On the Inequality of Lives
Inaugural Lecture delivered at the Collège de France on Thursday 16 January 2020
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1Mr Administrator,
Dear colleagues,
Dear friends,
Ladies and gentlemen,
2“It is of man I am to speak […]. I shall therefore defend with confidence the cause of mankind before the sages, who invite me to stand up in its defense; and I shall think myself happy, if I can but behave in a manner not unworthy of my subject and of my judges.” It is with these words that Jean-Jacques Rousseau opens his 1754 Discourse on the Origin and Foundations of Inequality among Men1. Admittedly, the Académie de Dijon, whose question he was answering, is not the Collège de France – an institution that was already over 200 years old at the time. Yet I address you this evening on the same theme and with a similar intention, although I will replace the word man with the term human being and, more importantly, I will base my talk on premises that are contrary to those of the Genevan philosopher, whose argument continues as follows: “I conceive two species of inequality among men; one which I call natural, or physical inequality, because it is established by nature, and consists in the difference of age, health, bodily strength, and the qualities of the mind, or of the soul; the other which may be termed moral, or political inequality, because it depends on a kind of convention, and […] consists in the different privileges, which some men enjoy, to the prejudice of others, such as that of being richer, more honored, more powerful”. There can be no “essential connection” between these two inequalities, he argued, “as it would be asking, in other words, if those who command are necessarily better men than those who obey”. In the eighteenth century, of course, the notion of what we now call “social health inequalities” did not yet exist.
3The idea that the place and environment in which individuals are born influence their physical and psychological state, exposure to illness, and probable age of death could emerge only after a process that Ian Hacking, who held the Chair of Philosophy and History of Scientific Concepts at the Collège de France, calls “the taming of chance”, a process through which, from the late eighteenth century onwards, the determinism of the “universal laws of nature” gradually made way to the “statistical laws of society”, expected to account for both the regularity and the variability of supposedly natural phenomena2. All scientific fields were concerned, from medicine to economics, from suicide to crime, through a combination of various factors: the emergence of the concept of population, the expansion of data collection, the development of political arithmetic, and the refinement of probabilistic reasoning, a result of the work of Condorcet, Quetelet, Poisson, and others.
4A major discovery was that the average lifespan depends on social circumstances. A noteworthy event in this history was Louis-René Villermé’s 1830 survey “De la mortalité dans les divers quartiers de la ville de Paris” (“On mortality in the various districts of Paris”). It contradicted the Neo-Hippocratic theories which had prevailed for more than a century, holding that physical and human environment – that is, insalubriousness and over-crowding – were the cause for spatial differences in mortality. Having noted significant differences in deaths per capita ratios in the city’s various districts, Villermé ingeniously drew on diverse sources, including tax data, to show that these differences reflected neither the sanitary conditions nor the urban density of a district, but instead corresponded almost exactly to the proportion of untaxed residences. The higher the rate of tax exemption – in other words, the poorer the population – the higher the death rate. Citing other contemporary studies, notably those of Louis-François Benoiston de Châteauneuf, he could thus conclude, after a long demonstration, that “[despite all that is said in the world], the health of the poor is always precarious, their size less developed and their mortality excessive, compared to the development of the body, the health and the mortality of people enjoying better fortune”3. In light of this burgeoning ensemble of research that quantified both the social and the medical characteristics of individuals, differences in life circumstances began to be understood not as more or less randomly distributed natural phenomena, but as social inequalities that obey statistical laws and reflect injustices.
5This evolution resulted not only from changes in thinking and science; it also stemmed from the context of the industrial revolution, with the rise of pauperism and a new awareness of the social question. The discovery of disparities with regard to death thus coincided with an increase in inequalities in life. One no longer spoke of the poor alone, now there was interest in the laboring classes as a whole, which were also destitute classes, and Louis Chevalier, for whom the Chair of Social History and Structure of the City of Paris was created, described their appalling condition as being “exacerbated during the worst crises, and as driving to hunger, sickness and death almost half of the population of Paris, that is to say, nearly all of the laboring population, although it remained prevalent in normal times and never dropped much below a quarter of the total population”4. While workers were thus depicted as victims of unbridled urbanization and mortiferous capitalism resulting in very high infant mortality rates, they were also perceived as being themselves the cause of their tragic situation by way of their depraved morals as alcoholic men, promiscuous women and neglectful parents. The fact is that, then and now, social reforms have seldom been devoid of moral judgements. The solutions put forward by scholars and the responses provided by governments often endorse paternalistic or liberal approaches, such as those of Frédéric Le Play or Alexis de Tocqueville respectively, rather than the scientific socialism that developed in parallel.
6Thus, between the time when Rousseau wrote his Second Discourse, shortly before the fall of the Ancien Régime, and Villermé’s survey on the eve of the July Revolution, a cognitive shift occurred in the understanding of the workings of society, whereby the consequences of social inequalities on the length and quality of human lives had been acknowledged. This shift was part of the rise of a new form of governmentality, which Michel Foucault described as the “birth of biopolitics” – the title of his 1978 course. Biopolitics, a concept of considerable influence in the social sciences and humanities, which operates as a means of population regulation, reflects the substitution of sovereignty, the old right “to take life or let live”, by biopower, “a power to foster life or disallow it to the point of death” as, “for the first time in history, no doubt, biological existence was reflected in political existence; the fact of living was no longer an inaccessible substrate that only emerged from time to time, amid the randomness of death and its fatality; part of it passed into knowledge’s field of control and power’s sphere of intervention” 5. Biopolitics is an association of new areas of knowledge on the population, with public hygiene, demography, epidemiology, economics, sociology, and new mechanisms to act on it, by means of family planning, health education, social policies, and immigration control. It thus outlines “a power whose highest function” has been “to control life completely”. Public health, the subject of the Chair which you have afforded me the honor of holding, is at the interface between this new knowledge and these new actions. According to Charles-Edward Winslow’s classic 1920 definition, it is “the science and the art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts”, which includes a goal “to ensure to every individual in the community a standard of living adequate for the maintenance of health”6. This project, both science and art, thus supposes the existence of forms of expertise and modes of intervention that were developed from the nineteenth century onwards, no longer at the individual level but on a collective scale.
7Even though there is room for debate on the chronology of what the holder of the Chair of the History of Systems of Thought called “biopolitics” – which I have shown to have already taken relatively sophisticated forms in contexts as remote as the Roman Empire at the beginning of our era and the Inca Empire in the fifteenth century –, the fact remains that the invention of this concept was a fruitful insight. By historicizing our understanding of the relationship between the social world and biological life, it shed new light on it7. This makes the fact that Foucault’s analysis of this relationship totally overlooked the question of disparities in lives all the more noteworthy, as they are at the very heart of the phenomenon he was analyzing. The word inequality does not feature in the thematic index of the three thousand plus pages of Dits et écrits; it did not exist in his intellectual lexicon. This should probably be interpreted in light of his refusal to adopt any normative posture. Injustice was addressed in his political engagements, not in his theorical work. His genealogical investigations, a legacy from Nietzsche, aimed not to change the world but instead to invite us to change our way of looking at it.
8The traditional division of intellectual labor tends moreover to assign inequality studies to scientific disciplines which rely on quantitative techniques, such as demography, epidemiology, and sociology, as it is generally assumed that disparities are objectified by statistical and probabilistic analysis. Thus, in his complementary doctoral thesis, Maurice Halbwachs – who would know one of the most tragic fates of all Collège de France professors as, after being elected in May 1944, he was arrested by the Gestapo in July and died in Buchenwald the following year – drew on a mathematical discussion to theorize differences in mortality, as a counter argument to Adolphe Quetelet’s idea of the average man. He wrote that variations in mortality according to occupation or income showed that, far from being only a fatal occurrence, “death, and the age at which it occurs, results above all from life, from the conditions in which it took place”, which are “at least as social as they are physical”. But his analysis goes further than a merely structural reading of disparities; it sets inequalities on a dual, political and moral, foundation. For him, “the essential cause” of these variations in mortality lies in variations in “the importance attributed to human life”, and “there are many reasons to believe that a society generally has the mortality that suits it, that the number of deaths and their distribution at different ages expresses the importance that a society attaches to prolonging life”8. He reached the same conclusion when looking at the distribution of deaths according to socio-professional category, level of wealth, and gender. In short, a mortality rate reflects the value that society places on human life in general and, more specifically, on lives in the various groups constituting it.
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9But how can this value be fully understood? There are two main approaches. The first is ethical, and considers life to be a priceless good, yet not precluding differential treatment in practice. The second is economic, and, on the contrary, places a price on life, which usually comes with disparities. Although the use of these words is not necessarily rigorous, scholars tend to distinguish the two approaches by speaking of value in the first case and worth in the second.
10Thus, on the one hand, the absolute value of life is an ethical pillar of many religions and philosophies. In Christian dogma, for instance, life is sacred. As an incommensurably superior good, it cannot be quantified, and even less so hierarchized. This explains the Catholic Church’s resistance to monetary compensation for murders in the High Middle Ages in Europe, as studied by Georg Simmel9, and Protestant churches’ opposition to the creation of life insurance in the United States in the nineteenth century, as shown by Viviana Zelizer10. Yet invocations of this absolute value in discourse did not keep it from being negated in practice, first with regard to Muslims during the Crusades and Jews during the Reconquista, and later with regard to Native American peoples and Black slaves. Philosophers likewise also see life as an absolute value, generally considering it to be a natural right. Many nonetheless submit it to comparative tests in the form of thought experiments. In 1797, William Godwin proposed the princeps case, in which he argued that, in accordance with utilitarian logic, assuming François Fénelon and his servant were caught in a fire from which only one of them could be saved, his duty would be to draw the author of Telemachus from the flames because of his intellectual contribution to the world, even if the servant in question was his mother or wife11. In recent decades, analytical philosophers have produced countless more or less similar scenarios in which one would have to save one or several individuals from drowning or from a trolley accident, as imagined by Philippa Foot, in order to test the principles underpinning judgement in moral dilemmas12. In fact, these tragic choices often involve the establishment of differences in the evaluation of human lives.
11On the other hand, the relative worth of lives is a product of economic analysis that judges employ to determine the compensation which may be due for damages, and that policy makers resort to when choosing between several options in the face of known risks. These two situations differ, since compensation for damages involves assessing a loss of profit due to a death that has already occurred, and thus calculating a concrete value, whereas risk involves assessing the probability that a death will occur, and thus calculating an abstract value. In the case of compensation for damages, it is the value of the lost life that is estimated. This is done by means of an actuarial valuation using what economists call “human capital”, measured in terms of what the deceased person would have contributed to their family in terms of salary and life expectancy, to which is sometimes added the moral injury suffered13. Such compensation is not granted in all instances of fatal events; victims of the 1995 Oklahoma City bombing did not receive it while those of the 9/11 attacks did, and the civilians killed during the Vietnam War did not receive any compensation, while those killed during the war in Iraq did. Moreover, the calculation method creates considerable differences in the sums paid out; for example, there was a compensation ratio of one to eight among 9/11 victims, depending on their occupation and gender, and of one to two hundred in Iraq, depending on whether they were national civilians or US soldiers. In the case of risk prevention, it is the statistical value of a life that is estimated. The procedure most commonly used by economists, based on the principle of cost-benefit analysis, aims to assess the price that society is willing to pay to save a life by implementing a project or policy14. This allows for comparisons to be drawn, even between different areas such as environment and transportation; for instance, between the introduction of bonuses for low-emission vehicles and the construction of traffic barriers on a road. However, this statistical calculation of a life’s worth does not account for differences in the willingness to pay according to socio-professional categories. These are particularly noteworthy in the field of labor, where the most exposed occupations, such as construction work, are also those in which workers have the most precarious legal status and social protection, which de facto devalues their lives.
12The difference between the absolute and relative value of life explains some of the tensions between clinical medicine and public health. The former deals with individuals, with a mission to save or prolong lives, literally at any cost, while the latter deals with populations, with an obligation to choose between strategies with differing cost-benefit ratios. Thomas Schelling provides a striking and barely hypothetical illustration of this difference when he compares the reaction of the public being asked either to finance expensive surgery to extend the life of a little girl until Christmas or to contribute to the rehabilitation of Massachusetts hospitals through a special tax in order to reduce the number of preventable deaths15. He concludes that in the first case donations would most probably flood in, whereas in the second the appeal would meet with nothing but resistance. This gap between the two logics was un-hypothetically exemplified by international responses to the AIDS epidemic on the African continent in the 2000s. Clinical medical practitioners, who wanted to use new antiretroviral drugs to treat their patients, often clashed with public health experts whose surveys showed that, given limited resources, prevention through condoms and safer sex education was less costly and more effective than treatment. This antagonism should however not be blown out of proportion. Indeed, clinicians sometimes found themselves in situations where they had to choose which patients to medicate, following a procedure known as triage, a term inherited from ancient French, while public health experts eventually recognized the role of drugs in reducing viral transmission.
13Yet, do the ethical approach, which gives life an absolute value, and the economic approach, which gives it a relative worth, enable us to grasp what Georges Canguilhem calls the “value judgement expressed in the abstract number which is the average human lifespan” – a value judgement that becomes even more salient if, instead of considering a population as a whole, we try to differentiate it according to social variables?16 This is doubtful. When it comes to the value of life, religions have an ideal conception, and philosophies a normative interpretation, neither of which says much about how societies actually treat human beings. Likewise, the worth of life, as produced by actuarial analyses for the calculation of compensations or by cost-benefit studies for policy choices, cannot be used to further our understanding of disparities in what is now called “life expectancy”.
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14We therefore need to take another approach if we are to link Halbwachs’ idea of the importance society places on human life, or Canguilhem’s idea of a value judgement on human life, to the theoretical average life span of a population. We can begin by acknowledging that this connection has some obvious limitations. If life expectancy is 53 years in the Central African Republic, compared with 84 years in Japan, the thirty-one-year difference between these two countries cannot be attributed solely to the difference in the way they value their inhabitants’ lives17. Problems of poverty, hygiene and sanitation, endemic malaria and other parasitic diseases, epidemics of AIDS and other infections, weak health structures and the situation of latent civil war account for Central Africans’s low life expectancy, which is largely due to a high childhood mortality rate.
15While international comparisons should therefore be interpreted with caution and in context, studies of disparities within a given society are far more illuminating. In France, where the first demographic surveys aimed at gaining knowledge on differences in mortality began in the 1960s, it took another two decades until Guy Desplanques’ work revealed their significance18. The probability of death for French men between 35 and 60 years of age is 7.1% for professors, 15.6% for low-level white-collar workers, 18.1% for qualified blue-collar workers and 25.3% for unqualified blue-collar workers. The probability is thus multiplied by a factor of three and a half between the first and last category. Life expectancy at the age of 35 is 43.2 years for professors, 38.5 years for white-collar workers, 37.2 years for qualified blue-collar workers and 34.3 years for manual laborers. The difference between the lowest- and highest-ranking categories is almost nine years. Two noteworthy findings of this study were never refuted in subsequent work: the considerable extent of inequalities in the face of death; and their distribution, which almost perfectly matches the socio-professional hierarchy.
16These gaps have not narrowed over time. The most recent surveys show that, while in four decades men have gained five years of life expectancy at the age of 35 on average, the gaps between them have continued to widen, up to a difference of over six years between workers and managers. Moreover, the former are more often disabled in their remaining years than are the latter, with a four-year gap for mild forms of handicaps and a two-year gap for forms that hinder activity. In sum, workers have ten years less of healthy life than managers19. Notably, most of these studies focused exclusively on socio-professional categories, which for a long time were deemed to be the only variable that could represent disparities in society.
17This approach results however in two partially related issues being overlooked. First, it does not account for people who do not work, even though their numbers have risen sharply with soaring unemployment, and epidemiological surveys show them to be in poorer health than workers. Thus, while the relative inequality index for premature mortality slightly increases over the last quarter of a century when only the employed are considered, it almost doubles over the same period when unemployed people are included. Secondly, actual standards of living are not analyzed, and therefore discounts the impoverishment of lower categories and the enrichment of wealthier ones. If we compare the richest 5% and the poorest 5%, the difference in male life expectancy at birth is 12.7 years20. In measuring inequalities in mortality, it is therefore crucial to include the whole population and take into account the evolution of its economic structure.
18Yet even if these two conditions are met, two blind spots remain, one of which is due to methodological difficulties and the other to obstacles of an ideological and legal nature. On the one hand, as surveys focus only on the people who are accounted for by the national census, data on the most vulnerable, those who are homeless or do not have a residence permit, are rarely available. On the other hand, due in part to qualms expressed around this issue and in part to a restrictive legal context, it is all but impossible to record measurements informed by ethno-racial categories, with the implication that there are virtually no data on the scale of disparities in life expectancy affecting minorities, even though they are known to be particularly exposed to unemployment and poverty.
19Based on existing studies, it therefore appears that inequalities of life expectancy in France are a fairly accurate reflection of the various expressions of social inequality, which has increased sharply since the 1970s due to the hardening of economic practices and cutbacks to social policies, resulting in the precarization of employment and the impoverishment of the working class. Having a higher status and a more stable job, and being richer and better educated not only guarantees a better social situation, greater financial comfort and more favorable living conditions, it also allows for a longer and healthier life.
20The French case is by no means exceptional, although international comparisons indicate that in France the inequalities in mortality among men are the deepest in Western Europe, especially when it comes to cancer, accidents and conditions linked to alcohol and tobacco consumption21. This may actually seem paradoxical, considering that in the year 2000, France was ranked first by the World Health Organization for its health care system, based on a composite indicator22. While the principle and method of such study may arguably be less than ideal, it nevertheless has merit in highlighting the discrepancy between the quality of a health care system and the extent of health disparities. Inequality in life expectancy is primarily the consequence of the accumulation of inequalities in society.
21The most obvious example is probably the United States which, despite having the highest per capita health expenditure in the world by far – more than double that of France – ranks 34th globally, behind Cuba and Chile, in terms of life expectancy. When it comes to infant mortality it ranks 29th, child mortality, 42nd, and maternal mortality, 51st23. In a country where 27 million people, a tenth of the population excluding elderly people, have no health coverage, these poor results reflect the impact of wide disparities which draw national averages down. In a famous study conducted in Harlem in the early 1980s, therefore before the AIDS epidemic, Colin McCord and Harold Freeman showed that Black men had twice the age-adjusted mortality of white Americans and were less likely to live to 65 than were Bangladeshis24. Contrary to what one might have thought, this was not due mainly to homicides and overdoses, but to high mortality from cardiovascular diseases.
22How can we characterize these disparities in the United States today? Looking at the income of the male population, the life expectancy of the richest 1% is 15 years longer than that of the poorest 1%, and in just over a decade, the wealthiest 5% have gained an extra two years on the more disadvantaged 5%25. Looking at the influence of education, white men with a university degree live fourteen years longer than Black men who have not completed high school, while Black men with higher education live four years less than white men with the same education, but seven years longer than white men who did not finish high school26. In other words, income, education and skin color are closely related. Remarkably, a historical reversal has occurred since 2014, with a decline in life expectancy occurring for the first time since the Second World War, due largely to the increased mortality of middle-aged men and women because of suicide, alcoholism and the increased consumption of opioids which, under pressure from large pharmaceutical companies, were liberally prescribed as a treatment for chronic pain27. This decline, affecting all social categories, is a sign of the grave social and moral crisis that country is going through.
23In this respect, one might be tempted to reduce the issue of race to a matter of wealth and education, and assume that Black people live shorter lives precisely because they are poorer and less educated. However, this analysis, which is often used in France to disregard the social inequalities that ethno-racial minorities face, overlooks two fundamental elements. The United States, which abolished slavery only to introduce legal segregation, and where the civil rights movement was followed by a backlash leading to the development of mass incarceration, provides keys to a clearer understanding. First, people of color have shorter lives than white people with the same level of income and education, and several recent epidemiological studies have been able to show the specific role of racial discrimination in health disparities, especially through disenfranchisement and self-depreciation28. Second, to adopt even this common “all other things being equal” reasoning is to deny that all other things are in fact never equal, given the considerable over-representation of Black men in disadvantaged environments and among early school dropouts – a product of a long history that is by far not over in that country29. There is probably much to be learned from this approach to the disparities experienced by minorities for the understanding of inequalities in French society.
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24At this point in the reflection, we need to take a step back. From the inequality of lives, we have imperceptibly shifted towards inequality in the face of death. For what we call life expectancy – a term as elegant as it is misleading – is basically only an abstract measure obtained by drawing a sum of probabilities of dying at different ages, and imagining a hypothetical generation that would be subjected to the mortality conditions of the year in question. But where has life gone? Life expectancy unquestionably informs us about a fact of major relevance, that is, the considerable disparities in longevity that exist in our societies: thirteen years in France, fifteen years in the United States, when comparing the richest to the poorest. But does this single figure hold within it all there is to say about the inequality of life? Two examples suggest that, while it is necessary, this quantification alone is not sufficient.
25Up to now I have discussed only the mortality and life expectancy of men. There is a reason for this: the data on women introduce a disturbing element. In France – and this also holds true in other Western countries – irrespective of their socio-professional category, women have a lower mortality rate than men. Thus, female laborers live longer than male managers, even if the gap between them has narrowed in recent decades. Despite being mostly linked to differences in behavior regarding health risks, such as smoking and drinking, this fact has often been held up as evidence of female privilege. Yet, while female laborers’ life expectancy at 35 is two years longer than that of male managers, their disability-free life expectancy is seven years shorter – a consequence, among other things, of unfavorable working conditions. Their apparent advantage is therefore deceptive. Moreover, and above all, life expectancy does not provide any information on quality of life, whether in terms of autonomy, emancipation, or self-realization. No need to emphasize the extent to which women have been and still are penalized in these respects, in a country where they have only recently obtained the right to vote and to open a bank account, access to contraception and abortion, joint parental authority and equality in the management of family property, and recognition of workplace discrimination, domestic violence and sexual harassment. As Françoise Héritier tirelessly repeated in her work and courses on the masculine and the feminine, in all known human societies, what she calls the “differential valence of the sexes” is the product of hierarchies that operate both in the symbolic realm and in the social world, with the former often serving as a justification for the latter to distribute power unequally30. Consequently, the fact that women live longer than men, in France or elsewhere, tells us nothing about what their lives are like or, more specifically, about what society does with them. In Happening, Annie Ernaux recounts her experience of having an abortion at a time when contraception and abortion were still illegal and when the only option for women who could not afford to travel abroad was therefore illegally hiring an abortionist and risking potentially fatal hemorrhages and infections31. Yet, above and beyond the danger she faced as a result of this procedure, the ordeal the author describes is the shame, contempt and silence surrounding her act.
26One can argue with a somewhat symmetrical logic regarding Black men in the United States, since they live shorter lives than white men. The deaths of African-Americans at the hands of police officers, and in particular that of Eric Garner, who was choked to death during his arrest for selling loose cigarettes, Michael Brown, who was shot several times as he walked down the street, Freddie Gray, who sustained spinal fractures during his arrest following an identity check, twelve-year-old Tamir Rice, who was killed on a playground while carrying a toy gun on his belt, and many others, have revealed how frequent these fatal incidents are. Investigations by journalists, conducted from 2015 onwards, have revealed that law enforcement has caused over a thousand deaths every year, with Black men being twice as likely to die in such circumstances as white men, despite being less likely to carry a weapon. But beyond this grim bookkeeping, what these tragic events have revealed to the public in the United States is the ordinary violence to which African-Americans are subjected: their fear at the sight of police officers and the humiliation they endure in interactions with them; what they learn from childhood, through education and the experience of their rights being denied or flouted; and, more broadly, the existence of what W.E.B. Du Bois called their “double consciousness”, that is, the construction of their own subjectivity through the eyes of others32. This is why it must be understood that the name of the “Black Lives Matter” movement, which has developed in response to these increasingly frequent tragedies, means that the lives of Black people matter not only because they are threatened with destruction, but also, and perhaps even more so, because they are faced with the permanent risk of being depreciated. Toni Morrison’s first novel, The Bluest Eye, draws from a conversation the author had with a childhood friend to tell the story of an eleven-year-old girl who prays every night to someday have blue eyes because, through the contempt of others, she has internalized the image of her supposed ugliness as a Black girl and believes that the eye color she covets, a symbol of white skin, would grant her the beauty she thinks she is deprived of33. The novelist later explained that she had written this book to tell, without pathos, the depth of the intimate pain – seldom articulated as such – of racial discrimination.
27My intention in presenting the situation of women in France and that of minorities in the United States side by side is most certainly not to equate them, as each situation has its own specific implications and workings. Instead, it is an invitation to think of life in the dual form that Hannah Arendt wrote of in her book on the human condition: “the birth and death of human beings are not simple natural occurrences but are related to a world into which single individuals, unique, unexchangeable, and unrepeatable entities, appear and from which they depart”34. There is thus, on the one hand, life that flows from a beginning to an end, as does every living being’s, and, on the other hand, life that constitutes human singularity insofar as it is made of events that can be recounted. We may term them “biological life” and “biographical life”. Life expectancy measures the length of the former; a life story relates the richness of the latter. Only by acknowledging both can the inequality of lives be comprehended. They should be conceived of as being both distinct and connected: distinct, because the paradox of French women shows that a long life is no guarantee of a good life; connected, because the experience of African-American men stands as a reminder that a devalued life is a damaged life.
28This dual distinction and connection is tragically illustrated in the sale of organs, generally kidneys, that can emerge as an extreme solution to ensure economic survival in the underprivileged areas of developing countries, usually at the cost of lasting pain and possible subsequent complications. This has been studied in Egypt, where it usually involves local transactions between poor and wealthy families; in India, where it often goes through organizations which harvest organs for foreign patients; and in sometimes Mafia-like international networks35. Although it is sometimes described as an ordinary marketplace for bio-capital, this trade involves true biological predation, where the most dispossessed have no choice but to sell body parts to feed their families and pay off their debts. The compensation is a spurious biographical accommodation between organ donors and recipients, based on the illusion of an altruistic exchange in which everyone stands to gain.
29The case of the AIDS epidemic, which spread to South Africa in the 1990s and, in barely a decade, made it the worst affected country in the world, with an estimated 5 million HIV-positive people at the time, allows for a better understanding of this complex relationship between biology and biography. Mining areas presented the most alarming situations. An epidemiological study conducted in the world’s largest gold mining complex in the 2000s showed that seroprevalence rates were as high as 28% among the 80,000 miners, 37% among women living in the neighboring township, and 69% among prostitutes in places labelled as “hot spots”36. How can these exceptionally high contamination rates be explained? Historical and ethnographic surveys show that, since the late nineteenth century, mining companies have relied mainly on Black laborers from rural areas, sometimes even from neighboring countries. These miners are housed in large compounds where the establishment of informal bars was facilitated, to fill their leisure time. Over half a million miners thus find themselves separated from their families for long periods of time. They often have extra-marital affairs with poor women from the surrounding area to whom they provide a form of protection, occasionally go to squalid prostitution sites, where “survival sex” is practiced, and sometimes engage in homosexual relations with young colleagues37. In such a context of overwhelming precarity, AIDS prevention is all the more difficult to implement as the extremely harsh conditions of the mine expose workers to a high risk of accidents, leading them to minimize the danger of potentially being infected. It is therefore certainly not irrelevant to speak of a “mode of production” of the epidemic developed by the international mining companies that operate in the country. A similar analysis can be made of the condition of farm laborers working far from home on the large estates that were set up in the first half of the twentieth century following the eviction of Black peasants from their land, and which are now being sold to food multinationals. The “necropolitics” analyzed by Achille Mbembe thus reaches far beyond colonization and apartheid, and even beyond the wars that stain the African continent with blood, into the consequences of aggressive capitalism38. Far from the culturalist interpretations that seek to explain the spread of infection through supposed idiosyncrasies in the sexuality of Black men and women, the political economy of AIDS in South Africa thus provides an understanding of how life in the biographical sense imprints its mark onto life in the biological sense, and how the decay of the former leads to the deterioration of the latter.
30Of course, this relationship is reciprocal, and physical degradation can in turn threaten the very possibility of social existence. This surfaced in many accounts collected in the Black township of Alexandra, in the heart of Johannesburg, where I have often heard people with AIDS describe their condition as the result of a nefarious government plan to get rid of a useless and superfluous population39. No way of phrasing the issue of inequality of life could possibly bear more violence than this genocidal discourse. But it is also expressed less explicitly. One of the young women I met in this neighborhood was suffering from an advanced form of the disease. Despite her emaciated body, the oedema that swelled her face and the skin lesions covering her arms, one could still make out what seemed to have been graceful features. A recluse in the single room of a basement deprived of any sunlight, which had been dug under a tin and wood shack and where she lived with her twelve-year-old daughter, she insisted on telling her story. Raised in Soweto by a mother whose alcoholic excesses, after her father's departure, had often led them to spend nights in the street together, she had been a promising pupil despite her family’s very precarious material conditions. When she was older, her younger brother had been shot dead by police at the age of 20 following a car theft. At that time she lived with the father of her child and learned one day that he had been having an affair with a woman who had just died. This is when she discovered that she herself was ill, but as she did not receive antiretroviral drugs, which were unavailable in public hospitals at the time, her condition swiftly deteriorated. “You see, that’s my life”, she concluded softly. “A life of misery. We suffered so much. And yet I had talent. I liked to write stories when I was a child. I even got a scholarship to study abroad. But there was a fire in my house and all the documents were burned. So I didn't leave. I liked to study. I wanted to become a doctor, because it's beautiful to heal people. I was really talented... Now my life is falling apart.” After she died, I discovered the two pages she had written to tell her story again in the notebook I had given her. They ended with: “This is all I can share with you about my life.” It was a deeply moving testimony of an existence interrupted at the age of 30, but whose insistence on preserving a biographical trace seemed to be a form of resistance to the predicted disappearance of its biological expression.
31Yet, there is more to read in this story. It shows what was, at least for some time, a hope, fueled by encouraging academic results and crystallized around the dream of a medical career: the promise of another possible life. We should thus reconsider the meaning of the term “life expectancy”. Demographers provide a measure of life expectancy which, being based on the probability of dying at each age for the year in which it is calculated, reflects the mark of the past on the biological calendar: a woman dying at the age of fifty carries with her the cumulative total of the past five decades. But it may be up to anthropologists to devise another meaning to it, one that takes both of its words seriously. Life expectancy should then be understood as an expectation, that is, as the projection of a future on the course of an existence. English renders something of this difference, with the distinction between life expectancy and expectation for life. On the one hand, how many years can one expect to live? On the other, what can one expect from life? Moving from the first to the second entails a radical shift of perspective. Discussions on the inequality of lives are no longer only about disparities in their duration, but about the differences between what they actually are and what individuals may expect from them. Here, we are talking no longer about quantity but quality, no longer about longevity, but about dignity.
32Conversely, it is in this sense that Orlando Patterson speaks of social death in relation to slavery40. Whether in the United States, in ancient Greece or in pre-colonial Africa, slaves were torn from their original environment, stripped of their family ties, dispossessed of their birth name, and finally reintroduced into a new social environment where they were alienated from their own destiny and that of their descendants. The same term has been used to describe long prison sentences, especially when, as is common in the United States, they involve prolonged stays in solitary confinement, during which inmates can spend years or even decades in individual disciplinary cells. In this regard, Lisa Guenther wondered how to understand the possibility of a suffering that blurs the distinction between life and death41. And this punishment within a punishment overwhelmingly concerns Black prisoners, who are over-represented not only in the prison system, but even more so in solitary confinement cells. More generally, whether we are talking about forms of exploitation of foreign labor that resemble modern-day slavery in some countries or forms of imprisonment for offenders from poor backgrounds, inequality of life refers not to a period of presence in the world, but to a form of being in the world. It should be conceived of less in terms of a quantity of life – even though mortality in these social categories is often high – than in terms of lives whose very quality is denied.
33This is also how we should frame the issue of refugees and migrants in the contemporary world. There are, of course, the literally countless deaths on the paths between the society whose violence, misery, or simple lack of prospects these forced nomads flee, and the society where they hope to find a better life, for themselves and above all for their children. I say “countless” because, while we know that 17,043 people have died in five years while trying to cross the Mediterranean, according to the International Organization for Migration’s official statistics, we do not know how many have drowned and left no trace except in the memory of potential survivors. And we have no data on deaths that have occurred during journeys that, from the sub-Saharan or Middle Eastern regions to the Mediterranean coasts, and then across Europe, are not even recorded in any way42. Yet these deaths are just as unspeakable, for even the name of those who disappear in this way is often lost, depriving them of receiving the final honor of a burial and of maybe having their death announced to their family, and thus dispossessing them of both their life and their death. A Milanese forensic anthropologist tries to pull them back out of oblivion by identifying the corpses recovered after shipwrecks43. These two aspects of these deaths, both uncountable and unspeakable, are certainly the most explicit marker of the lack of value accorded to certain lives. This is also evidenced on contemporary battlefields such as Iraq, where it is possible to count and identify each deceased coalition soldier, but impossible to tell how many civilians were killed, even to the nearest hundred thousand, let alone name them. In the Mediterranean, what is deadly is not war, but indifference – a proactive indifference which led the European Union to interrupt the Italian sea rescue operation, Mare Nostrum, estimated to have saved tens of thousands of lives in a single year. Today, humanitarian vessels trying to recover shipwrecked people from drifting dinghies are themselves being harassed by European authorities.
34But, beyond the dead, there are those who live, and the conditions imposed on them. In the investigation that I am conducting with Anne-Claire Defossez on the French-Italian border, we are collecting the stories of men and women, many of whom are from sub-Saharan Africa. Most of them were dispossessed of their meager possessions by looters during their journey, spent months in the hands of torturers in informal Libyan prisons, from which they were released only in exchange for ransom, crossed the Mediterranean in appalling conditions, sometimes lost companions to the sea, and spent months confined in camps in Italy until a change in policy forced them to leave. Rejected when they tried to reach France by train, they attempted to cross the Alps without equipment, took dangerous routes to avoid law enforcement, but benefitted, on each side of the border, from the solidarity of volunteers, who were themselves threatened with repression.
35These men and women are now often found in makeshift shelters around Paris and in the north of France. The tents which protect them from the cold and rain are regularly destroyed. City councils sometimes ban charities from distributing meals to them. They are always at risk of identity checks and arrests. When I conducted interviews in what used to be the Calais Jungle, with Syrian students who had fled the war in their country and had sometimes taken a year to make their way across Europe, each of them wanted to show me photos on their mobile phone of their family and their house before both were partially destroyed by the army of the regime44. All of them contrasted their honorable former life with the disgraceful existence in the mud of the wasteland to which they had been relegated, and exhibited the marks of the truncheon blows and dog bites they had endured when, trying to reach the port to cross the Channel, they were pursued by the police.
36From one border to another, these migrants and refugees thus experience the cruel inequality of life. One might think that migrants and refugees, after all, are only occupying marginal spaces – spaces which nevertheless concern almost 70 million people worldwide in terms of the forcibly displaced alone. Yet the way a society treats these margins is what reveals the values it is willing to defend.
*
37Mr. Administrator, dear colleagues, when you appointed me to this Chair, you asked me to set it in the field of public health and I proposed to do so from an anthropological perspective. However, as you would have noticed throughout this lecture, in an effort to grasp the complexity and depth of the inequality of life, I have cited sociologists, historians, economists, politicians, jurists, demographers, epidemiologists, philosophers, and novelists, sometimes through a critical lens. For those are the people, often friends, among whom I have learned and taught social science, successively at the Institut national de la santé et de la recherche médicale, at the University of Paris Nord, at the École des hautes études en sciences sociales, and now at the Institute for Advanced Study, within the School of Social Science – the word science, not insignificantly, being singular. I am indebted to them, just as I am indebted to the hundreds of people who, on three continents, have entrusted me with fragments of their lives and shared moments of them with me. There are indeed never enough resources to understand the world and render our understanding of it. Irrespective of the discipline, understanding is the very substance of scientific work. So is rendering research, for it is essential that this work be extended to broad and multiple audiences. These lectures, the Collège de France’s hallmark, fortunately afford an opportunity to do so.
38So, what about anthropology? Obviously, it has long ceased to be the exotic knowledge that its name still evokes for some. My investigations have taken place in a city in Senegal, among indigenous communities in Ecuador, and in townships in South Africa, but also in France, with an anticrime squad, in a prison, and in two border zones. They have focused on fertility rituals and traditional healers, on programs to assist the poor and on humanitarian operations in conflict zones. Anthropology is defined neither by its fields nor by its objects. As for ethnography, of which anthropology readily claims paternity, it is certainly not unique to it; other disciplines are making increasing use of it, although anthropologists often treat it in a less instrumental and more reflexive way.
39Starting with Claude Lévi-Strauss, the first holder of the Chair of Social Anthropology, many authors have endeavored to define and characterize this discipline45. I will not add anything to their analyses; I am not interested in its nature so much as in the windows it opens onto the world. As Robert Musil wrote, “the man without qualities” does not have a sense of reality, but a sense of possibility46. He is one of these individuals who, “if he is told that something is the way it is, then thinks: Well, it could probably just as easily be some other way”. Not that he neglects the realities of the world, but he is capable of seeing them differently. I believe this is also what anthropologists do, both by inclination and by profession. For having seen it elsewhere, or even just having read about it, they know that what we take for granted is only one of the possible forms of reality. This allows them to look at the world differently. We might call this difference in outlook a critical attitude. Such an attitude does not only have epistemological implications; it also opens political perspectives: if the world can be different, and indeed has been in the past and still is in other places, then change is always possible, which nourishes other hopes.
*
40Surely, as we reach the end of this journey – which has led us from the discovery of social inequalities regarding death to an understanding of the ways they are embedded in bodies, and from measuring disparities in the distribution of mortality to examining inequity in the treatment of lives –, I should justify my choice to explore this theme, a seemingly unusual opening for a course on the anthropology of public health.
41One does not decide what to work on, or what one wishes to present, based solely on intellectual criteria. In addition to scientific reasons, there are often personal reasons too. For we are all heirs to a social world and a family narrative. The only difference may well be between those who recognize this heritage and those who forget or deny it. While conducting fieldwork on the Italian border, I have in mind my paternal grandfather who crossed it to come to work in France just a century ago. Analyzing the disparities in life expectancy, I remember that, after having spent more than five decades on building sites in the Paris region as a journeyman bricklayer, he had finally retired and was living what he liked to call “the happiest year of his life”, when illness swept him away. Today, the escalating repression against migrants, which increasingly undermines their physical and mental state, and the current pension reform, which does not take into account the nearly thirteen-year difference in average longevity between rich and poor, are in a sense updating this memory of the inequality of lives.
42Pointing this out is obviously not where a researcher’s work stops. As was shown with his own biography by Pierre Bourdieu, who held the Chair of Sociology, and whose books introduced me to the social sciences, it is by taking a certain epistemological distance that one can transform an experience into knowledge and a social debt into a scientific work47. The question of inequality surfaced throughout his oeuvre, even though he named it otherwise: reproduction and domination, class and classification struggles. Of this inequality of economic and social capital, expressed in multiple ways, at school and at work, the deepest expression is inequality with regard to life itself. It is more than a major fact integrating many dimensions of social life, for which it offers new understandings. It is also the most elementary fact that characterizes the ethical quality and political ambition of a society. The trends that I have described suggest that both are in crisis in the contemporary world.
43The social sciences offer no easy answers to this crisis. But they can at least have the “courage of the truth”, which Michel Foucault had chosen as the subject of his final course at the Collège de France48 – courage that can in turn produce the “uneasiness” in which Locke and Leibniz saw that which gives us the will to act.
Notes de bas de page
1 Jean-Jacques Rousseau, Discourse on the Origin and Foundations of Inequality among Men, in Susan Dunn (ed.), The Social Contract and The First and Second Discourses, London, Yale University Press, 2002, p. 87.
2 Ian Hacking, The Taming of Chance, Cambridge, Cambridge University Press, 1990, pp. 1 and 46.
3 Louis-René Villermé, “De la mortalité dans les divers quartiers de Paris, et des causes qui la rendent très différente dans plusieurs d’eux, ainsi que dans les divers quartiers de beaucoup de grandes villes”, Annales d’hygiène publique et de médecine légale, vol. 3, no. 2, 1830, pp. 294-341, quotation p. 339.
4 [Our translation] Louis Chevalier, Laboring Classes and Dangerous Classes: In Paris During the First Half of the Nineteenth Century, New York, Howard Fertig, 2000.
5 Michel Foucault, Birth of Biopolitics. Lectures at the Collège de France 1978-1979 [2004], transl. Davidson & Burchell, London, Macmillan, 2008; and The Will to Knowledge: History of Sexuality Volume 1, [1976], transl. R. Hurley, London, Penguin, 1998, pp. 136 and 138.
6 Charles-Edward Winslow, “The untilled fields of public health”, Science, vol. 51, no. 1306, 1920, pp. 23-33, p. 30.
7 Didier Fassin, L’Espace politique de la santé. Essai de généalogie, Paris, PUF, 1996.
8 Maurice Halbwachs, La Théorie de l’homme moyen. Essai sur Quetelet et la statistique morale, Paris, Librairie Félix Alcan, 1912, pp. 94 and 97.
9 Georg Simmel, The Philosophy of Money [1907], transl. David Frisby, London, Routledge, 2004.
10 Viviana Zelizer, Economic Lives. How Culture Shapes the Economy, Princeton, Princeton University Press, 2011.
11 William Godwin, An Enquiry Concerning Political Justice, and its Influence on General Virtue and Happiness, London, G.G.J. & J. Robinson, Paternoster, Row, 1793, vol. 1, p. 82 sq.
12 Philippa Foot, Virtues and Vices, and Other Essays in Moral Philosophy, Oxford, Oxford University Press, 1978.
13 Kip Viscusi, “The value of life in legal contexts: survey and critique”, American Law and Economics Review, vol. 2, no. 1, 2000, pp. 195-210; Thierry Sénéchal, “Dédommagement, réparation, restitution : instruments de ‘justice’?”, Topique, vol. 1, no. 102, 2008, pp. 23-39.
14 Georges Dionne and Martin Lebeau, “Le calcul de la valeur statistique d’une vie humaine”, L’Actualité économique, vol. 86, no. 4, 2010, pp. 487-530; Janusz Mrozek and Laura Taylor, “What determines the value of life? A meta-analysis”, Journal of Policy Analysis and Management, vol. 21, no. 2, pp. 253-270.
15 Thomas C. Schelling, “The life you save may be your own”, in Choice and Consequence. Perspectives of an Errant Economist, Cambridge (Mass.), Harvard University Press, 1984, pp. 113-146.
16 Georges Canguilhem, On the Normal and the Pathological [1966], New York, Springer, 1978, p. 92.
17 World Health Organization, Life Expectancy and Healthy Life Expectancy. Data by Country, updated 6 April 2018: http://apps.who.int/gho/data/node.main.688?lang=en.
18 Guy Desplanques, “L’inégalité sociale devant la mort”, Économie et statistique, no. 162, 1984, pp. 29-50.
19 Nathalie Blanpain, “Les hommes cadres vivent toujours 6 ans de plus que les hommes ouvriers”, Insee Première, no. 1584, 2016; Emmanuelle Cambois, Caroline Laborde and Jean-Marie Robine, “La ‘double peine’ des ouvriers : plus d’années d’incapacité au sein d’une vie plus courte”, Populations et Sociétés, no. 441, 2008.
20 Annette Leclerc, Jean-François Chastang, Gwen Menvielle and Danièle Luce, “Socioeconomic inequalities in premature mortality in France: have they widened in recent decades”, Social Science & Medicine, vol. 62, no. 8, 2006, pp. 2035-2045; Nathalie Blanpain, “L’espérance de vie par niveau de vie : chez les hommes, 13 ans d’écart entre les plus aisés et les plus modestes”, Insee Première, no. 1687, 2018.
21 Johan Mackenbach, Irina Stirbu, Albert-Jan Roskam et al., “Socioeconomic inequalities in health in 22 European countries”, The New England Journal of Medicine, vol. 358, no. 23, pp. 2468-2481.
22 Philip Musgrove, Andrew Creese, Alex Preker et al., Health Systems: Improving Performance, The World Health Report, Geneva, World Health Organization, 2000.
23 Stephen Bezruchka, “The hurrider I go, the behinder I get: the deteriorating international ranking of U.S. health status”, Annual Review of Public Health, vol. 33, 2012, pp. 157-173.
24 Colin McCord and Harold Freeman, “Excess mortality in Harlem”, The New England Journal of Medicine, vol. 322, no. 3, 1990, p. 173-177.
25 Raj Chetty, Michael Stempner, Sarah Abraham et al., “The association between income and life expectancy in the United States, 2001-2014”, Journal of the American Medical Association, vol. 315, no. 16, 2016, pp. 1750-1766.
26 Jay Olshansky, Toni Antonucci, Lisa Berkman et al., “Differences in life expectancy due to race and educational differences are widening, and many do not catch up”, Health Affairs, vol. 31, no. 8, 2012, pp. 1803-1813.
27 Steven Woolf and Heidi Schoomaker, “Life expectancy and mortality rates in the United States, 1959-2017”, Journal of the American Medical Association, vol. 322, no. 20, 2019, pp. 1996-2016.
28 Nancy Krieger, “Discrimination and health”, in Lisa Berkman and Ichiro Kawachi (eds), Social Epidemiology, Oxford, Oxford University Press, 2000, pp. 36-75.
29 David Williams, Selina Mohammed, Jacinta Leavell and Chiquita Collins, “Race, socioeconomic status and health: complexities, ongoing challenges, and research opportunities”, Annals of the New York Academy of Sciences, vol. 118, 2010, pp. 69-101.
30 Françoise Héritier, Masculin/Féminin, 2 volumes, Paris, Odile Jacob, 2007.
31 Annie Ernaux, Happening [2000], transl. Tanya Leslie, New York, Seven Stories Press, 2001.
32 W.E.B. Du Bois, The Souls of Black Folks, in Writings [1903], New York, The Library of America, 1986, p. 364.
33 Toni Morrison, The Bluest Eye [1970], London, Vintage International, 1993.
34 Hannah Arendt, The Human Condition [1958], Chicago, The University of Chicago Press, 1998, pp. 96-97.
35 Sherine Hamdy, Our Bodies Belong to God. Organ Transplants, Islam and the Struggle for Human Dignity in Egypt, Berkeley, University of California Press, 2012; Laurence Cohen, “Where it hurts: Indian material for an ethics of organ transplantation”, Daedalus, vol. 128, no. 4, 1999, pp. 135-164; Nancy Scheper-Hughes, “Commodity fetishism in organ trafficking”, Body & Society, vol. 7, no. 2-3, 2001, pp. 31-62.
36 Brian Williams, Denise Gilgen, Catherine Campbell et al., The Natural History of HIV/AIDS in South Africa. A Biomedical and Social Survey in Carletonville, Johannesburg, Council for Scientific and Industrial Research, 2000. “Townships”, a legacy of a century of segregation, are neighborhoods where residents belong to the same discriminated “racial group”, in this case Black people. Here, “hot spots” are meeting places for prostitutes.
37 Dunbar Moodie, “Black migrant mine laborers and the vicissitudes of male desire”, in Robert Morrell (ed.), Changing Men in Southern Africa, Pietermaritzburg, University of KwaZulu-Natal Press, 2001, pp. 297-315.
38 Achille Mbembe, “Necropolitics”, Public Culture, vol. 15, no. 1, 2003, pp. 11-40.
39 Didier Fassin, When Bodies Remember: Experiences and Politics of AIDS in South Africa [2006], Berkeley (Ca.), University of California Press, 2007.
40 Orlando Patterson, Slavery and Social Death: A Comparative Study, Cambridge (Mass.), Harvard University Press, 1982.
41 Lisa Guenther, Solitary Confinement: Social Death and its Afterlives, Minneapolis, University of Minnesota Press, 2013.
42 International Organization for Migrations, Missing Migrants. Tracking Deaths Along Migratory Routes, updated 28 November 2019: https://missingmigrants.iom.int.
43 Cristina Cattaneo, Naufragés sans visage. Donner un nom aux victimes de la Méditerranée [2018], Paris, Albin Michel, 2019.
44 Didier Fassin, Life. A Critical User’s Manual, London, Polity Press, 2018.
45 Claude Lévi-Strauss, “Place de l’anthropologie dans les sciences sociales et problèmes posés par son enseignement”, in Anthropologie structurale, Paris, Plon, pp. 377-418.
46 Robert Musil, The Man without Qualities [1943], transl. E. Wilkins & E. Kaiser, New York, Capricorn Books, 1965, p. 12.
47 Pierre Bourdieu, Distinction. A Social Critique of the Judgement of Taste [1979], transl. R. Nice, Cambridge (Mass.), Harvard University Press, 1984.
48 Michel Foucault, The Courage of the Truth: The Government of Self and Others II: Lectures at the Collège de France, 1983-1984 [2009], transl. G. Burchell, London, Palgrave Macmillan, 2011.
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