Table of Con­tents | Arti­cle doi: 10.17742/IMAGE.IN.11.2.8 | PDF

Upstream the Cold Chain Jes­per Alvaer

Upstream the Cold Chain

Jes­per Alvaer

Upstream the Cold Chain is a film and an instal­la­tion of objects pro­duced in the process of pro­duc­ing the film. It is also an exper­i­ment in improv­ing access to vac­cines and cre­at­ing hos­pitable artis­tic inter­ven­tions in pub­lic health con­texts across bor­ders. Pre­sent­ed in the con­text of <Immune Nations>, Upstream the Cold Chain was first shown in Trond­heim, Nor­way, as part of the 2017 GLOBVAC con­fer­ence on glob­al health and then lat­er at UNAIDS on the occa­sion of the World Health Organization’s 70th World Health Assem­bly in Gene­va, Switzerland.

Upstream the Cold Chain est un film, et une instal­la­tion d’objets pro­duits dans le proces­sus de pro­duc­tion du film. Il s’agit égale­ment d’une expéri­ence visant à amélior­er l’accès aux vac­cins et à créer des inter­ven­tions artis­tiques hos­pi­tal­ières dans des con­textes de san­té publique trans­frontal­iers. Présen­té dans le con­texte de <Immune Nations>, Upstream the Cold Chain a été présen­té pour la pre­mière fois à Trond­heim, en Norvège, dans le cadre de la con­férence GLOBVAC 2017 sur la san­té mon­di­ale, puis à l’ONUSIDA à l’occasion de la 70e Assem­blée mon­di­ale de la San­té de l’Organisation mon­di­ale de la San­té à Genève, Suisse.

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.

Improvising Scenarios

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:

La main

The Hand

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.

Fig­ure 1: Thèrése Sinaré reads her poem at UNAIDS, Gene­va, 2017. Video still by Julien Duret.

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.

Fig­ure 2: Jes­per Alvaer, Upstream the Cold Chain, Burk­i­na Faso and Mozam­bique, 2017, 8 min.


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).

Work Cited

<Immune Nations>. Gal­leri KiT and UNAIDS, 2017. www​.immune​na​tions​.com/​u​p​l​o​a​d​s​/​1​/​2​/​6​/​2​/​1​2​6​2​7​9​6​3​/​i​m​m​u​n​e​n​a​t​i​o​n​s​_​p​r​o​g​r​a​m​.​pdf.

Image Notes

Video 1: Ms. Sinaré reads her poem at UNAIDS, Gene­va, 2017. https://​vimeo​.com/​4​4​7​2​6​8​018

Video 2: Upstream the Cold Chain, direct­ed by Jes­per Alvaer, Burk­i­na Faso and Mozam­bique, 2017, 8 min. https://​vimeo​.com/​4​4​7​2​7​0​067


  1. 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.

Instal­la­tion view with artist and col­lab­o­ra­tors Jes­per Alvær, Johan Holst, and Thérèse Sinaré, Upstream the Cold Chain, UNAIDS, Gene­va, 2017. Pho­to by Roman Levchenko.
Jes­per Alvaer, Upstream the Cold Chain, UNAIDS, Gene­va, 2017. 8 min­utes sin­gle chan­nel video. Pho­to by Annik Wetter.
Thérèse Sinaré at the open­ing recep­tion, Immune Nations, UNAIDS, Gene­va, 2017. Pho­to by Roman Levchenko.
Instal­la­tion view, Jes­per Alvaer, Upstream the Cold Chain, UNAIDS, Gene­va, 2017. 8 min­utes sin­gle chan­nel video. Pho­to by Patrick Mahon.