Improvising Medicine. Julie Livingston, Durham: Duke University Press, 2012, 228 pp.
This is a book about basic human problems—the problems of suffering, of pain, of caretaking, of relationship—as they play out in a particularly demanding venue: the cancer ward at Princess Marina Hospital, in Gaborone, Botswana. Biomedicine at PMH is locally contextualized, even as it is linked to a global system of knowledge and clinical practice. Livingston presents a beautiful, if often anguishing, account of individual experiences at the only specialized cancer service in Botswana, as they reflect the political and economic exigencies of a particular historical moment.
Livingston problematizes widespread assumptions regarding the epidemiological transition, as she traces the social history of HIV/AIDS and its treatments. Whereas cancer is often considered a “disease of development,” Livingston offers a compelling counter-argument that AIDS and ARVs are implicated in a cancer epidemic, as AIDS treatments generate a rise in the incidence of certain cancers in regions such as East and southern Africa. The life-threatening consequences of ARVs have emerged as the links between infectious disease and cancer also become increasingly evident.
Improvising Medicine is a brilliant and groundbreaking hospital ethnography, one that grips the reader with its narratives of an institution characterized by constant precarity, where supplies, medications, procedures, and staff are never assured. Patients desperate for pain medication are confronted with a chronic shortage of beds, not to mention medication, and improvisation in situations of scarcity is imperative. Livingston’s own role is foregrounded, as she observes and documents patient histories, but in a setting that requires participation in relations of care, from everyone—including the ethnographer. What is care in moments of existential crisis? This beautiful and poignant account illustrates the many faces of caregiving, from doctors, nurses, kin, friends, and patients who try to console and alleviate suffering for one another.
The author cautions that the book is not intended to be a story of redemption, yet the impact of certain charismatic individuals, working in extraordinarily difficult conditions, stands out, as they push themselves and inspire coworkers to carry on to the limits of endurance. This ethnography demonstrates that cancer is not a disease only of individual patients, but of kin, friendship networks, and what might be called therapy management groups.
Consequently, the book is an important comparative work, in the burgeoning anthropological literature on cancer. In this regard, it is invaluable for examining the notion of biographical disruption, so common in U.S. studies of cancer. These focus on the impact of cancer on the individual patient, and on the related concept of the survivor. One is motivated by this study to rethink biographical disruption and to broaden this concept to a more collective disruption of family and domestic networks. Moreover, nurses and other clinical staff experience obligations as caretakers that are emotionally consuming. Cancer in this context cannot be understood without attention to the significance of sociality, produced in the hospital, in the course of regimens of care by clinicians, family, and patients themselves.
Similarly, the chapter on pain and laughter adds substantially to our understanding of how pain may be understood as a social phenomenon. Livingston disputes other well-known works on pain as a highly individual experience, one that transcends language. In contrast, the cases presented here describe palliative care in the absence of analgesics for intractable pain. Family, nurses, and friends seem to embody the pain collectively, visibly sharing the patient’s suffering. The local meanings of pain for dying cancer patients are elaborated by a historical consideration of stoicism, including colonial perspectives on Botswana. The analysis of laughter as a response to pain by sufferers and by spectators, witnessing pain, is another significant dimension of this discussion.
Hospital ethnography in sub-Saharan Africa contributes to a small but emergent literature. Much has been written on biomedicine in other parts of the world, but less on hospitals in resource-poor countries or on specialized institutions such as the Princess Marina Hospital for oncology patients. Cancers in much of sub-Saharan Africa represent diseases distinct from those bearing the same name in other biomedical systems. Because late-stage diagnosis is common, cancers are often visible and disfiguringas well as unlikely to respond to such treatment as is available. Nonetheless, some patients are sustained, for uncertain periods of time, and serve as incentives and sources of hope for the entire community invested in cancer care.
The poignant narratives that punctuate the book reflect the deep rapport between Livingston, the patients featured, the German physician—Dr. P—and, above all, the nurses. Livingston assures the reader of her intent to avoid the gratuitous exposure of intimate patient suffering. Although graphic on occasion, descriptions of procedures to which patients are subjected, such as nurses cleansing maggots from a wound, are used selectively for readers to truly grasp the meanings of a cancer experience insofar as it is possible at a distance. It is difficult to imagine a more painful and challenging research context, rendering this compelling book even more powerful. It seems remarkable that a book fraught with distressing accounts of agony, debility, and death could be so riveting, yet not macabre.
Improvising Medicine should interest diverse audiences. These include medical anthropologists, sociologists, social historians of Africa, public health specialists, and scholars across disciplines with interest in the cultures and practices of biomedicine, the morality of care, and the comparative analysis of medical ethics.