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Didier Fassin Public Health (Annual Chair 2019-2020) Inaugural Lecture, 16 January 2020 Didier Fassin, on behalf of Thomas Römer, our Administrator, and all of our colleagues, I am delighted to welcome you here to deliver your lecture on the anthropology of public health. Public health has emerged as a key field in the biology community and among its doctors in particular. A partnership with the government agency Santé publique France,
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through the creation of annual sponsored chairs, means that we can deliver teaching covering the many different facets of this discipline. Last year, Arnaud Fontanet from the Institut Pasteur got the series off to an impressive start, presenting his epidemiological research into viral diseases, and in particular emerging diseases. Like Arnaud Fontanet, you are a doctor. The varied clinical experience, often in extreme conditions,
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which you have acquired, has certainly shaped your career. It has been extremely rich, and has gradually moved from investigations of classic public health issues in Tunisia to anthropology and then sociology, on the basis of research carried out in Senegal, Ecuador, and then South Africa. You have developed an interest in the health of people in human groups, particularly those who are suffering,
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from a social, historical and political angle simultaneously, in order “to understand and lead others to understand” – to quote one of your recent papers. In this respect, you are in alignment with the definition of health provided by WHO: “health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity.”
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Your current research, in particular in the context of your chair at the Institute for Advanced Study in Princeton, and at the EHESS, is seeking to shed light on the way in which societies deliver care, fight poverty, and punish crime. I am sure that in addition to your teaching, this year will provide an opportunity to forge links with colleagues, particularly in the human sciences. I would now like to hand over to Philippe Sansonetti, who sponsored your appointment,
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and will now present your work and the many distinctions and awards you have received. I wish you a warm welcome on behalf of all my colleagues to our institution and look forward to your inaugural lecture entitled “The inequality of lives”. Thank you. I would also like to welcome you all to the inaugural lecture
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by Professor Didier Fassin, this year’s holder of the Chair of Public Health at the Collège de France. This Chair is a partnership with Santé publique France. I would like to take this opportunity to extend my warmest thanks to François Bourdillon and Jean-Claude Désenclos for their whole-hearted support for the creation of this chair. and also to Geneviève Chêne, the new Director General of Santé publique France, for her ongoing interest in the continued existence
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and teaching of public health at the Collège de France. Public health is a jigsaw, and each individual piece is only meaningful in relation to the pieces which interlock with it. The aim of this annual chair is to explore the main pieces of this jigsaw and the way in which they connect. This is a huge agenda. We have explored epidemiology
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as the science of risk assessment with Arnaud Fontanet. This year, with Didier Fassin, we will explore the socio-anthropological and political determiners of public health. Public hygiene, the art of maintaining health in human society, is set to expand significantly and to provide numerous applications and opportunities for improvement in our institutions.
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The founding formulation for a multifaceted discipline like public health, which is constantly is attempting to define itself, was published in the inaugural volume of Les Annales d'hygiène publique et de médecine légale, in 1829, at a key moment in the emergence of this discipline and had the merit of highlighting at a level beyond clinical medicine, that public health is naturalist, cultural and political.
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In 1832, in the same journal, during the health crisis in France caused by the second cholera epidemic, Louis René Villermé wrote: “when diseases are widespread, they are more often fatal among the destitute than the wealthy.” This may appear to be stating the obvious, but this was not the case at the time. Disease, social inequalities, inequality of lives -
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diseases are a powerful determining force and ruthlessly highlight the inequality of lives. This is the crux of the matter, is it not, Didier? This inequality of lives is the thread running through your work, and will be the theme of your inaugural lecture. Didier Fassin is a doctor, with a Master’s in public health and a PhD in social sciences. He is an anthropologist, and is currently Director of Studies at the École des hautes études de sciences sociales,
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and Professor of Social Science at the Institute for Advanced Study in Princeton in the United States. In short, Didier belongs to the generation of doctors who became aware in the 1980s, perhaps for the first time with this degree of acuity, that an emerging epidemic such as AIDS was more than just a tragic biological and health event, but that it also uncovered
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powerful anthropological, sociological and ethical determiners. Didier initially followed a traditional medical and academic path, becoming in 1997 Professor of Infectious Diseases and Public Health at Paris Nord University, but forged an atypical career with numerous initiatives and research projects in France and worldwide: in Senegal, the Congo, Ecuador, South Africa,
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and now in the United States. This research has often involved taking a critical stance on social, moral and political issues, and he has made his mark on each occasion through his commitment, his long-term presence in the field his physical and moral courage, humanism, and non-conformism. With the same pertinence, he has studied subjects with a strong medical connection
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such as the behaviour of AIDS patients, inequality of access to prevention and treatment, maternal mortality, infant lead poisoning, psychological trauma, areas with a strong link to socio-anthropology such as humanitarian initiatives, and other fields including the experiences of prisoners, asylum-seekers, and illegal foreign workers...
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Very often, in a word, discrimination. He has pursued research on the police, the justice system, and prisons in order to gain a better understanding of how punishment is administered. He was awarded a European Research Council grant, and has developed a true philosophy of violence in human relationships in different geographical, political and socio-economic situations. This eclecticism and wealth of ideas,
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coupled with exceptionally relevant and far-reaching thinking, have earned him an international reputation which extends beyond his many high-level publications, to editorials in major newspapers, and prestigious lectures delivered for awards such as the Gold Medal of the Swedish Academy for Arts and Science and the Nomis Distinguished Award, presented to an anthropologist for the first time in 2018.
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It is impossible to summarise this list of national and international initiatives, lectures, summer schools, and contributions to humanitarian projects. He currently chairs the Medical Committee for Exiles in France. Lastly, Didier is well-known for his books, which have been translated into eight languages. I would like to mention a few titles, which reflect the scope of his work: “Humanitarian Reason: A Moral History of the Present”;
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“Enforcing Order: an Ethnography of Urban Policing”; “Prison Worlds: The Will to Punish”; and simply “Life”. Didier, I would like to extend my warmest congratulations to you, and invite you to speak to us about the inequality of lives. Mr Administrator, esteemed colleagues, dear friends,
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ladies and gentleman, “It is of man that I speak [...]. I shall confidently uphold the cause of humanity before the wise men who invite me to do so and I shall not be dissatisfied if I acquit myself in a manner worthy of my subject and my judges.” This is how Jean-Jacques Rousseau opened his “Discourse on the Origin and Foundation of the Inequality of Mankind”, in 1754.
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The Academy of Dijon, whose question he was answering, was admittedly not the Collège de France, an institution which was already over 200 years old, but it is on this same theme, and perhaps with the same intention, that I would like to speak to you this evening. The only difference is that I would like to replace the word “man” by “human being”, and more specifically that I shall base my argument on the opposite premise to the Genevan philosopher
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who continues: “I believe that there are two kinds of inequality among the human species: one which I term natural or physical, which consists of a difference in age, health, bodily strength and qualities of the mind or soul; and the other which can be termed moral or political inequality because it depends on a kind of convention, and consists of different privileges enjoyed by some
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to the detriment of others, such as being more honoured, more powerful.” He states that that there cannot be any “essential link” between these two inequalities as this would raise the question of whether those who rule are necessarily better than those who obey. In the 18th century, the idea of what we now refer to as “social inequalities of health” did not exist.
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In order for this idea that the place and milieu in which an individual is born influences their physical and mental state, risk of illness and probability of death, would have required what Ian Hacking, holder of the Chair of Philosophy and History of Scientific Concepts, calls “the taming of chance”.
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This was the process by which, in the late 18th century, the determinism of the “universal laws of nature” was gradually replaced by the “statistical laws of society”, which were deemed to account for both the regularity and variability of what were thought to be natural phenomena. This permeated every field, from medicine to economics, and from suicide to crime,
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due to the combined emergence of the idea of population, the expansion of data collection, the development of political arithmetic, and refinements in probabilistic reasoning, in connection with research by Condorcet, Quetelet and Poisson. We discovered that average life expectancy, is dependent on social circumstances. A striking feature of this history
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is the survey carried out by Louis René Villermé published in 1830 under the title “Mortality in different districts of the city of Paris”, which undermined the neo-Hippocratic theories that had held sway for over a century according to which the physical and human environment, i.e. insanitary living conditions and overcrowding, was responsible for spatial variations in mortality.
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Having recorded major disparities in the proportion of deaths among populations in the various districts of the city, he used a variety of sources in an ingenious manner, notably fiscal data, to demonstrate that these disparities reflected neither hygiene conditions nor population density, but corresponded almost exactly
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to the proportion of untaxed households. The higher the levels of exemption from tax, in other words, the poorer the population, the higher the percentage of deaths. Citing contemporary research – notably by Benoiston de Châteauneuf –, he was able to conclude: “(despite what the whole world thinks), poor people’s health is always fragile, they are smaller
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and their mortality is excessive, compared to the physical development, health and mortality of people in more fortunate circumstances.” Based on this proliferation of studies, the differences observed in relation to the vagaries of life began to be understood not as natural phenomena which were fairly randomly distributed, but as social inequalities
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obeying statistical laws and revealing injustices. This development did not merely reflect changes in the fields of thought and science. It was also part of the context of the industrial revolution, with the rise in pauperism and a growing awareness of social issues. The discovery of disparities in death coincided with growing inequalities in life.
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The focus was not just on the poor, but also on the working classes, who were also poverty-stricken classes, and Louis Chevalier – for whom the Chair in the History of Social Structures of the City of Paris was created – described their appalling situation. Although workers appeared at the time to be the victims of unchecked urban development and deadly capitalism, which were reflected in very high levels of infant mortality,
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they were also considered to be the architects of their own tragic circumstances due to depravity, alcoholism among the men, loose morals among women, and parental neglect of children. Then as now, social reform was almost always accompanied by moral judgement; the solutions advanced by experts and government responses
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favoured paternalistic approaches, in the manner of Frédéric Le Play, or liberal approaches such as those developed, for example, by Alexis de Tocqueville, rather than the scientific socialism which was emerging in parallel. A cognitive shift therefore occurred – between the discourse of Rousseau, at the end of the Ancien Régime and the survey by Villermé on the eve of the July Revolution of 1830 –
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in the way in which the functioning of society was understood, with the recognition of the consequences of social inequalities on the length and quality of life. It was a feature of a new form of governmentality which Michel Foucault described as “the birth of biopolitics”, in the title of his 1978 lecture. This concept had a significant impact
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on the social sciences and humanities. Biopolitics, which functions as a means of regulating the population, according to the holder of the Chair of History of Systems of Thought, involves replacing sovereignty – “the ancient right to cause death” – with biopower, “the power to foster life”. He wrote that “probably for the first time in history, biology is reflected in politics;
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the fact of being alive is no longer an inaccessible foundation which only emerges occasionally with the randomness of death and its fatality. It moves, at least in part, into the sphere of the control of knowledge and of the intervention of power.” Biopolitics combines on the one hand new areas of knowledge about population such as public hygiene, demographics, epidemiology, economics and sociology,
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and, on the other hand, new means of intervention such as family planning, health education, social policy, and immigration controls, which according to Foucault are the hallmarks of “a power whose highest function was to administer every aspect of life.” Public health, a chair which I now have the honour of holding,
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lies at the intersection of this new knowledge and its new applications. According to the classic definition advanced by Charles-Edward Winslow in 1920, it is “The science and art of preventing disease, prolonging life and promoting physical and mental health and efficiency through organized community efforts”. Straddling the sciences and humanities,
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it presupposes forms of knowledge and means of intervention. Although we can debate the chronology of what Foucault terms “biopolitics”, which I have demonstrated had already assumed relatively sophisticated forms as far back as the Roman Empire in the first century BC and the Inca empire in the 15th century, the invention of this concept is nevertheless a form of fertile explosion of light
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which illuminates our understanding of the relationship between the social sphere and biological existence by setting it in historical context. It is therefore all the more remarkable that when Foucault explored these relationships he totally overlooked the issue of disparities in life, despite their central role in the phenomenon which he was analysing. The word “inequality”, which is not cited in the thematic index to the 3000-plus pages of his “Dits et écrits”,
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does not feature in his intellectual lexicon. This absence can doubtless be attributed to his rejection of normative stances. Justice stems from his militant commitment, and not his theoretical apparatus. The aim of his genealogical research is not to change the world, but to change our perception of the world.
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The traditional division of intellectual research tends to leave inequalities to scientific disciplines which use quantitative techniques, such as demographics, epidemiology, and sociology, as it is generally believed that disparities are expressed by statistical and probabilistic analysis. Thus in his supplementary thesis for his doctorate, Maurice Halbwachs – who suffered one of the most tragic fates of any Collège de France Professor,
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as he was appointed in May, arrested by the Gestapo in July1944, and died in Buchenwald a year later – theorised differences in mortality on the basis of profession or income. He demonstrated that far from being a phenomenon dictated by fate, “death, and the age at which it occurs, are primarily a function of life and the conditions in which it is lived”,
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as these conditions are “as much social as they are physical”. His analysis goes beyond what could just be a purely structural reading of inequalities. It states that inequalities have dual political and moral foundations. According to him, “the key reason” for these variations in mortality lies in the variations in “the importance ascribed to human life”,
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and “there are good reasons to believe that a society, in general, has the mortality rate which suits it, and that the number of dead and their age distribution accurately expresses the importance which a society ascribes to prolonging life.” He makes the same observation for a distribution by socio-professional category, wealth and gender. In short, death rates reveal
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the value which a society places on human life in general and on the lives of the various groups of which it is made up in particular. But how can we understand this value? There are two main approaches. The first approach, which is ethical, considers life to be an invaluable asset, although this does not however preclude a differentiated treatment.
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The second approach is economic and, by contrast, places a price on life, which is usually associated with disparities. On one hand, the absolute value of life is at the ethical core of many religions and philosophies. In Christian dogma, life is sacred. It is a priceless higher good which cannot be quantified
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and therefore hierarchised. This explains the resistance of the Catholic church to financial compensation for murder in the Early Middle Ages in Europe, which has been studied by Georg Simmel, and the opposition of Protestant churches when life insurance was created in the United States in the 19th century, as has been demonstrated by Viviana Zelizer. However, citing this absolute value does mean that it was not violated in practical terms,
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firstly in the case of Muslims during the Crusades and then the Jews during the Reconquista, and secondly in the case of Native American communities and black slaves. For philosophers, life is also an absolute value, generally based on natural law. However, it was still subjected to comparative tests in the form of thought experiments. The first example was advanced in 1797
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by William Godwin who imagined a fire in which Fénelon and his maid were at risk of dying, but only one of them could be saved. He asserted, in keeping with utilitarian logic, that it was his duty to save the author of “Telemachus” from the flames on account of his intellectual contribution to the world, even if the maid in question
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was his wife or mother. In recent decades, analytical philosophers have come up with numerous fairly similar scenarios involving saving one or more individuals from drowning, or an accident, such as Philippa Foot’s Trolley Problem, in order to test the abstract principles governing moral dilemmas. These tragic choices often actually involve establishing differences in the value of human lives.
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On the other hand, by contrast, the relative value of lives is based on economic analyses used by judges, on the one hand, to determine the level of compensation for damages suffered, and, on the other hand, by political leaders to choose between several options involving known risks. The two situations differ because damages are based on
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the evaluation of loss of expected earnings due to a death which has already occurred, and hence the calculation of an actual value, whereas risk implies the evaluation of the probability of death occurring and hence the calculation of an abstract value. In the case of compensation, the value of the life which has been lost is calculated. In order to achieve this, an “actuarial valuation”
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using what economists call “human capital” is carried out, calculating what the deceased person would have contributed to their family in terms of salary and life expectancy, and additionally in some cases the pain and suffering caused. Quite apart from the fact that not all fatal events give rise to this type of compensation payment – victims of the Oklahoma bombing in 1995 received nothing,
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unlike victims of 9/11 in 2001, and civilians killed during the Vietnam War received no reparations, unlike those killed in the Iraq War – calculation methods lead to significant differences in the sums received. Thus in the case of the 9/11 victims, the deviation is between one and eight depending on profession and gender, and between one and two hundred in Iraq,
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depending on whether the victims were Iraqi civilians or American soldiers. In the case of risk prevention, it is the statistical value of a life that is calculated; the process most commonly used by economists based on cost-benefit analysis attempts to evaluate the price a society is prepared to pay to save a life by implementing a project or policy.
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Comparisons can therefore be made, even in very different areas, such as the environment and transport, For example between introducing an incentive for low-emission vehicles and the construction of safety barriers on a road. However, this statistical value of a life does not take into account differences in ability to pay depending on socio-professional class, especially in the workplace,
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where the highest risk jobs such as construction are those where workers also have the lowest levels of legal and social protection, a situation which devalues their existence. The difference between absolute value and relative value of life explains some of the tensions which exist between clinical medicine and public health. The former deals with individuals
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in order to save lives or preserve life, quite literally whatever the cost, and the latter cares for populations and has a duty to choose between strategies with different cost-benefit ratios. Thomas Schelling provides a striking illustration of this difference, which is very plausible, when he compares the reaction of members of the public asked to fund a costly operation
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to prolong the life of a little girl until Christmas, or alternatively, to contribute via a special tax to the refurbishment of hospitals in Massachusetts in order to reduce the number of preventable deaths. He concluded that without a shadow of doubt, donations would come flooding in for the first option whereas the second would encounter resistance.
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International responses to the AIDS epidemic on the African continent in the 2000s provide a real illustration in this case, of the gap between these two types of reasoning. Clinical medicine practitioners, keen to use the new antiretroviral drugs to treat their patients, often clashed with public health experts whose research showed that given the limited resources, preventive measures such as using condoms and education about safe sex
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would prove less costly and more effective than treatment. This antagonism should not, however, be exaggerated as on the one hand, clinicians themselves are often forced to decide which patient should receive drugs based on a process called triage in English, with its roots in the Old French language, and on the other hand, experts have finally accepted
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the role of therapeutic treatment in the reduction of viral transmission. But can the ethical approach which confers an absolute value on life, and the economic approach, which confers a relative value on life, capture what Georges Canguilhem called “the value judgement expressed in the abstract number which is average human life expectancy”, a value judgement which becomes even clearer if instead of considering a population as a whole,
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we attempt to differentiate on the basis of social variables. There is certainly scope for scepticism. Religions have an ideal concept of the value of life and philosophies have a normative interpretation, but neither presents an accurate picture of how societies actually treat human beings. Similarly, the value of life generated by actuarial analyses or cost-benefit studies does not allow us to understand
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the disparities in what we now call “life expectancy”. We have to take a different approach in order to connect the idea of the importance society confers on human life, according to Halbwachs, or the value judgement on human life according to Canguilhem, to the theoretical average lifespan in a given country. We should point out immediately that this relationship has obvious limitations. If life expectancy
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is 53 years in the Central African Republic, compared to 84 years in Japan, the thirty-one year gap between the two countries cannot be attributed solely to a different valuation of the life of their inhabitants. Poverty, hygiene and sanitation issues, endemic malaria and other parasitic diseases, AIDS epidemics and other infections,
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poor health infrastructures, and latent civil war, are all factors influencing the potentially short lives of the population of the Central African Republic notably due to high childhood mortality. Although interpretations of international comparisons should be made with caution, taking circumstances into account, the study of disparities within a given society prove more much more enlightening.
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In France, demographic surveys focusing on establishing differences began in the 1960s, and a paper by Guy Desplanques two decades later revealed just how significant they were. The probability of French men aged between 35 and 60 dying at that time was 7% for teachers and 25% for unskilled workers, i.e. their risk was three and a half times higher.
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Life expectancy at the age of 35 was 43 years for teachers and 34 years for unskilled workers, i.e. a difference of nine years. Two remarkable aspects of this study have never been contradicted by subsequent research: the extent of inequality around death, and a distribution mirroring the socio-professional hierarchy.
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The latest studies show that although male life expectancy in the last four decades has risen by five years at age 35, gaps continue to open up, although they are relatively small. Furthermore, remaining years of life are more often characterised by disability in the case of labourers than executives, with a four-year gap between them. The former therefore have an average
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of ten fewer years to live in good health than the latter. It is clear that this research focuses exclusively on socio-professional categories. This approach therefore overlooks two phenomena which are partly connected. First of all, people without occupation are not recorded, even though unemployment levels means that their numbers have increased significantly,
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and epidemiological research shows that they have poorer health than working people. Thus for premature mortality over a quarter of a century, the relative index of inequalities rises slowly if only employed people are taken into account, but doubles when the unemployed are included. Next, real quality of life is not analysed, which means that neither impoverishment of the lower categories
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or increased wealth in higher categories can be taken into consideration. If we compare the most affluent 5% and the poorest 5% today, the difference in life expectancy, measured at birth for men, is 12.7 years. It is therefore critical that the measurement of inequalities of death should include the whole population and take changes in the economic structure into account.
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However, there are two remaining blind spots, one of which is related to methodological difficulties, and the other to ideological and legal obstacles. Firstly, because research is based on people who are officially recorded, there is rarely any data on the most vulnerable people such as those who have no fixed abode or no residence papers. Secondly, since ethnoracial characteristics cannot be recorded,
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we do not have any information about disparities involving minorities, even though we are aware that they are particularly affected in social terms by unemployment and prison, and in medical terms by drug addiction and certain viral infections. Based on existing research, it would appear that inequalities of death in France mirror the various expressions of social inequality quite closely, increasing sharply since the 1970s,
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as jobs have become less secure and the working classes have become poorer. Having higher social status, a more secure job, being wealthier and better educated guarantees not only higher social status, greater affluence and better living conditions, but also a longer life in better health. France is not exceptional in this respect,
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although international comparisons show inequalities of death in men here seem to be the highest in western Europe, notably for cancers, accidents, and alcohol and smoking-related diseases. This may appear to be a paradoxical as the health systems performance table drawn up in 2000 by the World Health Organisation using a composite efficiency indicator
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ranked France in the top tier. While the principle of this type of research may be open to debate, it nevertheless has the merit of highlighting the dissociation between the quality of a health system and the extent of health disparities. Unequal life expectancy is actually first and foremost the result of cumulative inequalities in a society.
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The most striking example is undoubtedly the United States, where health spending per capita is by far the highest on the planet – more than double the figure in France – but the life expectancy of its inhabitants places it 34th in the world rankings, behind Cuba and Chile. These poor results, in a country where 27 million people, i.e. one tenth of the non-elderly population, have no medical cover,
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reflect the impact of the deep disparities which drag down national averages. If we consider income, life expectancy for men in the wealthiest 1% is 15 years higher than for men in the poorest 1%, and in the space of just over a decade the wealthiest 5% have gained an extra two years of life compared to the poorest 5%.
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If we look at the influence of education, white males who attended university live 14 years longer than black men who did not graduate from high school. Black men who went into higher education have a lifespan which is four years shorter than white men who pursued the same course. In other words, income, education and skin colour are closely linked.
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Remarkably, since 2014, a historic turnaround has occurred in this country, for the first time since World War II, with a drop in life expectancy due largely to an increase in mortality among middle-aged men and women attributable to suicide, alcoholism and especially opioid use which has reached epidemic proportions with the liberal prescription of these drugs as pain relief medication since the 1990s
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due to the pressure exerted by major pharmaceutical companies. This drop, which affects the African-American community in particular, is indicative of a major crisis sweeping the nation. In this respect, we might be tempted to play down the issue of colour in favour of focusing on wealth and education in the belief that longevity in the black community is lower because it is poorer and less educated. This type of analysis, which is often used in France to overlook social inequalities
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experienced by ethnic and racial minorities, ignores two fundamental aspects in the United States, where the abolition of slavery was followed by the legalisation of segregation and the civil rights movement suffered a backlash in the form of mass incarceration. Firstly, people of colour with equivalent income and education do not live as long,
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and several recent epidemiological studies have demonstrated the specific role played by discrimination in health disparities, notably through the effects of the denial of rights, and low self-worth. Secondly, adopting the common expression “all other things being equal” is tantamount to denying that they are actually never equal, given the significant overrepresentation of black men
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in underprivileged environments and among students dropping out of education the earliest, which is the product of a long history whose shadow will continue to hang over the United States. There may be some lessons to be learned in terms of understanding inequalities in French society. At this point in our thinking, we need to stand back a little. We have moved imperceptibly from inequalities of lives
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to inequalities of death. Fundamentally, what we elegantly and deceptively call “life expectancy” is just an abstract metric reached by the summation of the probability of dying at different ages and imagining a fictious generation subject to the conditions of mortality in the year in question. But what has happened to life? Admittedly, life expectancy provides us with information about a major fact:
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the significant disparities in longevity in our societies – thirteen years in France and fifteen in the United States –, when we compare the richest and poorest. However, does this metric tell the whole story about inequality of lives? Two examples suggest that quantification is necessary but not sufficient. Up to this point,
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as you will undoubtedly have noticed, we have only focused on male mortality and life expectancy. There is a reason for this: data relating to women introduces a disturbing element. In France, although this observation holds true for other western countries, women from all socio-professional categories, have a lower mortality rate than men. Unskilled female workers live longer than male executives,
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despite a closing of the gap in recent decades. This is can primarily be attributed to differences in approaches to risky behaviours in relation to health, and has often been described as one of the privileges of being female. Thus, although on the one hand unskilled female workers have a life expectancy at the age of 35 which is two years higher than male executives, their life expectancy free from disability is seven years lower,
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partly as a result of poor working conditions; this apparent advantage is therefore illusory. On the other hand, and above all, life expectancy does not provide any information about quality of life, in terms of autonomy, emancipation, exposure to sexism, and lastly self-realisation. It is unnecessary to highlight how often French women have been, and are still being, penalised in all these areas
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in a country where they have only recently obtained the right to vote and open a bank account, access contraception and abortions, shared parental rights, claim equality between spouses in managing the family’s financial and administrative affairs, and achieve recognition of domestic violence and sexual harassment. As Françoise Héritier has reiterated in her research and lectures on men and women, what she calls the “differential valence of the sexes”
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is, in every known society, the product of hierarchies operating in the symbolic as well as in the social world with the former often acting as a justification for the latter to distribute power unequally. Consequently, the fact that women live longer than men, in France or elsewhere, tells us nothing about their lives or, more precisely, what society does with them.
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In her book “L'Événement”, Annie Ernaux retraces her experience of an abortion before it was legal to access contraception or terminate a pregnancy, at a time when the only option for women who could not travel abroad was to use the services of a backstreet abortionist with all the associated risks of haemorrhage or infection. Above and beyond the dangers involved in this procedure, she describes the ordeal of shame, scorn and silence surrounding her actions.
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A parallel thought process could be developed around black men in the United States who live less long than white men. The deaths of African-American men and teenagers killed by police officers, notably Eric Garner who was choked during his interrogation for illicitly selling cigarettes, Michael Brown who was shot several times while walking in the street, Freddy Gray who sustained a broken neck when he was arrested
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during an identity check, and the child Tamir Rice who was killed in a playground because he was carrying a toy gun in his belt, to name but a few, revealed how frequently these fatal incidents occur. Investigations carried out by journalists beginning in 2015, uncovered more than one thousand deaths each year caused by law enforcement officers, with black men being twice as likely to die in these circumstances
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as white men, although they were less frequently in possession of a weapon. Looking beyond these grim statistics, what these tragic figures revealed to the American public was the casual violence to which African-Americans are subjected, their fear when they encounter police officers, their humiliation when they interact with them, their training from childhood and the lessons learned from experience about the denial or thwarting of their rights,
00:41:35
and more broadly the existence of what W.E.B. Du Bois terms “their double consciousness”, or the construction of their own subjectivity through the gaze of others. This is why we need to understand that the name of the Black Lives Matter movement, formed in response to the proliferation of these tragedies, means that the lives of black people matter not just because they are threatened with destruction,
00:42:00
but also, and perhaps more significantly, because their lives are permanently at risk of being devalued. Toni Morrison’s first novel “The Bluest Eye” is a story based on a conversation with a childhood friend, in which an 11-year-old girl prays every night for blue eyes as she has interiorised the image of ugliness associated with being black
00:42:26
which she sees in the scorn of others. She believes that this eye colour, a symbol of white skin, will give her the beauty of which she believes she has been deprived. The novelist later explained that she wrote this book to reveal without pathos the depths of this inner pain which is rarely described for what it is: racial discrimination. This comparison between the situation of women in France
00:42:50
and minority communities in the United States certainly does not intend to assimilate them, as they each have their own rationale and challenges. The aim is rather to think about life in terms of this dual form described by Hannah Arendt in her book “The Human Condition”: “the birth and death of human beings, are not simple natural occurrences, but are related to a world into which single individuals, unique, unexchangeable
00:43:15
and unrepeatable entities, appear and from which they depart.” On the one hand, therefore, life flows from beginning to end, and, on the other hand, life is what makes humans unique because it can be narrated. Biological life and biographical life. Life expectancy measures the extent of the former, and life stories narrate the richness of the latter.
00:43:41
Inequality of lives can only be fully grasped by acknowledging both. It must both differentiate and connect them. Differentiate them because the paradox of French women shows that a long life is not sufficient to ensure a good life. Connect them, because the experience of African-American men reminds us that a devalued life ultimately results in a damaged life. The AIDS epidemic which spread across South Africa
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in the space of less than a decade, making this the worst affected country in the world with an estimated 5 million HIV-positive people, provides a clearer understanding of this complex relationship between biology and biography. The situation in mining districts gives the greatest cause for concern. An epidemiological study carried out in the largest goldmining complex in the world, in the 2000s,
00:44:30
revealed seropositivity levels of 28% among the 80,000 miners, 37% among the women in the neighbouring township, and 69% among prostitutes in areas designated as hotspots. How can these exceptionally high rates of infection be explained? Historical and ethnographic research reveals that since the late 19th century,
00:44:56
mining companies have mainly employed black workers from rural areas, and sometimes from neighbouring countries, grouping them in shacks in camps on mine sites and allowing them to set up makeshift bars to occupy their leisure time. These miners, of whom there are over half a million, frequently spend long periods far away from their families.
00:45:20
They often have extra-marital relationships with poor local women to whom they offer a form of protection, occasionally visit makeshift brothels where selling sex is described as a means of survival, and sometimes form homosexual relationships with young co-workers. In this very difficult environment, AIDS prevention work is all the more challenging
00:45:43
as the extremely tough conditions in the mines which expose workers to a high probability of accidents means that they tend to downplay the potential risk of infection. It is appropriate, therefore, to talk about a “means of production” of the epidemic by the international mining companies operating in the country. A similar analysis could be applied to the conditions of agricultural labourers
00:46:08
working away from home on large estates formed after the seizure of land from black farmers in the first half of the 20th century and now owned by multinational food-processing companies. Moving away from these culturalists interpretations which seek an explanation for the spread of infection in the allegedly specific nature of black men and women’s sexuality,
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the political economy of AIDS in South Africa shows how biographical life makes its mark in biological life, how the decline in the former damages the latter. This is clearly a reciprocal relationship, and physical deterioration can in turn threaten the very possibility of a social existence. This is revealed by a number of accounts collected in the township of Alexandra,
00:47:01
in the centre of Johannesburg, where I frequently heard AIDS sufferers describe their circumstances as the result of a sinister government project to get rid of a useless population in excess. There could not be a stronger statement of the concept of the inequality of lives. One of the young women I met there was in the acute stages of the disease. Despite her withered body, her face swollen with oedema, and her arms covered in skin lesions,
00:47:26
you could still discern the traces of her former fine, regular features. Confined by her weakened state to the single room of a cellar with no natural daylight, excavated under the sheet metal and wooden shack where she lived with her 12-year old daughter, she was keen to tell her story. She spent her childhood in Soweto, where she was raised, after the departure of her father, by a mother whose alcoholic binges meant that she often had to spend the night with her on the street.
00:47:53
She was a promising student despite the family’s very difficult circumstances. Her younger brother was killed by the police at 20 years old following the theft of a car. She lived with the father of her child and learned that he had had an affair with a woman who had recently died. When she discovered that she had the disease and had no access to antiretroviral drugs, which were not available in public hospitals at the time,
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her disease progressed very quickly. “This is my life, you see,” she concluded quietly. “A life of poverty. We have suffered so much and yet I was talented. I liked writing stories when I was a child. I even got a grant to study abroad, but there was a fire in my home and all my documents were burned. So I never left.
00:48:40
I liked studying. I wanted to become a doctor as treating people is a fine thing to do. I was really gifted. Now my life is drawing to an end.” After her death, I found the two pages she had written to retell her story in the notebook I had given her. She closed with the words: “This is all I can tell you about my life.” This is a moving testimony of a life cut short at the age of 30, but her determination to leave a biographical trace
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seemed to be a form of resistance to the imminent extinction of her biological life. However, we can read something else in this narrative. It shows that for a time at least, there was hope, fuelled by promising school results and focused on the dream of a medical career: the promise of the possibility of an alternative life.
00:49:32
We now need to re-evaluate the meaning of the term “life expectancy”. Demographers provide a metric to give the probability of death at each age in the year on which calculations are based, which reflects the impact of the past on the biological calendar. A woman who dies at the age of 60 embodies the cumulative effects of six decades of living. Perhaps it is the role of anthropologists to find another meaning
00:49:56
by taking these two words seriously. Life expectancy should therefore be understood as an expectation, in other words as the projection of a future across the course of an existence. The English distinction between “life expectancy“ and “expectation for life” captures an element of this difference. On the one hand: how many years can we hope to live?
00:50:19
On the other hand: what can we expect from life? Moving from the first to the second involves a radical shift of perspective. Discussing inequality of lives does not just mean exploring disparities in their duration, but also considering the differences between what they are and what individuals have the right to expect. We are no longer talking about quantity, but about quality, not longevity but dignity.
00:50:45
It is through this lens that Orlando Patterson describes slavery as social death. A slave in the United States, Greece or pre-colonial Africa has been torn from their original environment, deprived of family ties, stripped of their birth name, and finally reintroduced into a new social environment in which they are denied any rights over their own fate and that of their descendants.
00:51:11
The term “social death” can also be applied to lengthy prison sentences, notably when they are accompanied, as is the case in the United States, by protracted periods of up to several decades of solitary confinement in a punishment cell. In these contexts, inequality of lives, does not refer to the duration of one’s presence in the world, but to a state of being in the world. The rationale is not “how long” but “how”.
00:51:35
The issue of refugees and migrants in the world today can also be viewed in these terms. There are literally innumerable deaths during the long journeys taking them from societies where they were victims of violence, poverty or just lacked any kind of future towards societies where they hope to enjoy a better life for themselves, and especially for their children. Innumerable, because while we know that in a five-year period 17,043 people have died attempting to cross the Mediterranean.
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We do not on know how many people have drowned without leaving a trace except potentially in the memory of any survivors, or the number of deaths at points during their long peregrinations from sub-Saharan or Middle Eastern regions to the Mediterranean coast, and beyond on the journey through Europe. But these deaths are also “unnameable”,
00:52:29
as even the names of these men and women are often swallowed up, thus depriving them of a burial, their families of any notification, and stripping them of both their life and death simultaneously. A Milanese anatomopathologist, is attempting to prevent this oblivion by giving bodies retrieved after boats sink an identity. The dual aspect of these deaths
00:52:54
which are both innumerable and unnameable, is certainly the most explicit indicator of the low value of certain lives. Significantly, in 2015, in a political gesture with tragic implications, the European Union ended the Mare Nostrum operation which is thought to have saved 150,000 lives in a single year. Today, even humanitarian vessels are being harassed by the authorities.
00:53:21
Looking beyond the dead, there are the living and the conditions in which they are received. As part of a survey I am conducting with Anne-Claire Defossez on the Franco-Italian border, we are collecting accounts from men and women, often from sub-Saharan Africa. Most of them had their meagre possessions plundered during their journey, spent at least two months in the hands of torturers in Libyan prisons
00:53:45
from which they were released in exchange for a ransom payment, crossed the Mediterranean in dramatic circumstances, often witnessing the drowning of their companions in misfortune, and spent months in reception centres in Italy until they were forced to leave due to a change in policy. They then tried to cross into France over the Alps, often without any equipment, putting their lives at risk by using dangerous routes
00:54:10
to avoid law enforcement officers, but receiving help on both sides of the border from volunteers who are themselves threatened with sanctions. Some of these exiles turned up in makeshift shelters around Paris and in the north of France. During interviews conducted in the Calais Jungle with Syrian students, who had fled the war in their country and sometimes taken a year to travel across Europe,
00:54:34
they all tried to show me photos of their family and home on their mobile phones taken before both were partially destroyed by the regular army. They pointed out the contrast between their respectable previous lives and the shameful existence they were now leading on the muddy wasteland to which they had been consigned, and bore the marks on their bodies of blows and dog bites
00:54:57
which they had received trying to reach the port to cross the Channel while being pursued by the police. From one border to another, these migrants and refugees had experienced the harsh reality of inequality of lives. You could argue that these exiles only occupy marginal spaces, – but these spaces actually represent 70 million people in the world
00:55:23
just counting those who have been forcibly displaced. However, it is the treatment of these margins which reveals the values which a society is willing to defend. Mr Administrator, esteemed colleagues, you asked me to situate the chair to which you have appointed me within the public health space and I suggested taking an anthropological approach.
00:55:46
But as you will surely have become aware during this lecture, I have drawn, occasionally through a critical lens, on sociologists, historians, economists, political scientists, jurists, demographers, epidemiologists, philosophers, and novelists, to try to grasp the theme of inequality of lives in all its complexity and depth. These are actually the colleagues and friends, among whom I learned and indeed taught social sciences,
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at the University of Paris-Nord, at the École des hautes études en sciences sociales and currently at the School of Social Science at the Institute for Advanced Study. I owe a debt of gratitude to them and also to the hundreds of people, in many places and environments, who, throughout my research on three continents, have entrusted fragments of their lives to me and shared some moments from them with me. Every resource is valuable when it comes to understanding the world and providing feedback on what we have learned about it.
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Understanding is at the heart of scientific work whatever the discipline. Providing feedback too, as it is crucial that this work continues through interaction with many diverse audiences. Fortunately, lectures, which are the trademark of the Collège de France offer such an opportunity. But what about anthropology? It has obviously long since lost that aura of exotic knowledge
00:56:58
which the name still conjures up for some people. The locations for my investigations have included a town in Senegal, American Indian communities in Ecuador and black townships in South Africa, but also a anticrime squad, a short-stay prison and two French border zones. They have focused on fertility rituals and traditional healers, but also on aid programmes for the destitute and humanitarian initiatives in war zones.
00:57:22
Anthropology cannot be defined by field areas or objects. Ethnography, which it often claims to have invented, is certainly not exclusive to it, and many other disciplines are increasingly drawing on it. Many authors, not least Claude Lévi-Strauss, the first holder of the Chair of Social Anthropology, have attempted to define and characterise this discipline.
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I am not bringing anything new to their analyses. I am more interested in the windows it offers on the world than in what it is. Robert Musil wrote that “the man without qualities” had no sense of reality, but a sense of possibility. He observed that he was one of those individuals who if he is told that something is the way it is, thinks that it could equally well be something else.
00:58:13
He did not overlook the realities of the world, but had the ability to see them differently. I think that anthropologists operate in the same way, by inclination as much as by training. They know, because they have seen it somewhere else, or simply read it, that what we take for granted is just one of the potential forms of reality. They can therefore see the world through a different lens. This different lens could be termed a critical attitude.
00:58:40
This type of attitude does not just have epistemological consequences. It also brings a political perspective. If the world can be different, and has been so in the past and is so in other places, then change is always possible. At the end of this journey which has taken us from the revelation of social inequalities in death to an understanding of how they are reflected in bodies,
00:59:04
and from the metrics of disparities in the distribution of mortality to an analysis of inequality in the way lives are treated, I should perhaps offer a justification of my choice of theme, which is probably unusual for the first in a series of lectures on the anthropology of public health. The choice of topics on which we work or which we want to present, is not solely driven by intellectual criteria.
00:59:31
Scientific reasons are often combined with personal reasons, We are all heirs, and we inherit a social world and a family narrative. Perhaps the only difference is between those who acknowledge this inheritance and those who forget or deny it. While carrying out a survey on the Italian border, I remembered that my paternal grandfather crossed this border just a century earlier to come and work in France,
00:59:56
and while analysing disparities in life expectancy, I recalled that after five decades spent labouring as a journeyman stonemason in the Paris region, he had just retired, in what he liked to call the best year of his life, when that life was suddenly cut short by illness. Today, increasingly repressive policies aimed at migrants which make their physical and mental health even more fragile,
01:00:22
and current pension reforms which do not take into account almost thirteen years’ difference in average longevity between the rich and the poor, bring this reflection on inequalities of life right up to date. But the work of a researcher obviously does not stop here. A holder of the Chair of Sociology, Pierre Bourdieu, whose books introduced me to the social sciences, demonstrated this in his own life. It is by adopting a degree of epistemological distance
01:00:49
that we can transform an experience into knowledge, and turn a social debt into a scientific work. The issue of inequality is present throughout his work, even though he gives it other names – reproduction and domination, the force of habitus, and classification struggles. Of the many forms of inequality, the most deep-rooted is inequality in life itself. It is a major fact which encompasses numerous aspects of our social life
01:01:15
for which it offers an alternative interpretation. It is the most elementary fact reflecting the ethical quality and political ambition of a society. The development which I have described demonstrates that both are in crisis in the contemporary world. The social sciences admittedly cannot offer a simple solution to this crisis.
01:01:39
May they at least have the “courage of truth”, which was the subject of Michel Foucault’s final lecture at the Collège de France. This courage may in turn foster the uneasiness in which Leibniz discerned the impetus for our will to act. Thank you.
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