Biomedicine in an Unstable Place: Infrastructure and Personhood in a Papua New Guinean Hospital
by Alice Street
Duke University Press, 2014, 204 pages
Social anthropologist Alice Street’s first book is a sensitive ethnography of personhood and recognition in Madang Hospital, an under-resourced provincial hospital in Papua New Guinea. The book shows how doctors, nurses, and patients endeavor to make themselves “visible” to others in order to initiate relations of care at multiple scales, while also emphasizing the uncertainties of diagnosis and treatment within an institution subject to perennial shortages of staff and supplies.
The book’s main section explores the treatment and experience of disease within the public ward of Madang Hospital. Street introduces the concept of “biomedical uncertainty” to describe how doctors must forego conclusive diagnosis and embrace a pragmatic approach to treating patients in an under-resourced setting. That this kitchen-sink method is the one best suited to the circumstances at Madang Hospital seems reasonable – after all, the doctors themselves say so. But Street’s optimistic claim that this “uncertainty…is another productive form that biomedical knowledge can take” and her apparent endorsement of what she terms “technologies of not knowing” feels out of step with the real ways doctors in this environment struggle to produce care amidst difficult constraints (111). What should be commended is the Madang doctors’ commitment to take action in spite of the prevailing biomedical uncertainty in their ward, not the uncertainty itself – the unenviable result of chronic resource shortages. It would seem essential to distinguish between this kind of uncertainty on the one hand and a positive strategy of diagnostic suppleness or nonclosure on the other. When, in other words, is biomedical uncertainty a stance that doctors actively choose, and when is it an unwelcome imposition?
The book is most compelling when it combines insights from the fields of New Melanesian Ethnography and medical anthropology to show how social inequalities present as differential possibilities of care within the hospital. The elusiveness of recovery in this space contributes to patients’ profound anxieties about being properly recognized and acted upon by other actors within and outside the hospital. In a Melanesian context, visibility prompts social action, and being properly “seen” by others is the basis of relational and physical wellbeing. Thus, patients at Madang Hospital are more concerned about making themselves the subjects of others’ care than they are about understanding the cause of their disease. Paradoxically, getting well in Madang Hospital presupposes the social viability it takes to make oneself appear as a person worth caring for. Street explains that patients attempt to “make themselves visible as socially viable and well persons” in order to initiate the relations of care (with doctors, nurses, and family members) through which they will actually be healed (118). Patients in the Madang public ward therefore suffer doubly: languishing in their beds due to inadequate attention and medical resources, while also blaming themselves for failing to appear deserving of care. If the doctors at Madang are often unsure how to diagnose patients because their symptoms are indeterminate, the patients actually appear to be doing much of this work themselves, though they often invoke so-called “cultural” explanations to rationalize their inability to get well rather than biomedical ones. It might have been interesting for Street to explore in greater depth how the burden of diagnosis in Madang Hospital is shared both between doctors and patients and across “cultural” and “biomedical” epistemologies.
The book’s final section further develops the theme of social recognition to show how institutional and collective entities – nurses’ unions, hospital administrators, clinicians, and researchers – engage strategies of visibility to attract the attention of other bodies and multiply the resources at their disposal. Street’s analysis of a partnership between Madang Hospital and an Australian research hospital shows how the production of reputable global health research depends on and reinforces an unequal geography of place. While Australian researchers need to use Madang Hospital to collect samples from the local population, they are not willing to use its unreliable lab facilities to analyze them. But instead of investing in the improvement of these facilities – one lasting way that local hospital staff and patients might benefit from international research agreements – the researchers elect to ship samples back to Australia for analysis. Local hospital staff grumble because they are not engaged meaningfully in the partnership, and the Australian team’s ceremonious gift of a single copy of a medical textbook feels tokenistic because it is incommensurate with the value generated by the research. These stories dramatize the inequalities that result when partnership is pursued without reciprocity. The question implicitly raised by these stories is a powerful one: What kind of exchange relationship is possible when one party is only a visitor within the transactional field?
Every anthropologist who has done fieldwork is familiar with the ethical concerns motivating this question, and Street is no exception. In the course of her research, she realizes that she has been drawn into the same world that she is studying, but that her powers have been inaccurately assessed. Patients believe she holds the key to unlocking “white people’s medicine”, evidently viewing her “as another ‘hospital technology’” they can leverage in the course of their treatment (32). Street (not a trained physician) notes with measured disappointment that she was unable to provide the care that patients sought from her, even if her attentiveness was soothing in other respects. But this problem of incommensurability, which is central not only to the modes of partnership and exchange that this book examines, but also to the enterprise of ethnography itself, deserves more expansive commentary from the author – indeed, from all of us. Is it enough for anthropologists to continually intone that “[g]ood description is not inert”? (33) Or do we also bear the responsibility of asking more precisely how the ethnographies we write participate in reality? I would suggest that our capacity to really see each other – that is, to attend to each other in real and lasting ways – depends on it.
Mackenzie Cramblit is a PhD Candidate at Duke University motivated by questions of intimacy, care and value in relation to rural places. She is interested in understanding what constitutes an “environment,” how environments are made livable, and how we become attached to each other in their midst. Her dissertation approaches these ideas through a study of a remote community and “wild” landscape on the West Coast of Scotland.