Duke University Press, 2012
Julie Livingston’s Improvising Medicine is a lucid, poignant, and devastating book about the stakes of a growing cancer epidemic in sub-Saharan Africa that is trailing the HIV/AIDS epidemic. This ethnography takes place mainly on the recently established oncology ward of Princess Marina Hospital in Gabarone, Botswana. It follows the labors of Dr. P, the tireless, irascible German oncologist, a staff of dedicated Batswana nurses, and family caregivers as they work to provide both oncological and emotional relief to cancer patients. These patients are often arriving at the ward with late stage tumors. Many of these tumors are themselves extraordinary—eyes bulge out of sockets and breasts fulminate and stink. A historian-ethnographer interested in the body as a moral condition, Livingston does not shy away from carefully examining the ways in which both caretakers and patients strive to maintain humanity and humanness in the face of disfigurement and disgust. She treats the cancer ward both as a microcosm that lays visible some of the fundamental hopes and challenges of life in present-day southern Africa. The cancer ward is also, as she puts it, “a powerfully embodied social and existential space,” where one can “contemplate the meanings, practices, and politics of care.”
The book advances three interwoven arguments. The first is that improvisation is a fundamental aspect of the practice and provision of biomedicine in Africa. In a context where drugs are constantly in and out of stock, where blood transfusion services are erratic, and where vital reagents for pathology diagnoses are missing, the striking unpredictability of what may or may not be available profoundly shapes medical practice.
Secondly, she argues that cancer is a fundamentally social experience. It is something that happens “between people.” Understanding cancer as an illness of rapidly dividing cells without end, is something that is actively created at PMH, and often becomes solidified by the unholy trinity of oncological practice—poisoning, cutting, and burning in an effort to shrink tumors and prolong life. And bodily experiences, such as pain and disfigurement, also emerge as deeply social experiences in a context where families are washing stinking wounds, nurses are taking care of their relatives on the wards, and beds stand close proximity to one another, making it impossible to not hear the chorus of vomiting after a round of chemo.
Thirdly, Livingston argues that cancer is emerging as an epidemic which will shape public health in sub-Saharan Africa. Cancer has historically been largely invisible in Africa, in part because of public health imaginaries that have constructed Africans as “biologically simple,” and the continent as a denizen of infectious disease crises. But especially in southern Africa, the advent of antiretroviral therapy has prolonged life, and has also unleashed an epidemic of HIV related malignancies, particularly cervical cancer and of course Kaposi’s sarcoma. This is a sad irony in which one pharmaceutical intervention, which has been so pivotal in softening and stemming mortality from AIDS, has created a context in which an epidemic of debilitating malignancies is now far more visible.
Livingston begins with the last argument, tracing the history of how cancer in Africa was rendered invisible, while highlighting the ironies and contradictions of imagining Africa as a place where life expectancy is so short that it would make sense to use the continent as a dumping ground for toxic waste, as Larry Summers infamously argued. From there the book takes the reader to the wards. The ontological politics of cancer are discussed, as Livingston asks, to what extent is cancer the same thing in New York and Gabarone? A chapter on the moral intimacies of nursing care and the ways in which allocating resources on PMH’s cancer ward echo larger concerns of Botswana’s state to equitably cut the national cake follows. The problem of pain and palliation emerge as profoundly social and historically situated experiences in the book, as does the politics of triage and prognostication, which make up the last two substantive chapters of the book.
The intimacy, care, intelligence, urgency, and fearlessness of Livingston’s writing and thinking make Improvising Medicine a truly masterful ethnography. Throughout the book, Livingston invites you to feel the human stakes, bodily dilemmas, and deep contradictions of oncology when its logic is ripped down to the studs and cannot be softened with chemo ports, recliners, and smooth jazz. Perhaps nowhere is this more powerful than in the pivot point of the book, the interlude “Amputation Day at Princess Marina Hospital,” in which we follow the oncologist and ethnographer on a particularly brutal day where the dilemmas of keeping limbs at the cost of lives are laid bare.
Livingston is quick to point out that Botswana’s cancer ward is just one possible manifestation of Africa’s emerging cancer crisis, and the book opens a broader research agenda for examining cancer in sub-Saharan Africa.
Since 2010, I have worked at the Uganda Cancer Institute in Kampala, which was established in the 1960s to do cutting edge chemotherapy trials on children with Burkitt’s lymphoma and adults with Kaposi’s sarcoma. Founded as a collaborative effort between the American National Cancer Institute and the Makerere Medical School’s department of surgery, this Institute weathered the storm of Idi Amin’s murderous dictatorship, the vagaries of structural adjustment, and an HIV epidemic. Today approximately 60 beds at the Institute provide public oncology goods to a population catchment of approximately 40 million Africans in the Great Lakes region. The Institute is also in a tremendous state of flux—two new buildings are dramatically reshaping the possibility of increasing cancer care capacity in the country.
Many of the improvisations, existential dilemmas, and bodily states that characterize the PMH cancer ward can also be found on the wards in Uganda. But the politics of care are quite different. The Institute’s history as a cancer research facility, where “Research is Our Resource,” means that for many years the Institute prioritized the treatment of cancers that were embedded in clinical trial research protocols. Today newly trained Ugandan oncologists struggle to meet the demands of their busy clinics, where they primarily manage late stage tumors, while remaining internationally relevant and conducting translational research for an emerging global oncology audience. Ironically, despite the Institute’s rich history, cancer has only come onto the Ugandan government’s radar as more and more politicians succumb to cancer themselves, or find that they are not in a position to shoulder the burden of sending multiple grannies to India for treatment.
Livingston is careful to not romanticize Botswana’s African miracle, but the Batswana’s commitment to social cohesion and equitable allocation does remain astonishing. Reading Livingston’s account of the oncology ward in Zimbabwe at Mpilo hospital, one has a sense that Mugabe’s state consumed itself from the inside out. One is reminded of the theorist Jean-Francois Bayart, who coined the idea of the “politics of the belly,” or the ways in which the symbolic power of eating can connote corruption and graft in African politics. Political power and its relationship to eating and consumption takes on a new and sinister twist when we think about cancer. The Red Pepper, one of Uganda’s tabloid newspapers that occasionally carries vital news, recently published an amazing photo essay of politicians stuffing their faces full of local food at an important meeting. The mouths open in mid-bite, the close ups of banana mash in groundnut sauce, the gigantic bellies—these images captured the vulgarity of a state intent on eating itself to death. The sad fact of the matter is that in many countries, and the U.S. is not exempted here, the politics can be downright malignant themselves. In an African context, it is unclear what sort of impact these dynamics will have on shaping cancer services in the decades to come.
I encourage readers to buy the book now and read it this weekend before the school year starts in earnest, if you have not yet had the pleasure of doing so. In addition to the intelligence and empathy of the writing, Livingston is making major contributions to scholarship on ontological politics, public health in Africa in the wake of structural adjustment, the history of the body, the plasticity of where infectious diseases end and chronic illnesses begin. Improvising Medicine would be indispensable in any global health, medical anthropology, or modern African history course. The book could also be read as the second volume of Livingston’s first work, Debility and the Moral Imagination in Botswana, which I recommend to readers if they are interested in a deeper historical and contemporary contextualization of the moral universe of care beyond the space of the cancer ward itself.
It is my hope that the Improvising Medicine, which highlights the pressing need to take cancer in Africa seriously, will be taken seriously by the broader global health community. There are no easy sociotechnological fixes or financial solutions to the dilemmas Livingston presents here. Improvisation will, no doubt, continue to be a fact of life in under funded public tertiary medical centers throughout sub-Saharan Africa. Perhaps what may be deemed the most immediately relevant to the emerging global oncology community is the fact that the cancer epidemic in Botswana, and indeed in Uganda, is in many ways a pain epidemic, and a sane redistribution of the world’s opiate consumption would greatly improve lives.
And closer to home, for all of us who have been touched by the slow and sad decline of a relative, or the untimely departure of a dear friend, or indeed the revelation of our own mortality, I hope this book challenges us to think a little more carefully about the limitations and double bind of the healing and harming qualities of oncological goods.
Marissa Mika is a historian-ethnographer who uses the lens of medicine, science, and technology studies to understand the ways in which ordinary people cope with social change and negotiate politics in modern Africa. Her current project, Malignant States: Creativity, Crisis, and Cancer in Uganda, traces the political and social history of a cancer research institute in Uganda. A second project on medical waste and occupational safety in African hospitals is in development. Marissa will defend her PhD in the History and Sociology of Science at the University of Pennsylvania in spring 2015, and is currently a visiting researcher at the University of California, Berkeley’s Center for Science, Medicine, and Technology Studies.