In recent years, Sri Lanka’s scientific and medical community has become increasingly involved in the study of an epidemic of chronic kidney failure among paddy farmers.^[1] A hospital nephrologist first discovered the disease in the early 1990s, after which the number of identified cases as well as deaths from kidney failure began to spiral. While estimates of disease burden and fatality vary, as many as 35,000 people in Sri Lanka’s North-Central Province may have succumbed, and up to 200,000 may be suffering from progressive kidney damage. The epidemic has garnered attention not just because of its sheer scale, but because researchers have yet to identify the cause of the disease – leading the WHO to label it Chronic Kidney Disease of Unknown Aetiology (CKDu). Over the decades since, at least 35 separate causal hypotheses have been proposed, only around half of which have been (inconclusively) tested. ‘Just when you think you’ve found a theory that fits all the facts, up pops something that ruins the whole argument!’ an NGO volunteer working on the problem recently told me. But reading even this as being progress of a kind, the island’s leading nephrologist and member of Sri Lanka’s CKDu Presidential Taskforce, proclaimed in a public meeting in May 2016: ‘it is no longer accurate to say CKD of unknown origin, we should now say CKD of uncertain origin.’ I suspect that most in the room, and the speaker himself, took the subtle change in name to mean that all of the available theories amounted to something, in the sense that at least one of them, or a combination of them, had to be right.

Limor Samimian-Darash and Paul Rabinow, editors of a book called Modes of Uncertainty: Anthropological Cases (2015), might disagree with this view. For them, the shift from ‘unknown’ to ‘uncertain’ would not be taken to mean a small reduction of risk for people living in affected areas achieved by an incremental advance in knowledge concerning the disease. Instead, Samimian-Darash and Rabinow would view the shift to uncertainty as the opening up of a new conceptual space through which members of the Presidential CKDu Taskforce might now study and manage the disease. Samimian-Darash and Rabinow argue that we live in an age when the dangers we face are increasingly unfit for traditional risk analysis, simply because many such dangers exist beyond the scope of quantifiable measurement. CKDu is a very good case in point. Despite its epidemic nature and the plethora of studies testing different theories, ‘no one has found the culprit’ as CKDu researchers like to say. Mostly trained in the health sciences, members of the CKDu research community often invoke the example of Dr John Snow – a nineteenth century British physician who is something of a hero in public health circles. Dr Snow, they point out, had been able to identify the cause and source of a cholera outbreak in Victorian London through the spatial analysis of public health records, which led him to a water pump in Soho. Switching off the pump ended the epidemic and proved, once and for all, that cholera was caused by a water-born contaminate. By championing what became the leading method of public health investigation ever since, Dr Snow demonstrated that by narrowing down the range of possible causes one would eventually arrive at the culprit – a method advocated too, of course, by Snow’s contemporary, Sherlock Holmes: ‘When you have eliminated the impossible, whatever remains, however improbable, must be the truth.’

Yet for Samimian-Darash and Rabinow, uncertainty is not simply a transitional zone between ignorance and knowledge – a blight on the Enlightenment promise of progress or one of Holmes’s stumbling blocks on the path to solving a case. For them, uncertainty is a new way of knowing, and one that brings in turn new ways of acting. ‘We make the case,’ they write, ‘that scholars should not only focus solely on the appearance of new risks and dangers in the world, which no doubt abound, but should also treat uncertainty itself as a problem and examine the forms of governing and experience that are emerging in relation to it’ (p.1). The central claim that Samimian-Darash and Rabinow make is this: if what anthropologists and sociologists have called ‘risk’ was defined as a negative state, in the sense that risk was a problem to be curtailed or controlled somehow, uncertainty should be understood as a positive state, because it allows us to react to the future before it is known or meaningfully predicted. For example, they summarise Mary Douglas’s path-breaking work on the subject (e.g. Douglas & Wildavsky 1982; Douglas 1966; Douglas 1992) as concerned with how cultures select only certain kinds of danger and risk and then try to establish certainty in the face of future ambiguities by attaching taboo or blame (p.2). They also summarise the work by Ulrich Beck and Anthony Giddens on risk (e.g. Beck 1992; Giddens 1990) as a project concerned with how ‘real’ risks in the world come about and are managed as various attempts to reduce dangers in the future (p.2).

Samimian-Darash and Rabinow mark out their own contribution as being distinct from those earlier approaches by how they understand ‘risk and uncertainty as concepts rather than as things in the world, through which certain knowledge and practices circulate and are made available’ (p.3). Uncertainty is not, then, the hesitation we might feel when asked to decide in the face of conflicting accounts or incomplete information, but a kind of anti-hesitation that makes decisions about the future possible. If risk is to be avoided, uncertainty is to be embraced. Samimian-Darash elaborated more clearly on what is meant by this in an earlier work, not reproduced in Modes of Uncertainty, where she explores Israel’s response to the threat of pandemic flu (Samimian-Darash 2013). Samimian-Darash calls the forms of preparedness designed by the Israeli state ‘technologies of uncertainty.’ That is, strategies of preparing for emergency before much or anything at all of the emergency is yet known, and through which risk is not reduced or assumed to be incalculable, but instead through which uncertainty is retained as a key hallmark of the possible response (ibid.).

Using a method adopted by Rabinow in most of his previous work, Modes of Uncertainty thus calls for the problematization of uncertainty. Foucault (1994, 670; quoted in Collier et al., 2004: 3) argued that problematization is an interesting analytical method because it reveals ‘the ensemble of discursive and non-discursive practices that make something enter into the play of true and false and constitute it as an object of thought.’ Thus, Samimian-Darash and Rabinow are less interested in questions of what is uncertain and whether things are less certain now than they were before, than they are in how uncertainty came to be deployed as a concept that seems to have explanatory power today but perhaps did not before. As Samimian-Darash and Rabinow put it, ‘We ask how observations about uncertainty come to circulate in the contemporary world, constituting a new problematic field for which certain policies emerge as solutions’ (p.3). To that end, Modes of Uncertainty is divided into three sections – ‘Economics and Entrepreneurialism,’ ‘Security and Humanitarianism,’ and ‘Environment and Health’ – each containing three to four contributed chapters that deal with specific examples of contemporary uncertainty governance. These are book-ended by a brief introduction and even briefer afterword by the editors, in which they develop their theory of uncertainty.

Part 1, which deals with the world of economics and entrepreneurialism, offers case studies of how uncertainty in global financial markets is utilised. Given that risk management has always been most elaborated in this field, but given also not just the rise of speculative trading but the recent spate of localised market crashes caused by ‘rogue’ trading, it is here that the argument concerning uncertainty’s desirability – and dangers – is most clearly developed. The chapters in this section do have much in common with other recent anthropology in this field, most notably Arjun Appadurai’s (2013) writings on financial futures, especially in how all share a concern to describe how uncertainty itself is a means of profit and financialisation processes are extending logics of uncertainty far beyond their traditional zones of operation. But if Appadurai remains content with a theory of uncertainty derived largely from Beck’s (1992) notion of the risk society, the three chapters offered here chart a path closer to that envisaged by Samimian-Darash and Rabinow. That said, the three chapters, by focusing on urban centres and urban elites, lack Appadurai’s concern to describe new subjectivities of uncertainty at the bottom of the pyramid – a criticism that can also be applied to much of the rest of the book and to which I return more fully below.

In Chapter 1, ‘Uncertainty Makes Us Free: Insurance and Liberal Rationality,’ Pat O’Malley draws from Peter L. Bernstein’s contention that risk is a ‘prison’ that traps action in a never-ending spiral of doubt, and John Maynard Keynes’ celebration of ‘uncertain knowledge’ as a space, created by not knowing, that releases action, imagination, and invention. O’Malley argues that insurance policy in Britain has always struggled to manage risk and uncertainty that seemingly move in opposite directions, yet through their relationship have created what the author calls British liberalism – the freedom to contract, unconstrained by risk. This theme is returned to in Chapter 3: ‘The Gaming of Chance: Online Poker Software and the Potentialization of Uncertainty,’ by Natasha Dow Schüll. To my mind the standout contribution to the volume, Schüll’s paper draws us into the glamorous, dystopian, fast-paced, high-stakes world of professional and semi-professional online poker players who thanks to their technical dexterity can operate across dozens of tables at once. To do so they run software designed to give them real-time information (as well as end of game debriefs) on how they are playing, how other players are playing, and to give nods on when to step up the game or when to bow out. Yet the software is not designed or able to reduce risk of loss or chance of winning per se, but instead to enhance uncertainty, in the sense of enhancing anti-hesitation. Gamers seek to meld with their software and tables, and attune to the perpetual uncertainty of online poker to achieve an almost transcendental state (my phrasing) defined by uncertainty. Thus the software is considered legitimate and fair to use, and becomes in a very important sense part of gamers’ habitus as they rapidly navigate across multiple simultaneous games that no ordinary uncertain player could cope with.

Part 2, which deals with security and humanitarianism, shifts the focus to the kinds of post-9/11 techniques and technologies that Collier, Lakoff, and Rabinow (Collier et al. 2004; Collier & Lakoff 2008) have previously called ‘distributed preparedness.’ In a world where the threat of attack or emergency is no longer thought of in terms of ‘if’ but ‘when,’ the four chapters in this section document new forms of policing and imprisonment (chapters 4 and 5), mental health treatment (chapter 6), and avian flu planning (chapter 7) that accept uncertainty and try to work with it. I am less convinced that the concepts of risk and uncertainty used in these chapters are so different from those that characterised Douglas’s and Beck’s understandings. Chapter 4, ‘Policing Uncertainty: On Suspicious Activity Reporting’ by Meg Stalcup, and Chapter 5, ‘Guantánamo’s Catch-22: The Uncertain Interrogation Subject’ by Rebecca Lemov, especially seem to me to deal with old-fashioned risk assessment problems in law and order. Samimian-Darash and Rabinow’s thesis works best in chapter 7, ‘The Malicious and the Uncertain: Biosecurity, Self-Justification, and the Arts of Living’ by Gaymon Bennett. Bennett explores medical research tasked with the job identifying possible future pandemics through the study of current biological strains that could, through change and circumstance, herald new outbreaks. Here, we find uncertainty not as a kind of anti-hesitation to be embraced for high-risk/high-gain games of profit and loss, but as a principle but incalculable variable to be worked with in its own right.

Part 3, which deals with environment and health, explores the uncertainties that abound in our understanding of global and environmental public health issues. With humankind ‘officially’ now recognised as a geological force, extreme weather events on the rise, and climate tipping points almost reached, the relative certainty afforded by the Holocene, upon which our societies and economies are built, is giving way to a future of considerable unknowns. This is the subject addressed in chapter 8, ‘What Is a Horizon? Navigating Thresholds in Climate Change Uncertainty,’ by Adriana Petryna. The thrust of Petryna’s chapter is the observation that future, lethal climate events are likely to be characterised by what she calls ‘blindsidedness’; that is, events emerging from the unseen and unknown and which leave little or no time for disaster response. Akin, then, to the kind of future planning for uncertainty that pandemics call for, planning for the uncertainty of climate change requires a reorientation of vision. Petryna calls this vision a ‘horizon,’ which, depending on quite where it is placed, accommodates some kinds of futures but excludes others. She argues that because the drawing of a horizon is necessarily an act which borrows time, in the sense that the act may be able to respond to some, but never all, risks, horizons ‘become tools of optimization…within apparently incoherent earth systems’ (p.150).

Individually, the editors’ introduction/afterword and contributors’ separate chapters are compelling, and sometimes riveting. The writing is bold and, for a collection of this kind, refreshingly clear. The range of disciplinary approaches included – not just anthropology, despite the volume’s subtitle – introduced an unexpected but welcome interdisciplinarity to the book. But I was left wanting more. Partly I think this was due to the brevity of the editors’ own contribution, which claimed much but offered little; I could not help thinking their chapters had been put together in something of a rush. When trying to make sense of the editors’ suggestive arguments by transporting them into the studies provided, it turned out that few went so far in their own development of a theory of uncertainty as the editors’ had tried to do, and of those that did, the most convincing were the papers found in Part 1. Thus, the argument worked best in those places at the forefront of contemporary developments in economy and society, especially the chapters on market gaming, pandemic preparedness, and environmental change. The argument was weaker in those chapters that dealt with crime and poverty. Taken together with the volume’s predominance of contributions focused on urban, elite populations, the old criticism levelled against much writing in the Foucauldian tradition seems as equally to apply here: just how relevant is all of this to the rest of the world?

If the main claim of Modes of Uncertainty is that if risk is negative, uncertainty is positive, this upending of accepted wisdom on danger and risk had been pre-empted long before. Mary Douglas made exactly this kind of argument about the nature of dirt and its role in the creation of the future. She wrote: ‘Eliminating…[dirt]…is not a negative movement, but a positive effort to organise the environment…There is nothing fearful or unreasoning in our dirt avoidance: it is a creative movement, an attempt to relate form to function, to make unity of experience’ (Douglas 1966, p.3). Although it could be countered that this might be all very well but Douglas lacked a theory of governance to make sense of that claim beyond her grid/group theory of culture, to do so would be disingenuous. However Douglas herself used her insight, she was cognizant of the wider scope of danger and risk beyond threat and control. If Samimian-Darash and Rabinow are to demonstrate the validity of their argument beyond those contexts where I have shown it works best – i.e. that uncertainty really is something that anthropologists in general should be problematizing – then they need to offer us something that Douglas had offered us when she argued that dirt was only matter out of place. That is, a theory so compelling in its simplicity and implications that it enters the cannons of anthropological certainty because it truly helps us to understand ethnography from anywhere.

In the final part of this review, I return to my opening vignette to explore what uncertainty could mean beyond Samimian-Darash and Rabinow’s urban elite. To do so, I seek a way of making greater use of Samimian-Darash and Rabinow’s argument through a dialogue with Mary Douglas, and return to my opening discussion of CKDu in Sri Lanka. To recall, Douglas’s Purity and Danger was only partly about avoidance and the elimination of ambiguity – that is, uncertainty as a negative. It was also a study of how ambiguity is essential to the generation of shared meaning – that is, uncertainty as a positive. Just as uncertainty for Samimian-Darash and Rabinow encourages a kind of anti-hesitation, danger/risk for Douglas encouraged a kind of anti-avoidance. Dirt was fundamentally not something to be avoided in its entirety, as it was precisely engagement with dirt that allowed the chancers and gamers of ‘primitive society’ to derive ritual power. With reference to the workings of contemporary power, Esposito (2011) makes exactly this kind of argument in his heavily biopolitical analysis of the ‘immunity’ trope as a fundamental form of modern governance, wherein exposure to contamination at the centre of the social immunises the rest. But that Douglas could make this argument decades earlier is I think indicative of an approach to uncertainty that is much more low-tech and, dare I say, ethnographically familiar than the view offered by Samimian-Darash and Rabinow.

Barrett’s (2008) study of Aghori renunciates in the holy Indian city of Banaras demonstrates what I mean with wonderful clarity. The low caste, Hindu Aghor sect has created a niche for itself as social and health welfare workers catering for patients and clients with diseases that produce revolt and avoidance in others. The Aghori are thus famed for their explicit consumption of ritually and biologically polluting substances – human flesh, faeces, ashes – in comparison to which the touch of a leper would be tame. Thus, the Aghori are both feared and respected by ordinary Hindus from whom deference and respect grows even though the Aghori are themselves hugely defiled. Barrett argues that the Aghori deal with this pollution in two ways, each of which resembles how the holy Ganga and the city itself deal with defilement. The first takes the form of a ‘transportive’ schema, through which the dynamic properties of water and ritual cleansing carry pollution away. This can be understood as a model of purification that seeks to externalise risk, where risk is seen as a problem. The second takes the form of a ‘transformative’ schema, though which internalisation of pollution operates as a purifying act. This can be understood as a model of purification that embraces risk, where risk is seen as a potential (ibid.: p.41-48).

I take the Aghori case as an example of people trying to make sense of danger, risk, and uncertainty in a way that encompasses both Douglas’ and Samimian-Darash and Rabinow’s understandings of those terms. In the Aghori’s orientation, we find something of the traditional shaman and the contemporary online poker player. Aghori explicitly play with the ambiguities of pollution not simply to rid others of pollution but so they themselves can achieve a transcendental state that is defined by ritual and welfare uncertainty. They rid themselves of risk (the transportive schema) just when they embrace risk (the transformative schema). It would be pushing Barrett’s ethnography too far to suggest that the Aghori, through their embracing of uncertainty, are ‘gaming karma’ in the same way that Schüll’s informants are ‘gaming chance’ through their own embracing of uncertainty. But I do propose that both communities are perfectly content to establish their niche specialisms in the world of uncertainty, and have strategies available to make life there not only tolerable but also desirable. Online poker players do so by using technologies of uncertainty like software that reads game movements across multiple tables; Aghori healers do so by using technologies of uncertainty like Ganges water and sacrificial fire.

The same pivot on a rejection and embracing of uncertainty characterises the Sri Lankan medical community’s response to CKDu. Our nephrologist introduced above expressed such a move when he called for the ‘u’ to shift from ‘unknown’ to ‘uncertain.’ After this proclamation, he went on:

If we don’t know then we can’t do anything. But if we are only uncertain, we have the obligation to do something. We have all of these theories. At least one of them, or some of them combined, must be right. We can, say, take this idea of water pollution [by far the most popular theory for CKDu in Sri Lanka] and then provide clean water. By doing that we might see a decrease in the number of cases. We can also try to get these farmers to drink more water in the fields [another theory is that CKDu is caused by growing heat stress among agricultural workers exposed to the effects of global warming].

The professor’s call to action was premised on the notion that uncertainty is not a barrier to act – as unknowing had been – but an opportunity to act. A raft of interventions – speculated to be remedial but far from proven – were subsequently offered up as things the Taskforce could be doing. These included the provision of clean drinking water to those residing in affected areas, information campaigns to warn against chronic dehydration, alcohol and drug use, and the consumption of sugary tea in the sun, and so on, and on. If Dr Snow found the solution to the cholera outbreak via the scientific method of the elimination of uncertainty, CKDu has proved resistant to definition precisely because it accumulates uncertainty. Yet through the accumulation, too, of some high- and low-tech technologies of uncertainty, uncertainty itself became a place to reside. Nowhere had this become clearer than in the diagnosis of CKDu, which is not really a diagnosis at all but a kind of anti-diagnosis. To have CKDu means to have certain kinds of renal failure for which the doctor cannot identify any of the traditional causes (diabetes, hypertension, overmedication, snake bite…). If the doctor is uncertain as to the presence of any of these, she will diagnose a patient with CKDu. In clinical terms, this is simply to say the doctor can make no determination of cause. But in Sri Lanka in 2016, CKDu had become a disease in its own right, the clinical feature of which was uncertainty. A diagnosis of uncertainty offered patients the chance to access social and economic support mechanisms that other chronic but identified diseases did not.

In this brief engagement with some of the ethnography of health and disease in Sri Lanka and India respectively, I have tried to show two things. The first is the complementarity that exists between Samimian-Darash and Rabinow’s theory and Douglas’ theory, not the displacement of the latter by the former. The second has been the value of exploring uncertainty far from the urban elite contexts that are predominate in Modes of Uncertainty. The result has also been two-fold. The first has been to argue that Modes of Uncertainty offers another reason not to consign Purity and Danger to history, a book which given the pollution crises we currently face as a planet retains an ability to illuminate anthropological understanding. The second, then, is the ground gained by also treating uncertainty as a concept rather than historical fact. The potential of Modes of Uncertainty does require some hard work on the part of the reader who is not prepared to simply assume Samimian-Darash and Rabinow must be right when they claim they are on to something by problematizing uncertainty. But it is worthwhile to make the effort.

References

Appadurai, A., 2013. The Future as Cultural Fact: Essays on the Global Condition, London: Verso.

Barrett, R., 2008. Aghor Medicine: Pollution, Death, and Healing in Northern India, Berkeley and Los Angeles, California: University of California Press.

Beck, U., 1992. Risk Society: Towards a New Modernity, London: Sage Publications.

Collier, S.J. & Lakoff, A., 2008. Distributed preparedness: the spatial logic of domestic security in the United States. Environment and Planning D: Society and Space, 26(1), pp.7–28. Available at: http://epd.sagepub.com/lookup/doi/10.1068/d446t.

Collier, S.J., Lakoff, A. & Rabinow, P., 2004. Biosecurity: Towards an anthropology of the contemporary. Anthropology Today, 20(5), pp.3–7. Available at: http://doi.wiley.com/10.1111/j.0268-540X.2004.00292.x.

Douglas, M., 1966. Purity and Danger: An Analysis of Concepts of Pollution and Taboo, London: Routledge.

Douglas, M., 1992. Risk and Blame: Essays in Cultural Theory, London & New York: Routledge.

Douglas, M. & Wildavsky, A., 1982. Risk and Culture: An Essay on the Selection of Technological and Environmental Dangers, Berkeley, Los Angeles, London: University of California Press.

Esposito, R., 2011. Immunitas: The Protection and Negation of Life, Cambridge: Polity Press.

Giddens, A., 1990. The Consequences of Modernity, Stamford: Stamford University Press.

Samimian-Darash, L., 2013. Governing Future Potential Biothreats. Current Anthropology, 54(1), pp.1–22. Available at: http://www.journals.uchicago.edu/doi/10.1086/669114.

1. ^[1]Research used in this article was supported by a Wellcome Trust Society and Ethics Research Fellowship (WT101561MA).↩