Global Health Geographical Contingency and Contingent Geographies

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Global Health, Geographical Contingency, and
Contingent Geographies
Clare Herrick
To cite this article: Clare Herrick (2016) Global Health, Geographical Contingency, and
Contingent Geographies, Annals of the American Association of Geographers, 106:3, 672-687,
DOI: 10.1080/24694452.2016.1140017
To link to this article: http://dx.doi.org/10.1080/24694452.2016.1140017
© 2016 Claire Herrick Published with license
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Global Health, Geographical Contingency, and
Contingent Geographies
Clare Herrick
Department of Geography, King’s College London
Health geography has emerged from under the “shadow of the medical” to become one of the most
vibrant of all the subdisciplines. Yet, this success has also meant that health research has become increas-
ingly siloed within this subdisciplinary domain. As this article explores, this represents a potential lost
opportunity with regard to the study of global health, which has instead come to be dominated by
anthropology and political science. Chief among the former’s concerns are exploring the gap between
the programmatic intentions of global health and the unintended or unanticipated consequences of their
deployment. This article asserts that recent work on contingency within geography offers significant con-
ceptual potential for examining this gap. It therefore uses the example of alcohol taxation in Botswana,
an emergent global health target and tool, to explore how geographical contingency and the emergent,
contingent geographies that result might help counter the prevailing tendency for geography to be side-
stepped within critical studies of global health. At the very least, then, this intervention aims to encour-
age reflection by geographers on how to make explicit the all-too-often implicit links between their
research and global health debates located outside the discipline. Key Words: alcohol, Botswana, complexity,
contingency, geography, global health.
健康地理学,已脱离了“医学阴影”, 浮现成为最活跃的次领域之一。但此般成功,却也同时意味着健康
研究逐渐在此一次领域范畴中受到孤立。如同本文所探讨的一般,这代表着研究全球健康的潜在契机
之丧失,并成为人类学与政治科学所主宰的领域。前者的考量中,最主要在于探讨全球健康的计画目的,
与其施展后的不经意或非预期结果之间的落差。本文主张,晚近地理学中有关偶然性的研究,提供了检
视此一落差的重要概念潜能。本文因而使用博茨瓦纳所施行的酒税案例——一个全球健康的目标与工
具——来探讨地理偶然性及其导致的浮现中且偶发的地理,如何可能协助对抗全球健康的批判研究
避开地理学的盛行趋势。此般介入的目的,至少在于鼓励地理学者反思如何使其研究与领域之外的全
球健康辩论之间过于隐晦的连结变得清晰可见。
关键词：酒精
,
博茨瓦纳
,
复杂性
,
偶然性
,
地理
,
全球
健康。
La geograf
ıa de la salud ha emergido desde la “sombra de la geograf
ıa medica” para convertirse en una de
las subdisciplinas mas dinamicas. Sin embargo, este exito ha significado tambien que la investigacion
sobre la salud crecientemente se haya enclaustrado dentro de este dominio subdisciplinario. Como lo
exploraesteart

ıculo, esto representa una potencial perdida de oportunidad en lo que concierne al estudio
de la salud global, que alternativamente ha llegado a caer dentro del dominio de la antropolog
ıa y la
ciencia pol
ıtica. Importante entre las preocupaciones de la primera son la exploracion de la brecha entre
las intenciones programaticas de la salud global y las consecuencias no intencionales o imprevistas de su
despliegue. Este art
ıculo sostiene que el trabajo reciente sobre contingencia dentro de la geograf
ıa pre-
senta un significativo potencial conceptual para el examen de esa brecha. Este utiliza por lo eso el ejem-
plodelatributacion del alcohol en Botsuana, un proposito global emergente de la salud y herramienta
para explorar de que manera la contingencia geograficaylasgeograf

ıas emergentes y contingentes que
resultan podr
ıan ayudar a contrarrestar la tendencia prevaleciente en geograf
ıa de ser soslayada dentro de
los estudios cr
ıticos de la salud global. Como m
ınimo, entonces, esta intervencion apunta a estimular la
reflexion de los geografos sobre como hacer expl
ıcitos los mas que frecuentes enlaces impl
ıcitos entre su
investigacion y los debates globales sobre salud ubicados fuera de la disciplina. Palabras clave: alcohol, Bot-
suana, complejidad, contingencia, geograf

ıa, salud global.
ÓClaire Herrick
This is an Open Access article. Non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly attributed, cited,
and is not altered, transformed, or built upon in any way, is permitted. The moral rights of the named author have been asserted.
Annals of the American Association of Geographers, 106(3) 2016, pp. 672–687
Initial submission, February 2015; revised submissions, July and December 2015; final acceptance, December 2015
Published with license by Taylor & Francis, LLC.
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This article emerges from two concerns: first, that
the potential health significance of much geo-
graphical research is being footnoted rather
than foregrounded; second, that this trend is particu-
larly acute in relation to the contemporary field of criti-
cal global health studies. The first concern originates,
somewhat ironically, in the hugely successful efforts of
health geographers in carving out a distinct subdiscipli-
nary identity (Andrews et al. 2012). Yet, the price of
this success is that research on health is too often siloed
within this relatively small subdisciplinary realm.
1
This
means that the potential of “health” as a powerfully
holistic conceptual and empirical vehicle by which to
interrogate a plethora of social, economic, political,
and biophysical processes, trends, and states remains
underrealized (Petersen and Lupton 1996). The second
concern originates in the observation that despite
“emerging work in health geography ...which calls for
a rethinking of the meaning of global health” (Dunn,
Le Mare, and Makungu 2015, 17), such advances have
been eclipsed by anthropological and political science
engagements with this novel field (see, e.g., Pfeiffer and
Nichter 2008; Elbe 2010). Indeed, geography has been
sidelined in a way that ignores how the compulsion to
do and understand global health emerges largely from
contexts that the discipline actively pioneers: urbaniza-
tion, globalization, political ecology, security, risk, vul-
nerability, resilience, geopolitics, more-than-human
natures, foodscapes, culture, governance, development,
and the environment, to name but a few (Herrick
2014). Furthermore, global health brings with it an
innate, powerful, and politicizing spatial logic that
forms the core of the geographical armory but is now
being touted as theoretical novelty by other social sci-
ences (Janes and Corbett 2009).
My intervention comes at a time of growing inter-
est in how to make better theory to explore and
explain the “obscure object” of global health (Fassin
2012). Indeed, celebrated physician and anthropolo-
gist Paul Farmer and colleagues made a clear argu-
ment for the application of social theory to help
global health’s transformation from an often ephem-
eral assemblage of knowledge, actors, practices, and
politics into a coherent “discipline” (Farmer et al.
2013). Such theories are needed, they argued, to
better understand the production, legitimation, and
experiences of global health, as well as the processes
by which these are made meaningful in a variety of
social, spatial, economic, and political contexts.
Theories are also needed to account for global
health’s failures, as much as to explain its successes.
Geographical perspectives could then help respond
to mounting calls for greater constructive (rather
than critical for critique’s sake) social scientific
attention not only to the policies and praxis of
global health but also to the disjunctures between
intentions and effects (Kleinman 2010; Holmes,
Greene, and Stonington 2014). Taking these dis-
junctures as a starting point, I argue here that con-
tingency—an often used but underelaborated phrase
in anthropological engagements with global health
(Panter-Brick, Eggerman, and Tomlinson 2014)—
and, more crucially, geographical contingency, offers
a conceptual opportunity to better elide geographi-
cal research with transdisciplinary critical studies of
global health. This elision offers great potential, for
as Barry (2014) noted, “one of the virtues of Geogra-
phy is that contingency is at the heart of its con-
cerns” (1).
To further develop this contribution, I proceed in
three parts. First, by way of context, I explore what
global health is and claims to be. I then turn to exam-
ine the domination of the critical global health field
by anthropology as a way of explaining not only the
relative sidelining of geography but also why so many
potential geographical contributions to (global) health
debates have failed to be positioned as such within and
outside the discipline. I then turn to the concept of
contingency to explore how this might help shed light
on the common anthropological concern with why
the imposition of health interventions so often produ-
ces unintended and unanticipated consequences. To
add empirical depth to this exploration of contin-
gency, I work through the example of alcohol taxa-
tion, an emergent realm of global health activity that
cuts across manifold spatial scales, legal jurisdictions,
trade agreements, epidemiological knowledge, public
health advocacy, and cultural significance. Drawing
on recent research on the consequences of Botswana’s
divisive alcohol levy, I critically reflect on the signifi-
cance of geographical contingency—or the sociospatial
relations and conditions inherent within the unfolding
of contingency—to the genesis of multiple, variegated,
and unanticipated effects of alcohol control measures.
I then argue that these effects can be understood as a
series of contingent geographies—or sociospatial forma-
tions and processes that emerge in dynamic and unpre-
dictable ways—before examining the implications of
these contingencies for a newly theorized, interdisci-
plinary global health.
Global Health, Geographical Contingency, and Contingent Geographies 673
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What Is Global Health?
Defining any unified field of global health has long
proved to be a significant challenge (Koplan et al.
2009), yet only recently has this been deemed a prob-
lem. Indeed, as Fassin (2012) suggested, “until now,
the expression global health seems to have been self-
evident, as if we should all know what it signifies and
share what it refers to” (100). The field is now subject
to critique for its lack of both a coherent theoretical
underpinning and status as a discipline, however.
Although this argument cannot be dissociated from
universities’ current obsession with global health pro-
grams (Macfarlane, Jacobs, and Kaaya 2008; Crane
2011), it is still the case that people generally engage
with global health only indirectly through its ration-
ales, problem frames, justifications, programs, and evi-
dence base. It follows then that “despite the
appearance of a shared moral and technical project,
global health is not a unified field ... it is not clear pre-
cisely what the term means” (Lakoff 2010, 59). In
brief, this “comparatively new multilateral enterprise”
(Garrett 2013, 2), has been largely guided by the
World Health Organization (WHO) and more
recently the World Bank and a plethora of philan-
thropic enterprises (McGoey 2015). It involves the
transfer of knowledge and resources from Global
North to Global South, a variety of efforts to act on
and reduce the global burden of disease, and a particu-
lar concern for and financial investment in the infec-
tious disease triumvirate of HIV/AIDS, malaria, and
tuberculosis (Ingram 2009; Koplan et al. 2009).
Global health is further characterized by its multi-
layered and complex architecture (Ruger 2007). By
this I mean the assemblage of biomedical knowledge,
technologies, agendas, initiatives, objectives, data, and
politics articulated through the interconnections
among nation-states, international organizations, pri-
vate companies, nongovernmental organizations
(NGOs), regional trade agreements, localities, philan-
thropies, lay people, and experts and through an array
of projects, interventions, and surveillance enterprises.
At the last count, this involved “26 UN agencies, 20
global and regional funds, 40 bilateral donors, and 90
global health initiatives” (Panter-Brick, Eggerman, and
Tomlinson 2014, 2). Global health is thus a dynamic
and opportunistic enterprise with geopolitical context,
funding streams, calculations of epidemiological need,
and modes of deployment that are constantly shifting.
This enterprise is, nevertheless, underpinned by a num-
ber of compulsions that coalesce (at least discursively)
around the will to secure health for all in the most effi-
cient way possible, redress fundamental inequities,
deliver value for money, and tackle the mounting eco-
nomic burden and security threats posed by disease and
suffering (Koplan et al. 2009; Lakoff 2010).
At present, the global health landscape is over-
whelmingly dominated by a metricized logic of tech-
nological “fixes,” efficiency, evidence, measurement,
and evaluation (Adams 2013), led by (but not limited
to) the Bill and Melinda Gates Foundation (BMGF).
This Gates approach can often be grossly at odds with
social scientific concern with the gap between pro-
grammatic intention, situated experience, and social,
political, and economic contexts in many global
health interventions (Adams, Burke, and Whitmarsh
2014; Storeng and Mishra 2014). The need to explain,
manage, and close this gap—if only for the sake of
greater efficiency—has not gone unnoticed and, in
late 2014, Gates announced a new set of more socially
minded “Grand Challenges.” Described by The Econo-
mist (“A New Challenge” 2014) as being “fuzzy” for
their lack of scientific “specificity,” this partial conces-
sion to many of the social science critiques levelled at
the BMGF represents a fascinating turn (“What Has
the Gates Foundation Done?” 2008; McCoy et al.
2009). It also shows that although the policies, practi-
ces, successes, and failures of global health touch the
everyday lives of countless individuals (Biehl and
Petryna 2014), great tensions still remain between
competing disciplinary truth claims about the nature,
genesis, and experience of suffering. Amid this disci-
plinary antagonism, geography has failed to develop
the same kind of critical conceptual mass that has
allowed anthropologists to stake a unique claim to the
global health field.
Anthropological Ascendency and
Geographical Opportunity
To date, medical anthropologists have arguably
come to occupy the most compelling and persuasive
niche in critical global health studies (Nguyen and
Peschard 2003; see also Somatosphere.net; Pfeiffer and
Nichter 2008; Farmer et al. 2013). Farmer, one such
“global apostle of health” (Fassin 2012, 114), argued
that global health must be understood as a biosocial
enterprise in which illness emanates from multiple
ecological scales (Farmer 1996b; Farmer et al. 2006;
see also Gandy 2005). This approach has found favor
as it decenters individual behavior as a default
674 Herrick
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explanatory category and medicine as the sole cure
and demands a series of more nuanced, contextualized,
and situated analytical tools. The allied anthropologi-
cal focus on “local biology” (see Lock and Nguyen
2010) represents an important counterpoint to the
framing of global health as a (macro) problem of glob-
alization that has prevailed in political science (Row-
son et al. 2012). It also represents a critique of the
epidemiological tendency to gloss over the lived expe-
riences of health and illness as “anecdotal distraction”
(Jeavons 2014, 462). So armed, anthropological
engagements with global health have proven particu-
larly powerful in arguing that the roots of poor health
are not just “historically deep and geographically
broad” (Farmer et al. 2013, 2) but must also be filtered
through the critical frameworks of ethnographic meth-
ods and social theory (Pigg 2013). The assertion that
ethnography is both an unparalleled “empirical
lantern” (Biehl and Petryna 2014, 376) and the singu-
larly most appropriate method for global health
analysis has culminated in calls for a new methodolog-
ical and social movement based on the mantra of
ethnographic “slow research” (Adams, Burke, and
Whitmarsh 2014). Such celebratory narratives of eth-
nographic (and thus anthropological) exceptionalism
have been further entrenched by the shift from tradi-
tional studies of single localities to new, multisited
and multiscalar ethnographies (Rajak 2011; Crane
2013; Fassin 2013) that are particularly well suited to
global health research.
Despite anthropology’s impressive ascendance, cri-
tiques of global health still remain relatively con-
strained regardless of discipline. This could be
because, “like evidence-based medicine, the ideal of
global health has assumed a certain rhetorical univer-
sality. ... Just as few would claim to practice
‘evidence-free’ medicine, it is quite difficult in this era
for anyone to argue against global health” (Holmes,
Greene, and Stonington 2014, 475). Biehl and Pet-
ryna (2014) thus pointed out that “initiatives are
booming ... [yet] critical analyses of the social, politi-
cal, and economic processes associated with this
expanding field—an ‘open source anarchy’ on the
ground—are still few and far between” (376). As
momentum gathers behind the post-2015 Sustainable
Development Goals (SDGs), however, criticism of the
current architecture, transparency, and funding priori-
ties of global health is starting to mount. This is partic-
ularly true in relation to global health’s relative silence
on noncommunicable diseases (NCDs; Livingston
2012; Marrero, Bloom, and Adashi 2012), despite the
Global Burden of Disease Study showing that they
now cause two thirds of global mortality (Reubi, Her-
rick, and Brown 2015). Moreover, and crucially for
the sustainability of global health, NCDs converge
with infectious diseases and poverty in low- and mid-
dle-income countries (LMICs) to represent a particu-
larly pernicious multidimensional burden of disease
with significant implications for development
(Bygbjerg 2012). This is only worsened as the behav-
ioral risk factors for NCDs (alcohol, diet, physical
activity, and tobacco) are inextricable from many of
the aspirations and lifestyle shifts that accompany
development. Although NCDs represent a powerful
challenge to current models of global health gover-
nance, funding priorities, and paradigms, they also rep-
resent a springboard for potentially vibrant
transdisciplinary concept building. This, in turn, could
offer an important vehicle for contributions to critical
studies of global health by geographers of all
subdisciplines.
The recent Economic and Social Research Council
(ESRC 2013) Benchmarking Review of UK Human
Geography describes health geography as the
“foremost” of the discipline’s “nascent fields.” This
vibrancy can be traced back to the 1990s and a con-
certed movement away from medical geography’s con-
cern with the distribution of disease, risk factors, and
health care facilities to a closer connection with social
and cultural geography’s then-emergent interest in the
body, the meaning of place, and social theory (R.
Kearns 1993). This need to move beyond the “shadow
of medicine” (R. Kearns and Gesler 1998, 3) and
emerge as a reformed, critical health geography echoed
the broader shift from a “biomedical model of disease”
to a social model anchored in the “new public health”
(Petersen and Lupton 1996; T. Brown and Duncan
2002; see also Parr 2004). It is interesting, therefore,
to remember this cultural and theoretical turn in the
subdiscipline, especially given that the conceptual
concerns of many health geographers—choice,
agency, and responsibility—remain real and ironic
absences in the highly medicalized field of global
health (Dry and Leach 2010; Clark 2014). In recent
years, there have been a number of calls for greater
geographical attention to global health (T. Brown
2011, 2014; T. Brown, Craddock, and Ingram 2012; T.
Brown and Moon 2012; Herrick 2014; Herrick and
Reubi 2016). This has been largely spurred by a drive
to make collective sense of existing geographical writ-
ing on inherently related themes including (bio)secu-
ritization (Ingram 2005, 2009, 2013), the geopolitics
Global Health, Geographical Contingency, and Contingent Geographies 675
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of infectious disease (Craddock 2000; Harris Ali and
Keil 2008), inequality and inequity (Pearce and Dorl-
ing 2009; G. Kearns and Reid-Henry 2009), liveli-
hoods and the political ecologies of health (King
2010, 2011; King and Crews 2013), pharmaceuticals
(Craddock 2012), geographies of care (Lawson 2007),
globalization (Sparke 2009; Sparke and Anguelov
2012), the situated “making” of global health (Brada
2011), the spatialized logics of epidemiology (Laurie
2015), the commodification of bodies (B. Parry 2004,
2008), and immunity, infectious disease, and the non-
human (Hinchliffe and Ward 2014; Hinchliffe 2015).
Moreover, given the current attention to NCDs, it
is worth highlighting critical geographical engage-
ments with their four major risk factors: obesity (Her-
rick 2007, 2009b; Evans, Crookes, and Coaffee 2012;
Guthman 2012, 2013), alcohol (Kneale and French
2008; Jayne, Valentine, and Holloway 2010, 2011;
Herrick 2012), smoking (Thompson, Pearce, and Bar-
nett 2007, 2009), and physical activity (Herrick
2009a; Hitchings 2013; Latham 2015). Despite their
clear relevance, however, only a handful of these
papers explicitly reference global health debates.
Global health is also a glaring absence in recent, well-
received health geography compendia (T. Brown,
Mclafferty, and Moon 2009; Gatrell and Elliot 2009;
Anthamatten and Hazan 2011). At the most practical
of levels, this means that this rich corpus of highly pre-
scient geographical writing rarely appears in keyword
database searches for global health literature, further
reinforcing the discipline’s absence. This is unfortu-
nate, given the potential of so many geographers to
both contribute to global health debates and raise the
profile of the discipline within these. This research
includes, but is in no way limited to, critical
approaches to political economy, scientific knowledge,
security and vulnerability, diplomacy and governance,
changing paradigms of aid and development assis-
tance, socioeconomic inequity, sustainability, embodi-
ment, social justice, globalization, rights and
responsibilities, risk and resilience, urbanization,
socionature, and the dialectical relationships between
people and places (see T. Brown, Craddock, and
Ingram [2012] and T. Brown and Moon [2012] for
excellent reviews). This is far from an exhaustive list
but gives a sense that the potential for geographical
contributions to global health’s “existential
challenges” (Garrett 2013) goes far beyond health
geography alone. I now turn to one conceptual
approach that offers the potential to make this contri-
bution more explicit and, furthermore, might offer up
a productive platform for better working across and
between geography and anthropology.
Geographical Contingency and Contingent
Geographies
Global health’s institutional location within medi-
cal and public health schools might have initially sty-
mied its engagement with social theory, but this
situation is rapidly changing. Kleinman’s (2010) Lancet
paper, for example, argued for the application of social
theory to help students to “generalize knowledge and to
develop a more systematic critical reflection on global
health problems and programs as a complement to epi-
demiological, health services, policy and ethical stud-
ies” (1519). Leaving aside my concern with the words
generalize and systematic, he drew particular attention to
Merton’s (1936) concept of the “unintended conse-
quences of purposive social action,” as well as the
anthropological framework of social suffering and struc-
tural violence (Farmer 1996a; Bourgois 2003).
Together, these two concepts have proved exception-
ally influential within critical studies of global health,
especially for those anthropologists keen to highlight
what happens when “the supposed beneficiaries of
interventions are generally lost from view” (Biehl and
Petryna 2014, 376). Here, however, I want to explore
how the concept of contingency might be able to bridge
current anthropological concern with the genesis and
experience of suffering with the very real need to better
understand how purposeful and well-intentioned
actions can produce unintended and unanticipated
consequences. In so doing, I wish to move beyond the
idea of contingency as simply the workings or influence
of local context so ably advanced in cultural anthropol-
ogy and instead make a case for how geographic contin-
gency might be read as the juncture of sociospatial
conditions of possibility with uncertainty, chance, and
fortuitousness. Moreover, these junctures often occur
without design, such that they can produce new emer-
gent and contingent geographies or the sociospatial for-
mations whose existence is only made possible by the
very contingency of their preconditions.
In many respects, exploring contingency necessi-
tates a brief return to Kearns’s oft-cited paper that
highlighted the “dynamic relationship between
health and place and the impacts of both health
services and the health of population groups on the
vitality of places” (R. Kearns 1993, 145). As he
argued, exploring this dialectic requires “models of
676 Herrick
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societyaswellasofhealththatrecognizethecon-
tingent relations that pertain for individuals and
groups at particular locations” (145). These ideas
have further advanced efforts to theorize place in
relational terms, where “individuals often influence,
and are influenced by, conditions in multiple
places” that, moreover, are produced and experi-
enced through dynamic (and often distal) social
and power relationships (Cummins, Diez Roux, and
Macintyre 2007, 1828). Although Cummins and
Kearns work from quite different epistemological
perspectives, the shared geographical concern with
the “processes and interactions” between people
and places of varying degrees of proximity is impor-
tant, as it helps introduce new “dimensions of
incertitude” into global health research (Leach,
Scoones, and Stirling 2010, 373). In this sense,
then, I am not working with contingency in the
sense of the measures that need to be put in place
to mitigate and manage potentially negative effects
of an intervention (i.e., a contingency plan).
Instead, my geographical reading of contingency is
one that starts from the belief that certain events,
processes, or outcomes cannot be predicted or
determined and their conditions of possibility are
inextricable from the locales in which they arise
(Barry 2014). Moreover, the complexities inherent
within this uncertainty act as a marked challenge
to a global health epistemology that demands logic
and predictability over instability and emergence.
The uptake of complexity theory as an “explanatory
schema” (Harrison, Massey, and Richards 2006) with
great potentiality for the study of health (Curtis and
Riva 2010) is worth briefly noting here for its concern
with interactions, flows, networks, agency, relationality,
nonlinearity, feedback, and emergence (Rickles, Hawe,
and Shiell 2007). This helps challenge the polarized
spatial logic of global health evinced in much anthropo-
logical writing—a global versus an embedded local—
where social suffering emerges through the embodiment
of distal processes outside individual control (Farmer
et al. 2006). This eschewing of control reinforces a ten-
dency among some anthropological writing to situate
“whole communities within a discourse of victim-
ization” (Panter-Brick 2014, 439). This focus tends to
underplay the novel forms and processes of emergence
charted by complexity theory that have become new,
“unanticipated anthropological terrain” and that also
characterize the “profound disconnections” between
“campaign designs and intentions and the complex
ways in which those campaigns are actually received
and critiqued” (Biehl and Petryna 2014, 380). Although
anthropologists have proved particularly adept at
chronicling the experiences of this disconnect (Bour-
gois 2003; Nguyen and Peschard 2003; Scheper-Hughes
2004; Livingston 2012), they have tended to pay less
attention to the relational and, indeed, the broader
sociospatial genesis and consequences of disjuncture
(however, see Crane 2013).
By contrast, here I both draw on and critique H.
Brown and Kelly’s (2014) recent work on “hotspots” of
viral hemorrhagic fevers (VHFs) as producers and
products of “radical and contingent relationality”
(292) that “[defies] scalar logic” (283). Their emphasis
on the “spatio-temporal heterogeneity” and “socio-
political substance” (282) that characterizes the condi-
tions of emergence for infectious disease is significant
and helps us uncover what they termed “the elaborate
temporal and material relationalities that cultivate
networks of pathogenic exchange” (288). Although
their work is a powerful contribution to our conceptual
armory for exploring the outbreak of viral infections
such as VHFs, it is of less use in the context of NCDs,
which have arguably more politically and economi-
cally contentious pathogens (i.e., alcohol, food,
tobacco) and processes of pathogenesis. This said,
their assertion that outbreaks emerge amid “radical
and contingent relationality” (292) offers an impor-
tant starting point for exploring the role of geographic
contingency in explaining why “universal” global
health solutions—in this case the “best buy” of
increased alcohol taxation—might produce not only
unintended consequences but also emergent and
unpredictable sociospatial formations that then act as
a visceral critique of the very policies from which they
have (directly and indirectly) emerged.
Contingencies can be thought of as instances that
“interrupt the operation of processes, thereby produc-
ing different empirical outcomes in different contexts”
(Jones and Hanham 1995, 186); in other words, new
and unanticipated forms of emergence. The complicat-
ing factor here is that the “processes” of so many global
health programs are merely either assumed or extrapo-
lated from the limited global compendium of “evidence
of best practice.” Contingency, therefore, might “signal
the possibility of multiple outcomes derived from simi-
lar causal processes due to the complexity of social rela-
tions embedded in spatially differentiated contexts”
(Jones and Hanham 1995, 186). When these “causal
processes” themselves are the products of inherently
imperfect epidemiological prediction that is often the
product of a very narrow geographic imagination,
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however, the range of possible “differentiated out-
comes” (186) becomes unfathomable. Moreover, this
becomes even more complicated if we subscribe to the
belief that “place contexts—with their differences in
social, political, economic, and environmental charac-
teristics—are obvious locations for the production of
contingencies” (190). Geography, as ever, matters.
This also means that Botswana is more than just the
context of policy deployment; it matters deeply because
of how, who, what, and where it is.
Contingency is consequently not only inherently
geographical but, in so being, sits uneasily with a bio-
medically framed global health enterprise in which the
“unexpected constitutes a threat ... [and] carries with
it an approach toward the unexpected which gives
pride of place to the quantification of uncertainties”
(Malaby 2002, 287). Places, then, can act both as con-
duits for and the emergent outcomes of contingency.
This idea was recently explored by Amin (2013) in his
work on the contingent vitality of cities of the Global
South in which he made a claim for the strategic impor-
tance of the “specificities of location” (141) as a tool for
the amelioration of some of the most pressing urban
problems. Moreover, he argued, the fact of urban dwell-
ers of the Global South being in the “practiced habit of
living in particular circumstances of lack and
uncertainty” (146) means that uncertainty is not erased
or neutralized in and by everyday life but rather (and
necessarily) worked with (see also Simone 2010) in the
production of new, contingent geographies. Although I
do not wish to glamorize the quotidian tedium and peril
that can be produced by living with uncertainty, these
ideas draw attention to the geographical foundations of
contingency and hint at the productive nature of the
emergent contingent geographies that they might inad-
vertently produce and to which I now turn.
The Multiple Contingencies of Alcohol
Taxation in Botswana
Alcohol occupies a liminal space within the global
health landscape. On the one hand, its use, abuse, and
health consequences are virtually absent from the pro-
grammatic priorities of the world’s most significant
global health philanthropies (Casswell and Thamar-
angsi 2009). On the other, mounting critique of this
lacuna has invigorated the advocacy efforts of the
global alcohol control movement, especially in the
Global South. With alcohol now framed as “a global
health problem” and a profound challenge to
sustainable development (Beaglehole and Bonita 2009;
WHO 2011), attention has turned to public health
interventions to reduce population-level consumption,
particularly in high-risk countries of the Global South.
Central to the alcohol control community’s lobbying
efforts has been the promulgation of a simple message:
evidence-based policy “best buys.” Interestingly, in its
fear of the “problem deflation” tendencies of ethno-
graphic research on alcohol (Room 1984), the alcohol
control community has not only made its view on
anthropology clear, but also eschewed contingency as
inconvenient to the implementation of its universal
public health policies (Room, Babor, and Rehm 2005;
Herrick forthcoming). Its global “best buys” focus on
the control and restriction of alcohol supply and advo-
cate for limited opening hours and outlet density,
increasing taxation, government monopolies on retail
sales, increasing age limits, drink driving counter-meas-
ures and advertising/ marketing restrictions (World
Health Organization 2010). In this paradigm, demand-
side interventions such as education campaigns or
labeling are rejected as unscientific and nonscalable
(see, e.g., the debate in Craplet 2006; Rehm, Babor,
and Room 2006) or as unwelcome evidence of industry
influence (Casswell 2013).
With this context in mind, Botswana—a midsized,
land-locked country whose significant mineral wealth
accounts for roughly 40 percent of all government reve-
nues—serves as a particularly interesting location for
an exploration of alcohol and global health for two rea-
sons. First, it occupies a paradigmatic place in anthro-
pological writings on global health through
Livingston’s fascinating corpus of work documenting
the profound sociobiological shifts that have occurred
alongside the country’s emergence as a rare postinde-
pendence African “success” story (Livingston 2005,
2008, 2012; see also Brada 2011). In particular, her
work on cancer reminds us how chronic disease has for
too long been viewed as “an esoteric distraction from
more pressing concerns in global health,” such as HIV/
AIDS (Livingston 2012, 9). Yet, and as she powerfully
argued, increasing rates of cancer are actually a deeply
contingent artefact of “African health after anti-
retrovirals” that highlight the extent to which biomedi-
cine can only ever be an “incomplete solution” to
complex global health problems (Livingston 2012, 7).
Second, Botswana has arguably spearheaded the cur-
rent southern African trend toward the stricter regula-
tion of alcohol. This trend cannot be dissociated from
work undertaken by the WHO in singling out the Afri-
can region as lagging behind in the uptake of alcohol
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taxation (WHO Regional Office for Africa 2008).
Their recommendations for taxation have been justi-
fied through numerous public health publications
highlighting the urgency of the region’s alcohol scourge
and the relative inadequacy of the current policy
response (C. Parry 2014; Ferreira-Borges et al. 2015;
Jernigan and Babor 2015; C. Parry et al. 2015) in the
context of the predatory tactics being used by the global
liquor industry to gain market share on the continent.
Alcohol has long played a role in southern African
life. Chibuku, a traditional, low-alcohol sorghum beer,
has, for example, been consumed in various guises
across the region for at least the last century (van Wol-
putte and Fumanti 2011). More recently, however,
alcohol has been implicated in the widespread moral
panic over the spread of social and economic “ills,”
including violence, crime, injury, unemployment, and
HIV/AIDS (Obot 2006). When teetotal President Ian
Khama took office in 2008, he acted on his “personal
distaste for alcohol,” concern with national “moral
weakness,” and lack of discipline (Burgis 2009) by uni-
laterally imposing a 30 percent levy on all alcohol and
warning that this would ultimately be increased to 70
percent (Good 2010b, 321; Gulbrandsen 2012).
2
According to Khama, “[Alcohol] is an enemy, anything
that causes people to lose their lives unnecessarily
before their time must be an enemy” (Burgis 2009,
italics added). Despite being challenged in court by
the country’s largest brewer, the levy was quickly
increased to 40 percent in 2010, 45 percent in 2012,
and 55 percent in 2014 after a government-commis-
sioned report revealed the resilience of public con-
sumption (Pitso and Obot 2011). The levy has been
combined with significant fines for drunk driving
(roughly 1,000 Pula or $90), promises of more active
policing, strict controls on drinking in public places,
restrictions on bar opening times, the regularization of
traditional beer production and retailing from
“depots,” and an (informal) ban on local television
advertising. Botswana’s comprehensive uptake of so
many of alcohol control’s “best buys” thus makes it an
exceptionally important global health test bed. More-
over, and as I explore, it also exemplifies how geo-
graphical contingency and the genesis of new and
emergent contingent geographies fundamentally call
the public health faith in universally applicable public
health interventions into question.
Health economists argue that alcohol, like tobacco, is
a commodity for which demand is fairly price elastic
(Elder et al. 2010). Thus, it is assumed that as prices rise
and affordability declines, population-level rates of
consumption and, therefore, alcohol-related harms will
also fall (Wagenaar, Salois, and Komor 2009; Wagenaar,
Tobler, and Komro 2010). Although this advice is pre-
sented as universally applicable, it is important to
remember that the evidence called to the service of such
arguments is often drawn solely from an exceptionally
limited number of Global North case studies (Herrick
forthcoming).
3
Just as with other (global) health inter-
ventions, the aspatialized and simplified evidence used
to justify alcohol taxation is itself, ironically, a product
of multiple geographical contingencies. Moreover, the
diffuse ways in which taxation is understood and acted
on by the public reveals the extent to which “people are
plural beings and not reducible to ‘populations,’ and
local realities still very much frame, constrain, and ori-
ent interventions” (Biehl and Petryna 2014, 385). Yet,
although local realities are undoubtedly important, the
alcohol levyrepresents more complex sets of confluences
that tend to “defy scalar logics” (H. Brown and Kelly
2014, 283) in efforts to manage the “contingent conver-
gence of pathogenic potential” (292). Indeed, instead of
managing the risks and uncertainties engendered by
alcohol consumption, the convergence of the levy with
sociospatial processes unique to Botswana offers up the
conditions of possibility for emergent geographical for-
mations. The point is that both geographical contin-
gency and the contingent geographies that result cannot
be predicted by the methodological arsenal of epidemi-
ology; they are instead the outcome of the happenstance
that is coproduced in unique and opportunistic ways by
the dialectic between people and places.
To explore these ideas in more depth, in 2014 I
undertook twenty interviews with alcohol (policy and
industry) stakeholders in Gaborone and conducted 300
surveys across five of the city’s districts exploring the
levy’s effects on attitudes toward drinking and con-
sumption behaviors. The survey research was under-
taken with the University of Botswana with the aim of
collating basic demographic data and exploring individ-
ual motivations for drinking, consumption habits, how
respondents’ drinking practices have changed through
time, attitudes toward the levy, the effect of the levy on
respondents’ drinking practices, and respondents’ per-
ceptions of its effects on other’s practices, as well as per-
ceptions of the nature and extent of Botswana’s
“alcohol problem.” The survey was piloted, collectively
refined, and readministered by three research assistants
in either Setswana or English, depending on the prefer-
ence of the respondents. The same survey was adminis-
tered across the city and the research assistants
recruited respondents from a variety of drinking
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establishments across middle- and low-income neigh-
borhoods to talk to customers. This purposeful sample
was chosen to ensure the recruitment of drinkers, rather
than nondrinkers, to better gauge the influence of the
levy on attitudes toward drinking and consumption
habits (something that nondrinkers would be less able
to answer). The survey was administered over the course
of two weeks and responses were recorded by hand in
the field for reasons of security and convenience.
The interviews were undertaken with a variety of
policy and industry actors, with respondents recruited
through contact networks and snowballing techniques.
As might be imagined in a capital city of only 200,000,
the worlds of alcohol production, distribution, retail,
and regulation are fairly small, so the sample size repre-
sents a very thorough cross section of key actors. The
semistructured interviews each lasted around an hour
and were audio recorded (where consent was given),
usually in respondents’ places of work. The interviews
aimed to elicit a sense of the multiple dimensions of
the alcohol control debate, the arguments for and
against the levy, and perceptions of its consequences.
The interviews thus act as a counterpoint to the public
and lay opinions evinced in the survey findings,
exploring the rationales for the implementation of the
levy from governance and public health perspectives
and the challenges that it poses to the private sector.
Given the autocratic nature of government in
Botswana, it was unsurprising that respondents
requested anonymity and many were reticent to
directly criticize the president, despite discussing a pol-
icy tool that was very clearly his personal moral pur-
suit. This fear of directly criticizing the leadership was
compounded by the small social circuit that respond-
ents tended to move within. In the text, anonymity is
maintained and context deepened by identifying
respondents by their domain of work.
Here I want to explore the effects of the levy
through the lens of geographical contingency before
examining their emergent contingent geographies.
Somewhat unhelpfully given the broader demonstra-
tion potential inherent in such a large-scale public
health intervention, no baseline data were collected
on drinking rates by the Ministry of Health before the
levy’s imposition. Press reports in Botswana (Gaotlho-
bogwe 2013) were, however, quick to pick up on
WHO data showing that drinking rates were already
on a downward trend between 2000 and 2005 when
the levy was first mooted as part of President’s Com-
mission of Inquiry into the “social vices” gripping the
country. The WHO Global Information System on
Alcohol and Health (GISAH) does show that con-
sumption levels dipped the year after the 2008 imposi-
tion of the levy (see Figure 1) from 6.54 to 4.99 liters
Figure 1. Alcohol consumption in Botswana, 1990–2010, in liters per person per year. Source: World Health Organization Global Informa-
tion System on Alcohol and Health (2015). (Color figure available online.)
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per person per year. By 2010, the last year for which
WHO data are available, drinking rates had again
risen by almost 20 percent to 5.98 liters per capita.
This rebound was corroborated by industry stakehold-
ers who noted a substantial drop in volume sales as the
initial price shock of the levy took effect. As one inter-
viewee thus noted,
With the introduction of the levy it was quite a shock
because the product got very expensive very quickly, ini-
tially we saw a decline in volumes, but I don’t think that
is the case anymore. (Alcohol producer, interview, 2014)
Since 2009 and despite annual rises in the levy rate,
however, not only has per capita consumption been
steadily climbing according to industry sources, but
drinking habits themselves have changed. As another
industry interviewee asserted,
As the levy has gone on and increased, people have car-
ried on moving downwards [in value terms] in what they
buy, so my business hasn’t declined at all, it’s just shifted.
(Alcohol distributor, interview, 2014)
As prices have gone up, value sales might have suffered,
but volumes of cheaper drinks have remained relatively
steady. This could be due to a reported surge in home
drinking where “they [now] go to bottle stores as it’s
cheaper” (Public health policymaker, interview, 2014).
Here, they can now pick up “DIY Chibuku” packs for
home consumption in a move designed by one major
national brewer to offset the effects of traditional beer
depot closures and concomitant falls in their Chibuku
sales. In asking about the consumer response to the
constant upward trend in alcohol prices, respondents
from the liquor industry highlighted a turn from mar-
ket-leading beer St. Louis (3.5 percent alcohol by vol-
ume [ABV]) to higher strength Carling Black Label (5
percent ABV), with Black label “Sharepacks” (750 ml
bottles rather than the 340 ml more traditionally pur-
chased) now enjoying the greatest sales growth. These
formats are seen as representing better alcohol unit-
per-Pula value but also represent new sources of risk as,
unlike other countries in the region where large bottles
are shared among drinkers, Batswana tend to consume
their own. Such trends were also leading to a “neglect
of the home in favor of drinking” (Alcohol distributor,
interview, 2014), with repercussions for the same
domestic violence and poor economic productivity
that the levy was brought in to combat.
The levy has also precipitated a collapse in the capi-
tal’s formal nightlife due to restrictive opening hours
and prohibitive pricing, much to the dismay of the
city’s musicians and young people. Some industry
interviewees were also (unsurprisingly) swift to offer
anecdotal evidence of a rise in drug use, a flood of
cheap nonbranded alcohol imports from India, and
the development of a significant cross-border liquor
trade (alcohol distributor and retailers, interviews,
2014). With prices in South Africa over 60 percent
cheaper than in Botswana and the Mafoeking branch
of wholesaler Makro only a couple of hours’ drive over
the border, professional bootleggers and couriers have
begun taking advantage of relatively lax border con-
trols (trade association, interview, 2014). As one
NGO interviewee noted:
If you ask government, they’ll say that the money from
the levy is going down so people must be drinking less,
but there are all these villages along the border where
people are just going across and buying alcohol. If you go
over the border on a public holiday, the queues of cars
coming back over the border, filled with booze ...
Another from an industry trade association did little to
hide his complicity in this trade:
I buy from South Africa by courier; you only need to pay
500 Pula. I buy a box of champagne, in South Africa is
only 2,000 Pula, in Botswana it is 3,500 Pula.
4
Industry representatives also noted a trend toward
underinvoicing imported liquor brands at customs, for
truckers to sell cheap South African–bought liquor to
highway bottle stores, and for shipping containers of
imported alcohol to go “missing” en route to Bot-
swana, something industry sources termed round trip-
ping. The alcohol levy is a thus a good example of the
contingent emergence of significant, new, and unan-
ticipated forms of human agency, commercial opportu-
nity, and risk taking that has not yet been explored by
the public health community even while they con-
tinue to argue for the universal efficacy of taxation
(Elder et al. 2010).
These effects of alcohol taxation could not have
been foreseen by the “evidence” used in the formula-
tion of evidence-based policy. Instead, they have
emerged at the junctures of sociospatial conditions of
possibility with uncertainty, chance, and fortuitous-
ness of which I highlight two clear examples. First,
Botswana’s location on the South African border
means that it shares its powerful neighbor’s liquor dis-
tribution networks and South African manufacturers
enjoy a significant market presence. Moreover, the
value differential between the Rand and the Pula has
precipitated bootlegging allied to a cross-border drug
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trade that has, in turn, reportedly led to new forms of
substance abuse: “a rise in self-mixtures, cough mix-
tures (codeine) and coke, sleeping tablets” (addiction
services NGO, interview, 2014). Furthermore, the
proximity and cultural influence of Johannesburg has
reinforced disquiet with the ways in which pricing
structures deny aspirant Gaborone residents access to
the brands and lifestyles enjoyed by South Africans.
This influence has, in turn, reinforced the resilience
of consumption for, as one industry interviewee
remarked, “Humans are humans and they’ll make a
plan.” Second, there are also interlocked geographical
contingencies inherent in President Khama’s military
education at Sandhurst after the interracial marriage
of his parents forced them to flee Southern Africa and
live in exile in the United Kingdom. The same British
education might have precipitated his fetishization of
“puritanical discipline” (reports abound of his daily
4:30 a.m. workouts) that he later brought back to Bot-
swana. Finally, there is his faith and inherent dislike of
alcohol (there is much speculation about a history of
alcoholism in his family), a stance that finds many
willing ears in a country where rates of lifetime absten-
tion are high and 70 percent of people self-identify as
Christian. This particular amalgamation of geographi-
cal contingencies has produced such a moralized policy
environment that “the message coming out from gov-
ernment is stay sober and this especially alienates
young people who don’t want necessarily to stop
drinking” (addiction services NGO, interview, 2014).
The multiple disconnects between the presidential
discourse of alcohol as “social scourge,” a biomedical
framing of alcohol as risk, and the ambiguity of public
opinion is borne out in the survey findings. For example,
despite the media attention on the levy and related
messaging around the evils of alcohol, only just over
half of the survey respondents (55 percent) believed
alcohol to be a “problem” for the country. This chimes
with the 20 percent of respondents who claimed to be
drinking more now than ever before. Yet, in contrast to
WHO data suggesting a rebound in consumption, 50
percent of survey respondents still stated that their alco-
hol consumption had declined in the last five years.
This is then notable because 60 percent of respondents
believed that other people had not decreased their alco-
hol intake since 2008, highlighting the extent to which
gathering data on alcohol consumption is fraught with
bias and self-reporting inaccuracies (Boniface and Shel-
ton 2013). Further dashing the hopes of health econo-
mists, even though 71 percent of respondents thought
the levy already too high, 78 percent of these stated
that they would continue to drink even if it was further
increased. This compulsion was particularly strong
among those respondents who stated that they now
drank as an act of political resistance against an auto-
cratic government that has overseen mounting rates of
youth unemployment and visible inequality (Good
2010a). This sentiment was also picked up by the oppo-
sition party leader in the run-up to the 2014 elections in
his assertions that “Batswana essentially consume liquor
because of the contempt they have for Khama ... [he]
has taken away taste and mystique of the forbidden fruit
and now Batswana want back the taste” (Bagwasi 2015).
It must not be forgotten that alcohol’s introduction
has also cross-cut profound shifts in urban lifestyles, as
new malls emerge across the Gaborone skyline, a new
central business district rises, and the cost of living
soars. The disparity between the capital and rural life
is becoming ever more marked, bringing new and
unpredictable societal concerns. Importantly, and as
so often ignored in the biomedical framing of alcohol,
these shifts go beyond public health to incorporate
questions of livelihoods, agency, coping, and resilience
(Herrick 2013). Moreover, they have also carved out
new contingent geographies, or spaces where the
effects of the levy coalesce and are amplified into new
topological formations across Gaborone’s rapidly
changing urban landscape. These include the opportu-
nistic and rebellious spaces created by illegal after-
hours drinking and “car pimping” (partying with music
blaring from parked cars) now found in the city’s
numerous scrubby open spaces under cover of darkness
and organized through social media (Pritchard 2015).
There has been a rise in music and drinking festivals
located far into Gaborone’s rural periphery and thus
removed from the gaze of urban enforcement agencies.
These human responses to the restrictions imposed by
the levy are not only made possible by Gaborone’s
unique topography but are accompanied by unantici-
pated forms of risk. For example, the levy has created
spaces of necessity and innovation for new spatial net-
works of cross-border trade, smuggling (both informal
and commercial), and new liquor distribution routes
designed to try and minimize the commercial damage
of the levy to industry. Finally, the levy has brought
emergent spaces of policy and knowledge creation into
being that reference international experts and case
studies of best practice in the Global North, sideline
regional knowledge (and especially, as interviews
revealed, the South African experience), and discount
the uncertain outcomes that characterize contingency
as epidemiological inconvenience (see Crane 2013).
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These new spatiotemporal topologies represent nei-
ther the successful deployment of the levy, nor are they
merely symptoms of its failure. Rather, and instead,
such contingent geographies represent the resilient
adaptation of pleasure-seeking behaviors through the
opportunities afforded by conditions of multiple uncer-
tainty. This resilience is inadvertently underlined by
Khama’s (2015) State of the Nation Address, which
noted that the levy had produced revenues of
P1,867,586,562 since 2008 and that “a 2012 evaluation
of the impact of our alcohol reduction campaign inter-
ventions indicated that there was a reduction in alco-
hol consumption from 8 litres per capita to 7 litres.” At
the time of interviewing, no respondent could explain
how the funds had been disbursed and many suspected
that they were being used to prop up general govern-
ment revenue rather than being channeled into the
alcohol harm-reduction programs promised as part of
the levy’s rationale. It is notable, therefore, that the
ever-mounting levy revenue, its annual increase, and
data suggesting that consumption has actually climbed
since 2010 to 7 liters per capita coalesce to confirm that
contingency should never be dismissed as either epide-
miological inconvenience or simply the workings of
local context. The obvious policy irony is that the levy
funds represent a very significant income stream, the
maintenance of which relies on the persistence of
drinking and the success of which is generally couched
in terms of the fund’s size rather than evidence of any
positive social changes brought about by the levy.
Alcohol taxation is promoted in ageographical terms,
yet as these findings have shown, the hope of universal-
ity can only ever be a geographical fallacy. The contin-
gent geographies of Batswana drinking highlight the
depth and extent of human agency and tenacity as well
as how complexity perpetually destabilizes biomedical
faith in global health “solutions.”
Conclusion
Global health programs are largely and necessarily
predicated on a great faith in the power of quantifica-
tion, prediction, and evidence. Global health is experi-
enced and enacted in grossly unpredictable ways,
however, and therefore actively produced in a complex
set of interwoven engagements and interrelationships.
Tracing these emergent processes is essential to under-
standing where global health might fail and also where it
might succeed. As the uptake of global health as an
object of study and a type of praxis grows within
universities, geographers have the conceptual tools to be
central to this. As I have argued, though, geography has
been sidestepped despite the call for the integration of
global health with the “socializing disciplines” (Farmer
et al. 2013). Although geography falls within this label,
the potential it offers to the changing agendas of a refor-
mulated post-2015 landscape of global health remains
underrealized. As I have argued, this could in part be
traced to health geographers’ highly successful creation
of a subdisciplinary niche and the resultant siloing of
health research within this. Thus, if this article repre-
sents a call of any kind, it would be for a greater degree
of reflexivity by geographers of all subdisciplinary persua-
sions on the (post-2015) global health significance of
their research. This means going beyond the biomedical
confines of diagnosis, disease, and treatment to think
about health in metonymical terms: as representing both
cause and consequence of multiple, entwined social,
economic, security, environmental, political, and cul-
tural issues. This is arguably even more significant in the
complex world of global health, especially given that the
“politics of contingency” have been so silenced in the
quest for biomedical certainty (Malaby 2002, 307).
The production of new, contingent geographies by
global health programs and rationales is consequently
an area that merits distinct exploration. Using the
example of Botswana, I have aimed to briefly sketch
one such instance where interventions have reshaped
the broader geographies not only of dwelling but also of
doing business, evading regulatory efforts, and justifying
political rationalities. This is not simply about locating
global health with far “greater specificity” in intellectual
and political terms than it has been to date (Holmes,
Greene, and Stonington 2014, 476) but rather an argu-
ment for theorizing global health interventions as crea-
tive forces that rarely delimit uncertainty but instead
produce emergent sociospatial properties (Gatrell
2005). The “changing landscape created by global
health initiatives” (Biehl and Petryna 2014, 386) could
therefore sometimes represent biomedical failure (Clark
2014), but it is also socially and spatially generative in
ways that speak clearly to the recent work of Simone
(2010) and Amin (2013) on the ability of people and
places to resist, evade, and exceed governance efforts.
Indeed, exploring contingency foregrounds how and
why the global health enterprise generates the kind of
“hybrid novelties, amplified reverberations, unantici-
pated lurches, and unintentional developments that
escape intentional governance” explored in Botswana
(Amin 2013, 151). Yet, as Pigg (2013) noted, “the ques-
tions arising from a hyper-consciousness of contingency
Global Health, Geographical Contingency, and Contingent Geographies 683
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and practice across scales and contexts of action can
appear to those in the global-health mainstream as (var-
iously) unproductive, unnecessary, overly abstract, too
ambiguous, or off-topic and therefore not really useful
for moving forward with getting things done” (133). In
seeking to mitigate this persistent tension between
interrogating and overcoming uncertainty, geographi-
cal perspectives on global health must harness contin-
gency as a conceptual tool not simply for further
critique but for getting important things done.
Acknowledgments
Thanks to Dr. Gwen Lesetedi at the University of Bot-
swana for her support and assistance with the research in
Gaborone. Thanks also to the four anonymous referees
for their most helpful comments and suggestions.
Funding
The research for this article was funded by a Well-
come Trust small grant (reference WT102456MA)
entitled “The 2008 Botswanan Alcohol Policy: Risk,
Politics and Consumption.”
Notes
1. It is interesting to note the following numbers of Acade-
mia.edu theme subscribers as a rough guide to subdisci-
plinary significance (figures as of 1 July 2015): human
geography (26,297), cultural geography (10,898), medi-
cal geography (539), health geography (522), medical
sociology (5,145), medical anthropology (20,650),
global health (7,269), and public health (135,027).
2. In addition to excise duty, which cannot be changed by
the individual member states of the Southern Africa
Development Community.
3. Wagenaar, Tobler, and Komro’s (2010) meta-analysis,
for example, cites fifty studies, all of which come from
either the United States, Canada, Finland, or Switzer-
land, all remarkably different contexts to the African
countries for whom alcohol taxation is being pushed.
4. At the time of research £1 DPula 10, $1 DPula 6.25.
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CLARE HERRICK is a Senior Lecturer in the Department
of Geography, King’s College London, Strand, London
WC2R 2LS, UK. E-mail: Clare.herrick@kcl.ac.uk. Her
research interests include critical approaches to global
health and the governance of the behavioral risk factors for
noncommunicable disease in urban contexts.
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