Entangled agencies: Rethinking causality and health in political-ecology

Introduction

One afternoon, I was sitting on a rough homemade bench in the hard-packed, red-dirt yard of one of the women I often visit. In the waning hours of the afternoon in this rural, mountainous area of KwaZulu-Natal, South Africa called Pholela, we chatted about health, illness, and healing. Glancing into the distance, we saw a few men dressed in mint-green, one-piece, long-sleeved uniforms meander past on the dirt road just below. They were heading home after a long week of working in the forest that surrounded this Zulu-speaking community. Seeing these men sparked a memory for Gogo Memela and she began telling me about isibhobho, an illness that manifests as a pain in the ribs. She told me that one of her grandsons had come down with isibhobho, which was particularly bad because it meant that he could not do his job in the forest chopping wood. At first, the family had thought that he had been injured at work, she explained, but after failed attempts to treat the problem at the local clinic, they were soon convinced it was something else. They settled on isibhobho, which is a witchcraft illness sent from an ill-wisher. The ill-wisher had hired an umthakathi (a person who sends witchcraft) to send the illness to this young man, and the umthakathi had succeeded; the sharp, debilitating pain her grandson felt was proof.

Gogo Memela explained that as her grandson’s condition had deteriorated, the family got more and more worried. They decided to visit an isangoma, a healer who works in consultation with the ancestors, to see if she too thought the young man might have isibhobho. The isangoma did and she prescribed an umuthi (in this case a medication but also understood as a potion), to treat the young man. After taking the treatment, Gogo Memela’s grandson’s health improved and he returned to work.

That Gogo Memela’s grandson was impaired by extreme pain was undeniable. Indeed, he had to take leave from work and could barely get out of bed. His successful treatment and his improved health as a result of the umuthi he received from the isangoma helped to confirm that he was suffering from isibhobho. While simple in this telling, understanding how witchcraft makes a person sick with isibhobho is a complicated affair. In this article, I start from the position that witchcraft makes people sick and that traditional healing makes people better. ¹ In doing so, I use a decolonial approach, by which I mean that I work from the lives and experiences of my research participants—from their ontologies (I explain this more below) (Hunt, 2014). Accepting that witchcraft causes physical illness, as a provocation at the very least, opens up important questions about how people get sick and how they get better, questions that biomedicine cannot answer. At their heart, these are questions about agency in health.

Questions of human–non-human agency have been of central importance in the sub-discipline of political-ecology (Bingham, 2006; Braun, 2004, 2005, 2008; Gareau, 2005; Goldman et al., 2011; Lorimer, 2007, 2012; Neumann, 2009; Whatmore, 2002). In this article, I build on this scholarship to incorporate questions of agency as they relate to health, specifically in political-ecologies of health. In this scholarship, causal chains are clear, even as they are made up of both humans and non-humans. This is like the common biomedical model of causality where A causes B causes C, where the steps are discreet, distinct, and predictable. In this model of causality, social forces (humans) and environmental forces (non-humans) are in important relationships, but they remain separate, at least analytically. Take the example of land degradation so famously articulated by Harold Brookfield and Piers Blaikie. In their analysis, which includes an attention to soil science and erosion along with an analysis of political-economy, they argue that a lack of land and labor in combination with the specifics of soil, topography, and vegetation result in soil erosion. This analysis challenges understandings that blame soil erosion on bad land management techniques by peasants and technocratic solutions (Blaikie and Brookfield, 2015). While significant for what it asserts about human agency, this political-ecology approach offers a model where the social acts on the biophysical—one causes change in the other—rather than a model where they act together.

By contrast, feminist science studies offers a different vision of agency, one where relationships are central. Using the concepts of entanglements and phenomena, drawing heavily on the work of Karen Barad and others, I argue that agency in health is the reconfiguration of entanglements (Barad, 2003, 2007, 2012; Haraway, 2003, 2008; Whatmore, 2002). Phenomena and entanglements highlight inextricability and the importance of relationships without being prescriptive about the form of those relationships and how they act in the world. By recognizing relationships as constitutional and agency as the reconfiguration of more-than-human entanglements, these concepts allow for an understanding of agency that embraces relationships and challenges the biomedical causality that is employed in political-ecologies of health.

To make this argument, I focus on isibhobho, how it is caused, and how it makes people sick. This attention to a witchcraft illness challenges current models of agency in geography and related disciplines and adds to the burgeoning sub-field of political-ecologies of health. I begin with an explanation of the methods necessary to investigate this kind of question, arguing for a decolonial approach. I then offer a grounding in the literature on political-ecologies of health followed by an examination of the literature on human–non-human agency, particularly actor-network theory (ANT) and assemblage theory, arguing for a slightly different approach that draws on feminist science studies. Putting the insights of that scholarship to work, I explore isibhobho, detailing how it works and how witchcraft more broadly works. I then use these insights to rethink agency, putting them to work to explore what agency as entanglement teaches us about agency and causality in health more broadly. Using these insights and focusing on another example—what locals call “these diseases”—I argue that mobilizing entanglements and phenomena offers new possibilities for political-ecologies of health. I finish by speculating about the political possibilities of using a decolonial approach to understand agency through the concepts of entanglements and phenomena.

Methods

In this article, I use feminist and decolonial methods to understand agency and health from the lives and experiences of people like Gogo Memela’s grandson. Feminist methodologies recognize that the divisions between research methods, empirics, and theoretical work are blurry, as each comes about through its relationship with the others (England, 1994; Haraway, 1988; Katz, 1994; Kobayashi, 1994; Moss, 2002; Neely and Nguse, 2015; Nightingale, 2003; Rose, 1997; Staeheli and Lawson, 1994, 1995; Sultana, 2007; Sundberg, 2015). Decolonial methods start from the position that stories—the material a researcher collects through interviews and less formal conversations—are ontologies; they are worlds (Hunt, 2014; see also: Nadasdy, 2007; Todd, 2016). Therefore, a decolonial approach allows us to “take seriously” the stories of research participants (an approach also taken up by the scholars of the ontological turn (e.g. Heywood, 2012)). This insight opens up space for the recognition that witchcraft makes people sick and allows the opportunity to examine how. A feminist approach, with its commitment to grounded theory, then allows for the stories collected (of isibhobho and other illnesses) to provide the material for new theoretical approaches to understanding agency. In other words, by exploring an ontology specific to Pholela through stories of witchcraft illnesses, new understanding of nature–society debates and relational approaches to agency emerge. This decolonial methodology, which centers the stories and experiences of residents, brings together the theoretical insights of the scholarship on agency, ethnographic research, and the reality of sickness in Pholela.

To enact a feminist and decolonial research praxis, I begin with ethnographic research. Since 2008, I have been conducting research in Pholela, KwaZulu-Natal, South Africa. This long-term research has led to strong and deep relationships with a number of families and individuals. These relationships form the bedrock of the research offered here. Central to my work as an ethnographer is continuing observation of everything in Pholela from everyday life to special rituals. This participation and observation of the everyday is central to the analysis I employ. In addition, this enduring presence has given me the opportunity to see many of Pholela’s residents go through various moments of illness and wellness, learning as they get sick and get better about the illnesses they suffer from and the treatment they seek. As a result, I know that the story of Gogo Memela’s grandson’s isibhobho is not unusual. Indeed, I know a number of people who have been sick with a witchcraft illness and got better with the help of izangoma (traditional healers who work with the ancestors). To complement this research, I conducted over a hundred individual interviews and oral histories to answer specific questions about health and healing. In addition to those who experience illness and seek healing, I have interviewed a number of izangoma and izinyanga (traditional healers), about their work, about illness, and about healing practices. I have also observed and participated in diagnosis and treatment for various illnesses, working with izangoma and izinyanga. In addition to my own ethnographic research, I draw on the observations and insights of other scholars, both in Pholela and in the region more broadly who have studied health and healing and witchcraft in particular.

In addition to ethnographic work in Pholela’s communities, I have spent a significant amount of time in the Pholela Community Health Centre and its satellite clinics observing as patients seek care and treatment for their illnesses. Informal conversations with health care workers and formal and informal conversations and interviews with health professionals and community members offer insight into understandings of biomedical illnesses in Pholela. Additional intensive reading of medical literature about illnesses like tuberculosis, how they spread, what they do to and in bodies, and what social and environmental circumstances are particularly amenable to their spread provide key components of my argument. Reading these texts through the lens of critical approaches in science studies offers insight into biomedical understandings of agency and causality in health and illness. Finally, I see ethnography, the research method with which I began, as a key aspect of a decolonial approach for its value as an analytical method. While not the same as inhabiting an ontology in which witchcraft makes a person sick, long-term deep engagement in a place and with its people provides a context at least as important as feminist science studies and other theoretical approaches for understanding isibhobho and what to teaches about agency and health. Embedding my analysis in the stories, lives, and health of Pholela’s residents—in their ontologies—decenters scholarship, offering a decolonial approach. Taken together, this combination of methods and sources, always first rooted in the lives and homes of ill people, offers a way to rethink agency from this place.

Political-ecologies of health

Over the past decade, there has been an increasing interest in questions of health in political-ecology. In geography in particular, the fast-growing sub-field of political-ecologies of health brings together social and biological understandings of and approaches to health. Scholars engaged in this work have taken political-ecology’s long-standing interest in nature–society relationships as shaped by political-economic contexts to better understand questions of health, illness, and medicine (Andrews, 2019; Guthman and Mansfield, 2013; Hausermann, 2015; Jackson and Neely, 2015; King, 2010, 2017; King and Winchester, 2018; Mansfield, 2008a, 2012; Robinson, 2017). Through this work, the broader environments in which people live, the biological processes at work inside their bodies, the social worlds they inhabit, and the political-economy that shapes lives and livelihoods manifest at multiple scales to cause both illness and wellness (Guthman, 2011a, 2011b; King, 2010; Nading, 2014; Neely, 2015). In other words, and in parallel with debates about human–non-human agency, political-ecologists see illness as the result of a combination of the social and the biological. For many, this has meant thinking through health as part of larger environmental questions, such as how and why certain raced, classed, gendered, and sexed bodies are exposed to and get sick with toxins and then how those toxins shape bodies differently (Guthman, 2012; Mansfield, 2011, 2012; Mansfield and Guthman, 2015). This has offered tremendous insight into health conditions that are explicitly environmental like dengue fever (a vector-borne illness, transmitted by mosquitoes), water-borne illnesses, and environmental toxins, as people and the environment are integrated in analysis (Carter, 2012; Nading, 2014).

More relevant to my argument, a number of scholars have taken the lessons of political-ecology to the body, opening it up as a site of inquiry into nature–society relationships (Guthman, 2011a, 2012, 2014; Guthman and Mansfield, 2015; Mansfield, 2008b; Neely, 2015). These scholars build on the long tradition of concerns over the relationships between bodies and environments in health geography (Jackson and Neely, 2015; Moss and Dyck, 1999). Take the example of the science of epigenetics, explored in depth by Becky Mansfield and Julie Guthman (Guthman and Mansfield, 2013, 2015; Mansfield, 2017; Mansfield and Guthman, 2015). They show that the field of epigenetics challenges the idea that bodies are separate from the environments they occupy by demonstrating that bodies are comprised of a number of gene expressions that can be turned on or off depending on various aspects of the environment in which people live. They argue that this understanding of genetics makes it clear that bodies and environments are porous; in other words, they exist in relation to one another. While it has not yet been taken up in all corners of political-ecology, this offers a framework for thinking about agency in health as both social and biological, human and non-human, even as these two components often remain distinct.

One important area for understanding witchcraft that has recently gained traction in political-ecologies of health centers on the question of uncertainty (see also: Murphy, 2006). For example, Nari Senanayake and Brian King (2019) have argued for the incorporation of complexity, uncertainty, and bodies into political-ecologies of health. They point out that in the existing scholarship, researchers understand uncertainty as multiple, coming from a lack of knowledge or measurement techniques, as well as from struggles over definitions, legitimacy, and responsibility, which are often related to complexity. They argue that complexity in this work “provides a strong foundation for re-theorizing cause and effect relationships between the environment and human health” in terms of relationships and multiplicity (Senanayake and King, 2019: 3). This is a particularly important insight for using witchcraft to rethink causality relationally. Senanayake and King also call on political-ecologists, and geographers more specifically, to increase attention to people’s experiences of uncertainty in their own health (this dovetails well with the decolonial approach I employ here). Rethinking health through the lenses of uncertainty and complexity and through the bodies and experiences of ill and well people is important for understanding witchcraft illnesses, as it opens up space for different visions of causality. But even in the inclusive analysis Senanayake and King offer, understandings of uncertainty and complexity remain rooted in biomedical and other scientific paradigms. As a result, while they open up space to think more expansively, their value is limited for understanding agency and causality in witchcraft illnesses and the lessons they offer more broadly.

Human–non-human agency

To better understand questions of agency in health specifically, I turn to debates about human and non-human agency rooted in science studies and mobilized in geography and political-ecology more specifically. In recent years, questions of agency in geography and cognate disciplines have come to focus on non-human and human–non-human agency, bringing the agential capabilities of animals, plants, and other non-humans into broader debates, especially in political-ecology (Bennett, 2009; Bingham, 2006; Braun, 2004, 2005, 2008; Gareau, 2005; Goldman et al., 2011; Latour, 2005; Law and Hassard, 1999; Lorimer, 2007, 2012; Neumann, 2009; Whatmore, 2002). Scholars who work on non-human agency seek to decenter people, recognizing that the things of everyday life—plants, animals, viruses, and even the built environment—help shape the course of events (Greenhough, 2012). In other words, they recognize that non-human things have agency too (Bennett, 2009). Generally speaking, understandings of non-human agency can be grouped into three broad categories: actor-networks, assemblages, and entanglements.

Exemplified by the work of Bruno Latour, Michel Callon, and John Law, among others, ANT sees various actants (a term significant for its openness to non-human actors) as connected to each other through a network (Callon, 1984; Latour, 2005, 2012; Law, 2009; Law and Hassard, 1999). Through the network, the actions of these actants, intentional or not, affect the other actants shaping their behavior. Each actant is therefore shaped by others, both directly and indirectly, as agency is distributed and emerges in the network. In its focus on relationships, ANT is fundamentally interested in shared agency, where agency is distributed among actants and is cumulative. Through its incorporation of humans and non-humans, ANT has had an important impact on political-ecology (Lave, 2015). Take the example of the Saint Regis Paper Company Superfund hazardous waste site in Minnesota, which Ryan Holifield (2009) writes about. Through an ANT-inspired analysis, Holifield asks how a human health assessment at the site might look different if it attended to “the wider webs of human–nonhuman [sic] relations that constitute traditional American Indian worlds” (Holifield, 2009: 650). He takes this a step farther, using ANT to open up questions of “traditional lifeways,” and “spiritual attachment” to land and environment, questions that trouble the separation of humans and non-humans (Holifield, 2009: 650). Holifield demonstrates that the openness of ANT to relationships and social worlds that move beyond the human sets up new ways of doing health–environment research. So doing, he asks how environmental risk assessments work, who they work for, and what they leave out. This approach is particularly generative for thinking about witchcraft illnesses, which, like “traditional lifeways,” do not fit neatly into quantifiable and scientific frameworks.

Drawing on the work of Deleuze and Guattari, the branch of assemblage theory most commonly mobilized in political-ecology understands non-human agency through the assemblage. In the assemblage, humans and non-humans act as they relate to one another. One difference from ANT is that assemblage theory scholars see all entities—human–non-human assemblages and their component parts—as relational (Anderson et al., 2012). Further, scholars who employ assemblage theory understand assemblages to be heterogeneous and productive, meaning that they act in the world and are more than their separate parts (Anderson et al., 2012; Deleuze, 2004; Deleuze and Guattari, 1987; Müller, 2015). Another significant difference with ANT is that in assemblage theory scholars who work through the assemblage often trace power hierarchies within the assemblage as emerging through the relationships of the different human and non-human components (Müller, 2015). As a result, questions of power are embedded in assemblages and the theory that explains them. One aspect of assemblages that is particularly useful for understanding illness and healing is the focus on relationships and process without detailing causal pathways. (This is different from ANT where relationships are mapped in a network, causality is additive, and relationships are more stable.) In this way, an assemblage helps us understand something like witchcraft illness where a person gets sick because of witchcraft, even as it is not clear exactly how the various components of the illness relate to each other. A number of political-ecologists have taken up assemblage theory to great effect (Braun, 2008; Braun et al., 2010; Escobar, 2008, 2010; Hinchliffe, 2008; Ranganathan, 2015). Take Laura Ogden’s (2011) work to reimagine cultural and natural landscapes as ever entangled in her study of the Everglades. She uses the concept of the rhizome to understand the Everglade’s landscape as “complex and changing assemblages” “that come into being only through their relations,” relations which are always about humans and non-humans and are clearly power laden (Ogden, 2011: 29), In this telling, the Everglades are a landscape constantly in the process of becoming thanks to the human–non-human relationships that have produced it. Moreover, it is the relationships, not the individual components, that matter. Through her use of assemblages, Ogden offers a human story of the Everglades that is always entangled with its natural story, so entangled in fact, that she leaves her reader questioning any impulse to see nature and culture as separate. From Ogden and others, the promise of assemblages for thinking about nature–society relationships is clear.

Finally, the work of feminist science studies scholars builds on and pushes beyond assemblage theory to think relationally from the start, making space for beings that are hard to categorize as either human or non-human. For scholars like Donna Haraway, Karen Barad, and Sarah Whatmore, everything is relational. This means that there are no distinct, individual elements, as is the case in ANT and assemblage theory (Barad, 2007; Haraway, 1991, 1997, 2008; Whatmore, 2002). As Haraway writes, “Beings do not preexist their relatings” (Haraway, 2003: 6). In this thinking, there are neither individuals nor individual elements; things and people come into being through their relationships with each other, relationships that are constitutional. As Whatmore demonstrates in her work on hybrids, the distinction between humans and non-humans is a false one, because everything and everyone is the product of relationships (Whatmore, 2002, 2006). Haraway further points out that it is through relationships that we get “bodies the matter,” in the words of Judith Butler (Haraway, 2003). ² This assertion is particularly valuable for thinking about agency in health and healing, as sick and healthy bodies like that of Gogo Memela’s grandson come into being—come to matter—through relationships.

As I mentioned above, feminist science studies offers a particularly valuable concept for thinking about agency and causality in health and illness: entanglements. I find entanglement useful for three main reasons. First, it offers a non-prescriptive way to think about relationships. By this logic, relationships are most important and exactly how elements relate is less important. Second, causality and agency are about relationships rather than individual elements; the entanglements that make up isibhobho act in the world through relationships. Third, entanglements open up space for beings which are neither human nor non-human, like ancestors and incantations; beings which are already relationships. For witchcraft illnesses and healing regimens where all sorts of beings—ancestors, healers, plant and animal parts, incantations, and more—come to matter as they relate to each other and as they heal or harm, entanglements offer a particularly useful framework for understanding agency. ANT and assemblage theory are invaluable for incorporating non-humans into thinking about agency and in understanding agency as relational and distributed. However, by starting with relationships, rather than individuals, entanglements eschew categorization. So doing, they question the division of humans and non-humans that underlies ANT and assemblage theory. This then offers space for still other relationships to cause change. In other words, a feminist approach helps us rethink agency as relationships and entanglement in health without a predetermined categorization to underpin it, thereby opening up a space for harder-to-categorize beings, different understandings of agency, and different modes of causality.

Witchcraft in action

To understand what witchcraft can teach us about agency and health, I turn to an in-depth examination of how witchcraft works, using the example with which I began of Gogo Memela’s son’s case of isibhobho. As we already know, isibhobho causes a debilitating pain in the ribs and overwhelming fatigue. To make a person sick with isibhobho, an ill-wisher hires an expert, an umthakathi, to make an umuthi to make a specific person sick, in this case Gogo Memela’s grandson. In this way, isibhobho is the product of intent. There are any number of reasons to send an illness: jealousy, a desire for revenge, general dislike, and so on. To send isibhobho, one goes to an umthakathi because abathakathi (the plural of umthakathi) hold specialized knowledge and have skills to send illness which others do not possess. The person who is sending the illness collects the umuthi from the umthakathi. And then, as one old woman told me (and as several healers confirmed), she puts the umuthi in her mouth in the morning and spits it out in her yard saying the name of the person she wants to make sick. This action sends isibhobho to the intended victim, who then develops a terrible, debilitating pain in their side, a pain that can only be cured by a healer who heals in consultation with the ancestors.

In this example, a person becomes sick as a result of an ill-wisher, an umthakathi, and the umuthi, though it is not yet clear how. In the most direct sense, the umuthi makes a person sick; it is the agent of illness. Designating an umuthi as a causal agent for illness is like saying that a lack of nutrients makes a person sick with malnutrition or that a bacterium makes a person sick with tuberculosis. It points to a specific causal agent without acknowledging the socio-material context from which that cause emerges. Examining the umuthi in detail tells a different, more complicated story. Witchcraft illnesses, like all illnesses, are embedded in complex socio-natural entanglements, which shape if and how a person gets sick. Therefore, in order to understand causality for isibhobho and other witchcraft illnesses, it is important to examine the specific entanglement of humans, non-humans, and others that make up the umuthi.

For an umuthi to be effective, for a witchcraft illness to spread, a number of people—humans—must be involved, as well as a number of ingredients—non-humans. There must be a person to send the illness and an intended victim to receive it, which means that there must be some unrest in the family or in the community. There also must be an umthakathi to make the umuthi. To make the umuthi, the umthakathi collects a specific set of ingredients that include plant and animal parts gathered from the forest and from markets and she prepares them in a particular way, combining them in specific quantities. The way she combines the ingredients matters: the order of that combining, the act of stirring, the process of combination. In other words, the production of an umuthi involves ingredients, quantities, and a procedure for combining them. That said, even if someone who is not an umthakathi knew all of the ingredients in a particular umuthi and the correct procedure for production, she would not be able to produce the umuthi because the umthakathi is a vital component. To be effective, the umuthi requires an umthakathi, a person who sends witchcraft and who, as a result, holds specialized knowledge and skills often rooted in her ancestors. Unlike most people in the community, an umthakathi holds the power to enlist the ancestors in her work to inflict physical harm on individuals from a distance.

A significant amount of an umuthi’s power comes from the fact that the umthakathi works with the help of her ancestors, the members of her family who have passed on and from whom she has learned how to harm. In Pholela (and throughout sub-Saharan Africa), a person’s ancestors have significant power over illness and wellness, possessing the ability to make individuals sick and to keep them healthy (Feierman, 1985, 2000; Feierman and Janzen, 1992; Ngubane, 1977; Wilson, 1936). Abathakathi are therefore some of the most powerful people in a community, thanks in part to their ancestors and to their close relationship with them. (The same is true for izangoma, who work with the ancestors.) The umthakathi talks with the ancestors while she is making the umuthi. The incantation she offers, significant as a way to enlist the ancestors, is also important in and of itself; any old words would not work. Insofar as they are integral to the umuthi, the umthakathi’s words help to cause illness, just as the ancestors aid in both harming and healing; they are constitutive of health.

For an umuthi to work—to cause a person to have isibhobho—all of these components must come together under the correct circumstances. If there is no intended victim, if the ancestors do not help, if the specific ingredients are not combined in the right order, in the right quantities, at the right pace, if an umthakathi is not involved, if she does not speak the right words, if the perpetrator of isibhobho does not take the umuthi into her mouth, spit it out, and say still more words—if just one of these pieces is missing—the person might get sick, but he or she will not get isibhobho. The umuthi that causes isibhobho—the proximate cause of illness—is all of these components simultaneously. The umuthi’s ability to cause isibhobho emerges from the relationships of its component parts.

Agency in health: unpacking isibhobho

To better understand agency for witchcraft illnesses and health more generally, it is helpful to return to feminist science studies and in particular to the work of Karen Barad. As detailed above, feminist science studies scholars stress relationality. To understand the world through relationships, Karen Barad offers the generative concept of the phenomenon (Barad, 2003, 2007, 2012). Through the phenomenon, she explores the relationships of “matter and meaning,” things and ideas, humans and non-humans. The use of “and” here is significant; it indicates a relational approach, rather than an oppositional approach, to understanding things that are often seen as dichotomous. For my purposes, phenomena are the specific entanglements of matter and meaning that make up illness and wellness. Barad sees phenomena as “the primary ontological units,” echoing Haraway’s insight that “beings do not precede their relatings” (Haraway, 2003: 6). By calling these phenomena the “primary ontological units” (Barad, 2007: 141), Barad asserts the primacy of relationships as the root of existence, noting that everything and everyone comes into being through their entanglements. Matter and meaning—knowledge about isibhobho, the pain in the side, fatigue, upset in social relations, the umuthi that caused isibhobho, and more—together make up the phenomenon of illness. These ontological units—the phenomena—are illness.

Following this logic, isibhobho as a phenomenon, is the product of the umuthi that harms, the efforts of the person who sends the illness, the physical experience of illness in the ill person, efforts to heal, and the social relations within and beyond Pholela that shape who gets sick when, why, and how. And all of these are the product of many, many more relationships. The idea of entanglements is particularly useful here. As explained above, it accounts for the relationships among all sorts of actors without a prescriptive account of how they relate. In other words, it allows for the possibility that witchcraft makes a person sick without necessarily knowing the exact form relationships take or the direct causal pathways of the components of illness. For example, whether an ancestor works on a single ingredient or through the umthakathi or directly on the ill person’s body does not matter; agency is the product of relationships of people, things, and others. This example highlights one other strength of thinking through phenomena and entanglements: the recognition of beings as relational from the start. Ancestors matter in relation to bodies and ingredients and vice versa. ³ In the phenomenon, the exact temporal and spatial details of the entanglements—the exact individual cause and effect chain, the exact agential pathways—are not important, because isibhobho emerges from the entanglement as a whole; isibhobho is the phenomenon. ⁴ Moreover, as Barad explains, the various components of the phenomenon do not preexist the phenomenon; they do not preexist their relationships with each other, at least not in terms of their importance for the umuthi and the illness it cause. Significantly, the concept of entanglement recognizes that the relationships that constitute a phenomenon need not be mapped; we do not need to see them in an actor-network or through a diagram because they are co-constituted and emergent. As such, entanglements offer a mode of thinking and a model of causality that not only accepts, but embraces uncertainty, at least in the scientific sense. This is one of the lessons from feminist science studies. So doing, it offers important possibilities for the excellent work on uncertainty in political-ecologies of health.

This understanding of illness as phenomenon helps to explain isibhobho, but we still need another piece to understand the illness; we need to examine how isibhobho becomes visible. For Barad, phenomena are made visible through the practices through which they are enacted—the act of producing the umuthi, putting it in the mouth, spitting it out, and saying the person’s name. The practice of sending illness, the perpetrator, the victim, the ancestors, incantations, and the umuthi are all entangled and it is through the enactment of this entanglement that isibhobho passes. Further, it is through practices that agency becomes visible in the phenomenon. In her work on atherosclerosis in a hospital in the Netherlands, Annmarie Mol points out that the notion of enactment allows a focus on practice and process without pointing to a precise actor or group of actors, and without detailing specifically how they act (Mol, 2002). ⁵ Following this logic, we can recognize illness and health as they come into being even if we do not fully understand the specifics of the relationships. Yes, we know that saying a name and spitting out an umuthi is necessary to pass isibhobho, even if we do not know how the ancestors infuse the umuthi with the power to harm or why one particular combination of words and ancestors is better than another. The debilitating pain Gogo Memela’s grandson experienced as a result of isibhobho makes it clear that more-than-human relationships matter to health and illness. When we focus on practices—the production of an umuthi, the act of sending illness, experiencing the physical symptoms of illness, and accessing healing—we see that illness is the product of the agency of entanglements; it is actively produced through phenomena made from specific entanglements of matter and meaning.

By focusing on practices and entanglements, an umuthi can make a person sick, witchcraft can make a person sick, even if causality within the umuthi remains unclear. The phenomenon exemplifies this approach as the primary ontological unit made up of relationships. Using this framework, once again, we see that isibhobho is a phenomenon that includes a victim, his family, an umthakathi, neighbors, some plants and animal parts, words, knowledge, ancestors, intentionality, and more. Understanding agency through entanglements not only reduces the role and importance of individual components, but it allows one to question the very existence of distinct components to begin with. Indeed, feminist science studies teaches that entanglements are irreducible. In isibhobho, therefore, the materiality of illness is irreducibly entangled with the sociality of illness; there are no separate components, there are only relationships. This is different from both ANT and assemblage theory, where actors and actants remain distinct even as they shape and are shaped by each other. But this is not the only difference. Certain key elements of isibhobho, like ancestors and incantations, defy the categories of the social and the material, human and non-human, which undergird ANT and assemblage theory. Indeed, these vital components of the umuthi and the phenomenon of isibhobho, components which are neither human nor non-human, highlight even further the primacy of relationships over individual components. And yet, enacting an analysis rooted in this approach from feminist science studies is tricky business. It teaches that the analysis of umithi and isibhobho I offer here where I break down the various parts, undermines the integrity of both the umuthi and isibhobho; it misunderstands the phenomenon.

The concepts of entanglement, phenomena, and practices are all helpful for understanding how witchcraft makes a person sick, but they do not answer the question of agency directly. For that, I turn again to Barad, who writes, “Agency is not held, it is not a property of persons or things; rather, agency is an enactment, a matter of possibilities for reconfiguring entanglements” (Barad, 2012). In this telling, agency comes through the particular entanglements, the configurations of people, things, ideas, and more—the “material-discursive apparatuses of bodily production”—that are enacted (Barad, 2012). Just as with Haraway, Barad’s focus on “bodily production” is particularly generative for thinking through health because health and illness are always experienced in the body. In the case of isibhobho, this means that the entanglement—the phenomenon—that is the illness acts through its relationships to disrupt the entanglements that have produced a healthy body; it acts by forming new relationships that disrupt bodily production. By this logic, ill bodies are more than straightforward examples of embodied illness; they are the reconfiguration of entanglements. ⁶ In this sense, a person’s health, just like an illness, is an entanglement. Because agency comes from the reconfiguration of entanglements that are phenomena, built through even more phenomena (which are the primary ontological units), agency does not precede the phenomenon, just as the various components of the phenomenon do not precede their relationships. Instead, agency emerges through relationships, which reconfigure other relationships; the phenomenon of illness reconfigures the phenomenon of the healthy body.

But even this is not enough. While Barad sees agency as “a matter of possibilities for reconfiguring entanglements,” in the case of illness, agency must be enacted; it must do the work of reconfiguring entanglements. In the words of AnneMarie Mol, it must be practiced. Agency is the result of entanglements in action. As Barad writes, “[A]gency is a matter if intra-acting; it is enactment, not something that someone or something has” (Barad, 2007: 178). The concept of “intra-action” as opposed to interaction is significant. Intra-action highlights the primacy of relationships as key for agency, rather than discrete beings interacting, the phenomenon itself intra-acts to cause change. In this telling, agency emerges through relationships, which are fundamental to being; agency is not something innate. This is quite different from ANT where actants, all of which hold the capacity to act, underlie the network, or in assemblage theory where all individual elements possess the possibility of action. Following this logic, words, plant parts, and angry neighbors do not possess the agency to make someone sick on their own, their agency emerges only through their relationships with each other. As Barad explains, this understanding of agency relies on a radically different idea of causality. In this approach, agency is a matter of intra-acting, it is relationships, and it does not preexist relationships. In biomedicine, political-ecology, and even in ANT, causality can be mapped, even if it is multiple. Further, in these frameworks, causality is clear, as each individual component interacts (as opposed to intra-acts) with the next to cause change. Isibhobho reveals that causality also works differently. Likewise, Barad and other feminist scholars offer something different: a causality that is about relationships, relationships that are always in the process of becoming. For these scholars, if phenomena are the primary ontological units and they are entanglements, then causality—agency—emerges through relationships, which become visible as they reconfigure other entanglements.

Conclusion: toward entangled agencies in health

A more relational approach to understanding causality, one that embraces uncertainty, is significant because it sets up the possibility for an understanding of agency as emerging from relationships. This model of agency is helpful for understanding illnesses beyond witchcraft too. While, the lessons of political-ecologies of health with which I began have started to trouble the strict biomedical models that frame common understandings of agency in health, the idea of entanglement does more. As I explained earlier, drawing on many of the same theoretical traditions that ground debates about human–non-human agency, political-ecology sees health as the product of nature–society relationships (Mansfield, 2008a). Through this orientation, humans and non-humans—bacteria, cells, families, livelihoods, and economies—cause illness as they interact with each other.

In spite of its more expansive approach, however, political-ecologies of health pose little challenge to biomedical notions of causality (beyond questioning separation of nature and culture, which is significant). There are, of course, good reasons for this continued focus. After all, causality offers an important language for talking and writing about agency. Take the example of tuberculosis, which is primarily a lung infection caused by bacteria. Once a person inhales the bacteria, the tuberculin bacilli interact with cells in a lung, changing them, multiplying, perhaps moving in the body, and causing a cough, night sweats, a sore chest, and fatigue. They also replicate enough so that they can be seen through a microscope in sputum (Jasmer et al., 2002; WHO, 2011). In this simplified biomedical explanation of TB, it is the bacteria that causes the illness as it interacts with parts of the body. By this explanation, treatment is obvious: antibiotics, which kill the bacteria and stop the spread of disease. A political-ecology of health approach offers something different. While the bacteria is the primary agent, whether or not a person becomes sick with TB depends on the number of infected droplets the person has been in contact with, the quality of the ventilation in the spaces she shares with others who are sick with TB, how often she is exposed to the bacteria and for how long, the virulence of the TB strain to which she has been exposed, and the strength of her own immune system. ⁷ And the strength of her immune system depends on her nutritional intake, other illnesses, access to medical care, housing, and more; it depends on political-economy. In other words, whether or not someone becomes sick with TB depends on a number of factors beyond the biological. In this telling (one which I have offered elsewhere), TB is caused by a bacterium as it comes into contact with people’s bodies and the landscapes in which they live, both of which have been shaped by poverty, inequality, and other broad political-economic factors (Neely, 2015; Packard, 1989). In this political-ecology of health approach, political-economy and the biophysical environment together—society and nature—have agency over health. While not exactly the same as the strict biomedical causality focused on bacteria that I offered a moment ago, in this telling, the various steps are discreet and clear, as together the environment and the political-economy—the non-human and the human—lay the groundwork for illness. In other words, in this combination of the social and biological sciences, discreet causality remains intact, even as this combined analysis poses a challenge to strict biomedical understandings of causality, and even if it is an explicit recognition that the social and biological are inextricably linked (which is, of course, a radical departure from biomedicine).

While perhaps useful for understanding diseases like TB, this approach is still limited, especially in terms of the decolonial approach with which I began. Exploring illness through the lives and experiences of Pholela’s residents and taking seriously their articulations of illnesses leads to the understanding of agency as entanglement. In addition to helping to explain isibhobho, this understanding can help explain diseases familiar to biomedicine but does so from the perspective of Pholela and its people. Take the example of the epidemic of illness among the youth (people aged 15–35) in 21st-century South Africa, what the people who live in Pholela refer to as lezizifo zamanhlange or “these diseases.” While often understood as HIV/AIDS, the formulation of “these diseases” indicates something more. In its plural articulation, it makes reference to the fact that in the first decade of the 21st-century, the youth were sick and often dying from all sorts of diseases recognized by biomedicine, including tuberculosis, shingles, pneumonia, meningitis, and more. In its translation as HIV/AIDS, the common assumption is that these diseases prey on the bodies of people whose immune systems have been compromised by HIV. But in Pholela, young people who die of chronic conditions like unchecked diabetes or a hypertensive episode or tuberculosis that they contracted even though they are HIV-negative also die of “these diseases.” When starting from Pholela, these diseases is not just HIV.

“These diseases” also provide a way to articulate the troubles with and of youth in the post-apartheid era. As such, it is a way to describe the failures of the state, the ongoing impact of racial capitalism in South Africa, the disappointment of parents and neighbors, insufficient health care, and unmitigated illness. As Pholela’s residents know well, the youth should not get sick and die. Their ill health is not only the result of a terrible virus and the microbes that prey on a compromised immune system; it is also the result of an inadequate health care system, unhealthy food, poorly ventilated spaces, a population weakened by poverty, and a state that should care about them but does not. For others still, it is the result of angry neighbors, the abathakathi they hire, and the imithi they send. This epidemic and the individual diseases that comprise it challenge scientific causality which often focuses on a single disease. “These diseases” are devastating and are the result of relationships among people, microbes, the state and its newly enfranchised citizens, political-economy, cheap food, angry neighbors, disappointed elders, uneducated youth, ancestors, healers, and more. In this articulation of a health problem, an articulation from Pholela, the causal chains that science relies on are impossible to map. The epidemic is all of these things at once as they relate to each other; causality is entangled, just as it is with isibhobho.

Employing a decolonial approach, which starts in Pholela with the ways residents explain illness opens up important questions about agency and causality in health. When coupled with Senanayake and King’s (2019) call to better attend to questions of uncertainty through an attention to context and relations in political-ecologies of health, an understanding of causality as more-than-human entanglement holds potential for both understanding health and working toward healthier futures. Indeed, an understanding of agency through entanglement opens up multiple places for interventions and treatment for illnesses like “these diseases” and isibhobho. In the case of “these diseases” where ill health is the result of the entanglements of a number of illnesses, poverty, the unmet promises of the end of apartheid, a lack of respect for the elders, compromised immune systems, unhealthy food, unemployment, and more, a change to just one of these relationships would help to reconfigure the bodily entanglements of the sick person and help make her or him healthy. Of course, a shift in something like overall poverty (as opposed to pharmaceuticals that treat a virus or control blood sugar) would have a much bigger impact on the bodily entanglement that makes certain people more susceptible to illness than others. And here again, drawing in part on assemblage theory, a feminist science studies approach to agency incorporates and highlights an attention to power differences. This means that certain components of the entanglement can and do have more influence than others. This is, of course, one of the lessons of political-ecology—that uneven power relationships, often read through political-economy, have an enormous impact on biology. And it is a lesson that has been mobilized to great effect by many scholars, including myself. But it is an approach that remains insufficient. An attention to the unevenness of the phenomenon teaches us that while antiviral medication or slow release insulin will help to reconfigure the entanglements of the sick body to help make it healthy, they will only do so for one of the diseases that make up “these diseases.” By contrast, a shift in livelihoods or broader political-economic structures will lead to a reconfiguration in the entanglement of the body which will make it more resilient to illness more generally, leading to much more far reaching implications. Herein lies another important insight to understanding agency as the reconfiguration of entanglements: because illness is the product of a phenomenon that reconfigures the entanglement of a body, illness can be treated or stopped by either reconfiguring the entanglement of illness or the entanglement of the body, or both. This plurality of possibilities opens up even more potential for change.

This same logic can be applied to isibhobho, where getting treatment from an isangoma can reconfigure the bodily entanglement of illness, but, where a change in social relationships—an improvement in relationships among family members or the resolution of a dispute within a community—can prevent witchcraft illnesses from passing at all. In other words, because isibhobho, like all illnesses, is an entanglement that reconfigures the bodily entanglement of the victim, a reconfiguring of isibhobho and/or the body could treat or prevent sickness in an individual. The lessons of isibhobho and “these diseases,” the lessons of feminist science studies—that agency is relational and that causality results from the reconfiguration of entanglements—would not be possible without a decolonial approach that resists translation and recognizes stories, the articulation of health problems, as ontologies. This perspective leads to an understanding of agency and causality through the stories and experiences of Pholela’s residents, through the illnesses and the healing they articulate and practice. By tracing these stories and the practices through which illness and good health are enacted, a new understanding of causality emerges. An understanding which is significant for the multiple openings it offers for healthier futures.

The lesson of agency as the reconfiguration of entanglements and a decolonial approach is significant beyond health and illness and beyond political-ecology. By starting analysis from ontologies that are never entirely reachable by biomedicine, a decolonial approach offers possibilities not available to the sciences. In addition, if agency is the reconfiguration of an entanglement, and entanglements are many things at once, then multiple entry points for (material) political change emerge. This is markedly different from other approaches and other models of causality where the path to change is prefigured. The possibility for reconfiguration offers more possibilities for entry, for change, for healthier futures. Moreover, because entanglements are about relationships, reconfiguring them will necessarily mean that all aspects of the entanglement will change. This model for change is flexible and resilient as it embraces unintended consequences. This multiplicity holds significant potential for reframing agency in health through entanglements and opens up new avenues for inquiry and analysis in political-ecology and beyond.

Highlights

Draws on feminist science studies to offer a relational agency for political-ecologies of health