomedical technologies they manufacture. To be sure, regardless of its (un)stated aims, both these outcomes are likely satisfied in the successful marketing of the HPV vaccine to the Barbadian public. As David, too, incisively claimed, in addition to providing lifesaving technologies to the public, the Barbadian government is also embedded in for-profit pharmaceutical assemblages that profit on the risks of adolescent girls’ (sexual) health by marketing technologies like the HPV vaccine.
Parents’ suspicion thus attaches not only to biomedical technologies and devices like the vaccine and the presexual adolescent female body upon which the vaccine intervenes but also to wider transnational biopolitical, technoscientific networks or “global assemblages” of exchange in which the Barbadian state has immersed itself since the 1980s and that have become increasingly technologically oriented.43 Bio-, communication, and information technologies play a pivotal role in mediating and transforming national and transnational economics, health, intimacies, and, I argue, colonial and postcolonial affects of suspicion and the politics and questions such affects engender.44
Rather than equating their suspicion with pharmaceutical or government mistrust or the act of refusal, Pamela’s, David’s, Selena’s, and Darcy’s claims tell of a careful being with and thinking through of these factors in the present context of HPV vaccination promotion, and in light of the past. As the late Caribbean anthropologist Michel-Rolph Trouillot reminds us, “The past—or, more accurately, pastness—is a position. . . . In no way can we identify the past as past.”45 Invoking affective memories of pastness, Afro-Barbadian parents’ suspicions ask of the motivations behind care. They reveal care’s inequalities and political stakes by mapping how health care work, biomedical authority, state priorities, assemblages, and noninnocent histories of colonial medical injustice often unwittingly intertwine. And yet, understandably frustrating to many, Afro-Barbadian parents’ questions, revelations, and ambivalences, and their often fraught repercussions, exist in a context in which care for and about cervical cancer is urgent.
But perhaps, as Michelle Murphy encourages, we ought to resist the urge to wholly conflate understandings of care with positive affects.46 Indeed, like the “grammar” that has historically overdetermined Black women as hypersexual, deviant, and in need of care and salvation, the dominant grammar of vaccine hesitancy inadvertently and paternalisti-cally naturalizes care via vaccination as uncomplicatedly benevolent.47 A willingness to interrogate this script might open up space to rewire our approach to the sensibility of hesitancy as something that ought merely to be overcome. This need not conflict with efforts to improve vaccine compliance and prevent cervical cancer but, in fact, might do the opposite. Appreciating and taking parents’ suspicions seriously amid efforts to improve HPV vaccine compliance in Barbados means rethinking how we learn to care and what we view as care, so that we might better witness and support the holistic health of our populations. Perhaps, as these interview excerpts suggest, suspicion embodies a radical potential to teach of a care rooted in deep witnessing and reflection as a precursor to prescription, mediation, and medical innovations.
Rethinking suspicion and care calls on medical practitioners and public health workers to release investments in conceiving hesitancy as a refusal of care, in conceiving suspicion and refusal as subsumed by scientific ignorance, and in conceiving vaccine acceptance as a value-neutral willingness to receive care. Further and more challenging still, it requires that social science and scientific researchers/practitioners critically reflect on our conditioned means of studying and offering care; listen more closely to and wrestle with how biomedicine’s rationalities around care intersect with histories of injustice, postcolonial state building, and contemporary neoliberal priorities and agendas; and accept the ways in which these rationalities might be understood to inflict more harm than good. Suspicion, suspicious refusals, ambivalence, and hesitancy hold a mirror to the violence often implicit in our caring and naming practices. They unveil the histories of care and, too, the lingering power of historical narratives of ignorance that surface within discourses of vaccine hesitancy and refusal. They necessitate yet again more pause and hesitancy to more ethically revisit the question of care.
Heeding Trouillot’s call to shift the lens of analysis inward, to a small place, to capture the “agentive capacities of ordinary people” amid evolving and converging historical and contemporary processes of domination, this article has sought to map the not-so-obvious stakes of biomedical modes of care and suspicion toward that care in the context of postcolonial Barbados.48 From this perspective, we are faced with care’s underbelly. Indeed, as the parents whom I interviewed offered, when framed within a noninnocent history of biomedical experimentation and “care,” (post)colonial stereotypes and politics, and pharmaceutical-state assemblages, the historical etymology of the word care and its conflation with fear, anxiety, and grief seems more intuitive.
In describing their suspicion, these parents collectively repositioned the crisis of cervical cancer in the Caribbean (indeed, the crisis of caring for this crisis) within and against the anxious paternalism of the post-colonial state and histories of surveillance and neglect, colonialism, biomedical experimentation, and suspicion toward Black women and Black female (hyper)sexuality in Barbados and transnationally. In so doing, they complicate what it means to be suspicious of (the care of) this vaccine in a place such as Barbados and amid popular understandings of vaccine hesitancy and refusal in the Western world. Eschewing the binaries that structure/d both colonial discourse and medical discourse around rationality and irrationality, suspicion implores us to look more closely at the enmeshment of risk, care, and fear in the postcolonial Caribbean and asks that social science and humanities researchers and health-care practitioners alike recognize and accept the histories, ideologies, and practices that we might yet comprehend. To follow suspicion and rethink care is to embrace the ambivalence of care and vaccines, both, and the incomprehensible, seemingly impossible not-doing that hesitancy might constitute in favor of compassionate recognition, close listening, difficult reflection, and cautious pause. And perhaps this is radical.
This article has evolved over many years of conversation and through the generous feedback of several persons, including Hi‘ilei Julia Hobart, Tamara Kneese, Zoë Gross, and the anonymous readers at Social Text, to whom I am so grateful.
Notes
The other is the hepatitis B virus vaccine that prevents a common form of liver cancer. See Mamo and Epstein, “Pharmaceuticalization of Sexual Risk.”
While initially targeted to girls in this age group, the vaccine was eventually opened up to preteen boys under the national vaccination program in 2015.
See Schlich, “Risk and Medical Innovation”; Magnello “Introduction of Mathematical Statistics”; and Zachmann, “Risk in Historical Perspective.”
See Altink, “‘Fight TB with BCG.’” As Henrice Altink notes, while BCG vaccination campaigns against tuberculosis in the mid-twentieth-century Brit-ish Caribbean were promoted through the lens of public health and its benefits for political, social, and economic advancement, such initiatives ultimately aimed to reinvigorate the British Empire.
See Casper and Carpenter, “Sex, Drugs, and Politics.” See also Connell and Hunt, “HPV Vaccination Campaign”; and Lock and Nguyen, “Biomedical Technologies in Practice.”
I thank this article’s anonymous reader for pointing out that vaccines, like all technologies, are inherently pharmako-logical in the Derridean sense—that is, both poison and remedy. For more on pharmakon, see Derrida, Dissemination, 127.
Oxford English Dictionary Online, s.v. “care,” www.oed.com/view/Entry/27899.
See Connell and Hunt, “HPV Vaccination Campaign”; Charles, “Mobilizing the Self-Governance of Pre-damaged Bodies”; Mamo, Nelson, and Clarke “Producing and Protecting Risky Girlhoods”; and Polzer and Knabe, “From Desire to Disease.”
Connell and Hunt, “HPV Vaccination Campaign,” 67. Despite the vaccine being offered to preteen boys and girls under Barbados’s national vaccination program since 2015, popular and professional discourse around the vaccine and its promotion attaches disproportionately to female sexuality.
De Barros, Reproducing the British Caribbean, 35. In the wake of widespread cholera epidemics in the 1850s and resultant labor shortages in such places as Barbados, Jamaica, and Trinidad, a medical tax system was imposed in many islands. British physicians reasoned that, by taxing populations to pay for medical care, they could maintain dominance and economic profit in the colonies and train Black people on the benefits of rational, scientific advice in lieu of irrational, folk, and obeah quackery prescriptions.
See Paton, “Enslaved Women and Slavery”; Challenger, “Benign Place of Healing?”; De Barros, Reproducing the British Caribbean; Putnam, “Global Child-Saving”; and Bourbonnais, “Out of the Boudoir.”
Beyond the racially motivated anxieties and eugenic concerns that under-girded the support of birth control from white elites in places like Barbados and Jamaica, Barbadian middle-class Black politicians, professionals, and reformist elites also advocated for birth control.
As Kaushik Sunder Rajan observes, biocapitalism indicates an important shift in the constitution of symptoms to be treated and cared for “away from disease manifestation and toward disease potential” (Biocapital, 283). Such a shift necessarily expands the potential market for pharmaceuticals “from ‘diseased’ people to, conceivably, everyone with purchasing power” (Sunder Rajan, “Subjects of Speculation,” 24).
See Hobson-West, “‘Trusting Blindly Can Be the Biggest Risk of All’”; Leach and Fairhead, Vaccine Anxieties; Lawrence, Hausman, and Dannenberg, “Reframing Medicine’s Publics”; and Poltorak et al., “‘MMR Talk’ and Vaccination Choices.” Comparative ethnographies on vaccine hesitancy across the developing world similarly highlight the multifaceted factors that can impact one’s hesitancy, including history and politics, religion, mode of vaccine delivery, distrust of the pharmaceutical industry, and the broader health system in which particular vaccines are introduced. See Babalola, “Maternal Reasons for Non-immunisation”; Closser, “Chasing Polio in Pakistan”; and Ghinai et al., “Listening to the Rumours.”
Parents’ excerpts trace what they perceive to be extensions of postcolonial biopolitics through contemporary forms of biocapitalism and its concomitant com-modification of care and female sexuality via pharmaceuticals and biotechnologies like the HPV vaccine.
I conducted all interviews in Barbados between 2015 and 2018.
The rationale for targeting eleven-and twelve-year-old children is based on scientific evidence that indicates increased efficacy of the vaccine if introduced prior to the initiation of sexual contact.
As Sarah Sharma notes, “in the meantime” is an approach to time that captures the minutiae of social politics, control, and coordination between overlapping temporalities (In the Meantime, 7).
See Collier and Ong, “Global Assemblages”; Horst and Miller, Cell Phone; Murray, Flaming Souls; and Padilla, Love and Globalization.
I borrow the term grammar from Hortense Spillers, who refers to an “American grammar” as the discursive parameters around which understandings of gender and race are constructed and made legible (“Mama’s Baby, Papa’s Maybe”).
