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  • Improvising Medicine: An African Oncology Ward in an Emerging Cancer Epidemic

    Author(s): Julie Livingston
    Published: 2012
    Pages: 248
    Illustrations: 13 photographs, 1 map
    Sales/Territorial Rights: World
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  • Preface ix

    Acknowledgments xiii

    1. The Other Cancer Ward 1

    2. Neoplastic Africa: Mapping Circuits of Toxicity and Knowledge 29

    3. Creating and Embedding Cancer in Botswana's Oncology Ward 52

    Interlude. Amputation Day at Princess Marina Hospital 85

    4. The Moral Intimacies of Care 93

    5. Pain and Laughter 119

    6. After ARVs, During Cancer, Before Death 152

    Epilogue. Changing Wards, Further Improvisations 174

    Notes 183

    Bibliography 205

    Index 221
  • Winner of the 2013 Victor Turner Prize, presented by the Society for Humanistic Anthropology

    Winner, 2013 Welch Medal (presented by the American Association of the History of Medicine)

    Winner of a 2013 MacArthur "Genius" Grant

    Winner of the 2013 Wellcome Medal for Anthropology as Applied to Medical Problems

  • "An unflinching light on cancer, exposing both the brutalities of cut-and-burn care and the intimacies of moral labor it occasions." — Catherine M. Montgomery, New Genetics and Society

    “This book will find a ready readership among Africanists and medical anthropologists. I envision its wider use in g'lobal health' courses, where it will challenge aspiring health workers accustomed to locating hope for medical development in scalable technical interventions... Cancer care, Livingston shows us—like medicine, like development—often requires starting over, usually entails improvisation, and always calls for hard labor by particular individuals in the face of destructive political and economic forces. Improvising Medicine reminds us effectively, sometimes devastatingly, how intractably human this thing called 'health care' is.” — Claire Wendland, American Ethnologist

    “This is an excellent ethnography that should (and undoubtedly will) be read and taught by anthropologists, historians, science studies scholars, and interdisciplinary scholars of Africa…. students and practitioners of global health should be reading Improvising Medicine, in which African cancer is made visible and the clinical science of oncology is never divorced from the moral labor and political conditions of care.” — Johanna Crane, African Studies Review

    Improvising Medicine is best suited to those who are interested in global health or who provide medical care across cultures. While its primary subject is cancer, the points the author makes regarding the view of medical care priorities in resource-poor countries, as well as the culture-dependent experience of disease, are well taken and can be applied to work in other areas of the world.” — Holly Salzman, Family Medicine

    “In Improvising Medicine, Julie Livingston presents a vivid ethnography of cancer management in an African hospital ward...This book is rich in textual and visual data and is theoretically well informed. It is a model of ethnographic work and an excellent monograph in global medicine and health systems research.” — Benson Mulemi, Social History of Medicine

    “Although this scholarly work explores a harsh and distressing reality, it is well written, with a warmth and compassion that will make it accessible and appealing to a broad readership… This book will have a direct and sustained impact across fields of social sciences and medical humanities – as it can provide an important perspective often lacking within the paternalistic global health debates.” — Karen Barnes, Journal of Southern African Studies

    “Improvising Medicine constantly challenges the reader to consider the intrinsic and intimate relations between the isolating nature of cancer and disease and the role of sociality in cancer care. In doing so, she reminds us that not only is oncology a field with immense questions, but it is also one where answers to these questions are often blurred, unknown, improvised and situated within larger conversations on bioethics, politics, and global health agendas…. Cancer control will continue to necessitate multi-faceted approaches and perspectives from various disciplines, and Livingston’s work is a superb contribution in further understanding cancer control in Africa.” — Zachary Obinna Enumah, African Studies Quarterly

    “This ethnography of a (or more accurately the) cancer ward in Botswana is beautifully written, uncompromisingly honest and an uncomfortable read. I’ve always thought that the hallmark of great ethnography is that it transcends the specificities of time and place, of the particular, to offer a glimpse of the universal. I think this book qualifies; the quality of the writing and the limpidity of the ethnography make it a path-breaking work of anthropology tout court. They give the reader the sense of being allowed to behold a truth otherwise not accessible.” — Vinh-Kim Nguyen, Social Anthropology

    “The intimacy, care, intelligence, urgency, and fearlessness of Livingston’s writing and thinking make Improvising Medicine a truly masterful ethnography. . . . 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.” — Marissa Mika, Somatosphere

    “The book as a whole is extremely readable, rendering complex concepts in science studies and medical anthropology accessible to nonspecialists through exceptionally clear prose. This is achieved thanks in large part to Livingston’s eye for ethnographic detail, her attention to the singularity of individuals’ experiences, and her appreciation of the multidimensionality of individuals themselves.” — Betsey Brada, Bulletin of the History of Medicine

    Improvising Medicine is an exquisite ethnography, replete with both specific, richly observed encounters at a cancer ward in Botswana and broader, urgent arguments for anthropology and global health. . . . Drawing on beautifully rendered ethnographic evidence, Improvising Medicine tells a compelling story that is relevant for anthropology and beyond.” — Anne Pollock, Journal of Anthropological Research

    “That Improvising Medicine is at times difficult to read is a testament to Livingston’s observational and storytelling skills, her ability to allow us to imagine what it might feel like to be a patient, caregiver, nurse, or doctor in an African hospital. This is a remarkable book that deserves and will surely attract a wide readership.” — Neil Kodesh, Journal of African History

    "Improvising Medicine is a brilliant and groundbreaking hospital ethnography, one that grips the reader with its narratives of an institution characterized by constant precarity, where supplies, medications, procedures, and staff are never assured.... Improvising Medicine should interest diverse audiences. These include medical anthropologists, sociologists, social historians of Africa, public health specialists, and scholars across disciplines with interest in the cultures and practices of biomedicine, the morality of care, and the comparative analysis of medical ethics." — Carolyn Sargent, Medical Anthropology Quarterly

    Awards

  • Winner of the 2013 Victor Turner Prize, presented by the Society for Humanistic Anthropology

    Winner, 2013 Welch Medal (presented by the American Association of the History of Medicine)

    Winner of a 2013 MacArthur "Genius" Grant

    Winner of the 2013 Wellcome Medal for Anthropology as Applied to Medical Problems

  • Reviews

  • "An unflinching light on cancer, exposing both the brutalities of cut-and-burn care and the intimacies of moral labor it occasions." — Catherine M. Montgomery, New Genetics and Society

    “This book will find a ready readership among Africanists and medical anthropologists. I envision its wider use in g'lobal health' courses, where it will challenge aspiring health workers accustomed to locating hope for medical development in scalable technical interventions... Cancer care, Livingston shows us—like medicine, like development—often requires starting over, usually entails improvisation, and always calls for hard labor by particular individuals in the face of destructive political and economic forces. Improvising Medicine reminds us effectively, sometimes devastatingly, how intractably human this thing called 'health care' is.” — Claire Wendland, American Ethnologist

    “This is an excellent ethnography that should (and undoubtedly will) be read and taught by anthropologists, historians, science studies scholars, and interdisciplinary scholars of Africa…. students and practitioners of global health should be reading Improvising Medicine, in which African cancer is made visible and the clinical science of oncology is never divorced from the moral labor and political conditions of care.” — Johanna Crane, African Studies Review

    Improvising Medicine is best suited to those who are interested in global health or who provide medical care across cultures. While its primary subject is cancer, the points the author makes regarding the view of medical care priorities in resource-poor countries, as well as the culture-dependent experience of disease, are well taken and can be applied to work in other areas of the world.” — Holly Salzman, Family Medicine

    “In Improvising Medicine, Julie Livingston presents a vivid ethnography of cancer management in an African hospital ward...This book is rich in textual and visual data and is theoretically well informed. It is a model of ethnographic work and an excellent monograph in global medicine and health systems research.” — Benson Mulemi, Social History of Medicine

    “Although this scholarly work explores a harsh and distressing reality, it is well written, with a warmth and compassion that will make it accessible and appealing to a broad readership… This book will have a direct and sustained impact across fields of social sciences and medical humanities – as it can provide an important perspective often lacking within the paternalistic global health debates.” — Karen Barnes, Journal of Southern African Studies

    “Improvising Medicine constantly challenges the reader to consider the intrinsic and intimate relations between the isolating nature of cancer and disease and the role of sociality in cancer care. In doing so, she reminds us that not only is oncology a field with immense questions, but it is also one where answers to these questions are often blurred, unknown, improvised and situated within larger conversations on bioethics, politics, and global health agendas…. Cancer control will continue to necessitate multi-faceted approaches and perspectives from various disciplines, and Livingston’s work is a superb contribution in further understanding cancer control in Africa.” — Zachary Obinna Enumah, African Studies Quarterly

    “This ethnography of a (or more accurately the) cancer ward in Botswana is beautifully written, uncompromisingly honest and an uncomfortable read. I’ve always thought that the hallmark of great ethnography is that it transcends the specificities of time and place, of the particular, to offer a glimpse of the universal. I think this book qualifies; the quality of the writing and the limpidity of the ethnography make it a path-breaking work of anthropology tout court. They give the reader the sense of being allowed to behold a truth otherwise not accessible.” — Vinh-Kim Nguyen, Social Anthropology

    “The intimacy, care, intelligence, urgency, and fearlessness of Livingston’s writing and thinking make Improvising Medicine a truly masterful ethnography. . . . 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.” — Marissa Mika, Somatosphere

    “The book as a whole is extremely readable, rendering complex concepts in science studies and medical anthropology accessible to nonspecialists through exceptionally clear prose. This is achieved thanks in large part to Livingston’s eye for ethnographic detail, her attention to the singularity of individuals’ experiences, and her appreciation of the multidimensionality of individuals themselves.” — Betsey Brada, Bulletin of the History of Medicine

    Improvising Medicine is an exquisite ethnography, replete with both specific, richly observed encounters at a cancer ward in Botswana and broader, urgent arguments for anthropology and global health. . . . Drawing on beautifully rendered ethnographic evidence, Improvising Medicine tells a compelling story that is relevant for anthropology and beyond.” — Anne Pollock, Journal of Anthropological Research

    “That Improvising Medicine is at times difficult to read is a testament to Livingston’s observational and storytelling skills, her ability to allow us to imagine what it might feel like to be a patient, caregiver, nurse, or doctor in an African hospital. This is a remarkable book that deserves and will surely attract a wide readership.” — Neil Kodesh, Journal of African History

    "Improvising Medicine is a brilliant and groundbreaking hospital ethnography, one that grips the reader with its narratives of an institution characterized by constant precarity, where supplies, medications, procedures, and staff are never assured.... Improvising Medicine should interest diverse audiences. These include medical anthropologists, sociologists, social historians of Africa, public health specialists, and scholars across disciplines with interest in the cultures and practices of biomedicine, the morality of care, and the comparative analysis of medical ethics." — Carolyn Sargent, Medical Anthropology Quarterly

  • Improvising Medicine is a luminous book by a highly respected Africanist whose work creatively bridges anthropology and history. A product of intense listening and observation, deep care, and superb analytical work, it will become a canonical ethnography of medicine in the global south and will have a big impact across the social sciences and medical humanities.” — João Biehl, author of Will to Live: AIDS Therapies and the Politics of Survival and Vita: Life in a Zone of Social Abandonment

    "Improvising Medicine is as good as it gets. It is a book that will be read for decades to come. I have always thought that great ethnography transcends the specificities of time and place, of the particular, to offer a glimpse of the universal. This gripping book does just that, and the subtle and grounded way that it speaks to global health and debates in medical anthropology makes it a major addition to both fields." — Vinh-Kim Nguyen, M.D., author of The Republic of Therapy: Triage and Sovereignty in West Africa's Time of AIDS

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  • Description

    In Improvising Medicine, Julie Livingston tells the story of Botswana's only dedicated cancer ward, located in its capital city of Gaborone. This affecting ethnography follows patients, their relatives, and ward staff as a cancer epidemic emerged in Botswana. The epidemic is part of an ongoing surge in cancers across the global south; the stories of Botswana's oncology ward dramatize the human stakes and intellectual and institutional challenges of an epidemic that will shape the future of global health. They convey the contingencies of high-tech medicine in a hospital where vital machines are often broken, drugs go in and out of stock, and bed-space is always at a premium. They also reveal cancer as something that happens between people. Serious illness, care, pain, disfigurement, and even death emerge as deeply social experiences. Livingston describes the cancer ward in terms of the bureaucracy, vulnerability, power, biomedical science, mortality, and hope that shape contemporary experience in southern Africa. Her ethnography is a profound reflection on the social orchestration of hope and futility in an African hospital, the politics and economics of healthcare in Africa, and palliation and disfigurement across the global south.

    About The Author(s)

    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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