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Improvising Medicine

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Anais Wicke

on 6 October 2014

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Transcript of Improvising Medicine

Improvising Medicine
Julie Livingston
Medical Historian and Anthropologist
Winner of McArthur Fellowship
Debility and moral imagination
(Botswana 2005)
Suicide (New York 2014)
History professor at Rutgers University
Quote from Interview
"I think this sort of evolution of the research question often happens to historians and anthropologists. One of the many strengths of ethnography (the method at the heart of this book) is that is enables us to flexible in the face of unfolding research.
As we carefully listen and watch, and experience, new questions necessarily emerge, which in turn are folded into the research process.
In this way careful ethnography can also operate as an "early warning" system of sorts. And this is what happened to me. I arrived in Botswana preparing to study questions of pain and laughter, historically and ethnographically. I entered Botswana's cancer ward as one potential research site among many I intended to visit, and instead of moving on to the other sites, I stayed in the cancer ward. What I found there were important answers to some of my questions about pain and laughter, but also a host of other questions about the emerging cancer epidemic in Africa and its attendant politics of causation and care."
6 chapters, interlude, epilogue
PMH as microcosm

Synergy Aids & cancer
Horizontal healthcare

Main arguments
Links to readings
Strengths and weaknesses
Main Arguments
Main Arguments 2
Links to Readings
Strengths and Weaknesses
Who is Dr. P?
German ocologist
Exile in Botswana
'difficult' character:
impatient, directive
Sense of urgency
Paying treatment
'In PMH he works hard, and he works seven days a week. He handles all outpatient clinical oncology, seeing usually between twenty and thirty patients a day (though the worst days bring up to forty patients to the clinic), directs a twenty-bed ward [..]. He feels the contours of lumps, lymph nodes, tumors, skin, and organs on the patient's body. [..] He pushes against the bureaucracy [..]. He counsels the families [..].' (p. 62-64)
" Improvisation is a defining feature of biomedicine
in Africa. Biomedicine is a global system of knowledge and practice, but it is also a highly contextualized pursuit. Everywhere, doctors, patients, nurses, and relatives tailor biomedical knowledge and practices to suit their specific situations. In hospitals and clinics across Africa, clinical improvisation is accentuated."
" Cancer produces moments and states of profound loneliness for patients, serious illness, pain, disfigurement, and even death are deeply social experiences. Understanding cancer as something that happens
people is critical to grasping its gravity. In this respect, what I seek to make visible in PMH's oncology is not uniquely 'African'. Rather, it is an imperative that is often papered over or under threat in the techno-bereaycratic rituals of European or American wards, but which is nonetheless still there, beneath the surface:
Hospital based ethnography
- prior research
- research described in "Improvising Medicine"
pain and laughter as the initial research idea
- participant observation
-knowledge of Setswana language
- Van der Geest
- Goodwin, Pope, Mort & Smith
- Gerrits
- Goldstein
- Pool

"Laughter often comes in moments when cultural norms fail to be enacted [..], in its recognition of the absurd, laughter reinforces the norm by socializing it."

"Her joking and her laughter were a way of saying that everything was going to be fine, that this was nothing serious- even though her visit showed how very serious it was, even as the laughter allowed tears streaming down her face."
Fieldwork and methodology continued
A good doctor is not paternalistic
but supports and respects patient autonomy.
Medical paternalism
: a philosophy that certain health decisions are best left in the hands of those providing health care

"You haven't the right to decide this. This happens every time, and then you will be back in two months begging me to amputate, but it will be too late then" (Pp. 88)


"Oncology produces knowledge and uncertainty, therapy and futility constantly and simulatenously and
provides much-needed ballast for well-meaning and sometimes desperate people" (pp. 170)

The author looks at "how phenomenological experiences of pain, palpation, bodily change, fear, nausea, and, often, rot merge with technoscientific practices of cytology, chemotherapy, radiation, and surgery to create cancer in PMH oncology, and how clinical communication reveals the highly unstable nature of this new entity." (pp. 55)

Focus on the interaction between patients and the oncologist in an effort to understand the microprocesses by which this cancer epidemic emerges on the clinical ground.
" Cancer in Africa is an epidemic that will profoundly shape the future of global health, raising fundamental policy, scientific, and care-giving challenges for Africans and the international community alike. Cancer is a critical face of African health after antiretrovirals (ARVS). As such, cancer experiences in the ward expose the unfortunate fact that biomedicine is an incomplete solution."
Main arguments 3
Improvising medicine

Medical paternalism

Pain and laughter
Easy and fun to read
Long- standing knowledge of and engagement with healthcare and bodily vulnerability in Botswana.
Participation and observation in the Cancer ward
Written in the first person
Quite graphic:

"Dumisane, the guy with the hole in his head, is here. His blood is OK, so he will have chemo, but first the wound (from the tumor in his neck) has to be cleaned. The nurse who brought him says (in the clinic) at Letlhakeng there were maggots in the woundm and they cleaned it with hydrogen peroxide. It must not have been todat, because the bandage is very dirty."

And more..
"Pain is a relationship [..] in other words, pain begs a response".

"Sometimes that response it laughter".
Pain (Poetics of endurance)
Full transcript