Global Health: The Debts of Gratitude

It permits us always to say: “Careful, you think there is gift, dissymmetry, generosity, expenditure, or loss, but the circle of debt, of exchange, or of symbolic equilibrium reconstitutes itself according to the laws of the unconscious; the ‘generous’ or ‘grateful’ consciousness is only the phenomenon of a calculation and the ruse of an economy. Calculation and ruse, economy in truth would be the truth of these phenomena.”

Jacques Derrida, Given Time: I. Counterfeit Money

In early April 2013, Madonna’s ongoing troubles with Malawi boiled over in a spat with President Joyce Banda that aired across the Internet (Gumede 2013; Ross 2013). Without delving into the disputed details of Madonna’s pitfalls trying to “do good” (Fisher 1997) in the country, it is worth repeating a small part of the lengthy statement released by President Banda’s office as Madonna departed Malawi in a flurry of complaints, her public relations team still sparring with critics (Ross 2013). The statement, which President Banda later said she had neither seen nor approved, nevertheless resonated so powerfully with many in the country that few expected a retraction (Harding 2013; “Joyce Banda Disowns” 2013). An early section reads: “Granted, Madonna has adopted two children from Malawi. According to the record, this gesture was humanitarian and of her accord. It, therefore, comes across as strange and depressing that for a humanitarian act, prompted only by her, Madonna wants Malawi to be forever chained to the obligation of gratitude. Kindness, as far as its ordinary meaning is concerned, is free and anonymous. If it can’t be free and silent, it is not kindness; it is something else. Blackmail is the closest it becomes” (Ross 2013).

To focus solely on Madonna’s sense of entitlement or her misbehavior here is to miss the larger source of Malawians’ anger and take all-too-easy aim at the pitfalls of celebrity philanthropy. African leaders and their citizens are no strangers to the “obligation of gratitude” incurred while at the receiving end of philanthrocapitalism, development schemes, or humanitarian aid. Even the most elementary student of theories of exchange will remind us that no gift is merely a symbol of generosity but is embedded in complex relations of hierarchy and expectations of reciprocity (see Derrida 1992; Graeber 2001; Mauss 1990). The language of “obligation” and “blackmail” reflects the ways in which “gifts” become debts, and charity creates subtle forms of peonage. What is notable in this incident—and indeed, vaguely titillating for critical Western observers—is that Banda steps so boldly outside her role in the contrived theater of aid recipiency.

Even on the eve of African independence, however, Frantz Fanon (1963) unmasked the dangers of colonial charity:

And when we hear the head of a European nation declare with hand on heart that he must come to the aid of the unfortunate peoples of the underdeveloped world, we do not tremble with gratitude. On the contrary, we say among ourselves, “it’s a just reparation we are getting.” So we will not accept aid for the underdeveloped countries as “charity.” Such aid must be considered the final stage of a dual consciousness—the consciousness of the colonized that it is their due and the consciousness of the capitalist powers that effectively they must pay up (59; emphasis in the original).

Fanon reframes the seeming generosity of the developed nations as material and psychological reparations. Here, the final step toward liberation requires a psychological shift, in which the mystifications of charity fall away, and what is given becomes what is owed.

The perceptual shift Fanon once anticipated seems long forgotten, buried under layer upon layer of initiatives for the betterment of the Global South. More recently, the vast expansion of global health programs has provided a new platform for the mystifications of donation, aid, and generosity. Although many recent critiques of global health endeavors have emphasized their unintended costs, and the exacerbations of inequalities and hierarchies they can elicit (see, for example, Benatar 2005; Crane 2011, 2013; Lewis 2007; Swidler 2009), a more explicit focus on debt may help us to fully grapple with the obligations...