Improvising Medicine: An African Oncology Ward in an Emerging Cancer Epidemic by Julie Livingston

I read this for my Ethnographic Methods Seminar. The descriptions of the cancer epidemic in Botswana were harrowing and so gut wrenchingly sad. But Livingston does a wonderful job describing the ways in which doctors, nurses, patients and relatives work together in an overcrowded hospital in a system of universal health care and a culture of humanism or Botho ¹ to improvise solutions that embody care in the face of overwhelming suffering. She makes a beautiful, nuanced and impassioned case for a specific hospital setting (Princess Marina Hosopital) as a fractal of health care, politics and culture.

There are many memorable characters and moments in the book, but Dr P stands out as a unique blend of artisan, empiricist and Marxist – and seeming tirelessness and courage. Livingston details his work habits and process which span many activities to show how improvisational medicine can be:

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 (where capacity is overstretched and extra beds are often packed in), and supervises aspects of care for cancer patients housed in other wards in the hospital. He is also the hospital hematologist. He feels the contours of lumpy lymph nodes, tumors skin, and organs on the patient’s body. He smells necroses, listens to whistling lungs and gurgling tracheotomies, and lays his hand on the back of each patient during ward rounds to feel for fevers. The nurses joke about his thermometer-like “magic hand”. He performs fine-needle aspirations, extracting cellular material from lymph nodes and possible tumors, pressing it onto slides. He also aspirates bone marrow and performs bone-marrow biopsies by boring into the sternum or pelvis of a patient and extracting a core sample to slice, or a tube of blood and fragments, to place on slides. Since the hospital lacks a cytology lab, he is also the one to examine the slides under the microscope, actively blocking out his image of the patient’s clinical presentation as he places a drop of oil on the slide, then searches for tumor cells. Cytology, as he told me, “is like trying to understand the architecture of the house from a few bricks.” But he strives to make cytologically based diagnoses and to avoid requesting biopsies, because waiting times fro minor theater are long, as is the wait for histological results, which can take weeks. He also tries to avoid the need for histological confirmation because there are numerous errors and inconsistencies in the reporting of histology. (pp. 62-63)

…

This oncologist continually tacks back and forth between different kinds of firsthand knowledge, creating cancer and the cancer patient in multiple registers simultaneously (visually, tactilely, socially, microscopically, clinically, economically, bureaucratically), rather than in a series of disconnected or abstracted parts, as is the case in a larger oncology setting, with a more complex division of labor. (p. 65)

Along the way there are some useful theoretical pointers, one which I noted down was the idea of bracketing from Dutch ethnographer and philosopher Annemarie Mol. Bracketing, or really its counterpart unbracketing is the ability to evaluate, question and apply information in context. The concept is offered as a key ingredient in Livingston’s portrayal of improvisation, and draws heavily from Mol’s The Body Multiple, which could be a useful book to follow up on. Interestingly Mol has worked closely with John Law, who is a Science and Technology Studies scholar that I have run across in my practice theory independent study. This connection got to thinking about the ties between medicine and grounded theory, as well as the conceptual ties between grounded theory and ethnography. It seems both qualitative approaches rely heavily on so called thick description and participant observation from which theory can be extracted (or not). But ethnography is ultimately about understanding culture, whereas grounded theory can be used in other contexts.

Speaking of participant observation, and returning to Improvising Medicine, Livingston’s ability to enter into Princess Marina Hospital in Botswana and to participate in the often grisly and heart rending activities was really astounding. It added a personal dimension to the book that is extremely important for her analysis of medicine–and keeps the pages turning.