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Biopolitical regimes and the production of truth through speculative objects1.

Dr. Jorge Castillo-Sepúlveda*


Mariana Gálvez*
Marjorie Espejo*
Jorge Tapia*

*School of Psychology, University of Santiago de Chile.

Accepted on Sociological Research Online on June 27, 2018.

In the last three decades, several authors and important researchers have documented profound
transformations in medicine which are related to epistemological changes, ways of organizing medical
activity, methods and approaches, and so on. One of the main transformations refers to evidence-based
medicine. This change has implied a rethinking of biopolitical design scenarios about the regular
processes of population disease –endemics–, and especially about how to produce truth, which are the
truth grids, understandable statements or propositions, and the effects on population life. This paper
gathers the relationship between biopolitics and knowledge, addressing a specific case of information
production for the formulation of government technologies applied to health in Chile. We analyse the
ways of producing truth by experts and professionals in the Explicit Health Guarantees Regime, a
political technology designed ten years ago that integrates the epistemology of evidence-based
medicine to prioritize attention to a certain number of diseases considered important at the population
level. The results show a double process involving the emergence of an obligation regime, associated
with the need to produce and substantiate a truth, and the creation of speculative objects, such as
indexes or calculation tables, that allow the opening of conjectures, regardless of the existence of exact
information or the totality of ‘facts’ that make up a situation. We conclude in a general way on the
contingent quality of biopolitical production and the political agency of the objects into the stabilization
of the process of ordering life.

Keywords: Biopolitics, Regime of enforcement, Speculative Objects, Evidence-Based Medicine.

1
This work is part of the research project FONDECYT Nº 11140590, entitled "Contributions of
Science and Technology Studies to the understanding of diseases addressed by evidence-based
medicine: regimes of subjectivation, embodiment and biosociality in the EHG", funded by
CONICYT Chile.
We are forced, condemned, to confess the truth or to find it.
Michel Foucault.

We want to invite you to read the following cite, extracted from an interview to a health economist, who
participate in the design of public health policies:
Let's assume that you have a fixed budget that is given to you by the National Health
Budget and your goal is to achieve maximum health with that (…) that is already
assigned to the different things that the health system does: you assign it to benefits, to
salary payments, assign it to technologies, etc., etc., and with that you produce X quantity
health, that we do not know how much it is, but it is a quantity of health. And tomorrow
you have the next challenge: they give you more money (…) and you say: well, what do
I spend it on? and you have a line of people demanding things to spend. So, the question
is: this additional dollar that they gave me, do I give it to the new technology or leave it
here in the health system to continue doing what I know how to do today? So, what you
do is a comparison of the benefits that you would get for that additional dollar, buying the
new technology or new health intervention. (Íñigo, personal communication, August 17,
2015, paragraph 59)

And also, the following excerpt, from an interview to an expert designer of public health policies:
Then I was in charge of the revision process of the sixty-nine [diseases covered by the
health policy]. What we tried to see was the evidence that existed with respect to new
interventions in these sixty-nine pathologies. But as we could not cope, because we were
a very small team (…) what was done was to try to collect the opinion from the specialists.
For each of the pathologies, a meeting was held with a group of specialists, and among
interventions they selected, try to prioritize, look for quick evidence, etc., etc. (...) Without
thinking about the cost-effectiveness, because no, there was no time. Neither in the
preference of the patients [a specific preference study], because no, we were not going
to be able to collect that, there are very few studies of that too... (Fernanda, personal
communication, April 9, 2015, paragraph 106)

As we can see, extracts refer to processes by which propositions about population life are formulated.
The first one, accounts for the need for specific cost-effectiveness calculations to define the trajectories
of investment in health at the population level; the second, the variability in the use of such indexes.
Despite the apparent differences, in both we appreciate processes for the production of certainties
about the population and its biological conditions, and how they assume a relative condition to the
practices and entities that are articulated.

Three specific aspects are derived from the above. The first one refers to the necessary relations for
the production of certainty. In the definition of the processes for the regulation of the population life,
heterogeneous elements participate that enact regular states of the biological conditions that must be
governed: calculations, cost-effectiveness relations, evidence, expert meetings, are used as references
that articulate technical accounts. The second refers to the effect of such articulations: through various
technical and social detours population processes emerge as an objective entity, nevertheless, is
relative to such practices and objects. The globality of the descriptions is a local production subject to
specific practices that configure them and give discrete meaning (Timmermans and Berg 1997). The
vectors that address endemic diseases –constant biological risks in the population– are elaborated by
the interaction of technical and social elements that have a contingent character. Finally, the
propositions emerge from a supposed requirement of such certainty. Such certitude acquires a
particular character: it is speculation about the population lives, about the value that acquire certain
procedures and technologies to promote their longevity, and the validity achieved through various
procedures to assert some biological processes over others for proper attention. These conjectures,
however, acquire an epistemic condition that articulates biological politics.

In this work, we address the contingent and relational conditions through which the truth is produced
for the development of health governance technologies. Specifically, we refer to social and technical
mediations –i.e., the formation of mutual and permanent relations between technology and society
(Latour 2005b)– in the production of such certainties. In that mediations, some relations formulate very
specific conditions of possibility to elaborate population biological regularities. We denominate such
entities as speculative objects, insofar as they are entities that emerge from technical relationships that
enable the development of conjectures about the conditions of population life and the effects of the
intervention on it. These entities create conditions of objectivity for the development of a biological
policy, in the sense of Michel Foucault’s biopolitics.

The notion of biopolitics in the work of Michel Foucault accounts for a major break in the order of politics,
relocating it around new knowledge practice: the entrance of the particular phenomenon of human life
in the sphere of political techniques, knowledge and power (Foucault 1992, 2003). This relation to
knowledge implies a dissociation and abstraction from the life of its concrete physical barriers, inscribing
it in a new field of epistemic conflicts. It is through knowledge about life –its production, legitimation and
application– that biopolitics acquires a fundamental ubiquitous dimension and distance from other
government technologies described by the author1.

The above-mentioned relationship between biopolitics and knowledge is brought up, addressing a
specific case of production of knowledge for the formulation of government technologies applied to the
field of health. To this end, one of the most recent and important health reforms in Chile, emerging in
the mid-2000s as part of a complex economic, legal, and epistemic framework: The Explicit Health
Guarantees Regime [EHG] (Ministry of Health of Chile 2004) is considered as a case study. This system
was specifically formulated in 2004 as ‘a set of benefits guaranteed by Law for persons affiliated with
Fonasa and the Isapres [public and private insurance systems]’ (Ministry of Health of Chile 2013: 1), as
part of an intentional and sustained process of progressive structuring of new health canons in the
country, which has involved considering: (a) the variable links between the State and the market; (b)
the decentralization of services; (c) the role of patients' rights; and (d) the role of public health (Ferrer
Lues 2004b).

The EHG is offered as a special case to address the relations between knowledge and biopolitics,
inasmuch as: (a) it is formulated from production and mass information evaluation processes, to
consider the state and qualities of certain biological processes and their incidence on the longevity of
the population; (b) in its implementation, an explicit commitment has been established with specific
epistemological modalities. The Evidence-Based Medicine supports a scheme both for the
establishment of parameters, practices, technologies, and care temporalities, as well as for the design
of the regulations themselves (Cambrosio et al. 2009); (c) EHG emerges in a specific economic and
political scenario which assembles a series of legal and material provisions in order to articulate new
forms of government based on public and private participation.

In this work, we present the so-called speculative objects, analysing processes of production of
biopolitical ordering in a scenario of prioritization of attention to endemic diseases. To do this, we first
describe the regime that serves as the basis for the analysis: the EHG and its biopolitical implications.
As a second aspect, we describe the interplay between practices of knowledge production and
biopolitics. Third, from the case presented, we point out the existence of an epistemic regime that forces
the production of truths. With regard to biopolitics, this is fundamental, as it conceives biological policy
as an eminently epistemic process that enforces truths. Finally, we point out how speculative objects
participate in such processes and how they are important components in the formulation of biopolitical
regimes.

The episteme of EHG: valued endemics.


At the beginning of the 21st century, a series of intentional, sustained, and systematic processes of
changes in the structure of the health service began in Chile, involving the mobilization and
reorganization of various normative, economic, and epistemic resources (Bastías and Valdivia 2007;
Grau Cunill et al. 2011; Lenz 2007). This entailed the constitution of a whole network of measuring
technologies in terms of epidemiological as well as biomedical aspects related to the position of the
subjects in the system, making use of discussions in this regard from the international sphere, and the
mentioned developments of the Evidence-Based Medicine [EBM] (World Bank 1993; Infante and Paraje
2010; Paraje and Infante 2015; Valdivieso and Montero 2010).

This so-called EBM has led to the reorganization of a number of quite specific assumptions and
activities in relation to the conception of knowledge and legitimate acts in health matters (Knaapen et
al. 2010; Timmermans and Kolker 2004). Although the term may mean different things in common
medical discourse, it mainly denotes the use of clinical practice guidelines to disseminate the knowledge
and diagnoses that have been tested (Claridge and Fabian 2005; Sackett et al. 1996; Timmermans and
Berg 2003). On the basis of this transformation, several authors point to a triple process involving the
redefinition of clinical practice, its epistemological commitments (Akobeng 2005), and the relationship
between the healthy and the ill. The first remits to the progressive realignment of the relations between
biology and medicine, and with this to a new configuration of clinical and laboratory practice called
biomedicine (Cambrosio et al. 2006).

The second refers to the emergence of new criteria to define the adequacy of diagnoses and treatments
based on the systematic use of collective procedures for the production of tests, and the introduction of
conventions in the framework of reflective practices involving the inscription of measurement and
evaluation techniques that define the objectivity of a clinical judgment: a regulatory objectivity (Bourret
et al. 2006; Cambrosio et al. 2009; Moreira et al. 2009).

And the third refers to the fact that the health-pathology tension is reconfigured according to what is
established by a series of propositions inscribed in these clinical guidelines, that set up systems of
understanding and technologies that enact contexts of normality or abnormality and what is understood
by corporality (Tirado et al. 2012).

The EHG is constituted by and gives shape to several of these processes. It arises as one of the main
axes that articulated a reform plan initiated in the year 2000, established on the rhetoric based on: (a)
the treatment of the population’s longevity; (b) the need to select and prioritize the health problems to
be guaranteed, according to various indexes; (c) the consideration of health as care provided in a given
manner by health services coordinated by public and private insurance systems, and by particular
technologies; and (c) focus on the person responsible for the use of such benefits.

It establishes four guarantees, related to access (criteria associated with the configuration of a health
problem qualified to receive benefits), quality (providers registered and evaluated for this purpose),
financial protection (maxima established to be paid for the benefits), and opportunity (regulation of
temporality or maximum periods for the use of the benefits) (Ministry of Health of Chile 2004). These
benefits are associated to a prioritized set of programs, diseases, or health conditions which are
established based on a series of health and financial analyses that integrate ‘epidemiological studies
that identify a list of priorities in health and interventions that consider the health situation of the
population, the effectiveness of the interventions, their contribution to the extension or quality of life
and, when possible, their cost-effectiveness’ (Ferrer Lues 2004a: 3).

The EHG manages temporalities, practices and techniques for people who comply with a variety of
symptoms or indicators that can be verified according to the criteria stipulated by the clinical guidelines
(Ferrer Lues 2004b; Grau Cunill et al. 2011). But above all, it implies the management of knowledge
that allows prioritizing both the pathologies that are part of the system and the associated benefits.

It also establishes a certain regime of activities and materials that must participate in any care
relationship, regardless of the source of services, whether they are provided by public hospitals, clinics,
or specialized private centres. Both the Quality Explicit Guarantee and the Opportunity Explicit
Guarantee (Bastías and Valdivia 2007) imply the accreditation and assurance of certain basic
procedures and conditions that must participate in any diagnostic and treatment instance. This does
not only imply the enactment of a set of collective actions, actors, and materials, but also the control of
the variability of human and biological phenomena: a standardization of the disease (Timmermans and
Berg 2003).

The EHG operates as a biopolitical resource oriented to the prioritization of the risks inherent in the
biological life of the population, that is, of its endemic processes. It refers to the management of constant
processes subject to variations related to interventions calculated and mediated by biomedical
technologies. As a contemporary measure of risk associated with the development of certain
pathologies, it implies, first, the evaluation of such risk based on empirical referents (mainly indexes
based on studies or epidemiological estimations) and decision making on such estimations,
contemplating a wide range of uncertainty (Beck 1992).

Somehow, the EHG regime consists of what Caduff (2014) defines as a syndrome monitoring system
in the present tense. This implies the generation of reference or prediction systems to establish a
relationship with risk. Such elements are not always reliable and involve the formulation of complex
schemes of expert deliberation. According to Caduff (2014), the present risk in epidemiological matters
leads to acts of faith, intervening even though it has not been completely determined.

The EHG emerges as a biosecurity regime for regular processes of biological disease at the population
level. It has involved the configuration of a technical and epistemological framework that allows to
legitimize certain decisions and interventions financed to promote population longevity, intervening
directly in the biopolitical register, in terms of the processes tending to generate knowledge about life
to intervene in it.

The regularization of power over life.


When Foucault characterized biopolitics in the course of March 17, 1976 (Foucault 2003) he did so
from the description of a power technology that takes care of the form, the nature, the extent, the
duration, and the intensity of the diseases prevalent in a population as permanent factors, i.e.,
endemics. Thus, the medicine acquired since the nineteenth century is not only an epistemic dimension,
but also social and political. The generation and accumulation of data on biological issues, and decision-
making criteria at the population level, placed medicine itself and epidemiology at the centre of
government practices from that time to the present (Casper and Moore 2009). For Foucault (2004) and
authors such as Rose (2007) and Rabinow and Rose (2006), medicine has managed to have influence
in various spaces of political and social life, to the point that it is difficult to think of an area where it has
no influence. For them, medicine has important implications at the governmentality level, that is, in
terms of the link between the various state and private devices in the constitution and understanding of
the self, and the latter in terms of the management of freedom itself (Foucault 2007).
All this brings up the notion that medical practice has progressed to become an area considered as a
source of veridiction, an epistemic field in itself that holds a truth about life and how to live it. The power
to ‘to make live and to let die’ (Foucault 2003: 241), to have an influence on the ‘how’ of life, depends
in that sense on the ability to establish regularities over what is alive: it is a power for regularization
(Foucault 2003).

To regularize is to generate awareness of the processes of life; it implies access to elements that allow
the produce such awareness at the same time that they are produced. By placing biopolitics as a power
that observes, describes and governs the regularities of life, it in turn is about a power that creates and
tries to produce and install such regularities: it is a power of regularities, no longer directly on society
and the individual, but from science and to the population. And since life cannot be appreciated in itself,
but through the epistemic resources generated and used for its description, what is regulated is nothing
but power over life: regularization of knowledge, especially of that which has the power to define life.

That is why biopolitics not only poses possibilities of apprehension between life and politics, but also of
both, with the knowledge and the will for truth about life. The processes of production of knowledge
about it, its canons of appreciation and valuation, as well as its political implementation is due to the
relation of a series of resources that allow this truth to emerge.

The multiple composition of veridiction in health.


Foucault (2014) has defined a regime of truth as what forces a series of acts of truth, determines the
form of those acts and establishes the conditions of realization and the specific effects determines the
rate of individuals in relation to the procedures for the manifestation of what is true. At the same time,
he points out that such regimes, with their procedures, operators, witnesses and objects, are not
confined to the scientific and mundane dichotomy, but rather implies taking into account the multiplicity
of truth regimes and each truth regime, whether scientific or not, implies specific ways of connecting
the subject that carries it out and the manifestation of what is true (Foucault 2014).

To address how biopolitical truth is generated in the EHG, we have begun the analysis of expert
discourses in the design of health policies, mainly related to ministerial spheres and universities. For
the purposes of the investigation, the confidentiality of their stories and institutional affiliations is
respected.

We conducted a total of nine interviews to experts involved in the design and updating of the EHG
regime, working for the Ministry of Health of Chile, and a total of 31 professionals who work in hospitals,
public health care centres, and private clinics, considering their knowledge of production of the
prioritisation process.

Beyond the truth: the biological obligation.


Access to the discourses of experts involved in the design, evaluation, and implementation of the
policies associated with the EHG have revealed a multiple and complex composition of the
objectification of health conditions. In that sense, what counts as an operative truth refers to figurations
and argumentation processes that are formulated by the participation of heterogeneous actors and
acquire meaning according to widely dissimilar criteria.

For example, in the following quotation, an economic and a practical regime (in which criteria, operators,
and objects operate) is founded on evidence:
[Referring to the steps to prioritize diseases] Therefore, you could just as well do them
as not do them, right? in that sense, but nevertheless the requirements say, and in the
logic of prioritization, that pathologies that have a heavy charge of disease that has been
proven to have interventions that are effective, right? And that is demonstrated through
evidence-based medicine, that interventions are cost-effective, that they are a priority for
patients, and that they are implementable in the network. So, if you imagined that, you
would say, ‘Well, I need a series of studies to carry this out, and it is an up-to-date disease
burden study,’ is it not? To have well-done clinical practice guidelines, in order to be able
to see which interventions have been shown to be effective, to have cost-effective
studies, and to have a study showing that the network's capacity is to offer, right? And in
the end, also a study that talked about the preferences of the patients. (Fernanda,
personal communication, April 9, 2015, paragraph 100)

However, evidence is not the only referent on which priority is given or recommendations for intervention
are based on each local context in which a health or disease problem becomes real. This is one of the
other components, political, economic, and, above all, contingent, in which the relationships between
health and disease, and what is composed as both are defined.
Of course, but since it was very expensive, we knew that [the Ministry of] Finance was
not going to let it pass. My boss said, ‘No, you have to prioritize’, and there, that was
rather a meeting, in the first instance, to get it out, in which he, the division chief at that
moment with the doctor, and I. It was not well done, but in some way it said: ‘No, this is
not because…’, any argument, I do not remember today, but: ‘No, look at this, not this
because this is all bad, so if we stick it in it...’, criteria that were not…, judgments of the
moment, for the head of the moment. And there it was defined, the same with the
interventions of the eleven new [diseases]. The pathologies were already chosen, but do
not forget that within the pathology there are a series of interventions that you can... and
the thing is that. Then we went on to a second stage in which they were shown to the
authorities, and the authorities also in a way gave their vision, but a vision much more
macro. (Fernanda, personal communication, April 9, 2015, paragraph 184)

As seen in the previous quotation, the truth or veridiction process of prioritization emerges as an
eminently contingent question, of crossings, opportunities for argumentation, memory exercises, in
interaction with other epistemic elements. Different health regimes of truth are enacted in the same
process: a technical rationality, the same evidence, economic calculations, "macro visions" associated
with institutional discourses of the future. The objectification of health does not refer to a specific
dynamic, but is composed as a field of epistemological, practical, and political struggles, in which a
specific product, an intervention, is obtained.
It's like the message, they could not be seventy-nine, okay? Because there is a political
theme behind it. Then that happened, we bothered… Then the minister calls me and
says, ‘I want to inform you that…’, the undersecretary was there, also, ‘… that
glaucoma…’ –as I told you, glaucoma was my boss's struggle flag–. And he said,
‘Glaucoma no, it cannot go in, there is no budget’. And I said, I tried a little... ‘But Minister,
you know it is important...’. And he said, ‘I am not asking you, I am telling you because if
not, the President is not going to give us a budget, for… they're not going to give us the
money for the EHG’. And look at what he said, how terrible... (Fernanda, personal
communication, April 9, 2015, paragraph194)

Oh no, but the glaucoma! The boss told us that she had a new vision, but nevertheless
the process was almost finished then, so she did not do much (...). Then she informed
us that no, not because of budget issues, but glaucoma was not going to be able to enter,
and a pathology was going to have to be divided in two, which is mitral and aortic
insufficiency, well. And that finally had to be divided as into subcategories. And that
happened... (Fernanda, personal communication, April 9, 2015, paragraph 190)

Therefore, what is integrated or not is part of epistemological and political struggle processes, in which
what is legitimate is expressed as the translation of all these elements. Throughout this whole process,
the epistemic takes on a fundamental value: it is not a matter of managing bodies, but of producing
effects of truth, certainty about some biological regularities or how to intervene, depending on a series
of technical and political resources that operate on a contingent basis and according to different
epistemological, but also ethical, canons:
Now, the issue of prioritization does not only necessarily respond to a criterion of
efficiency of resource allocation, but could respond to other social values also, then you
could say: ‘Look, for example, I am willing to finance a technology that is expensive, that
gives few health benefits, but I am willing because it affects two patients in Chile and
they are children and they have an ultra-rare disease’. Then you value it in a special way
and then you do not apply the same rule to it. (Íñigo, personal communication, 17 August
2015, paragraph 83)

Beyond the truth, in the processes of prioritization and definition of benefits, of health as a benefit, is
what has pointed out as enforcement: the complement of vigor and obligation, of coercion that makes
one really obligated to pose something as true, even if one knows that it is false, or that one is not sure
that something is true, or that it is not possible to show what it is true or false (Foucault 2014).
EBM is not a truth, but a way of producing it. However, new agents are continually entering the process
of redefining the same prioritization or process of obligation. For example, the same bioeconomic
interests (Rose 2007) associated with the pharmaceutical industry:
Precisely, but it is rather any intervention that has the potential to generate health. Now
in practice we make more drugs and technologies than one has in mind intuitively,
because there is more demand... That is, behind the drug is the pharmaceutical industry
that wants to sell its medicines, so in many countries for the pharmaceutical industry
there is a need to have these studies, so then the industry pays for those studies, as well
as it pays for randomized clinical trials to be able to register its products; it pays for
economic evaluations in those countries, in order to show and demonstrate to the
governments that the use of resources is efficient after buying these new technologies,
these new medicines. (Íñigo, personal communication, 17 August 2015, paragraph 79)

The production of truth is composed of the obligation or the enforcement –an obligation regime– related
to the need to establish a statement, a decision, or the articulation of an object as true. As we have
seen, there are complex processes of mediation of actors and objects that articulate a proposition at a
certain moment as true in relation to the qualities of biopolitical organization or of the ways of intervening
on the processes of population health. Therefore, the regimes of obligation in the prioritization
processes are subject to multiple objects that constitute, in a contingent way, heterogeneous truths
about life, its diseases and processes. However, their truth value is relative to the processes that
constitute them, they depend on reflective activities that urge a truth that is always open to its
problematization. These are conjectures about life that can be hardly managed to be captured in its
completeness.

Speculative objects: the production of biopolitics.


To enact truth, experts in the design of health policy require the action of certain elements that allow a
relative stabilization of certain definitions and assumptions about vital human processes. This is defined
through the creation of certain objects that participate in the projection of present action scenarios,
configured through activities mediated, at the same time, by confidence and uncertainty.

As a first aspect, these objects allow the establishment of a certain common language about certain
population processes. That is, through them, certain relevant dimensions in the dynamics of biopolitical
definition and argumentation are objectified. These objects record concepts and assumptions about the
modes of organization of population disease processes, and participate in decision making on what to
prioritize, how to intervene, how often, and according to what temporalities. In the following quotation,
expert reports on the existence of different indexes or objects that can participate in the estimation of
the importance that certain diseases can have to constitute the regime:
Now, we must agree on how we measure it. In cost-effectiveness analysis we usually
measure it as Quality-Adjusted Life Years: QALY. Others, as in the WHO, have
suggested occupying the DALY, the Disability-Adjusted Life Year, AVISA [in Spanish].
Another possibility is to occupy years of life. We believe... health economists in general
in the world have been feeding on the subject of psychology, that is, the Quality-Adjusted
Life Year has been constructed in a communication between several social scientists
fundamentally by the work of health psychologists, and at some point, that joined with
the whole welfare theory of economists... (Íñigo, personal communication, August 17,
2015, paragraph 87)

Regarding the burden of disease, Fernanda, the expert cited previously, says:
The burden of disease, as a variable that measures the years of life lost by disability and
premature death (...) died at the age of forty, but had a life expectancy of eighty, seventy,
I don’t know, any life expectancy (...) Therefore he lost forty years because he died
prematurely. (Fernanda, personal communication, April 9, 2015, paragraph 120)

The created indexes translate theoretical, technical, and economic interests on population health care.
They imply that epidemiology ceases to be an aseptic field of study and becomes an eminently
biopolitical field. These indexes reduce the complexity on issues as heterogeneous as the projections
of life, subjectivity, vital quality, impact of illness, cost of technologies, or availability of economic
resources. The indexes replace these aspects and create objects with which to formulate new proposals
about the qualities and possibilities of reorienting the composition of the population’s biological life.

Specifically, the burden of disease is a key factor or epidemiological vector for the process of defining
certainty relative to the prioritization of population health problems in Chile. This index or technical
object allows engaging in conversations about the relative importance of various biopolitical
dimensions, without it being necessary to know fully its meaning:
Of course, but there I have doubts that if they measure it according to... I would have to
review the method, but I have doubts if they measure it from the sense that years for
work or they measure it also according to life expectancy, that is not clear to me.
(Fernanda, personal communication, April 9, 2015, paragraph 128)

Now, as a second aspect, it is necessary to point out that these objects hardly involve the complexity
associated with the need to prioritize attentions whose meaning is anchored in the populations health.
The composition of the actions that make it possible to figure out a biopolitical organization is rather
ambiguous, and depends on the interplay of heterogeneous criteria, truths, or obligations. As one same
expert mentioned previously, in relation to the prioritization of intervention technologies:
Now, one could also say that one we can express it in slightly more negative terms, if
you want, saying: ‘Look, if you pay for those two patients what you are doing is to sacrifice
ten others that you stopped saving because you are paying for this, but well, you can
keep doing it even being aware that you're saving lives elsewhere, but because it has a
greater social value’. (Íñigo, personal communication, August 17, 2015, paragraph 83)
For the above, there is a resource called "Study of Social Preferences" that summarizes the qualitative
sample inquiry about population options of what to finance by the regime ( Department of Epidemiology
2008). These are articulated with the previous indexes, counting with the possibility of influencing the
redefinition of the hierarchy. According to one expert, such a study suffers from conditions that allow
stabilizing its meaning for various actors:
but operationalization is its large (debt). How do you assure that the patient that was
claiming there in the Senate with Crohn's disease, whose monthly treatment is worth in
the order of one hundred twenty thousand pesos [USD 190], which for him is
catastrophic? (Íñigo, personal communication, 17 August 2015, paragraph 118)

Biopolitics implies the need for an order that lies in the production of objects of knowledge that objectify
the qualities of the biological processes to be regulated. However, no index implies a truth in itself, but
rather through other actions that give veridiction. The indexes carry a truth relative to the actions of
experts who use them to justify their course of action, although, in different ways, they are associated
with reflective practices that consider the knowledge gap. As we showed at the beginning of this work:
I talked to experts and they told me to take something that had already been done when
we had thought of the sixty-nine [diseases previously integrated to the regime], since
there was some left sort of at the end of the line, right? And they were supposed to be
based on a study of disease burden, the study I think is dated 2004 [i.e., 11 years before
the need to make a decision about it]. (Fernanda, personal communication, April 9, 2015,
paragraph 102)

Therefore, a quality that permeates the practices of veridiction refers to its contingent nature. These
record an eminently temporary character to the definition of the biological population qualities or the
interventions recommended to intervene in them. The production of certainty in such contexts responds
to the articulation of available evidence and other indexes, but also to the ability of people to give
meaning to such information, or to develop strategies for the creation of an adjustable environment,
whose ontological nature is based more on the plane of what is virtual than of what is actual:
Then you have the group, the group proposes to you a list of... I will invent it to you,
eighty actions, or eighty health technologies, ranging from a drug to a test. So, you go
and take that to the office and start looking, ‘Well, and... Is there evidence for all these
things?’ Because they can actually tell you that there is, but actually there is no evidence
for that drug. And you are going to check the weight that that intervention can have (…)
but even at the minute I was doing it, we were reviewing very crafty way how the
panorama was around the world, and whether or not there was evidence. (Nicole,
personal communication, 25 July 2016, paragraph 56)

In this scenario of biopolitical design, the biological order follows a situated production, relative to
veridiction practices that give meaning to objects that transport a value of truth more or less adequate
to its reference processes. Biopolitics consists of a local production, a link between epistemic elements
and expert rhetoric that generates a certain temporal truth effect, subject to an obligation regime that
stresses the production of certainty.

The indexes or objects that participate in this process are very important components to justify the
decision making. Its quality is to objectify, in the sense that its presence guarantees a stability of the
provoked judgments (Latour 1996, 2004). Such objects are not necessarily discrete, at hand (Heidegger
1962), but they consist of a cluster of relationships that integrate subjects and technical processes, that
derive in a malleable epistemic element, recognizable and articulable to activities that contribute to
shape a biopolitical regime. They are what Latour (2005a) points out as things: assemblies of
heterogeneous elements, entities that bring people together, produced and elaborated through many
actions. In the case we try to expose, they participate in the articulation of possible worlds for which
concrete references do not always exist. Its presence allows to generate conjectures about how the
population life is organized, how it is distributed, and changes by certain planned actions.

We consider that an important part of the formulation of what we understand by biopolitics refers to
such a contingent production of truths about population life. As we have seen, this is possible thanks to
the existence of technical objects that allow dialogues and negotiations on the qualities that make up
this biological policy. Muller (2013) and Domecq (1996) have raised the notion of ‘speculative object’ to
refer to the existence of these types of objects. A speculative object consists of an element that allows
the opening of conjectures, regardless of the existence of exact information or the totality of the "facts"
that make up a situation. They also necessarily refer to a present or future intervention or future
temporality, considering that the future itself is uncertain. For the authors, to speculate implies a relation
with the unknown, but at the same time it implies a proposal that organizes an existence in that respect;
leading to the generation of proposals that promote modes of existence, considering that such existence
is always local.

Three aspects could allow to characterize these speculative objects. First, they are a local production.
These objects inscribe the perspectives of agents that produce them, and their validity is circumscribed
to a relatively limited social and technical network in which they acquire and enable meaning. Second,
they generate the impression of access to a whole, a Big Picture. They are what Latour has defined as
a panorama: The Greek word pan, which means ‘everything’, does not signify that those pictures survey
‘the whole’ but that, on the contrary, they paper over a wall in a blind room on which a completely
coherent scenery is being projected on a 3608 circular screen’ (2005b: 187). Finally, such objects allow
to objectify the dimensions that make up the reality of the biopolitical processes that they address. For
this, however, and like the panoramas, they enable the imagination from the generation of conjectures
about the aspects they describe and, at the same time, about the aspects that are not covered by such
descriptions or that cannot be described.
The elements that form part of the biopolitical design in the described case are articulated thanks to the
existence of such speculative objects. These serve as entities that organize local reflections, allow the
articulation of narratives about biopolitical composition, but at the same time integrate the uncertainty
and the need to negotiate the meaning of the proposed actions. Biopolitical design involves the
establishment of a relationship with ambiguity. This is mediated by the existence of such objects,
referring to a composition or an object that exists only by the presence of its speculation referent.

Conclusions.
At certain times we are faced with instances that imply an ongoing relationship with uncertainty. The
truth that makes up an existence requires other elements to verify the possibility of establishing
relationships with it. In the case of biopolitical design, this becomes a fundamental process: the
population, the object of reference for the manufacture of biological-policy orientations, is an effect of
entities that allow establishing relations with it, insofar as it refers to an intangible reality.

Experts in biopolitical design are subjected to important challenges that involve the need to argue their
practices and decisions, while at the same time generating certainty about some decisions will have an
appreciable effect. For this, as we showed, they are subjected to a double process: first, to the
enforcement concerning the need of having to decide and produce a truth; second, to the formation of
alliances with objects that allow that truth to be created.

The analyzed case shows how the notion of biopolitics consists of a fiction, when it is considered as a
regime that encompasses a totality. As has been pointed out, and as Timmermans and Berg (1997)
has described excellently, the totality obeys to an eminently local and situated production, and, at the
same time, and inscribes the values and perspectives of the agents that participate in its production. If
it is possible to point out a total power over biological life, it is necessary to pay attention to the
conditions, practices and social and technical trajectories by which biopolitics is produced, in terms of
the regularities it indicates and the interventions over which it operates. Such totality obeys to the local
conditions in which it operates, either as a formulation, or as a practice articulated to the interweave it
sustains. The image of biopolitical totality obeys to its contingent conditions of elaboration, but above
all of uncertainty over which it operates.

In such scenario, speculative objects provide the opportunity to reflect and articulate a rhetoric on
population. They are a resource of certainty, which integrates imprecision at the same time. They are
a means of surveillance that opposes the idea of control, and they lay down certain bases to consider
the inventive, creative, and dynamic nature of knowledge production practices linked to the exercise of
biological policy in areas of expert design. Such objects, such as indexes, results of calculations, or
studies on certain population processes, involve considering the political agency of the objects
themselves and the ways how objects created by science enact and propose biopolitical present and
futures.
1
If the main quality of the exercise of anatomopolitics described by Foucault (2003) is the individualization and composition of a
striated and disciplined body through institutions and surveillance, for biopolitics the function of governing is exercised through
a new series of technologies necessary for the production of a body-species and the regularization of its knowledge. In both
cases it is a technology of the body, but in the former it is the composition of an individual body endowed with capacities, and in
the latter of ‘bodies that are relocated in the biological processes of the whole’ (: 225), which depends for their consideration on
a heterogeneous collective of measures and the formation, distribution, and evaluation of knowledge.

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