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Improvising Medicine: An African Oncology Ward in an Emerging Cancer Epidemic Paperback – August 29, 2012
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About the Author
Julie Livingston is Associate Professor of History at Rutgers University. She is the author of Debility and the Moral Imagination in Botswana and a coeditor of Three Shots at Prevention: The HPV Vaccine and the Politics of Medicine's Simple Solutions and A Death Retold: Jesica Santillan, the Bungled Transplant, and Paradoxes of Medical Citizenship.
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Livingston’s analysis provides for an interesting comparison between Botswana and the global north/Western world. She writes, “Healthcare (including oncology) is provided as a public good for citizens under a program of universal care. Most notably, Botswana has not accrued foreign debt, and so has been spared the predations of structural adjustment” (pg. 17). Despite this, Livingston cautions her readers against reading any utopian vision into oncology in Botswana. She writes, “Botswana’s position as an African nation that against all odds on the continent prioritizes universal healthcare and corporate capitalism simultaneously, and as a place where the cancer epidemic itself is in some part an outgrowth of a philanthropic project by Merck pharmaceuticals to extend the lives of those with HIV through the provision of antiretrovirals suggests a somewhat different, but not less compelling politics afoot” (pg. 171). Livingston contrasts this with Annemarie Mol’s discussion of similar systems from her book, "The Logic of Care". Livingston writes, “In Botswana, a country with universal access to healthcare for citizens, and with a historically deep and explicit understanding of care as a densely social dynamic, we encounter a particular pragmatics and an ethos of clinical medicine that at least partially diverges from what the philosopher Annemarie Mol calls ‘the choice model’ of healthcare” (pg. 153). Even with guaranteed healthcare, limited resources, physical distance to sites of treatment, and cultural views of medicine and pain management create a dynamically different situation than the one Mol described in "The Body Multiple", in which Dutch patients seek cutting-edge treatment for atherosclerosis at all stages of the disease and have a variety of options open to them, as well as a different cultural understanding of disease itself.
A final interesting point Livingston makes deals with patient’s autonomy in the social culture of Botswana. Livingston writes, “There are several problems with fetishizing autonomy as progress, as some would do. First, there is a temporality to prognostic desire, even in places that privilege autonomy…Second, deeming autonomy as progress implies a uniformity of desire by patients within a particular national culture and historical epoch” (pg. 166). The social networks of Botswana only recently allowed the medical autonomy Americans expect in their doctor-patient interactions. Doctors in Botswana deprive patients of their autonomy in cases of terminal disease, instead socially distributing “to their kin through customs of prognostication that allow for frank, if brief, discussions with relatives, but not with patients” (pg. 159). Western patients expect medical control over the manner of their death in cases of terminal diagnosis, but this expectation does not exist in Botswana.
She puts the things she observes in the context of rising cancer rates in Africa and general unavailability of treatment, especially given forced-by-IMF privatization and expensive cancer drug patents. In a still-public hospital in Botswana which at least has an ethos of caring and an excellent oncologist, Livingston is, as she realizes, in one of the better possible settings in the environment, but the hospital staff struggles mightily with limited resources, hordes of patients, lack of treatment drugs and palliative drugs, and in general tremendous difficulties. How the patients and the staff manage and conceptualize things is astutely observed.
Yet at the end the book leaves me touched, yes, but also angry about the marginalization of African health care and disease and about the drug patent system, as well as somewhat frustrated at how ephemeral any local gains can be without any sort of steady or rational progress, but grateful for people who are willing to deal with things as best they can regardless of that. And grateful for this fine book.