Biomedicine in an Unstable Place: Infrastructure and Personhood in a Papua New Guinean Hospital. Alice Street, Durham: Duke University Press, 2014, 290 pp.
Alice Street has undertaken a difficult and delicate task in writing an ethnography of a public hospital in Papua New Guinea: How should one represent an institution charged with caring for and, ideally, healing the sick when it often fails at this task and is painfully lacking the resources (human, financial, infrastructural, technological) necessary for success? Too blunt a portrait risks embarrassing or angering the various persons and governmental bodies responsible for the hospital’s working. Too euphemistic a portrait risks betraying the patients who have died unnecessarily. Street manages this challenging undertaking marvelously well, clearly conveying the frustrations of the clinical staff as well as the desperation and bewilderment of patients and their families, while also analyzing the resourceful strategies staff use to provide care.
One of the most thought-provoking aspects of the book is its transposition of Molian (as in Annemarie Mol) theory into a context where hospital practices often fail in their work of making disease objects cohere. In Mol’s (2002) examination of atherosclerosis in a Dutch hospital, atherosclerosis is enacted differently by different hospital specialists and sites: The vascular surgeon enacts artherosclerosis through documenting such symptoms as leg pain and cold feet, while the pathologist enacts artherosclerosis through viewing the thickened intima of a blood vessel wall. Nevertheless, a range of tactics and practices work to make atherosclerosis cohere and emerge as an ontological object.
I’ve often mused, as I’m sure many medical anthropologists have, what Mol’s analysis and theory might look like if transposed to a more disordered and dilapidated hospital setting where units are often pitted against one another and where all departments are chronically short of what they need to function as intended—in short, where all those tactics of coordination, distribution, and inclusion that Mol discusses don’t work, at least not reliably or regularly.
Some of Street’s book is about exactly that and shows that disease entities don’t cohere and remain ontologically tenuous where these tactics cannot be deployed. More concretely, this means that in many cases it is impossible to arrive at a diagnosis. For example, patients’ bodies exhibit fevers, weight loss, cough, and crepitation in the lungs, but the hospital’s imaging technologies cannot provide a clear visualization of internal disease because of poor quality film, the lack of chemicals to develop the film, or faulty calibration of the X-ray machine due to regular electrical outages. As one doctor says: “You might think this is miliary TB because there are white dots covering the lungs … but in fact that is from the chemicals they are using. It is a bad picture” (p. 95).
This diagnostic indeterminism has wide-ranging consequences. Most significantly, it results in a particular kind of biomedical practice—one that is more pragmatic and improvisatory. Because blood slides may be inaccurate or nonexistent, everyone with a fever receives anti-malarial medicines. If they don’t respond to those, chloramphenicol, a powerful, broad-spectrum, cheap antibiotic, is prescribed. If the patient recovers, he or she might have been suffering from meningitis, but it could just as well have been typhoid or some other bacterial infection.
Street does an excellent job at evoking just how disconcerting this kind of biomedical practice is from a Western perspective, where there is at least a lay assumption that diagnosis must come first and determines treatment. In contrast, in this hospital, “Asking ‘what can we do?’ does not depend on asking ‘what does he have?’ In fact, keeping multiple possibilities of diagnosis open is often preferable to closing them, and ancillary pathways for action, down” (p. 106). Nevertheless, the ideology of diagnostic precedence—or perhaps simply the observation that patients with a diagnosis do better than those without—preoccupies patients, and Street demonstrates that they and their families doggedly pursue doctors to get them to painim nem (find the name or diagnosis).
This pursuit of a diagnosis leads to the other theme in the book that I found ethnographically and theoretically riveting and perceptive: the quest for visibility. Visibility is a principal trope throughout the book: the fear of having become invisible and the attempts to make oneself more visible preoccupy nearly everyone. As Street observes: “The importance of painim nem was not that patients could now know and see what was inside them, but that, in being rendered recognizable and knowable within the conventions of biomedicine … doctors would feel compelled to cure them” (p. 131).
Patients thus rightly worry about being medically invisible to their doctors. Moreover, distant from their rural kin for long periods of time, they also worry that they have become socially invisible and thus excluded from networks of support, care, and good will. Hospital staff, for their part, worry about having become governmentally invisible to politicians and the national health department and thus deprived of essential medicines, technology, training opportunities, and decent housing. Street nimbly contrasts these aspirations for greater visibility with the anxieties about hyper-visibility that scholars, influenced by Foucault, have tended to emphasize, upending assumptions we might have about biomedicine producing, normalizing, or disciplining particular kinds of subjects.
Street’s book is theoretically sophisticated and is more wide-ranging than I have discussed. For example, she analyzes historical data to show that the failings of Papua New Guinea hospitals, though represented by donors and development organizations as a postcolonial phenomenon resulting from public sector corruption and inefficiency, can be traced back to colonial-era policies. She also has a very interesting chapter on hospital-based medical research (e.g., to test new malaria treatments) and the tensions that result between hospital doctors, who don’t have the infrastructure they need to diagnose and treat patients, and international researchers, whose projects entail using a wealth of laboratory and other resources. Here, too, the issue of visibility emerges: Expatriate research scientists produce knowledge that achieves international visibility while “hospital doctors and their idiosyncratic knowledge practices, by contrast, remain firmly entrenched in the particularities of the institution” (p. 197). Moreover, “the dilapidated public health infrastructure of the hospital wards was crucial for establishing the authenticity and real world relevance of the knowledge produced” (p. 208). In other words, as Street persuasively argues, the renown that international researchers secure through proving the effectiveness of one treatment over another depends on what Street sometimes refers to as the ruination of the hospital.
There are some weaknesses in the book: It is an ethnography of a hospital, but it is weighted heavily toward internal medicine, and one learns relatively little about the maternity ward, primary care for infants and children, sexual and reproductive health, or the out-patient ward. And, to my taste, analyses of issues concerning gender were sorely missing. Nevertheless, given the overall excellence of the book, these are minor quibbles. It makes an enormous contribution to Melanesian ethnography, is an exciting and exemplary use of STS theory, and is a path-breaking analysis of how hospitals work and don’t work in a postcolonial context. The book could be usefully paired in a graduate seminar on medical anthropology with The Body Multiple and/or The Birth of the Clinic. In an upper-level undergraduate class, one might pair it with the 20-year old, yet still highly relevant film, Donka: X-Ray of an African Hospital (Icarus Films).
2002 The Body Multiple: Ontology in Medical Practice. Durham: Duke University Press.