The term ‘partnership’ has recently risen to prominence in the field of global health, in the process acquiring multiple meanings, and as a result, as Barnes, Brown, and Harman (2016, 22) write, ‘there is little shared understanding of what good partnership is meant to include or resemble in practice’.

What to do with this multiplicity of meanings? One approach, which comes more naturally perhaps to bioethicists and those who move in the world of policy, involves working to disciplinethis unruly proliferation by making a case for the (one, true, good) definition that should guide thinking and action with regard to ‘partnerships’. Another approach, preferred by many social scientists, is to decode the term, working to see through and behind its misleading surface appearance to the (grimmer and uglier) reality that lies behind it.

Both approaches have their advocates, and each has its merits, but I would like to propose here a different tack. I propose that it might be interesting and helpful to take the messy multiplicity of meanings attached to the word ‘partnership’ not as a problem to be solved (by participants or by analysts) but instead as a central feature of how the term does its work. Those who seek to discipline or decode the term ‘partnership’ are arguably engaged in ‘telling the truth’, where truth is understood to inhere in a mimetic relationship between word and world. What if we instead turn our curiosity and attention toward what Arthur Frank (201o, 92) calls ‘the truth of the telling’ and ask, in the spirit of dialogical narrative analysis: how does this term do its work in the world?

The Oxford English Dictionary entry for the word ‘partner’ suggests some of the ways that the word ‘partnership’ itself, by the range of meanings it encompasses, may play a role in suturing together unequal parties who hold quite different or even incompatible views of what it is they have jointly embarked upon. At one end of this spectrum of meanings, a ‘partner’ is someone who has a share of ownership, an investment, and thus a stake in sharing the expenses, and profits and losses, of a business enterprise. Such joint interest and shared stakes are implicit as metaphorical referents in the narrow biological meaning of ‘partner’ as one of a group of two or more symbiotically associated organisms. But ‘partner’ can also refer to a friend, lover, or spouse, a resonance that is picked up in Iruka Okeke’s discussion of ‘divorce’ and Yap Boum’s reference to ‘prenuptial contract’, in their contributions to this issue. Or then again, a ‘partner’ can be a teammate, the person with whom one engages in structured activities such as dancing, cards, tennis, or cricket. Unless, of course, what one is voicing is the less common meaning of ‘partner’, as referring to an ‘adherent or worshipper’.

So what are we talking about, when we talk about a ‘partnership’? The answer may depend on which of these meanings are activated and mobilized in any instance of the term’s use.

Sometimes, the term may refer to a (quasi)legal (quasi)business arrangement, in which ownership, risk, gains, and losses are to be divided and shared according to formalized protocols. In other instances, it may refer to a social relationship that entails emotional attachments, love, attraction, ongoing moral obligations, and expectations of reciprocity (though not necessarily of equality). Then again, the word can be deployed to describe (and perhaps thus to claim) a role as a participant in a collaborative activity that adheres to rules based in aesthetic and sporting traditions, pursuing art, fun, or fame and glory. This range of meanings creates conditions ripe for mutual misunderstanding, as the same term may, for different parties and/or for the same party on different occasions, convey very different frameworks for conceptualizing what is being embarked upon in the ‘partnership’.

I do not wish to suggest, however, that this is merely a matter of miscommunication, to be solved simply by having everyone sit down together and talk things through, and explain what they really mean. Quite the contrary: the capacity of the word ‘partner’ (or by extension ‘partnership’) to encompass such divergent understandings, and in effect to facilitate mutual misunderstandings, is arguably precisely why it can bring together assemblages of people and organizations across great distances and steep gradients of inequality. The specific contribution of this (or any other) linguistic usage, of course, takes shape always in the context of political-economic arrangements – in this case, the vast institutional, infrastructural, and financial investments already in place around ‘global health partnerships’ – that powerfully constrain what people can do, including what meanings they can enact, and how. Framed thus within a practice-oriented analytical approach, the term ‘partnership’ might usefully be conceived as a boundary object, in the sense articulated by Susan Leigh Star and James Griesemer (1989, 393), who explain:

Boundary objects are objects which are both plastic enough to adapt to local needs and constraints of the several parties employing them, yet robust enough to maintain a common identity across sites. They are weakly structured in common use, and become strongly structured in individual-site use. They may be abstract or concrete. They have different meanings in different social worlds but their structure is common enough to more than one world to make them recognizable, a means of translation. The creation and management of boundary objects is key in developing and maintaining coherence across intersecting social worlds. 

Ethnographic studies of organ transfer offer an interesting comparison. As Lesley A. Sharp (2001, 2006) has shown, competing and incommensurable metaphors are used to describe organ transfer to different parties at different stages of the process. The metaphor of the organ as a ‘gift’ is implicit within the technical language of ‘donation’, and is used to encourage organ donation among family members of a person whose death happens under circumstances that make it an option. Bereaved family members are encouraged to think of organ donation as a gift, and to imagine the person who died as ‘living on’ through others who will be helped. An organ construed as a ‘gift’, however, places an impossible burden upon the recipient, who is left with a debt that by definition can never be repaid. With recipients, the language used to describe organs instead uses metaphors that refer to ‘life’ more neutrally in relation to plants, through terms such as ‘harvesting’ and imagery featuring greenery, and for them the organ is a form of commodity. Donor families, in other words, are motivated to give a ‘gift’, an act implying the creation of a social relationship that involves ongoing ties of obligation reciprocity, but what recipients understand themselves to be accepting is an organ that has been ‘harvested’, and is described in terms that detach it from the person who died. Here too, these meanings are enacted in the context of powerful institutional, professional, and financial investments in organ transfer; mutual misunderstanding is critical to how the whole system works.

Annemarie Mol’s (2002) ethnographic description of ‘ontology in medical practice’ also offers a model for how to attend to the multiple, sometimes incompatible, realities that the single term ‘global health partnerships’ may encompass (and let us simply note, in passing, that each of the three words of which this compound term is comprised is, in its own right, similarly multiple). In an ethnographic study of atherosclerosis, carried out in a hospital in the Netherlands, Mol shows how this disease gets enacted across a wide range of sites: ‘If we no longer presume “disease” to be a universal object hidden under the body’s skin, but make the praxiographic shift to studying bodies and diseases while they are being enacted in daily hospital practices, multiplication follows. In practice, a disease, atherosclerosis, is no longer one. Followed while being enacted, atherosclerosis multiplies’ (Mol 2002, 83).

Mol’s account reveals how atherosclerosis ‘is’ one kind of entity as performed in the pathology department, but at the same time ‘is’ something quite different as enacted in clinical encounters and elsewhere. In the outpatient clinic atherosclerosis is (or more accurately, gets enacted as) a particular set of signs and symptoms presented by a person whose legs hurt when they walk; while in the pathology laboratory it is a thickening of the layers of cells inside a cross-sectional slice of artery, as visualized under a microscope. Clearly, these two ways of ‘doing’ the same disease are incompatible; the living breathing person complaining of pain cannot at the same time be the body sliced up for examination under a microscope. Mol (2002, 116) details how this irreducible multiplicity is managed, by being distributed, so that the disease continues to ‘hang together even so’.

Recent ethnographic work attending to the ways that ‘global health partnerships’ are described by parties who are very differently positioned similarly reveals how they suture together, though never without friction, competing and incompatible expectations, metaphors, and ontologies. For example, Johanna Crane’s (2002) ethnographic study of a global health partnership in Uganda documents the very different expectations that African and US-based scientists brought to their research partnership. As she shows, a computerized data system installed in the Ugandan clinic was understood by some parties as a ‘donation’, by others as a collaboration, or by still others as a means of generating income; these different expectations and understandings gave rise, in turn, to quite different emotions, ranging from gratitude to resentment to a sense of entitlement. And as Hannah Brown (2015, 550) points out, in an insightful discussion of a partnership between the Kenyan Ministries of Health and organizations funded by the US President’s Emergency Fund for AIDS Relief (PEPFAR): ‘it was what fundamentally differentiated the two partners that held them together; the Americans had access to resources and the Kenyans had legitimate sovereign responsibility for Kenyan citizens. For each side of the partnership, governance without the other was impossible. These differences brought and held the partners together, structuring the form of their integration and constraining possibilities for renegotiating the terms of the relationship’.

The ambiguities and misunderstandings inherent in the term ‘partner’ are, in short, productive: they are part of how the word accomplishes its work, through being enacted in multiple ways, just as they are part of the reality to which it refers. Attending to these multiplicities encompassed within ‘global health partnerships’, how they are activated and what kinds of work they accomplish in the world, is an important contribution that humanistic scholarship can make to improving how we understand ‘global health partnerships’. The elusive hope, and the great challenge, is to translate this insight into improving how they are practiced.

About the author

Janelle S. Taylor is Professor in the Department of Anthropology at the University of Washington. Her research has addressed a range of topics in medical technology, medical education, and medical practice. Most recently, she has been exploring issues of recognition, care, and social inclusion in regard to dementia.

References

Barnes, Amy, Garrett W. Brown, and Sophie Harman. 2016. ‘Understanding Global Health and Development Partnerships: Perspectives from African and Global Health System Professionals’. Social Science & Medicine 159: 22–29. https://doi.org/10.1016/j.socscimed.2016.04.033.

Brown, Hannah. 2015. ‘Global Health Partnerships, Governance, and Sovereign Responsibility in Western Kenya’. American Ethnologist 42 (2): 340–55. https://doi.org/10.1111/amet.12134.

Crane, Johanna Tayloe. 2013. Scrambling for Africa: AIDS, Expertise, and the Rise of Global Health Science. Ithaca, NY: Cornell University Press.

Frank, Arthur. 2010. Letting Stories Breathe: A Socio-Narratology. Chicago: University of Chicago Press.

Mol, Annemarie. 2002. The Body Multiple: Ontology in Medical Practice. Durham, NC: Duke University Press.

Sharp, Lesley A. 2001. ‘Commodified Kin: Death, Mourning, and Competing Claims on the Bodies of Organ Donors in the United States’. American Anthropologist 103 (1): 112–33. https://doi.org/10.1525/aa.2001.103.1.112.

Sharp, Lesley A. 2006. Strange Harvest: Organ Transplants, Denatured Bodies, and the Transformed Self. Berkeley: University of California Press.

Star, Susan Leigh, and James R. Griesemer. 1989. ‘Institutional Ecology, “Translations” and Boundary Objects: Amateurs and Professionals in Berkeley’s Museum of Vertebrate Zoology, 1907-39’. Social Studies of Science 19 (3): 387–420. https://doi.org/10.1177/030631289019003001.