The <Immune Nations> exhibition brochure describes Upstream the Cold Chain thusly:
“Following a group of young scientists / healthcare professionals from their practical health work in the Global South to a conference on Global Vaccination in Norway and Switzerland, this single channel video gathers local narratives on vaccine access—specifically the experience of navigating the temperature-controlled supply chains that are needed for vaccines to remain effective—juxtaposing footage from the Global South with so-called ‘first world’ footage in order to consider the ‘cold chain’ both practically and allegorically.” (9)
Indeed, rather than focussing on the logistics and statistics of the cold chain, this project juxtaposes those aspects with a more evocative, poetic approach.1
To accomplish the project, it was initially important to establish contacts with individuals living in or connected to end-user communities. Invitations were sent to representatives from the Ministry of Health in Ouagadougou in Burkina Faso, a contact received from the Norwegian epidemiologist Johan Holst. Another invitation was sent to health professionals in Niassa Province, in the northern part of Mozambique, through an organization called Villagereach, which specializes in cold-chain improvements with a focus on reaching out to last-mile communities.
The first confirmed collaborator was a physician in Niassa Province, Dr. Ramos Mboane. After receiving this confirmation, contacts in Burkina Faso were asked to nominate a female participant so that the project could be gender-balanced. They eventually proposed Ms. Thérèse Sinaré from the Department of Vaccines at the Ministry of Health. She was contacted and accepted the invitation to take part in Upstream the Cold Chain.
Recognizing the competence of these end-user communities is key to thinking through the cold chain, both in terms of practical know-how and in rhetorically or allegorically balancing a predominantly white, top-down, north-south, hopeful-hopeless international structure. Since the project required travels both to Burkina Faso and Mozambique for filming and working with cold-chain operators, Dr. Mboane and Ms. Sinaré planned both visits and workshops, including their own journeys to the conference in Norway and Switzerland. In both cases, travel visas for partners to travel to Europe turned out to be our first major challenge.
Working with Clay
At the same time, in the opposite direction, a visa was organized for me at the Burkina Faso Permanent Mission to the UN in New York City, and I travelled to Ouagadougou. There, we organized an artistic workshop for ten local health professionals who work with vaccines.Everyone found a space to lie down on their backs on the floor. Then, each participant was given a brick-sized piece of fresh clay. Lying on our backs, the weight of clay on our bellies, the only rules for the next 30 minutes were to not look at the clay, just feel it with our hands, and so give it a form, all while staying concentrated and trying not to talk or observe each other. Of course, this was a bit of a surprise as an exercise, coming from a “consultant,” but everyone obliged me, and at the end of the 30 minutes—a very long time for such a strange activity—I asked them to set the clay aside, still without looking at it, and then to join me again at the meeting table.
The next instruction was return to the clay, see it for the first time, and after looking at it for two minutes, give it a title. The title could be a sentence, one word—anything. We wrote the titles down by the clay and then returned to the meeting table. Next, we looked at each other’s pieces of clay, giving each work an additional title of our own. We continued like this until everyone had given titles to all the pieces of clay, and then we met again at the table. The final, and perhaps most challenging, task was to return to our own clay, read all the titles, and then use them to compose a poem. Everyone took this job quite seriously, sitting individually and putting their texts together in less than an hour.
After lunch, having gotten into the rhythm of what must have seemed to be a strange kind of work, everyone was curious about the next step. This was when I brought out my video camera and asked each person to perform their poem before the group and then read the poem to camera. Although everyone had agreed to be filmed in advance, doing it in this way surprised and delighted many of the participants. Indeed, if I’d explained all the steps beforehand, the exercises would not only have lost a lot of their spontaneity, but also would probably have brought up a lot of resistance. Feeling our way forward, with hands and then eyes and then brains and voices, created a very different outcome.
On the next day, we engaged in a more advanced exercise. In sessions of 40 minutes each, we created imaginary situations that targeted issues and challenges relating to the operation of the cold chain. In the first ten minutes, two participants sat in front of the group. One explained a specific challenge relating to the cold chain, simple or complex, while the other person tried to understand the issue and ask questions about it. Then, after ten minutes, the listener led the speaker in a 20-minute imaginary scenario. The only rules of this exercise were that they not directly mention the issue they’d just been discussing (while somehow still dealing with the topic at hand) and that they both remain in the imaginary scenario for the whole 20 minutes.
For example, one might ask the other, “Is it OK that I walk with you?” “Yes, come along,” the other might reply. “Where are we heading?” the first might ask, and the reply might be that they are going back to the village. It was the listener’s job to keep the speaker challenged and engaged, so if the latter had trouble imagining what came next, the listener might say, “Look, there is an animal coming this way. It seems to be carrying something! Look, it has a letter around the neck. Let me see…Oh, I forgot my glasses, can you please read it? What does it say?” And so the other would thus be invited to take up the challenge, reading, “Go across the river and take the smaller path to the village. We are having other guests, so wait and watch from the hill until you get more information.”
Twenty minutes can seem a long time in such a situation. At the end, each participant took a moment to talk about the scenario, and then one person in the audience provided an aesthetic response, not clapping but offering some other gesture or some more elaborate reiteration of one of the elements we had all just observed. These sessions continued the whole day. Filming them allowed for another kind of insight—more imaginative than analytic—into the challenges of cold chains and into the people who operate and maintain them. Spending time and communicating in this manner with the end users of cold chains is uncommon; as I detail further in the next section, it is a way of recognizing their local competencies and their dignity as human beings.
Following the visit to Ouagadougou, I returned to Norway, where I met up with Dr. Mboane. Over the next few days, Dr. Mboane worked with me to edit the first version of Upstream the Cold Chain, based on footage taken in Ouagadougou.
Some months later, I myself arrived in Niassa Province in the north of Mozambique after a one-day stopover in Maputo. Dr. Mboane picked me up, and as a member of his staff and another fellow doctor happened to be on the same plane, we all rode together. I was introduced to the director of the hospital, given a room in a nearby hotel, and then given a tour to meet some of the cold-chain operators and see their facilities, cold rooms, storage space, vehicles, and the like. The next morning, I was introduced to the whole staff, and I explained to them, through a translator, what I was working on and what I planned to do. The day before, I had gone to fetch the clay, with the help of the translator, in a village outside town. Two young girls dug the fresh clay straight out of a nearby creek.
The workshop went much as it did in Burkina Faso. This time, we did the first part outdoors. Having a tight schedule, I returned after less than a week, editing the video at a local video-editing office in Maputo, which we located with the help of a taxi driver. We worked overnight to edit the video with subtitles.
A few days later, I travelled to Geneva to install and premiere the full video at the UNAIDS building and meet up, once again, with not only my colleagues on the project but also with Ms. Sinaré. After introducing her to the team, I screened the current version of Upstream the Cold Chain for her, which included her, her colleagues, and the group in Mozambique, in order to give her the chance to veto any content or suggest any changes before the work was installed in the exhibition.
Happy with the final version, Ms. Sinaré and I discussed how we might introduce the work the next day at the special preview of the exhibition for dignitaries and heads of state. We decided to use the poem she had composed during the first workshop; she read the text in French, while I read an English translation:
Toi, qui m’aide dans tout ce que je fais,
You, who help me with all things
à porter le masque sur la tête
To carry the mask on my head
Pourquoi es-tu toujours cinq, mais pas plus et pas moins?
Why are you always five, but not more, or less?
Parce que la main forme un ensemble indispensable
Dans tous les gestes.
Because the hand constitutes an ensemble, indispensable
in all gestures.
La main, toi qui ressemble à la paume des pieds
et conserve tout, comme une caisse conserve l’argent,
tu es formidable. Je te dis merci, merci,
The hand, you who look like the sole of the feet
and conserve everything, like a cash register keeps money,
you’re amazing. I thank you; thank you.
car sans toi, les mains, ma mère ne pourrait pas me porter au dos et ne m’emmenerait pas à la
vaccination, pour que je recoive mes doses de vaccins.
Because without you, hands, my mother could not carry me on her back and would not bring me for vaccination, so I could receive my doses of vaccine.
Oh, la main, je t’ adore.
Oh, my hands, I adore you.
Proud and without hesitation, she read the poem aloud with the full attention of the many attendees at the opening. Speaking in French, a black woman from a third-world country, not a formal dignitary but a low-paid, hard-working public health employee, a single mother dressed in Burkina Faso finery for the occasion, she represented her community, her country, and the poetic and practical hardships of motherhood and vaccination. It was an important moment, rewarding us all with a sense of integrity and of meaningful work well done.
Important here was the presence of someone from an end-user community to be represented in an international context where decisions are being made. This kind of access can carry a strong symbolic charge, particularly when these communities do not normally have any access whatsoever to what is happening “upstream.” That said, like any project that engages with relations between those who are “upstream” and “downstream” in terms of power and privilege, Upstream the Cold Chain is obviously entangled in a wide range of challenges.
Both Dr. Mboane and Ms. Sinaré made useful comments about the project in the aftermath. Dr. Mboane commented on how great it was to get connected with other researchers working in the field of cold chain when he was in Trondheim. Learning of their successes and failures and of how they overcame difficulties through collaboration and community mobilization offered important insights for his work. Similarly, Ms. Sinaré found the project valuable as a multidisciplinary team of intellectuals working in various sectors who sacrifice their time and energy to help further the dream of a world without disease. Her only regret on that front was that she joined the overall project very near the end, so did not have time to contribute more fully.
As for improving the project, Ms. Sinaré pointed out that it would be best to involve more different and varied African countries in the process and include more political leaders. Dr. Mboane, too, strongly suggested that local artists in the countries in question be involved from the initial stage of the project.
Indeed, he mentioned in this context that they were planning on using some of the strategies used in <Immune Nations> for their upcoming, very first, cholera vaccine mass campaign in Niassa, explaining that the experience in Trondheim made him more than confident that art can be a strong tool for change.
Jesper Alvaer would like to acknowledge the support of VillageReach, Ramos Mboane (MD, MPH - DPS Niassa), the ministry of health in Ouagadougou, and Madame Thérèse Sinare for making the Upstream the Cold Chain project possible. Thanks for structural support are also due to the Office for Contemporary Art Norway, the Oslo National Academy of the Arts, and Academy of Fine Arts in Prague (AVU).
<Immune Nations>. Galleri KiT and UNAIDS, 2017. www.immunenations.com/uploads/1/2/6/2/12627963/immunenations_program.pdf.
Video 1: Ms. Sinaré reads her poem at UNAIDS, Geneva, 2017. https://vimeo.com/447268018
Video 2: Upstream the Cold Chain, directed by Jesper Alvaer, Burkina Faso and Mozambique, 2017, 8 min. https://vimeo.com/447270067
Editor’s Note: See Sahar et al., “Overview of Key Legal, Political, and Social Challenges Facing Global Vaccination Efforts” and Humphrey, “Imagining Co-Immunity in Shadowpox: The Antibody Politic” in this volume for more on the cold chain.↲