The waiting room at the Pitanguy Plastic Surgery Service Center, located in a public teaching hospital in Rio de Janeiro, has a huge bronze plaque listing the names of surgeon "donors" that have made this service possible. Facing that plaque, there are dozens of benches lined one after the other, which are completely filled every Tuesday morning with middle and working-class patients anxiously waiting for their turn. These patients, a great majority of whom are women and have endured waiting lists of up to a year, have not come seeking medical treatment, but for the final medical examination before their long-awaited plastic surgery is scheduled. Women, seeking to erase the traces of motherhood from their bodies, and men, seeking to remasculinize and rejuvenate their appearance, are trying to remake their bodies as modern bourgeois subjects but cannot afford it elsewhere. For it is only at public hospitals like these that they have access to affordable plastic surgery, either partially or fully subsidized by the state and by surgeons' non-profit organizations. Some complain that they will be operated on by student-residents, and gossip about the "botched jobs" that occur every once in a while, yet they unanimously reiterate what I have already heard from plastic surgeons and from the popular media - the immense respectability of this service, which expands "the right to beauty" to all strata of society, rather than limiting it to those consumers who can afford it. Through cosmetic surgery, these patients imagine themselves to be actively participating in a national project that epitomizes medical modernity, and thus to be assimilating into the nation as modern citizens. I want to suggest, however, that plastic surgeons and the state depend on these patients and their bodies to market Brazil as a global player in the cosmetic surgery industry; and that charitable organizations such as the ones I described, may in fact be key mechanisms to transnational capital accumulation.
Most of the clinics that provide low-cost plastic surgery were founded in the 1960s as educational centers for medical students, and originally provided only reconstructive procedures for burn victims and people with congenital defects. In the last few decades, however, these clinics have increasingly catered to aesthetic demands. They receive state support for their medical practices by blurring the difference between what are reconstructive and aesthetic designations. By privileging aesthetic procedures, these clinics have also become the main centers for the generation of innovative procedures through clinical trials. Most plastic surgeons have parallel private and public practices, so they are able to market the new techniques they develop in the low-cost clinics to their more wealthy clients. In fact, many foreign doctors and foreign patients come to Brazil every year in search of those cutting-edge, marketable techniques. In turn, this increases the national and international reputation of Brazilian surgeons, and raises the demand among Brazilians of all economic backgrounds. The dependence of this transnational commerce on subsidized plastic surgery, however, is deemphasized by most Brazilian surgeons, who instead favor a narrative where their creative and altruistic role as "surgeon-artists" is of utmost importance. The medical ideology thus performs an erasure of the complex networks by which medical knowledge and medical technologies are produced, a process Latour calls "black-boxing" (Latour 1987). A black box is always constructed after-the-fact, when one can look back and attribute one's discoveries to personal genius and to "Nature," rather than to specific circumstances made possible by the cultural politics of global medicine.
This paper attempts to reopen the black boxes of Brazilian plastic surgery by questioning the teleological narrative of medical progress and the discourses of democratic access and beneficence that surround the practice. Brazil prides itself on having the largest rate of plastic surgery per capita in the world, and their most famous plastic surgeons are considered great humanitarians and national heroes. Physical beauty has become inextricably tied to the nationalist and global imaginary about Brazil, such that it has become hard to conceive of a Brazilian national identity without an aesthetic component to it – what I call "cosmetic citizenship." Having the right to consume not only plastic surgery, but all the beauty products, dietary practices and physical regimes that produce a "fit" body, is seen as central to forming part of the modern Brazilian State, especially in big urban centers like Rio de Janeiro. Yet this form of citizenship remains simply "cosmetic," in the sense that it conceals and reproduces the structural inequalities that make of Brazil an exceedingly stratified society. I want to explore how the cosmetic industry markets democratic ideals of equal access and equal opportunity, at the same time that its very development depends on unequal access to health care, at a local, national and global level.
Feminist scholars have extensively critiqued plastic surgery, denouncing it as a site where the medical gaze constructs the female body as fragmented and incomplete, giving the surgeon the authority to reinscribe gender norms onto the body (Balsamo 1992; Bordo 1993; Wegenstein 2005; Wolf 1991). Histories of plastic surgery have similarly argued that plastic surgery was first developed to erase ethnic markers considered deviant, and thus impose a conventionalized notion of what an "American" body should look like (Gilman 1999, Haiken 1997). More recent ethnographic interventions, however, have put into question the uncomplicated imposition of social norms onto the body through plastic surgery. Patients are now seen as active participants who imagine, enact and shape the practice of plastic surgery in ways that are paradoxically empowering and disempowering at the same time (Blum 2003; Davis 1995, 2003; Gimlin 2002). My research follows this line of ethnographic work, and attempts to examine how in the Brazilian context race, class and gender are restructured through the practice of plastic surgery rather than simply reinforced. I am indebted to recent feminist and queer theory, where the body is not understood as a passive object to be inscribed on by cultural norms and technology, but rather as a lived cultural object that comes into being through social forces, and in its very materiality, exceeds and resignifies what is culturally intelligible (Butler 1993, 1997; Grosz 1994; Hayles 1999).
My work also seeks to contribute to the growing field of feminist science studies, whose initial interventions critiqued how common beliefs about gender, race and class were embedded in everyday scientific language, thus naturalizing cultural norms (Martin 1987; Rapp 1990; Spanier 1991, Terry 1989). Newer arguments propose that science does not merely retain traces of culture, but is an inherently social process that imbricates the social and the material into the production of new knowledges and new technologies (Haraway 1997; Latour 1987). Anthropologists and other scholars began to recognize that, apart from scientists, there were other crucial actors and networks involved in the development of science and medicine. There is much scholarship on the socio-cultural dimensions of AIDS, for example, and how AIDS activists formed alliances with scientists and the state in order to challenge the disparities that enable the disease (Farmer 1993; Patton 1990; Treichler 1999). A more recent development is the organization of advocate groups around genetic disorders like Marfan syndrome, dwarfism and Huntington's disease, among many others. These groups have formed coalitions with medical researchers, congressional lobbies and biotech industries, in their efforts to secure resources and research subjects for the development of medical innovations that might benefit them. The formation of collective identities and advocacy movements under new biomedical categories has been alternatively termed "biosociality" (Rabinow 1992), "genetic citizenship" (Heath, Rapp and Taussig 2004) and "biological citizenship" (Petryna 2002; Rose and Novas 2004). While most of this literature claims that such biologized identities transcend national forms of citizenship, my research sees nationalism as central to the concept of citizenship as applied to cosmetic surgery, a medical practice that is dependent on a coalition between patients, clinicians, the media and the state. To understand medical technology as inherently social, we might also have to understand it as imminently national, even as it becomes increasingly dependent on transnational flows.
The state has traditionally had a direct role in the development of science in Latin America. Histories of Latin American medicine emphasize how medical progress has always been tied to the management of populations through the eradication of disease, the regulation of sexual behavior, the emphasis on hygiene and other such Foucauldian "tactics of governmentality" (Leys Stepan 1991; Nelson 2005; Ruggiero 2004). In Brazil, projects of medical innovation, as signs of the country's alleged "medical modernity," have traditionally been a source of national pride – from the development of tropical medicine under Carlos Chagas (Coutinho 2003), to the National AIDS Program that provides free antiretroviral therapies (Larvie 2003). Medical anthropology has challenged that narrative, by emphasizing the abject Brazilian populations who remain excluded from the real benefits of state health programs (Biehl 2005; Gregg 2003; Scheper-Hughes 1992). New forms of transnational commerce like organ trafficking (Cohen 2004; Scheper-Hughes 2002), clinical testing (Biehl 2001; Petryna forthcoming) and the biotech industry (Landecker 1999; Sunder Rajan 2005), have further exacerbated a global health system where certain human bodies are constituted as the "bare life" (Agamben 1998) available for commodification, but that ultimately refuses those bodies the recognition of full biological citizenship. "Cosmetic citizenship" is an attempt to theorize how inclusion into the nation through surgery is perhaps at the very same time a way to reduce the body to a valuable resource, and how a medical practice that seems to objectify the body may also render that embodied identity more flexible for the patient.
In an article titled "Operability: Surgery at the Margins of the State," Lawrence Cohen develops two key concepts that are central to my reading of subsidized plastic surgery in Brazil: "operability" and "bioavailability" (Cohen 2004). To be "operable," on one hand, is to be assimilated into the norms of modern citizenship through the act of submitting one's body to surgery. To be "bioavailable," on the other, is to be that body whose human tissues are available for extraction and redistribution, under the rhetoric of the "charitable gift" that deploys life and hope for the future. An organ recipient in India, for instance, becomes an operable citizen in his or her subsumption to the modern medical order, participating in the modern nation through state-sanctioned surgery. A subaltern organ donor becomes bioavailable through a logic of exception, which allows for the "gift of life" of a kidney and the ensuing monetary compensation. This same logic, however, refuses the organ donor the status of an operable citizen and rather constitutes that body as "bare life" to be simply given away. Depending on what side of the operation one is on, one is ethically recognized as a legitimate beneficiary of state intervention, or is politically reduced to a legitimate resource of life itself. However, operability and bioavailability, Lawrence Cohen warns us, are not mutually exclusive terms, and are not restricted to the matter of transplants. They are articulations that occur on the margins of the state, where state structures play merely a passive or complicit role, even if the national imaginary remains central to their deployment.
Let me return to plastic surgery in Brazil, where I argue that operability and bioavailability are simultaneous attributions of certain bodies on the operating table. All recipients of plastic surgery seem to be operable citizens, to the extent that they participate in a national project of medical modernity, confirming Brazil's global reputation as the Mecca of plastic surgery. Yet it is the middle and working-class patients, paradoxically, that seem to be the most strongly interpellated by the call to transform the Brazilian body politic into a beautiful citizenry. In absolute numbers, there are many more Brazilians getting plastic surgeries in the run-down, state-funded clinics than in the lavish private clinics, even if the latter still produce much larger profits. Do patients of lower income, however, really count as citizens when they are operated on? When I discussed with patients why they had opted for this service, many of them mentioned the national reputation of plastic surgeons, and the importance of plastic surgery to Brazilian national pride more generally. They saw the foreign patients and the foreign surgeons who come to Brazil as confirmation of the role Brazil plays globally in this medical area. Some patients who had gone through one or more surgeries already were not necessarily uncritical about the practice, but rather stressed the pitfalls of a culture of beauty that put unrealistic pressures on women. First-time patients, however, would emphasize health reasons over beauty in their desire for plastic surgery. This was clearly related to the negotiation that took place between surgeon and patient during the consultation, where they had to agree on how best to define the surgery as reconstructive, and therefore necessary. For example, a blepharoplasty or eyelid surgery was approved in Belo Horizonte after the doctor suggested, and the patient agreed, that the bags on her eyes were deteriorating her eyesight. On the side, however, the patient admitted to me that some of her friends had had this surgery already, and were very pleased with the aesthetic results that made them look younger and healthier. The case was similar with breast lifts, abdominoplasties and gastric bypasses, which were worded very carefully in order to justify them for state subsidies. Other surgeries like gynecomastia (breast tissue removal in men), were always approved because they were perceived as "correcting" gender abnormalities.
The investment of the surgical community in these patients comes from a construction of their bodies as a resource – both to teach medical students about plastic surgery, and to develop surgical techniques that are marketable in private clinics and abroad. After attending a conference on cosmetic surgery in Brazil, it became clear to me that a surgeon's reputation – and consequent profit – is directly dependent on the innovations he or she can develop and name after him or herself. I also became aware of the discourse of creativity surrounding the practice of plastic surgery, where surgeons compare themselves to Renaissance men who combine art and science into one discipline. This cult of the "surgeon-artist" ranges from books that showcase plastic surgeons' paintings, as evidence of the artistic talents that translate into great surgeries, to academic articles that compare surgeons to poets and sculptors. As one surgeon expounded during a private interview, "I am not a plastic surgeon – I am a reconstructor of people, an instigator of happiness, a catalyst of change, a creator of passion in the patient for herself, a force for well-being." The insistence on the surgeon's creativity seems to deny the dependence of plastic surgeons on subsidized plastic surgery to develop new surgical techniques. An American surgeon who I met in that same conference, and who had come to learn the latest technical developments, explained,
"Brazilian surgeons are pioneers. They always have been. Our techniques we borrow and develop from their techniques. You know why? Because here they don't have the institutional and legal barriers to generate these new techniques. They can be as creative as they want to be. In the US that is not the case, you always have the regulations, the FDA on your back."
The lack of institutional and legal barriers unleashes the "creativity" of the surgeon in that it renders the bodies on the operating table bioavailable for clinical trials, without the need for cumbersome consent forms or other forms of stifling red tape. Even I, as the guest anthropologist, was allowed to listen in to private consultations and see live surgeries without the need for permission from the patient at public clinics. This was not the case in private clinics, where I was never allowed to speak to a patient, since plastic surgeons always argued that getting the consent of those patients was unfeasible. They kept asking me, why not study the patients at public clinics, instead? I quickly realized that only certain patients were publicly bioavailable subjects of study, their lives and bodies open to scrutiny.
Operable, yet also bioavailable, it is the patients at the public clinics that are giving the "gift of life" to the cosmetic surgery industry in Brazil. The gift is construed, though, as occurring in the other direction: it is the surgeons that are granting "the personal right to beauty" to Brazilians of low income. It is the humanitarian public service of plastic surgery, with the complicit beneficence of the state that allows for the breast lifts, abdominoplasties and facelifts to continue and increase every year. The gossip of botched jobs circulates around the waiting rooms, yet as a woman who had had several surgeries said to me, in a tone of resignation,
"It's a question of luck. Sometimes a surgery comes out well, sometimes you have to get it redone. Even in a private clinic there is the possibility that something might go wrong, but the difference is that there you can get it redone immediately; here, you have to get on the waiting list all over again."
The compressed time of capital accumulation allows for the immediate satisfaction of bona fide consumers of the private clinic, the genuine citizen-patients, but has no time for the cosmetic citizens that are attempting to remake their body as if they were modern, bourgeois subjects. Modernity appears to reside in the new technologies of the self that promise beauty and youth; and yet for cosmetic citizens, modernity is always beyond grasp. At the same time, their bodies and subjectivities are always in excess, beyond the full grasp of the technologies that are attempting to reinscribe them in familiar ways. The surgeons kept warning me against the "bad patients" – those who are never content with the results of a surgery, those who insist on altering their bodies beyond the recognizable, beyond the culturally intelligible. We can join the surgeons in their efforts to pathologize those patients, or read such queer forms of body modification as challenging and expanding what is in the realm of the possible – in disturbing ways. One example is the aesthetization of the scars left behind by surgery, where the failure of suture is fetishized as desirable because it makes visible what is meant to be invisible. These new trends do not necessarily work against the interests of capital, however, but can in turn become desirable commodities that give plastic surgeons more business.
Cosmetic citizenship gestures towards a theorization of that paradox in the anthropology of social inequality, where one finally belongs to the modern nation, yet, at the same time, one can never fully belong. It takes issue with recent literature on biological and genetic citizenship, which argues that patient organizations forming new networks with scientists, pharmaceutical companies and state bureaucracies in the pursuit of innovative treatments, have the potential to alter the way medicine has traditionally been developed. While I see the potential, I also see the ways in which a discourse of patients' rights and altruistic medicine works in the service of capital accumulation, by promoting new ways in which the body can be commodified and fostering the proliferation of medical interventions we can be subject to. In the case of Brazil, where surgeons are winning international humanitarian awards for their cosmetic work on the poor while using those very same bodies as commodified resources to increase their revenue, these contradictions need to be examined. Why has subsidized cosmetic surgery become so important in a country where a third of the population – by and large Afro-Brazilian women and children – lives under the poverty line? The so-called "right to beauty" might be at the same time an obligation to render one's body "bioavailable" for capital (Cohen 2004), such that altruistic services are now the biggest asset of the "magicians of beauty," as the members of the cosmetic industry are known in Brazil. The suturing of structural inequalities in a sharply fragmented Brazilian body politic is perhaps the biggest illusion brought about by these "magicians of beauty," whose interventions on the patient's bodies attempt to produce a unified nation under the name of cosmetic citizenship. Is this a form of suture that threatens to become visible and unravel at any moment?
Even though my research is committed to a politico-economic reading of power in the production of medicine, it also attempts to push the anthropology of science beyond the familiar structure-agency debate, by understanding that the techno-bodies produced by cosmetic surgery are potentially in excess to the parameters of their production (Butler 1997). My aim is to examine how "flexible biopolitics" (Cohen 2002) meets "flexible citizenship" (Ong 1999) at junctures where the technological self is constituted as a transnational and hypermodern way of being and of consuming. I am interested in the ways in which the practices of self-improvement that Foucault termed "technologies of the self" (1988) have become globalized, challenging the very perception that any nation could be medically advanced on its own. We have come to depend on transnational trends to know what is fashionable and technologically sophisticated – and body alterations are no exception to this development in global capitalism. Brazilian cosmetic technologies gain transnational reputation only when the desire to look "Brazilian" goes global.
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