The familiar term “Alzheimer’s disease” was coined by Emil Kraepelin to honour his pupil, Alois Alzheimer. However, little is known about the life of the man after whom this important and well-known disease was termed. On the centennial of the discovery of Alzheimer’s disease, it is appropriate to report some aspects of the life and scientific work of Alois Alzheimer. The authors contacted all the libraries of the Universities where Alzheimer studied and/or worked to receive any original material regarding Alois Alzheimer. This review is based for a most part on an original biography written by Konrad and Urlike Maurer after the interviews to Alzheimer’s nieces, Hildegard Koeppen, Ilse Lieblein, Bärbel Lippert, Karin Weiβ, and his nephew, Rupert Finsterwalder. The authors obtained this biography from the Central Library of Medicine in Koeln. Alzheimer’s prodigious capacity as a researcher and pathologist is reflected in the tables in his graduation thesis. His analytical and descriptive talents contributed to the use of microscopy in the study of psychiatry. Two of his distinctive characteristics are that he was a good microscopist and that he placed importance on dialogue with patients. On 12 May 1888, Alzheimer passed the graduate examination and on 4 July was granted a doctors degree to practice medicine in the territory of the German Kingdom by the Royal Bavarian Statal Minister of the Church and School. On 19 December 1888, Alois replaced Emil Sioli as the assistant to Heinrich Hoffmann, director of the Institute for Lunatics and Epileptics in Frankfurt/Main. He was appalled at the inadequate sanitary measures and living conditions at the Institute, as he and Sioli espoused non-restrictive treatment of patients. Franz Nissl, who also worked at the institute, had an important influence on Alzheimer. Nissl developed Nissl’s stain and discovered Nissl’s lumps . Sioli, Alzheimer and Nissl changed the institute into a proper psychiatric clinic and making it a caring facility. They used a non-restrictive policy characterized by bath therapy and dialogue between physician and patient. In Alzheimer’s words, “all restrictive methods were abandoned … [using methods such as] introducing an intensive medical service, introducing treatment next to the bed of the patient and into the day room, avoiding the isolation room, introducing permanent baths. [Sioli’s Institute] is one of the most progressive institutes”. A very important element for the three physicians was research into the organic causes of mental diseases using histological preparations made during autopsy. In April 1894, Alois married Cecilie Simonette Nathalie Wallerstein in the Civil Status Office of Frankfurt. When Cecilie converted to Catholicism on 14 February 1895, their marriage ceremony was conducted in the Franciscan Church in Frankfurt. A daughter, Gertrude, was born on 10 March 1895 and Nissl was named as her godfather. On 21 July 1896, Alzheimer was appointed head of the mental hospital in Frankfurt. Their son, Hans, was born two days after his appointment. The closing years of the nineteenth century were very profitable for Alzheimer but the year 1901 was to be pivotal for his future: his status as a professional was firmly established and the Institute was expanded, but his wife died. During the first years of the twentieth century, Alois abandoned his academic aspirations for a more applied role in which he could link theoretical and practical science. He moved to Heidelberg at the invitation of Emil Kraepelin. When Kraepelin took up a chair in psychiatry in Munich in June 1903, he asked Alois to accompany him. In Kraepelin’s words, “Before his establishment as university lecturer in Heidelberg it was my appointment in Munich where he went together with me”. On 9 November 1904, Kraepelin and Alzheimer opened their psychiatric clinic. The institute was relatively modern in respect of therapy and hygiene. There were no isolation rooms, and all patients were treated using baths. According to their circumstances, patients were admitted for days, weeks or months. About 2,000 patients were admitted each year. On 16 November 1904 Alzheimer was appointed a lecturer in the Faculty of Medicine at Ludwig-Maximilian University. He then applied for venia legendi, leave to teach in psychiatry, and was appointed a private teacher. Alzheimer was very devoted to his work, but also spent much time in educating and instilling a love of nature in his sons. His son, Hans, wrote, “it is very important to my father that we possess animals and love them”. Their house, where Alzheimer’s niece presently resides, borders on Weβlinger Lake and was thus very suitable for such pursuits. Despite his almost military gait, Alois had a quiet nature and a great sense of humour. He loved good cigars, and had a habit of leaving-and forgetting-his partially smoked cigars on students’ desks so that by evening the laboratory was filled with cigar smoke. On 22 February 1909, Alzheimer resigned from office to devote himself to scientific research, and on 30 December 1909 was granted a teacher’s degree in the Court of Bavaria by Prince Luitpold. Three years later, he was appointed as ordinary professor of psychiatry at the neurologic and psychiatric clinic of the Friedrich-Wilhelm University in Breslau. This was important for his scientific career: he competed with Eugen Bleuer, researcher of cerebral anatomy and pathology; Paul Schröeder, head of the clinic in Breslau; Oswald Bumke, head of the clinic in Freiburg. The minutes of the appointments committee describe him as,“… a great authority for the studies of the histology and pathology of the brain, and he has successfully studied organic psychosis, paralysis, cerebrallues, arteriosclerosis and epilepsy … he is always interested to show the comparison between the clinic and the clinical diagnosis … his studies considered landmarks from a clinical point of view … he is a good teacher and a good physician … the faculty is persuaded that he would accomplish his task in an optimum way”. On 10 July 1912, Emperor Wilhelm II personally signed the appointment. Alzheimer went to Breslau but became severely ill. Kraepelin described his affliction as, “infective angina associated with nephritis and inflammation of the articulations [contracted] during travel to the new residence”. He continued to work despite his illness. In the summer of 1913, Alzheimer taught courses in psychiatry and its relationship to the anatomy and pathology of the brain, and histology and histologic pathology of the nervous system at the University of Breslau. Ludwig Mann, Ottfried Förster, and Georg Sterz were coworkers of Alzheimer. Stertz was to become Alzheimer’s son in law. In February 1913, Alzheimer was hospitalized in a private clinic. His spirits remained high, but by the end of November, he developed severe renal and respiratory failure and died on 19 December 1915. Many obituaries were written. Of particular note are the words of Clemens Neisser at the Congress of the Oriental German Association for Psychiatry in Breslau on 9 December 1916: “… in the Congress on 7 December 1912 in which he agreed to the Association, with his conference paper on ‘About some previously unknown clinical cases’, he opened a common element of stuffy on the paralysis for the clinic and provincial Institute. He allowed us to enter into his personal fields of studies, and so, we hope, in a common and scientific union among scientists and a promotion of our own work”  were devout Catholics from Spessart, and Alois remained sentimental about this region. His great grandfather, Michael Alzheimer, was born in Rengersbrunn in 1757. He married Margarethe Günter on 7 February 1792, and their son Johann, Alois’ grandfather, was born in 1797. Johann, who became a teacher, was compelled to remove to Cassel, a town in the north-west of Low Franconia. Karl Gorge, the first son of Johann, was born on 6 October 1827. Their second son, Edward, was born on 22 March 1830. Both sons became esteemed member of society: Karl Gorge as a well-known prelate and Edward as a notary. Edward, who married Eva Maria Sabina Busch in 1861 in Würzburg and later moved to Marktbreit on the Main in Low Franconia, was the first notary to work at the royal provincial law court. Eva Maria Sabina died on 31 July 1862 at 336 Würzburger Street, a house that still stands. Edward married Therese, Eva Maria Sabina’s sister, who lived nearby at 273 Würzburger Street. This house is peculiar in that it has a central tubular space in which a birch was planted. The birch is still alive and the house was proclaimed a museum on 19 December 1995. Alois Alzheimer was born in this house on 14 June 1864. He was the second son of Edward and Therese, and was a healthy infant. He attended the catholic School of Marktbreit from 1870 to 1874, but his father believed that this city did not offer sufficient cultural depth and so sent him to Aschaffenburg when he was ten years old. Alois attended the high school there and was educated by teachers better than most in those times. In 1878, his family also moved to Aschaffenburg. During high school, Alois was attracted to natural science and concentrated on this area. In 1883, Alois obtained the general certificate of education. Faced with the choice of tertiary courses in either natural science or medicine, he chose the latter. At this time, Berlin was considered the centre of excellence in medicine and was home to scientists such as Rudolf Virchow, the cellular pathologist, and Robert Koch, who discovered the mycobacterium responsible for tuberculosis and vibrio cholerae. Inspired by these scientists, Alois relocated to Berlin and was enrolled at the Royal Friedrich Wilhelm University of Berlin from 1883 to 1884. He attended anatomy lectures and dissections under the supervision of Wilhelm von Waldeyer and studied zoology under Marteus, experimental inorganic chemistry under Adolph Pinner, and botany under August Wilhelm Eichler and Reiner Westermeier. Importantly, he attended Carl Westphal’s psychiatry lectures. Westphal’s emphasis on the role of cerebral disorders in psychosis had a formative influence on Alzheimer’s way of thinking. Alzheimer was impressed by the English principle of non-restraint that was advocated by John Conolly; this entailed treatment for mental patients without constrictive methods. In the summer of 1884, Alzheimer attended his second six-month period at Würzburg, where the left side of his face was disfigured in a fencing duel. From this time, only the right side of his face is shown in photographs. During the winter of 1884 – 1885, Alois attended the physiology lectures of Adolf Flick, who formulated the laws of microscopic physics and the mathematics of diffusion, and the microscopy lectures of Albert von Kölliker. Alzheimer worked with Alfonso Corti, who discovered Corti’s gland, and with Franz von Leydig, who discovered Leydig cells. During the winter of 1885-1886, he attended Hubert Grashey’s lectures on general pathology and legal psychiatry. The next winter he went to the Eberhard-Karl University of Tubingen where he attended lectures in specialized pathology and treatment, clinical medicine, clinical surgery, and gynaecology and obstetrics. Alois returned to Würzburg the following summer to write his graduation thesis titled, “On earwax glands”. The chairmen of his examination committee were von Kölliker and Stöhr. In Alzheimer’s words, “psychical disorders are brain disorders”. Moreover, Heinrich Hoffmann based his principles on non-restrictive or free treatment, which became the basis of Alzheimer’s work. The first publication by Alzheimer and Nissl describes a patient with progressive general and muscle weakness due to degeneration of the grey matter of the spinal cord and diffuse damage to the neurons of the cortex. Alzheimer’s diagnosis of progressive spinal muscular atrophy was confirmed by an autopsy. Alzheimer had three main tenets: non-restrictive treatment, dialogue therapy, and research into the organic causes for the psychical diseases. At beginning of his scientific activity, he made over 200 histological preparations from patients with syphilis. He worked in the pathological anatomy section with Carl Weigert, the inventor of aniline staining, and Ludwig Edinger, who discovered pathways for pain and temperature sensibility, who both assisted him. Alzheimer used Nissl’s stain for his preparations and advised “… the use of this method everywhere is urgent, not only in those cases that are characterized by a loss of fibres, but also to show the pathological changes of the neurons”. In 1892, Alzheimer wrote a detailed report on the positive effects of treating mental patients using baths and presented it in Karlsruhe to the Congress of Psychiatrics of South-West Germany. He described arterisclerosis of the brain in 12 syphilis-free patients at the meeting of the Association of German Psychiatrics in Dresda on 21 and 22 September 1894. In this communication, he emphasized that the clinical signs of arteriosclerotic atrophy differ from those of other diseases. A characteristic feature of this disease is a hearth’s image of the arteriosclerotic degeneration respect to diffuse paralytic changes. Alzheimer anticipated dementia that is caused by multiple infarcts a century before its discovery. On the causes of the arteriosclerosis, Alzheimer wrote, “I can exclude trauma, diabetes, nephritis, or a non-compensated cardiac insufficiency … I believe that my patients are near to senile dementia and someone considers them as a progressive paralysis. I can separate them clearly by praecox senile dementia”. This is a very important affirmation because the difference between pre-senile and senile dementia played a key role in Alzheimer’s diagnosis of Auguste D. seven years later. At the 66th Congress of Psychiatrics in Vienna, Alzheimer the age at which progressive paralysis develops: “I studied three young girls. I wish to describe one case as an example. I studied an illegitimate daughter … when 21 years old, was hospitalized due to a reduced visual capacity. This was diagnosed as atrophy of the visual nerve, headache, backache, and loss of peculiar reflexes; when the patient was 26 years old, she was hospitalized in our institute because she was very excited. She exhibited lingual fibrillar twitching, twitching of the face muscles, dementia, paralytic signs, temporary excitation … our colleagues, who assigned us the patients, had difficulty with the diagnosis as each had a different opinion … but nobody diagnosed paralysis”. Alzheimer’s faith in microscopy and pathological anatomy is evidenced by his statement, “I am sad to affirm that only autopsy will provide certainty”. He published a report on these three cases in 1896, showing that the paralysis begins between 13 and 16 years of age and lasts for five years, which is longer than is the case with adult paralysis. In contrast to adult cases with this disease, in which males become more clinically ill than females, in juveniles, both sexes fall ill and there is no clinical difference between them. In 1896, Alois Alzheimer published an interesting article, “A born felon” in the Archive of Psychiatry and Nervous Diseases. He describes Oskar M., who was admitted to the mental hospital on 16 March 1894. Alzheimer measured the cranium and documented a marked asymmetry of the face and cranial bones, which was diagnosed as an inherited mental degenerative disease according to Benedict Morel. From Alzheimer’s words, “We believe that the disorder of Oskar M. is a hereditary degenerative disorder. The more evident symptom is a sexual perversity showing a typical fetishism. Moreover, a great obsession united to signs of a forced action are present … Moreover, Oskar M. shows character anomalies which are peculiarities of those who show psychical hereditary vices”. Alzheimer was well acquainted with the theory of Cesare Lombroso regarding the “delinquent man”. However, Lombroso believed that the stunted growth of the cranial bones was because the patient had the mental and physical traits of ancient man. In 1897, Alois published a work about psychoses resulting from nervous exhaustion entitled “Contribution to the pathological anatomy of the cerebral cortex and of the anatomical bases of some psychoses, in which he described pathological changes of neurons in the cortex, its supporting tissue, and in the connective tissue. In 1898, he published “A contribution to the pathological anatomy of epilepsy” in the Journal for Neurology and Psychiatry. Referring to the patients in his clinic, he wrote, “There are cases of epilepsy which are said to be ‘genuine’ or ‘inbred’, and are characterized by pathological-anatomical changes. From a macroscopic perspective, it is evident that there is a wrinkled surface of the circonvolution characterized by a hunch image and a sclerosis … From a microscopic perspective, an increase of glia is evident … a great loss of fibres of the marrow and of neurons in the cerebral cortex. The degeneration extends along the all of the cerebral cortex … many reasons lead us to believe that the nervous substance is ill primarily … All the histological changes explain the presence of epilepsy”. In 1898, Alzheimer published “New contribution on senile dementia”, a pathology in which the brain shows signs of a praecox aging in the Journal for Psychiatry and Neurology. Alzheimer had previously studied senile dementia in Frankfurt: “Then I examined a patient showing a presenile dementia related to numerous atrophic nervous cells without any change to the ateromatous vases. Leaving nutritional disorders out of consideration, this disorder shows … a weakness of the central nervous system, which can be acquired due to hereditary vice and have praecox atrophy of gangliar cells as a consequence. Admitting this … in typical cases of senile dementia … the degenerative changes of gangliar cells can be present … naturally other research can confirm this diagnosis”. These studies aroused Alois’ interest in senile dementia, which led to his concern with Auguste D. In 1901, Alzheimer began to study a subcortical arteriosclerotic encephalopathy, later known as Binswanger’s disease, in which “… the patient become lame, dull-minded, physically flabby, talkative, shook”. His scientific reputation was reinforced by his participation in various congresses. In September 1895, he presented microscopic preparations from two patients with brain degeneration to the Congress of the Association of German Psychiatrists, which was held in Hamburg. In 1896, at the Congress of German Researchers and Physicians, held in Frankfurt/Main, Alzheimer gave a talk on “The anatomical propagation of paralytic processes of degeneration”. In 1896, he talked at the Annual Congress of German Psychiatrists in Heidelberg about five patients showing arteriosclerosis. In 1898, Alzheimer talked about delirium acutum and mental disorders of aging at the 22nd Congress of Oriental German Psychiatrists held in Baden-Baden. In 1903, Alzheimer qualified for university teaching with his dissertation, “Histological studies about progressive paralysis”, which contained 11 tables and photographs taken by Alzheimer. This monograph was the foundation for subsequent studies on mental disorders, as it shows that pathological anatomy is an important research tool. Alzheimer then turned to the study of psychoses, dementia, schizophrenia and depressive maniacal madness. In 1904, he published “Something about the anatomical basis of idiocy” in the Central Journal for Psychiatry: “… observing macroscopically the brain of the idiotics it is evident some peculiarity as the microencephalia and the macroencephalia … the microgiria and the macrogiria … the poroencephalia and the hydrocephalia …”. Moreover, he wrote about amaurotic idiocy, a disorder of fat metabolism that causes psychomotor degeneration and paralysis. In 1907, Alzheimer published “Some methods to fix the cellular elements of cerebral-spinal fluid” in the Central Journal for Psychiatry in which he described the technique of lumbar injection. In the same year, he was invited make a presentation to the German Association for Psychiatry in Frankfurt because of his expertise on the etiology of various mental diseases. He discussed brain lesions, brain tumours, idiocy, encephalopathy, syphilis, alcohol poisoning and lead poisoning. Later that year, he published a detailed article titled “About indications for the artificial interruption of pregnancy in psychic patients” in the weekly Journal of Medicine in Munich and began writing a manual on the histologic pathology of psychosis with the aim of distinguishing schizophrenia from depressive maniacal madness using histological preparations. In 1909, Alzheimer wrote an article titled “Contribution about the knowledge of the pathologic neuroglia, and its relationships with the course of the decomposition of the nervous system”, which he published in 1910 in the journal Histologic and Histopathologic Studies on Cerebral Cortex. Following an article that Alzheimer published in 1911, “Is the institution of a psychiatric division within the Royal Igienic Office desiderable?”, Kraepelin founded the German Institute for Psychiatric Research in Munich, now know as the Max-Planck Institute of Psychiatry. Alzheimer never forgot his patient, Auguste D., who he studied in Frankfurt during the early years of his scientific career. When Auguste D. died on 9 April 1906, Alzheimer studied his brain to confirm his “ancient” hypothesis of senile dementia. Assisted by Gaetano Perusini and Francesco Bonfiglio, Alzheimer detected atrophy of the cerebral cortex accompanied by the loss of cells, a great excrescence of the glia of the fibres, and numerous glial rod cells. Moreover, numerous plaques throughout the cortex were associated with excrescences of the vessels. This pattern, which could hardly be described as atypical for a patient of 70 to 80 years of age, is significant because Auguste D. was only 50 years of age when he died. Alzheimer presented these results at the 37th Congress of Psychiatrists of Southern Germany in Tubingen. The Meeting was attended by prominent scientists such as Oswald Bumke, after whom the “Bumke’s syndrome” in schizophrenia was named; Otto Binswanger, after whom the “Binswanger’s disease” was named; and Hans Curschmann after whom the “Curschmann-Steinert disease” was named, but nobody attached importance to Alzheimer’s results. In 1909, Perusini published the case of Auguste D. together with three other cases in an article titled “On the psychic disorders in the late age which are peculiar from a clinic and histopathologic point of view” in Nissl and Alzheimer’s Histologic and Histopathologic Studies on the Cerebral Cortex. In the preface to his 1910 book, general Psychiatry and Clinical Psychiatry, Emil Kraepelin thanked Alzheimer: “I express my satisfaction to my faithful co-worker, Professor Alzheimer, who allowed me to insert the results of pathologic anatomy of the Institute useful for my tables and images”. Moreover, Kraepelin included a section titled “Senile cerebral sclerosis or Alzheimer’s disease” in chapter VII, “Senile and pre-senile madness”. On page 624, Kraepelin wrote that “the clinical interpretation of Alzheimer’s disease is, until today, still not clear. In spite of the clarity of anatomical evidence showing a serious type of senile dementia beginning at about fifty years … in these patients it may be called ‘praecox senium’”. The details of the disease of Auguste D. were found in 1995. The Chronicle in Munich of 4 June 1997 reports that “For two years, Maurer, Volk and Gerbaldo searched records of patients … 12 patients called A.D. were traced … but nobody was coincident with Alzheimer’s description of Auguste D. … the real record was mistakenly collected in the year 1920”. In 1909, Alzheimer published “Studies on the fundaments of the motorial disorders and histological changes of epilepsia”. In 1910, Alzheimer became editor of the psychiatric section of the Journal for General Neurology and Psychiatry. In the first edition, he wrote articles on “The diagnostic difficulty in Psychiatry and degeneration and regeneration of peripheral nervous vessels”. The period from 1903 to 1912 was his most fruitful. In Nissl’s words, “Alois was very impartial in his judgements, unwilling to overstate or speculate, … zealous in doing his duty, he is not only a defender but a supporter of this research’s direction”. In 1913, Alzheimer gave lectures and wrote treatises; he published 11 articles on dementia praecox in the Journal of General Neurology and Psychiatry and published a review of psychiatry on the occasion of the venticinquennial of his professional, Emil Sioli. In November 1914, Alzheimer gave his last lecture, on the “Mortal effect of war on the nervous system and on the psyche”, and wrote one last publication, “The war and the nerves”. The first case of Alzheimer’s disease was described by Gonzalo R. Lafora, a histopathologist from Madrid, and coworker of Ramon y Cajal , in a manuscript titled “Uber das vorkommen amyloider korperchen im inner der ganglienzellen; ein beirtrag zum stadium der amyloiden substanz in nervensystem” published in Virchow’s Archiv. Pathol. Anat., CCV, 295-303, 1911. We wish to honour the scientific activity of Alzheimer in the words of the rector of the Friedrich-Wilhelm University of Breslau, “The Medical Science misses … one of the best researchers … all the mad men miss a worried father … the war hospital misses a friend and a soldier”.It is important to stress that the scientific thinking of Alois Alzheimer, from beginning, influenced by that of Heinrich Hoffmann. In 1851, Hoffmann was director of the Institute for Lunatics and Epileptics in Frankfurt and in 1859, he wrote “Observations and experiences about psychical disorders and about epilepsy in the Institute of Frankfurt am Main from 1851 to 1858”. Hoffmann belonged to the school of “somatics”, who considered all psychic diseases to be effects of organic diseases, as did Alzheimer. This group was in opposition to the “psychics”, who considered the psyche to be the cause of mental diseases. Hoffmann followed the teaching of Wilhelm Griesinger, a psychiatrist from Berlin who initiated the scientific era of psychiatry with his treatise on “Pathology and therapy of physical disorder”. The essence of Griesinger’s teaching is that


Anthropogens have in common an ability to induce a form of chronic, low-level systemic inflammation (“metaflammation”). A review of anthropogens, based on inducers with a metaflammatory association, is conducted here, together with the evidence for each in connection with a number of chronic diseases. This suggests a broader view of lifestyle and a focus on determinants, rather than obesity and lifestyle per se as the specific causes of modern chronic disease. Under such an analysis, obesity is seen more as “a canary in a mineshaft” signaling problems in the broader environment, suggesting that population obesity management should be focused more upstream if chronic diseases are to be better managed.The obesity epidemic and associated chronic diseases are often attributed to modern lifestyles. The term “lifestyle” however, ignores broader social, economic, and environmental determinants while inadvertently “blaming the victim.” Seen more eclectically, lifestyle encompasses distal, medial, and proximal determinants. Hence any analysis of causality should include all these levels. The term “anthropogens,” or “… Modern western lifestyles are often blamed for the current obesity and associated chronic disease pandemics . This seHowever, lifestyle (“a mode of life chosen by a person or group”-Macquarie Dictionary) infers volitional behavior on the part of an individual. This has a pejorative meaning for some social scientists as it is thought to ignore the deeper social, economic, and environmental determinants of both lifestyle and disease, while focusing on individual responsibility, that is, “victim blaming” . A more Infectious diseases benefited from a monocausal focus  providedChronic diseases began to replace the decline in infections in the west in the late 20th century, taking health experts somewhat by surprise. Epidemiologists noted a phase in the development of a country called the “epidemiological transition”  when chrWhile infectious disease can usually be ascribed to microbial causes, causality in NCDs is more problematic. In most cases the agent of causality is ill-defined, but there are layers of influence. As shown in Unlike the germ theory for communicable diseases, there has been no equivalent underlying link between the determinants shown in  necessary condition for the chronic diseases with which it is associated or just a sufficient condition in some circumstance and whether lifestyle and environmental inducers which may (or may not) lead to obesity can be independent determinants of disease as indicated by metaflammatory processes.The discovery, in the 1990s, of a “new” form of inflammation, which appears to be present in many if not all chronic diseases, offers the prospect of an underlying generic disease marker pointing to determinants beyond the diverse explanations of aging and lifestyle. The term “metaflammation”  has beenman-made environments, their by-products and/or lifestyles encouraged by these, some of which may be detrimental to human health” [Inducers of metaflammation, which have largely arisen since the industrial revolution , 18, hav health” . AnthropAn individual's susceptibility to a range of anthropogens clearly varies with genetic predisposition to chronic diseases carried through the genome including obesity, diabetes, many cancers, and cardiovascular disease. However, during the second half of the 20th century, a revolution in our understanding of environmental influences and lifelong gene expression has emphasized the importance of early environmental influences on the later development of chronic disease. It is now clear that epigenetics, the heritable changes in gene activity not driven by change in the DNA sequence, has a major influence on the susceptibility to chronic disease for both individuals and their offspring. Chronic disease driven by a mismatch between the environment one is programmed for and the environment one is born into is highlighted by the extreme susceptibility of indigenous and developing communities to anthropogens and related chronic diseases.Obviously, not all anthropogens are unhealthy for all people. The identification of those that have negative health effects however is important for developing a focus on chronic disease aetiology. We consider that a review of anthropogens could focus the attention of health workers and hence provide such a review below. We provide evidence of metaflammatory reactions from either inadequate or excessive exposure to these and evidence for their association with a number of chronic diseases. A list of disease categories is shown in A summary of anthropogens associated with these disease categories, discussed in the text, is given in In discussions of modern chronic disease etiology, smoking, poor nutrition, excess weight, and alcohol use stand out as the dominant preventable determinants . HoweverNutrition. The importance of nutrition for the prevention and management of chronic disease is well known [ll known . Inadequll known  and a sill known . Health ll known  and overll known , with inll known , 26.Excessive energy intake, particularly of high energy-dense, but low nutrient-dense products, is a major problem of industrialised societies. Still, excessive intake of even healthy foods can increase postprandial  metaflammation , suggestIn relation to nutrition quality, studies have reported increased risk and elevated metaflammation from excessive amounts of sugars, salt, alcohol, and (saturated and trans) fats, as well as inadequate levels of fibre, fruit, vegetables, grains, and certain nutrients , 26. Lev (In)Activity. Inactivity, as well as sedentary activities like sitting, in contrast to insufficient physical activity, is an independent risk factor for disease [ disease . It is o disease .Movement, physical activity, and exercise can be conceived of as gradations along a scale and all have a role, to different degrees, in primary prevention of a range of diseases and, in some cases, treatment and reversal of risks and/or disease entities . This is mainly through the modems of aerobic capacity and/or muscle strength and integrity. Flexibility and balance provide musculoskeletal integrity that can enhance quality of life.any activity is better than none, and more is better than a little”, and for individuals to “think of movement as an opportunity, not an inconvenience” [While controversies exist about type, intensity, frequency, and duration of physical activity, there is no dispute about the health value of an optimal physical activity requirement for humans. A generic prescription based on “volume” (intensity × frequency × duration) incorporating both aerobic and resistance training is appropriate in the absence of a more detailed individual-genetic understanding . In the enience”  are apprenience” , 39.Poor nutrition and inactivity are the best-known inducers of weight gain. Several studies however now show that either poor nutrition or inactivity can independently modify metaflammation without significant changes in weight , 41. Stress, Anxiety, and Depression. The nature of stress has changed in recent times from an acute warning signal to a chronic strain on physiological adaptation. Typically, the body's reaction to a stressor has been “flight” or “fight,” but these options are less viable in the modern environment, leading to chronic effects such as elevated adrenocortical hormone concentrations, activation of the sympathetic nervous system [s system , ailments system , and accs system , 44. Of s system  is vitala thin stream of fear trickling through the mind. If encouraged, it cuts a channel into which all other thoughts are drained” [Anxiety is a form of “feared helplessness” defined as “…drained” . Anxietydrained”  can resudrained”  to Alzhedrained” . A considrained”  or indepdrained” . Technology-Pathology. The association of chronic disease with certain modern forms of technology is often overlooked or disregarded. This can range from death or chronic pain initiated from motor vehicle or machine injuries to auditory problems from amplified music [ed music . At the ed music , other sed music , impaireed music , and reped music .Other recent problems within this category are acute and chronic problems that occur while focusing on use of social media  whilst carrying out other activities, such as driving . BecauseInadequate Sleep. Healthy sleep is the anchor for a healthy life, thus interacting with other chronic disease determinants discussed here [sed here . Togethesed here . Poor slsed here , as wellsed here  and signsed here . The cumsed here . As manysed here . Accordised here .Modern lifestyles are often in direct competition with sleep so much so that it could be argued that the majority of modern sleep problems have a basis in lifestyle choices. The combination of sufficient sleep with other lifestyle factors  has additional value in heart disease prevention than sleep alone . Sleep dEnvironment. Aspects of the environment have always been a consideration in public health. However the rise of chronic diseases has led to a more structured approach to this. Swinburn et al. [n et al. , for exan et al.  environmSmall particle pollution from exhaust and industrial fumes  as well Sociocultural influences are reflected, for example, in attitudes to feasting in some cultures which may have been suitable in historical times but are contraindicated with the imposition of a western culture and diets. Political environments make the “rules” that allow, for example, smoking or drinking in the family or unrestricted sales of unhealthy foods and products  in society. Overarching all of this is the macroeconomic system, including the modern economic growth model which demands consumption that is not necessarily conducive to health , 85.Recent findings relating to the gut microbiome suggest that the inner environment (“in”-vironment in contrast to “en”-vironment) should also be considered within this category . ChangesSome protection against unhealthy environments may be provided by positive lifestyle changes , 89. It Occupation. Meaningful work is an important component of good health. Generally however it is the direct effects on health and safety—exposure to machinery, chemicals, injury, and so forth—or the adverse health effects of work hours and shift work [ift work  and theiift work  that areift work ). Poor jift work  and exceift work . In workift work , “burn oift work , and socift work , 99 relaDrugs, Cigarettes, and (Excessive) Alcohol. Drugs, both licit and illicit, are responsible for a significant and increasing degree of morbidity and mortality in modern societies. The stand-out amongst licit products is cigarette smoking and its links with cancers, heart disease, and respiratory problems [problems . Legal mproblems  categoriproblems . IllicitIts more ambiguous outcomes make alcohol a more diverse problem. Some health and social benefits of moderate consumption  are diffOver- and Underexposure. While many lifestyle-related behaviours have a linear association with health , others have a “U” or “tick-shaped” relationship . Exposure to ultraviolet radiation (UVR) from sunlight is a case in point. UVR is classified as a carcinogen and a major determinant for several forms of skin disorders. The incidence of melanoma, the most deadly form of skin cancers, has doubled in recent years [nt years , 107, alnt years . Intermint years . Overexpnt years . Passivent years .At the other extremes, underexposure to sunlight can lead to deficiencies in vitamin D, thus increasing risks of heart disease , type 2 Relationships. The quality of personal and social relationships is clearly linked to chronic disease outcomes [outcomes  includinoutcomes , stroke outcomes , some caoutcomes , and alloutcomes .The pathways for this are, as yet, unclear and psychological mediators have not been proven , but infSocial Disadvantage. Social disadvantage is associated with diseases like type 2 diabetes [diabetes  and carddiabetes . Disadvadiabetes  and incodiabetes  but alsodiabetes .According to the Commission on Social Determinants of Health , inequitMuch has been made of the mechanisms underlying social disadvantage, socioeconomic status, and inequality. Stringhini et al.  show thaWe have categorized a number of determinants of modern chronic diseases within a hierarchy using the acronym NASTIE ODOURS . In doinAn obvious omission from our classification is obesity. There are two reasons for this. In the first place, obesity should be seen as a risk factor, rather than a primary determinant of disease, which is downstream, sometimes, but not always resulting from some of the determinants considered here, like overnutrition, inactivity, stress, social pressure, and so forth. A second reason is the variability of causal links between obesity and disease as exemplified in the “obesity paradox”  and metaThere are a number of implications stemming from this discussion. Firstly, arguments about the best “diets” for weight loss and chronic disease become less relevant when looking at this big picture pattern of disease . Secondl


Sweet wine, unblended, served Odysseus well in the escape with his companions from the Cyclops’ cave during his epic return to Ithaca. The wine, a gift from Maron, grandson of Dionysus, was exceptional. “When he drank it he mixed twenty parts of water to one of wine, and yet the fragrance from the mixing bowl was so exquisite that it was impossible to refrain from drinking.” Odysseus carried a large skin with this wine, in case on the way he had to deal with some unknown savage of great strength who “would respect neither right nor law.”Mixing wine with water before drinking was a mark of civilized behavior in ancient Athens and an essential feature of the symposium, a gathering in which drinking together was intertwined with conducting business. The practice spawned a line of equipment for transporting, mixing, and consuming wine. One such implement was the krater, a vessel in which wine was diluted to the right consistency for drinking. Kraters, often too large to be used for serving, were positioned in the center of a room and sometimes were decorated with images of symposium proceedings.Athenian pottery was common in the Mediterranean region as far back as 2,800 years ago. Clay vessels of different sizes, shapes, and uses were widely traded. And while little painting of that period has survived, even on stone, intact and fragmented painted vases from various locations abound because they were exceptionally durable, more so than metal. As a result, they became a repository, not only of painting but of religious and social norms and daily activities, from raising children to burying the dead. Historical and mythologic scenes, also used heavily, provided the opportunity to inject life scenes with life lessons.Pottery was difficult work half art, half magic. Clay pots were created in workshops, usually led by master potters, who knew how to manipulate kiln temperature by letting air in and out at different times, never knowing for certain how the final product would turn out. Many pots were clearly signed. Others are recognizable as products of a certain workshop or area known for a distinctive style. The potter was not necessarily the painter, although many times they were one and the same. The painter who created the krater on this month’s cover was named after Sappho, the famous poet of antiquity, a popular subject for artistic representation. His name, “the Sappho painter,” came from a vase, now in a museum in Warsaw, showing perhaps the oldest portrait of Sappho, a woman playing a long-armed lyre. The name “Sappho” is incised next to the figure.The black-figure technique, featured on the krater on this month’s cover, evolved from earlier geometric designs in Corinth and then Athens. The surface of the pot was covered with a black pigment on which details were incised that would turn red in the final stage of firing. Certain conventions prevailed in the painted scenes. Figures were flat, although not entirely without perspective. Faces were shown in profile, young men generally beardless, older women heavyset. Inscriptions floated conspicuously in-between figures.Odysseus Escaping from the Cave of Polyphemos is the image on a wide mouth black-figure krater with two columnlike handles. The theme was a popular one: a famous hero set against Polyphemos—“A horrid creature, not like a human being at all, but resembling rather some crag that stands out boldly against the sky on the top of a high mountain.” The tired Odysseus and his crew found the monster’s cave. “His cheese-racks were loaded with cheeses, and he had more lambs and kids than his pens could hold.” But what he had in prosperity, Polyphemos lacked in hospitality. “The cruel wretch … gripped up two of my men at once and dashed them down upon the ground as though they had been puppies. Their brains were shed upon the ground, and the earth was wet with their blood. Then he tore them limb to limb and supped upon them.”Homer’s hero realized that extraordinary measures would be needed for him and his companions to get out of the monster’s cave alive. “Look here, Cyclops … you’ve been eating a great deal of man’s flesh, so take this and drink some wine.” The undiluted potion had the anticipated effect. “This drinks like nectar and ambrosia all in one,” the Cyclops exclaimed. “Be so kind … as to give me some more and tell me your name at once.” Odysseus obliged. “My name is Nobody … This is what my father and mother and my friends have always called me.”Drunk and sick, the monster fell “backwards and a deep sleep took hold upon him.” Odysseus and his men then thrust a burning beam of wood into the monster’s eye “till the boiling blood bubbled all over it as we worked it round and round.” The Cyclops cried and shouted “in a frenzy of rage and pain,” alerting his friends that Nobody was killing him, “by fraud or by force.” For Odysseus and his friends, the problem now was how to get out of the cave when Polyphemos moved the huge bolder to let the sheep out in the morning.“The male sheep were well grown and carried a heavy black fleece, so I bound them noiselessly in threes together … there was to be a man under the middle sheep, and the two on either side.” And, “There was a ram finer than any of the others, so I caught hold of him by the back, ensconced myself in the thick wool under his belly, and flung on patiently to his fleece, face upwards, keeping a firm hold on it all the time.”On the krater depicting the story, the faces betray no emotion. Polyphemos has just lost his vision. “Nobody,” tied with rope under the ram and clinging for dear life, awaits the outcome of his daring escapade. The ram receives a tender stroke from his master. “My good ram, what is it that makes you the last to leave my cave this morning?”Outside the cave at last, his men safely on the ship, Odysseus cannot contain himself. “Like a craftsman, I had to leave my name on my handiwork,” he shouts. “Cyclops …. If anyone asks you who it was that put your eye out and spoiled your beauty, say it was the valiant warrior Odysseus, son of Laertes, who lives in Ithaca.”In the times of Homer, monsters lived in caves, the mountains, and the sea. They symbolized humans’ worst fears—being eaten was one of them. “He gobbled them up like a lion in the wilderness, flesh, bones, marrow, and entrails, without leaving anything uneaten.” There was a clear dichotomy. Cyclopes were bad, sheep good. Cyclopes ate humans. Humans ate sheep and shared food and wine with others.In our times, the landscape of monsters has expanded to include the dark side within us and even within sheep. In the absence of the mythical Cyclopes, humans can still be eaten, now by disease, which sometimes devours the brain, disabling and finally destroying the body. Unbeknown to Odysseus, his escape vessel, Polyphemos’ prized sheep, could destroy him if its self-replicating prions could be transmitted to humans. For BSE, a prion disease of domestic cattle, good evidence exists from natural exposure and laboratory studies that this could happen. For scrapie, a prion disease of sheep, the evidence is not there, although the risk remains unknown.Like pottery making, models of disease are fraught with uncertainties. They can be influenced by subtle differences in prion strains from different species of animals. The difficulty lies in demonstrating human susceptibilities in animal models. However, animals are not humans, humans are not identical to each other, and small risk is difficult to demonstrate statistically. We cannot tell if atypical scrapie prions cause human disease because, despite the names we ascribe to atypical proteins, we do not know who they are or what they are capable of until, like Odysseus, they finally announce themselves.


Diagnostic and Statistical Manual (DSM), I considerthe reification of the term ‘FSD’, and the activism and scholarship that the rise of thecategory has occasioned. I suggest that analysis of FSD benefits from scrutiny of a widerrange of sources . I explorethe multiplicity of FSD that emerges when one examines this wider range, but I alsounderscore a reinscribing of anxieties about psychogenic aetiologies. I then argue thatwhat makes the FSD case additionally interesting, over and above other conditions with acontested status, is the historically complex relationship between psychiatry and feminismthat is at work in contemporary debates. I suggest that existing literature on FSD has notyet posed some of the most important and salient questions at stake in writing aboutwomen’s sexual problems in this period, and can only do this when the relationship between‘second-wave’ feminism, ‘post-feminism’, psychiatry and psychoanalysis becomes part of theterrain to be analysed, rather than the medium through which analysis is conducted.In this article I discuss the emergence of Female Sexual Dysfunction (FSD) withinAmerican psychiatry and beyond in the postwar period, setting out what I believe to beimportant and suggestive questions neglected in existing scholarship. Tracing thenomenclature within successive editions of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) is a term that has gained in medical, psychiatric andmedia prominence in recent decades, especially in the last 15 years. It is not in itself adiagnostic category, but has gained a currency that can sometimes suggest otherwise. Femalesexual problems are currently classified in the American Psychiatric Association’s 4thedition of the al (DSM), in a seal (DSM).The DSMfeminism  – criticfeminism .The FSD debate plays itself out in the public and popular domains as well as in themedical, psychiatric and sexological realms. Existing historical scholarship on femalesexuality in the postwar period focuses primarily on sexology e.g. . In thisDSMs. I then give an account ofthe emergence of DSM-III in 1980, and the classifications of sexualdisorders in this manual. I then discuss both the reification of ‘FSD’ as a term, inrelation to Viagra’s emergence in the late 1990s, and the recent activism and scholarshiparound FSD. I explore the multiplicity of FSD that emerges when one examines a wider rangeof sources, but also underscore a reinscribing of anxieties about psychogenic aetiologies. Ithen argue that what makes the FSD case additionally interesting, over and above otherconditions with a contested status, is the historically complex relationship betweenpsychiatry and feminism that is at work in contemporary debates. I conclude with somethoughts about ‘post-feminism’ and the historiographical challenges raised by FSD.I begin by outlining a brief sketch of female sexual problems in the 20th century, andtheir rendering in the first two postwar vaginal orgasm , problems such as impotence and frigidity are an instance of‘Psychophysiological autonomic and visceral disorders’ , of which a ‘psychophysiological genito-urinary reaction’ is an instance. We aretold that these include ‘some types of menstrual disturbance, dysuria, and so forth, inwhich emotional factors play a causative role’  and itsve role’ : 30.  that it argued were unsupported.Disorders were discrete, and operationalized reliably by sets of symptom criteria   see . The manrs’. See DSM-III-R of 1987 changed ‘Psychosexual Dysfunctions’ to ‘SexualDysfunctions’, and lists the various disorders under the overarching categories of ‘SexualDesire Disorders’, ‘Sexual Arousal Disorders’, ‘Orgasm Disorders’ and ‘Sexual PainDisorders’, among other changes . The revisednges see . DSM-IVnges see 2DSM-III, is much indebted to the work of Mastersand Johnson, whose Human Sexual Response and Human SexualInadequacy were published in 1966 and 1970 respectively. Masters and Johnson werenot the first to approach sexual problems with a form of behavioural conditioning, or toemphasize the clitoris in female sexual pleasure , and three female sexual disorders: dyspareunia, vaginismus and orgasmicdysfunction (primary and secondary)  , 1970.   , it appeDSMs;the chapter headings are ‘Psychosexual Disorders’ (DSM-III) or ‘SexualDisorders’ (DSM-III-R), under which the various subtypes appear.In Masters and Johnson’s books, the term ‘female sexual dysfunction’ operated simply as ageneric description rather than as a specific diagnosis; it signified any problem withsexual function as identified in the human sexual response cycle. But the term ‘FemaleSexual Dysfunction’ becomes more prominent after their publications, however. It begins toappear in medical and scientific journals as a phrase only from 1977 onwards; half a dozenresults appear in the 1970s, and the same number in the 1980s – a period when the term‘frigidity’ is waning in frequency. Occurrences of ‘FSD’ from the 1990s onwards jump tobeing in the 500s. And yet there is in fact no such term ‘FSD’ in the This jump in FSD discourse occurs around the time of Viagra’s licensing for ErectileDysfunction (ED) in 1998. Viagra’s apparently phenomenal success, and its astounding sales,put a premium on finding a similar drug for women. Pharmaceutical companies rushed to testViagra in women and sought to develop other compounds , 2006. WWhile they go on to specify particular areas of diagnosis such as ‘vaginal lubrication,pain and discomfort with intercourse, decreased arousal, and difficulty achieving orgasm’,they also state that ‘our knowledge and understanding of the anatomy and physiology of thefemale sexual response and the pathophysiology of female sexual dysfunction is limited’. Andyet, some of the diversity of sexual problems having been roll-called, the slippage to thephrase ‘pathophysiology of female sexual dysfunction’ assumes that the pathway to thesediverse phenomena is one and the same, though it remains to be clearly elucidated. In otherwords, it casts ‘female sexual dysfunction’ as a condition in itself. This pattern is muchrepeated elsewhere, and articles frequently use the term ‘FSD’ in the title, but quicklymove in the text to specifying disorders under consideration . A recenFemale sexual dysfunction (FSD) occurs when a woman is unable to fully experiencepleasure during sexual activity. This dysfunction can affect a woman’s quality of life andlead to personal distress and interpersonal impairments. It is defined as disorders ofsexual desire, arousal, orgasm, and sexual pain. An estimated 40% of women are affected bysexual dysfunction and 1 in 4 is unable to achieve orgasm. : 156definition of ‘FSD’ as ‘disorders of desire, arousal’ and so on – whereasthese categories are not definitions of a disorder, but the diagnosticcategories subsumed under a generic term for them. Moreover, it emphasizes pleasure, whichpotentially brackets out desire problems.In this particularly confused example, FSD is cast as a disorder in itself, offering aone diagnostic category applicable tomen in the ‘Sexual Disorders’ section of the DSM, while FSD is not itsequivalent – it is a generic umbrella term for diagnoses that vary significantly. Thisreification of ‘FSD’ both reflects and bolsters the desire to see ‘FSD’ as a discrete,bounded diagnostic category amenable to a technology that would target it in the allegedlyspecific way Viagra did for ED – a desire that nonetheless has yielded little in the way ofconcrete results.4What we are seeing here is FSD being used as an analogue – a counterpart – to ED, as in anarticle entitled ‘Lifestyle/Dietary Recommendations for Erectile Dysfunction and FemaleSexual Dysfunction’ . But ED The rise of ‘FSD’ and pharmaceutical efforts around it has provoked considerablecontroversy as well as activism. New York sexologist Leonore Tiefer founded the New ViewCampaign, ‘challenging the medicalisation of sex’ see , after tDSM and pharmaceutical developments for sexual problems , part of a larger movementchallenging the ‘medicalization’ of problems seen as social, political, contextual andrelational in nature ‘A lack of desire can be due to many things’, hormone imbalance included, … but usuallyit’s down to a psychological or emotional block. There are so many reasons to freak outabout sex – what if I’m no good? What if I don’t orgasm? It could be that you letnegative thoughts freeze desire before it starts. … Adding pressure will only make itworse, and stress, depression and anxiety are libido killers. Sexuality can’t be forced– it has a life of its own. Talk to your GP and ask for psychosexual counselling., and prolific in medical journals also, advocate a significantly medicaland pharmacological framework for sexual problems, especially the virtues of Viagra andtestosterone; but they too see fantasy, imagination and thoughts as key to ‘helpingyourself’ with your sexual problems. In these texts, emotional, behavioural and cognitivehabits are on a par with medical drugs, pornography and sex toys; factors key to enhancingpleasure and overcoming sexual problems. Likewise, health information websites such asNetdoctor identify a range of factors in sexual problems ’; the stresses ofeveryday life, or being ‘bored by a long-standing sexual routine’  as proof that ED is ‘physical’, not psychological (In the wake of Viagra, much-cited articles state that the context of female sexuality ishighly important, but their priority remains to frame FSD as medical rather than psychiatricor psychological, as in ological .reality of symptoms. Describing a condition as psychological isinterpreted as meaning that it is non-physical; what is not physical is thought to be notreal. So saying that something is psychological is equated with saying it is unreal,imaginary, or fake. ‘Psychosomatic illness’, in popular usage, tends to connote deception,if not of others then at least of oneself, raising sensitive questions about wilfulmotivation and individual culpability (We are seeing here the slippery power of terms with deep ontological and moralreverberations. Claims about what influences diagnostic categories, aetiological narrativesand symptoms themselves are repeatedly interpreted as claims about theThe fraught ontologies in the FSD landscape are, to be sure, not dissimilar fromcontroversies regarding other conditions, Chronic Fatigue Syndrome most notably, wherebitter and tail-chasing debates ensue about the ‘reality’ of conditions (The fact that FSD scholarship tends to be activist-related explains another phenomenon inthe existing literature: a failure to scrutinize, as an object in landscape, the feminismthat sustains the critique of it. Feminist critics were vocal in the criticisms ofpsychiatry, and especially of psychoanalysis, from the 1960s, underscoring gender biases andthe violences these were seen to enable e.g. , 1989. T5 As such, it reveals its own historically contingent identity as part of a particularstrand of Anglo-American second-wave feminism, evincing an antipathy towards thepsychological discourses of sexuality associated with Freud – rather than as part offeminisms that have wrought sympathetic if critical engagement with psychoanalysis (6While feminist critiques of FSD emphasize the social, psychological and contextual factorsinvolved in sexual problems, they sidestep the thorny question of psychodynamicunderstandings of symptoms, or of any potential role of the unconscious in forming symptoms.They articulate a complex position via the nature and causes of sexual problems, but do sounder the shadow of the sins of the fathers – the abuses perpetrated in the name ofpsychiatric and especially psychoanalytic conceptions of sexuality.analysis . And whiIn seeking to understand the FSD landscape, I suggest, it is helpful to widen the lens ofcriticism from discerning the norms of sexuality and gender expressed in explicitlymedico-pharmaceutical discourse – vital though that is – to also scrutinizing feminismitself as a category that is discursively managed across a range of realms: medical texts,popular texts, and indeed feminist texts themselves.Debates about female sexual problems in the postwar period are characterized byambivalences towards the past, and indeed towards the very act of looking back at the past.Medical, feminist and popular texts evince discomfort with harking back to the past ofpsychiatric theorizing – which, in psychodynamic psychiatry, involved precisely a commitmentto the importance of the past in creating symptoms. Moreover, scholarship on these mattersembodies a reluctance to look back, inclusively, at the history of feminism itself: at itscomplex relationship to psychiatry and its past, and how that shapes the modes in whichcritique is articulated.Angela McRobbie has described a post-feminist sexual contract, in which, under the guise ofan equality assumed to have been achieved, young women are attributed with political,economic and sexual capacity. ‘Young women are able to come forward’ – as high-achieving,economically powerful figures – ‘on condition that feminism fades away’, and that theyabandon the critique of hegemonic masculinity and sexism associated with feminism : 16. We rejecting theactivity of looking back at the past. FSD scholarship provides us, I think, with anopportunity – as yet not taken up – to rethink the relationships between ‘second-wave’feminism, ‘post-feminism’, psychoanalysis, medicine and psychiatry. It provides anopportunity not only to think about the intertwined legacies of psychiatry and feminism, butalso to listen to complex discourses about history itself; about what is past, and what ispresent. It is, in other words, an opportunity to ask, and to find out, what kind ofscholarship this particular moment – in psychiatry, feminism and their historiography – ischallenging us to write.What relationship, then, does this historical activity – of including feminism as acomponent in the landscape to be analysed – bear to a ‘post-feminist’ stance that has beendiagnosed as a symptom of a contemporary rejection of feminism? How should one look back,historically and critically, at the feminisms of the postwar period? It is my view that anadequate analysis of the landscape requires, in addition to a critical relationship torejections of feminism, a critical relationship to modes of


This article explores the orientations of lay people in Kenya to science—specifically to biomedical knowledge about HIV—and their struggles to convert this knowledge into meaningful futures. In Kenya, the global response to the HIV-AIDS epidemic has resulted in a highly stratified landscape of intervention. Globally-funded treatment programs and clinical trials, focusing on HIV, channel transnational resources, expertise, and knowledge into specific sites—HIV clinics, NGOs, and research stations—inscribing these spaces as ‘global’ while leaving others decidedly ‘local.’ Rolled out in the form of ‘projects,’ these interventions offer resources and opportunities for a limited time only. Based on ethnographic fieldwork in the city of Kisumu, this article follows the circulation of biomedical knowledge through such projects and its conversion in ways beyond those imagined by policy-makers, as it meets the aspirations of city-dwellers and enters into local livelihoods. Mediated by nongovernmental organizations through workshops and certificates, this knowledge is both fragmentary and ephemeral. I explore the temporal and spatial implications of such knowledge for those who seek to attach themselves to it and shape their identities and futures in relation to it. And I remember when I got [my certificate]…. I never put it down I walked with it for almost like … four days, I just admired it and, ah, I could feel proud of myself because… because I had secured one thing that had taken me a long time. 1 He had been working for this organization and other NGOs as a largely unpaid volunteer for much of the previous five years. During this time the NGO sent him to various workshops that aimed to ‘disseminate’ knowledge about HIV and to train lay people in HIV education, ‘outreach’ work, counseling, and testing. Elias managed to gain several certificates relating to HIV work from his attendance at these workshops. He also signed up as a research subject for a large clinical trial investigating the effect of male circumcision on the risk of HIV infection, and he became a member of the NGO's youth group and got involved in their projects providing health education to the city's youth. He lived in a single room with a friend and gained some income from attending workshops, from the few hundred shillings a month he collected when attending the male circumcision clinic, from his activities as a ‘volunteer’ with the youth group, from the extra tuition he gave to primary school students, and from occasional positions he found within youth ‘outreach’ projects, when he would receive between 100–300 shillings a day (US $1.2 to $3.5) Occasionally he found himself without any of these opportunities, and at these times he sold bottled drinks (‘sodas’) from a stand at the entrance to Youth For Life, which was owned by one of its employees. Alongside this rather piecemeal livelihood, he pursued several courses of further training and education, which he paid for himself in small installments. These included a computer course , a course in ‘community health’ offered by a college in Kisumu , and a course in ‘HIV counseling and testing,’ offered by a counseling college. He managed to complete this last course, and it is his narration of the euphoric moment when he eventually gained this publically recognized and highly sought-after certificate, after five years of volunteering and pursuing piecemeal projects, that I have quoted previously. With the certificate, he was able to act upon his contacts within Youth for Life, and he applied for and secured a one-year job as an ‘HIV counselor.’ By this time his wife had given birth to their first child and he was saving up to bring Ayie (‘I accept’) gifts of money to her father's home. First, however, he intended to save some money, complete his course in community health, secure a diploma, and help his wife to enroll for a counseling course herself. He was hopeful that, with his new job, he would be able to pay the fees little by little, and that his one-year contract with the NGO would be extended.Elias is a young man in his early thirties living in the city of Kisumu in western Kenya. When I met him in November 2008, he had just been employed as an “HIV counselor” at a national nongovernmental organization (NGO) called Youth for Life, whose activities focused on HIV and reproductive health among Kenyan youth.When I began my research in Kisumu in 2008, I was struck by the degree to which HIV and biomedical knowledge related to it infused the city. This took shape materially—in newly built HIV clinics, youth centers, and NGO offices running HIV-related projects; in the density of clinical trials and public health research groups operating in and around the city; in posters and billboards advising people to ‘know your HIV status,’ advertising college courses in ‘HIV counseling’; or offering information about projects, jobs, and workshops on HIV-related interventions. It also took shape in the aspirations, identities, lives, and imaginations of many of the city's residents. While HIV is still surrounded by secrecy and stigma, particularly in intimate relationships between women and men, it is also true that knowledge about HIV and the pursuit of this knowledge have become central to life for many of Kisumu's residents, and this in ways beyond those imagined by AIDS policies that encourage people to shape their lives around ‘positive-living’ and proper forms of ‘self-care.’ Such knowledge concerns not only that required for biological survival—the knowledge of one's HIV status, of the virus, how it behaves, how to protect oneself, or how to live with it—but also the ‘exposure,’ as people call it, to particular ways of knowing, speaking, and acting that are associated with particular institutions such as NGOs and their discourses. Here, one's orientation to scientific, biomedical knowledge, and associated discourses concerning healthy and responsible living, marks one out as someone who is ‘moving ahead.’2Due to its association with science, progress, and the future, the pursuit of knowledge about HIV has become the focus of intense desires and forms of self-fashioning among aspiring young people who have secondary school (and sometimes tertiary) education but few prospects of gaining formal employment, let alone a profession. Associating oneself with HIV-related knowledge allows them to gain visibility as actors within HIV interventions. Yet it is not only people like Elias, who try to gain knowledge, recognition, and eventual employment by attaching themselves to sites of intervention. Middle-aged widows and younger men and women who have little formal education and are HIV-positive find that their own ‘exposure’ to HIV, and thus to clinics and clinical trials, opens up opportunities for them to gain knowledge and skills, to create new identities, insert themselves into new social networks, and become attached to new collectives.In telling me of his struggles over the years to become an HIV counselor with an NGO, Elias returned again and again to two issues. One issue was his pursuit of a certificate and his oft-thwarted attempts to gain one. He had finished secondary school but he had never secured his school-leaving examination certificate, as his father had died the same year, leaving the school fees unpaid, and his relatives had not been able or willing to help him. He had then moved to Nairobi to stay with his older brother, who paid for Elias to begin a computer course, but the tension this caused with his brother's wife forced him to leave. In the following five years, Elias’ struggles to gain a certificate—any kind of certificate, whatever the type or level of qualification—had ended in failure.The second issue was Elias’ attachment to Youth for Life. Over the years, this attachment gave him something he referred to as ‘exposure’—to new knowledge and new ways of talking and acting, which are associated with both NGOs and the growing prominence of HIV and ‘global health’ interventions in Kenya. According to Elias, his exposure began when, after returning from Nairobi to his parent's rural home, a friend had suggested he come to Kisumu and offered to share his rented room. The friend was a member of the NGO's youth group, and he had got Elias the job of selling sodas from the mobile stand located outside the NGO's offices. By placing himself physically in this particular space, Elias had become visible: he met the people who came in and out of the NGO's offices; he saw the NGO staff (and the volunteers attached to its projects) on a daily basis; and he was able to keep abreast of its activities and to take advantage of any opportunities for workshop attendance and volunteering for projects. Through this exposure, as much as any formal training he received, he learned particular ways of seeing, speaking, acting upon, and also moving through the city and its hinterlands. He could observe and pick up some of the professional language and culture of NGOs (which include many foreign organizations and projects). He also learned to orientate himself to the city as a globalized space of intervention and a ‘truth-spot’  concerniNext, I explore the ‘epidemic of knowledge’  about HI3In recent years, ‘Global Health’ has become a dominant term for health interventions in the Global South that involve transnational organizations and actors. Drawing transnational resources, expertise, and discourses into particular privileged sites, such interventions inscribe these spaces as ‘global’ while leaving others decidedly ‘local’ . Rolled 4 Many of these (recorded) interviews read like transcripts of job interviews, as volunteers often initially associated me with the world of NGOs and were eager to make a good impression. As the interviews progressed, however, they also began to voice anxieties and frustrations. The story Elias presented, for instance, was articulate, polished, and emotionally intense. His sentences flowed seamlessly, giving the impression of a practiced performance, and yet, when he narrated how he finally received a certificate, he broke down in tears. Like Elias, I ‘succumbed to the pull of these documents’ (5The article was set in motion by the interviews I conducted with around 40 ‘volunteers’ attached to various institutions (mostly NGOs) on various topics concerning their life histories, families and education, their aspirations and motivations, and their experience of volunteering.cuments’ :8, and I6 Transnational research organizations  run clinical trials of HIV treatment and test interventions such as male circumcision. Since 2004, with funding mainly from the United States, HIV ‘care and treatment’ programs providing free tests and counseling, antiretroviral medicines, and health checks have been made available in HIV clinics  in government and NGO sites.7 Across the city, public health campaigns proclaim that you must ‘know your status,’ while outreach projects encourage lay people to become involved as ‘volunteers’ in promoting the ‘HIV gospel.’ Together, these interventions and activities connect the city and its populations to transnational flows of recourses, medicines, technologies, and expertise. They also locate it as a ‘truth-spot’ , and it congeals in mega-supermarkets, arcades and Internet cafes, fast food restaurants, and evening bars. Fifteen years ago, the streets of Kisumu were trundled over by old cars, decrepit government land-rovers, and the occasional vehicle of a donor-funded project. Today Kisumu is saturated with 4 × 4 s inscribed with the logos of NGOs, donor organizations, and groups conducting HIV research, while the city streets are congested with the newly bought private cars of its middle-class residents. In 2011, the Kisumu International Airport opened, built by the Chinese. Such mobility, wealth and opportunity are not accessed by the majority of the city's inhabitants, however, who live in the equally fast-growing informal settlements and slums, which lack piped water and sewage, rubbish collection, and electricity.The transnational flows of resources, medicines, technologies, expertise, and knowledge of ‘global health’ produce privileged enclaves of globalized medicine, fed by external resources and surrounded by a sea of under-resourced health care. However, not all movements are similarly bounded. HIV/AIDS policies encourage laypeople to become involved in interventions, addressing them as ‘responsible subjects’ who can become orientated to the ‘truth’ of HIV and can disseminate such knowledge and related skills to others. This circulation of knowledge relating to HIV, backed by resources, has shaped its value. Knowledge of HIV, and even the virus itself, has become an economic resource for people at all levels of the social strata. It has also become a means of claiming a moral identity and moral value.bodaboda (bicycle taxi). Life is precarious. Unstable incomes mean that many families live from one meal to the next while medical costs and funeral expenses leave them economically devastated or heavily indebted. In this environment, the clinic's injunction to ‘live positively’—to take on the ‘HIV gospel,’ as one informant put it, of embracing one's HIV status and ‘taking control’ of one's health and life by managing one's medical regimen, diet, and sexuality—is incongruous, to say the least. Some people, especially young women who are dependent on relationships with men, may have no wish to reveal their HIV positive identities. Still, many appreciate the care and advice offered by the HIV clinics, and for the poor, the material support offered by NGOS to those who are HIV positive can be a crucial lifeline. Managing one's HIV positive identity does not therefore necessarily imply a whole-scale ‘conversion’ to a new identity, akin to religious conversion , but rather a more subtle shift between different registers of revealing and concealing, visibility and secrecy. Being positive can be a source of stigma and rejection, but ‘knowing HIV’ can also be of value.The majority of Kisumu's residents survive on the informal economy: selling vegetables, charcoal, or second-hand clothes on the streets, transporting water, or working a For the salariat—professional people with a monthly salary—HIV is a less ambiguous resource. The NGOs and other organizations involved in HIV research and interventions provide good salaries, training, and perks such as travel and per-diems . Those who work for these organizations attend workshops across the country, are exposed to new networks and contacts, and have lifestyles aspired to by many. While few outside the professional classes manage to access such salaried employment and the lifestyles that accompany it, people like Elias can make themselves visible by attaching themselves to NGOs and clinics, seeking ‘exposure’ to workshops and seminars, and thereby gaining knowledge and skills. In this way they gain recognition as people who ‘know’ about HIV and can teach others about it. They may be taken on as ‘volunteers’ for outreach or clinic work, through which they gain further contacts, skills, and some (very basic) remuneration. The ability to ‘know’ HIV opens up not only an (unstable and uncertain) livelihood; it allows one to claim a particular identity and gain visibility and mobility within the city's spaces of intervention. Next I trace the trajectories of some volunteers, focusing on their attempts to position themselves as actors within this economy of knowledge and intervention.Omondi is a community health worker who lives with his wife Star and four children in a solid two-roomed rental house in one of Kisumu's informal settlements. He works at the newly expanded HIV clinic of an NGO, where he registers patients, conducts basic health checks (such as weight and pulse rate), asks them about their health and treatment adherence, and updates patients’ files. In the afternoons, he visits or ‘follows up’ patients who are too ill to come to the clinic or who have not turned up to their appointments.After an introduction by the director of the NGO, Omondi invited me to accompany him on some of his follow-up visits. The first time we did this, as we threaded our way through one of Kisumu's informal settlements, he told me he was HIV positive. He had discovered his status in 2004, when his wife Star, who was then pregnant, tested positive, and took him to get tested too. His CD4 counts were still relatively high and, he told me, he was “doing well.” I was struck by his desire to talk about his own status, and by the language he used: “I know who I am, the person I am, I know who my wife is and who my child is.” On subsequent occasions, Omondi would often talk about how ‘knowing HIV’ had changed his life and transformed his marriage: “Before, I did not know, we hid from each other. Now we are open with each other.” Moreover, ‘knowing’ himself had opened up a new trajectory. As a young man, he had completed secondary school and started a college course, supported by his parents, until the family had run into hard times. He had been forced to return to his rural home and farm, where he met Star and started a family. Frustrated with rural life and unable to use his education, he had turned to alcohol, and Star left him for another man. She eventually returned to Omondi, and the family moved to Kisumu, where she became pregnant with her fourth child. Life remained hard though. As Star told me,sekumaweke [green vegetables], and we would have to eat our daily meal from that money. We could not afford breakfast or any evening meal. We were staying in a house for 400 shillings [US $8 a month] and it was difficult to find the rent. So he left that work and started doing bodaboda [bicycle taxi]. [Later] he left that too. Why? He got a stroke, you've seen his eye? One eye is not good. I think it was the cycling, and the stress. You see he is a learned person, he finished form four and went to college and started architecture, and then all his documents got lost, so now he does not even have a secondary school certificate, someone stole his bag and all the documents got lost.[At that time], I was just about to cry… we had no job, no money. Omondi would get 20 bob [20 Ksh or US $0.40] a day for carrying a sack of 8 which he supplemented by running a bicycle taxi, while his wife sold charcoal, vegetables, or homemade chapatti. Omondi told me that he much preferred volunteering: “I learned so much from that work. I went for further training.” He also continued to be an “active” member of the support group and the NGO sent him on several workshops, for each of which he gained a certificate of attendance. When the NGO began to expand its HIV clinic in 2007 with funds from the US Presidential Emergency Fund for AIDS Relief (PEFPAR), Omondi, armed with more certificates—one in ‘community health work,’ another in ‘adherence counseling’—gained a position as a community health worker with a monthly salary of 11,000 Kenyan Shillings (approximately US $125) on a one-year contract.9During her pregnancy, Star discovered her HIV status and enrolled in a Prevention of Mother-to-Child Transmission (PMTCT) clinic. She joined an HIV positive ‘support group’ and became a volunteer ‘peer counselor,’ spending one day a week talking to pregnant women at the antenatal clinic. She told Omondi of her status, and after initial resistance, he too took an HIV test. This was a turning point, as he narrated it to me. Encouraged by his wife, he joined the support group that met at the NGO-run health center near their lodgings. He became an ‘active’ member of the group, regularly attending the meetings and becoming one of its leaders. The manager of the NGO's health clinic sent him on a training course in ‘HIV/AIDS counseling,’ which gave Omondi a much-coveted certificate. With the certificate and through the contacts between the NGO, he managed, like his wife, to get an unpaid position as a ‘volunteer’ counselor at the new HIV clinic attached to the Provincial hospital in Kisumu. Omondi spent almost three years as a volunteer, gaining a little remuneration (100 shillings (US $1.80) a day if he got work),Many people like Omondi and Star attach themselves in similar fashion to clinics, NGO projects, or community-based groups. Few, however, manage to gain employment. Mariam, for example, had been a volunteer for several projects. She was a widow and lived with the orphaned children of her sister and her own youngest child, who was HIV positive. She had found out her own status after being forced by her husband's family to leave their rural home. A friend had taken her to get an HIV test and introduced her to a patient support group attached to the provincial hospital. Like Star, she became a volunteer ‘peer counselor’ at the hospital's HIV clinic, advising pregnant women about HIV at the antenatal clinic. An NGO trained her as a community health worker, and another NGO enlisted her as a ‘community mobilizer’—someone who walks around a neighborhood and talks to people about HIV prevention and treatment. Later, the hospital started a tuberculosis program and used her as a volunteer ‘tracer,’ connecting patients to the clinic and checking on their adherence to medication. Like her attempts to sell vegetables in her own neighborhood, the income she gained from her attachments to these interventions was unpredictable: some projects paid 100 shillings per day, others 3000 per month (US $50), others promised money that never materialized. Still, she insisted that knowing about HIV had enabled her both to live and to make a living: “I just tell people, this is who I am.”For Mariam, the act of positioning herself within spaces of HIV interventions as a ‘volunteer’ provided a source of income, although it was unstable and had to be combined with other kinds of work. Yet volunteering was about much more than income. Mariam was known among her neighbors as someone who had personal connections at the hospital and the clinic, and at NGOs. Her connections were the outcome of years of volunteering and attendance at patient support meetings, workshops, and training days. They were important to Mariam: through her position in this network she had gained a degree of social standing and recognition, albeit negligible economic advancement. Her volunteering enabled her to make a life in the city, to gain some status and recognition, contacts and networks, all of which fed into a livelihood. Meanwhile, Elias’ ‘exposure’ to NGOs, research, and health interventions held out the possibility—however chimerical—of placing him on a trajectory leading to an office job, further education, economic advancement, and social mobility. It was the access to knowledge and skills associated with the global and immersed in narratives of personal ‘empowerment’ that attracted him. Exposure to spaces of globalized intervention open up, he hoped, a future, one that was tantalizingly visible—he glimpsed it in the lifestyles and mobility of NGO staff, expatriates, and globe-trotting anthropologists. It was almost within his grasp—present and yet absent.Asebedo empowered, “I've been empowered”), while the meanings of ‘graduation’ and being ‘enlightened’ refer to the experience of western Kenyans since the early twentieth century with modern education and Christian conversion as a means of self-making and a route to social mobility. Christian converts referred to themselves as ‘walking in the light’ (this is still a common expression), and the contrast between the darkness of the past and the brightness of the present and future resonates with the globalized meta-narratives of ‘positive living’ through knowing the truth of one's HIV status (10Elias, Omondi, and Mariam often referred to themselves as ‘HIV graduates’ and as being both ‘enlightened’ and ‘empowered.’ This talk of graduation, enlightenment, and empowerment suggests that the process of attaching oneself to a project, navigating the space of intervention, learning new knowledge and skills and gaining certificates, is also a process of fashioning the self as a particular kind of actor, one who moves at ease across the city's global health landscape. The term ‘empowerment’ is closely associated with development and global health interventions (and there is no vernacular translation, people simply insert the English term, V status , 2011. SEconomic empowerment is thus not the sole motivation for people who try to attach themselves as volunteers. They are also attracted by exposure to knowledge itself and to the network of contacts that may open up within and beyond the city, to England and America. The yearning for knowledge is underlined in Omondi's appreciation of his years spent volunteering: “I learned a lot.” Another widowed volunteer, Pamela, joked about her certificates of attendance at HIV workshops, “I have graduated, and people think I'm going to America!”The knowledge one gains from attending workshops and training days is, however, very different from that associated with formal education leading to a college diploma, a degree, or professional training. It is more ephemeral. Moreover, it appears more important in its form than its content. Next I take a closer look at the role of certificates in this economy of knowledge.Unlike Omondi, Mariam had no secondary school certificate but she had gained several certificates of attendance at various HIV-related workshops and seminars. Every inch of wall space in her single rented room, divided into bedroom and living room by a hanging curtain of material, was covered with posters about HIV and AIDS, proclaiming messages such as ‘Know your status’ and ‘Know your rights.’ A large poster displayed two photographs of the same person, ‘before’ and ‘after’ antiretroviral treatment; another showed Barack Obama getting an HIV test when he visited Kisumu as a US senator in 2006. Several framed certificates held pride of place next to a photograph of Mariam at a training workshop on ‘peer counseling’ about HIV. She showed me photocopies of these and other certificates, carefully wrapped up in a plastic bag and locked up in a small cabinet next to her bed. These documents certified her attendance at workshops and training programs; each bore the insignia of the NGO, government ministry, and donor agency involved.juakali economy, defined by physical labor ‘under the hot sun,’ aspired to less exhausting ‘office work.’ They talked to me about their lack of opportunity in terms of missing a vital certificate, such as the school-leaving certificate, and their desire to gain some ‘training’ and ‘move ahead.’ Even those with monthly salaries and office jobs, whom Kenyans refer to as the ‘working classes,’ are not immune to this desire for further knowledge and skills. Many are enrolled in college courses and are pursuing diplomas or further degrees. New colleges have been established and existing colleges have expanded to offer a range of courses—in computing and IT, community development, pharmacy, and HIV counseling—from certificates to diplomas to degrees. Many employees enroll in several different courses consecutively or concurrently, and colleges offer flexible timetables, such as night classes, vacation studies, and long-distance learning courses, to accommodate people's working hours. Staff members of NGOs and research organizations often stay in the office after hours to use the computer for study purposes. Although they often enjoy good perks and higher salaries than government employees, they are mostly on one-year contracts, with little economic stability, and their future is uncertain. Building up a profile of courses and qualifications, they hope, will make them more attractive to their employers.Mariam's hoard of certificates was not unusual. People often showed me certificates, usually wrapped up in a plastic bag and kept in a safe place in the house. As Elias’ narrative reveals, certificates are repositories of much hope and anticipation, as well as pride. Not everyone hoards these certificates, of course, but many people working in the informal or For those, like Elias, Omondi, or Miriam, who lack professional qualifications and formal employment, and who cannot afford diplomas or degrees, certificates that give evidence of exposure to spaces of global health intervention are highly valued documents. Such certificates are part of a broader economy of development  which foCertificates are the focus of much care, hope, pride, and anticipation because they make a claim to knowledge. But on closer inspection, this claim appears rather empty. Workshops on ‘HIV prevention’ or ‘treatment’ provide little information that laypeople do not already know: HIV is a virus transmitted through sexual contact or through the blood, and HIV can be transformed into a life condition through careful self-management of diet, sexuality, and pharmaceutical regimes. What people do learn is the ability to speak about and transmit this knowledge through a particular—global—language, and in doing so, to project a particular identity. Certificates give evidence of this ability and mark the holder as someone who has been ‘exposed.’ They lay claim to a kind of ‘technical know-how’—underlined in the language of ‘graduation’—but also to ‘technical know-who’ , as theyFor those outside the professional ‘working’ class, but who are trying to enter it and thereby, as they put it, ‘move ahead’ in life, certificates offer a hope of recognition, which may open up opportunities within the city's globalized interventions. Yet the kind of knowledge that is circulated through training sessions and workshops is quite different from professional knowledge. Each certificate gives evidence of a specific skill: ‘peer counseling,’ for example, or ‘family life training,’ ‘HIV counseling,’ and ‘treatment adherence’ counseling. Knowledge is fragmented, organized as ‘information’ in discrete units, clustered around specific problems and solutions, and tailored to a specific issue see . The valAs more people acquire these certificates, their value decreases. In Kisumu, ‘HIV counseling’ certificates had a high value when few people possessed them, but their value decreased as people rushed to take courses in counseling. The struggle is then to get a diploma or a degree. In this field, gaining a position, even as a volunteer, is intensely competitive. As the director of a national NGO told me, “There are many who just come by our facility here asking for the same position, to work as volunteers. But they fail to get taken on.” Such organizations may receive 100–200 applications for a position such as data clerk or HIV counselor.In light of this constantly changing landscape of opportunity, people who have decided to live as openly ‘positive,’ such as Omondi and Miriam, as well as aspiring young people like Elias, must continually position themselves in relation to the circulation of new knowledge, and to do so, they have to maneuver themselves into particular spaces, from which they are visible and available to those in authority. Omondi and Miriam positioned themselves within HIV clinics as ‘good’ clients and ‘active’ members of patient self-help groups, as people able to ‘talk the right talk and walk the right walk.’ This involved cultivating relationships, particularly with those who are in responsible positions, who manage and distribute resources. As already noted, Elias sold sodas outside the NGO, offered himself as a clinical trial subject to a transnational research group, joined a youth group, gained some training in ‘life skills’ relating to HIV infection, began several training courses, and, as he put it, ‘tarmacked’ between various institutions, as he built up a network of contacts and a repertoire of skills, while pursuing various courses and certificates. Along the way, to position himself in the right place at the right time, he had to negotiate a changing landscape of NGOs, research groups, and donor-funded projects.Elias’ story reveals the importance of navigation, involving physical presence, availability, and ‘exposure,’ through which people are able to convert knowledge explicitly associated with global health interventions. But his story also points to the instability and uncertainty of these trajectories, as projects fail, resources run out, and colleges disappear. In a landscape of tenuous projects, unstable flows of donor funds, unreliable training programs, and intense competition, projects can be closed down and jobs lost in the space of a few months, and people must return to making do by combining multiple forms of income—selling sodas or second-hand clothes, making chapatti or offering bicycle taxis. The institutional partnerships that produce Kisumu's global health interventions are themselves unstable, dependent on the flows of external funds and on relationships between donors, the Kenyan government, research groups, and various NGOs. Colleges, projects, and interventions may disappear overnight. The one breakthrough that Elias experienced during his five years of ‘tarmacking’ between the youth group, the clinical trial, and the soda stand was when he was taken on as a volunteer ‘district coordinator’ for schools within a project called ‘Straight Talk’: for this he received a regular income of 4000 shillings a month. The project was funded by the German development agency and organized through a national NGO. But when this project came to an abrupt standstill, amidst accusations of management mishandling funds, Elias lost work literally overnight. In recounting the episode to me, he said with a sigh, “So I lost everything, and I could not continue that college course I was following. God knows. I then had to look for an alternative.” He returned to his soda stall and it was some months before his contact with a teacher in a local college gave him a lucky break: the opportunity to pursue an HIV counseling course, and to pay for it in small installments.In Kisumu, as across much of eastern and southern Africa, global health interventions, rolled out in response to the HIV/AIDS epidemic, involve intense efforts to persuade individuals to shape their lives around new regimes of biomedical knowledge. A growing body of scholarship examines how such biomedical regimes and technologies bring into play new rationalities and temporalities, new subjectivities and ‘biosocial’ collectives orientated around forms of self-care . EthnogrIn this article, I have examined the movement, diversification, and conversion of biomedical knowledge beyond forms of self-care, as it enters people's lives in intimate ways. My material suggests that knowledge of HIV is not necessarily inward-looking, used as a technology of the self to shape biological survival and create a ‘responsibilized subject.’ It is also outward-focused, shaping the knower in a wider field of recognition, as an actor within globalized interventions and an ‘enlightened’ person. Here, one's ‘exposure’ to biomedical knowledge and associated spaces and projects of intervention is a form of ‘empowerment.’ It enables the actor to place herself in a forward-moving trajectory. This process is captured in two expressions I often heard among volunteers, project staff, and other city residents: “I am developing myself,” and “I am moving ahead” . While tCertificates operate as extensions of such capacities. They are highly affective documents, deeply entwined with identities and relationships and invested with hope and anticipation see . They caWhy do people invest their identities, hopes, and futures into gaining knowledge and accumulating certificates when their value is so uncertain? Certificates provide evidence of their holder's having embraced a key message of HIV intervention: the empowerment of the self through becoming responsible for one's health, life, and future. They mark an individual's status as a ‘proper’ subject of development . In a shThe production of Kisumu as a truth-spot of knowledge about HIV thus feeds into a particular ‘politics of temporality and affect’ :246. Thi