Making Fast-Track Surgery Transportable: Sino-Danish Travel Work

Abstract

This article examines the concrete travel work that enables the global transport of Fast-Track Surgery (FTS), a set of evidence-based, standardized protocols and guidelines for perioperative recovery. Having ethnographically followed FTS training for medical staff from provincial hospitals in China’s Gansu province at a local hospital in Denmark, I show how FTS is made transportable through interactions between Chinese and Danish healthcare professionals in a series of workshops, meetings and educational activities. I argue that the transportability of a health-promoting infrastructure like FTS is neither a matter of technology transfer nor of evidence as such. Rather, it requires a specific kind of travel work in the form of traveling comparisons as a constant two-way dynamic between hospital settings in Denmark and China.

Keywords:

• Infrastructures
• health solutions
• comparison
• training
• travel work

1 Introduction

In October 2015, a delegation of six health professionals from Gansu Province in China arrive at Hvidovre Hospital in Denmark to participate in a two-week training program on evidence-based Fast-Track Surgery (FTS), an approach that includes a set of protocols and standards for enhancing patient recovery after surgery. At a time when the Chinese healthcare system is in crisis (Blumenthal and Hsiao 2005; Duckett 2011; Song 2017), public health administration officials in Gansu Province, a poorly resourced region in western China, have started to look abroad for solutions to crowded hospitals, overrun facilities, shortages of healthcare professionals, and long hospitalization rates.

At the FTS workshop on the first day of training, as the executive director of Hvidovre Hospital finishes his introductory presentation, a Danish FTS lecturer enters the room. Through an interpreter, the executive director says, “This is Stephan. He will tell you something that you never thought possible.” Stephan nods: “Yes, I think you will get quite an experience here. At this hospital, a patient who gets a new knee can walk a few hours after the operation and go home the next day. Can you beat that?!” He teases the Gansu delegates with his question, well aware that they will immediately compare his boast with the eight to twelve days of recovery required following a similar knee operation in Gansu Province. The Gansu delegates look at Stephan in disbelief, and I can hear them whisper: “It’s impossible” (Xíng bùtōng de 行不通的). “A Danish patient can eat and drink immediately after surgery,” Stephan continues, provoking another spontaneous flood of protests from the delegation. “No way” (bù xíng 不行), one nurse cries out, looking utterly shocked. A doctor queries defiantly: “I hear and read about it, but I do not believe.” Stephan smiles and says, “That is why you are here: to see that postoperative recovery can be done differently.”

FTS¹ was pioneered by Professor Henrik Kehlet at Hvidovre Hospital in Denmark in the early 1990s. It is a multimodal approach that consists of a set of evidence-based standards and protocols describing various techniques used in caring for patients in order to expedite their recovery after surgery (Kehlet and Wilmore 2008, 2005, 2002). The aim of FTS is to “reduce physiological and psychological stresses associated with operations, thereby reducing potential complications” (Kehlet and Wilmore 2005). Based on interdisciplinary collaboration between surgeons, anesthesiologists, nurses and physiotherapists, the key FTS principles include patient education, minimally invasive operating techniques,² multimodal pain treatment, early mobilization and early and increased dietary intake (Kehlet and Wilmore 2008, 189; Wilmore 2001: 473).³ In combination, these evidence-based elements have shown that FTS consistently provides quicker functional recovery and reduces the lengths of hospital stays without an increase in morbidity, complications or readmissions (Ansari et al. 2013; Kehlet and Wilmore 2005, 2002; Wilmore and Kehlet 2001).

As a set of evidence-based protocols and guidelines, FTS serves as an empirical example of what colleagues and I have termed health-promoting infrastructures (HPIs) (Andersen et al. 2019). Building on Brian Larkin’s work (Larkin 2013), we define HPIs as “built networks that allow for the circulation of health expertise and standards with the intention of promoting solutions that address global health problems” (Andersen et al. 2019: 608). HPIs take a specific standardized form “as a space within which differences between technical practices, procedures, and forms have been reduced, or common standards have been established” (Barry 2006). At the same time, despite this standardized method of guiding the norms for a given set of practices, HPIs never guarantee more or better health for the world’s population and represent solely an explicit promotion of solutions to proliferating global health challenges (Andersen et al. 2019: 608). As such, FTS is neither a concrete technology nor a physical device but an infrastructure that relies on a platform of material and immaterial fabrics. As an infrastructure that proposes a solution to enhancing patient recovery after surgery, FTS comprises material core components such as documents, equipment and medical technologies to perform operations and perioperative care that are assembled through the work that protocols, standards, regulations and operating procedures do. At the same time, FTS relies on immaterial components such as expertise and learned practices that are exchanged through training sessions, workshops and various types of steering group and committee meeting (Andersen et al. 2019: 608).

In this article, I examine the concrete work and efforts that have led to an HPI like the FTS approach traveling from Hvidovre Hospital in the Capital Region of Denmark to hospitals in Gansu Province in China. By ethnographically following three groups of Chinese delegates from Gansu Province through a two-week FTS training program at Hvidovre Hospital, I show how FTS is made transportable through interactions between Chinese and Danish healthcare professionals in a series of workshops, meetings and educational activities. As I will elucidate, the travel work required to make the FTS transportable takes its specific form from “traveling comparisons” (cf. Mohacsi and Morita 2013) which drawn attention to the connections and associations that emerge between places when health-promoting infrastructures such as FTS circulate globally.

I begin by situating the study within the existing literature on global flows of standards, protocols and procedures, and the travel work their movement requires. I then go on to describe my own ethnography of traveling comparisons. In doing so, I describe the initiation of the Hvidovre-Gansu cooperation and how Gansu officials and hospital leaders stumbled across FTS, including insights into the political economy of health in China today. In the subsequent analysis, I explore traveling comparisons in three different settings: a workshop, clinical practice involving the Gansu delegates’ first encounter with a Danish FTS patient and a period of reworking as delegates prepare to return home to China. I argue that it is through such activities, which continuously invoke and generate traveling comparisons, that FTS becomes transportable.⁴ In conclusion, I revisit the concept of traveling comparisons and discuss my use of the concept and the ways in which I expand it.

2 Travel Work

As I will show in this article, workshops, education, and training are formalized transnational undertakings through which HPIs such as the FTS approach are made to travel. In recent years, a number of scholars have thrown light on the effectiveness of transnational training activities that underpin the global circulation of HPIs (Hörbst 2012; Nielsen and Jensen 2013; Nielsen and Langstrup 2014; Rogvi, Juul, and Langstrup 2016; Rosemann 2014). Rogvi, Juul, and Langstrup (2016) analysis of the travel of Danish diabetes-monitoring software to Indonesia is an important example in this regard. They show how a training workshop with Danish experts and Indonesian general practitioners established the sameness and differences between the two contexts that invoked Indonesia’s need for this software. Rogvi et el. argue that this established need was a precondition for the software to travel at all (2016: 257). Also in his study of the formation of the China Spinal Cord Injury Network, Achim Rosemann (2014) shows how a training program for staff members revealed local conditions that posed a challenge in adjusting clinical practice to international research standards. Notwithstanding these studies, as David Kaiser has argued, questions of how pedagogy and training have crafted scientific practices and the practitioners who put them to use have received little attention in studies of the history, sociology or anthropology of science (Kaiser 2005). By ethnographically tracking the FTS training program and its sequence of activities, this article contributes to filling this gap in the literature by examining the travel work that is required to make an HPI such as the FTS approach transportable. Indeed, we shall see that difficulties associated with the traveling of FTS have very little to do with the actual science or “evidence base” of FTS and much more to do with what actually happens at the human site (Collins and Pinch 1998).

By conceptualizing FTS as an HPI, I draw empirical attention to the global travel of an infrastructure made up of a set of standards, protocols and procedures. Past studies have investigated the global spread of clinical trials and explored the traveling of the regulatory frameworks, standards, technologies and protocols that enable pharmaceutical companies to develop, produce and distribute pharmaceuticals across the globe (Petryna 2005, 2009; Sariola and Simpson 2011). Scholarly attention has also been directed to the traveling of treatment procedures and protocols to assist reproduction (Hörbst 2012; Simpson 2012) and of management systems for chronic diseases (Nielsen and Jensen 2013; Nielsen and Langstrup 2014; Rogvi, Juul, and Langstrup 2016). In East Asia, scholars have contributed empirically to the study of the global traveling of infrastructures, such as Margaret Sleeboom-Faulkner and her research on the establishment of human embryonic stem-cell research in Japan (Sleeboom-Faulkner 2010; Sleeboom-Faulkner, Chen, and Rosemann 2018) and Wen-Hua Kuo’s study of Taiwan’s engagement with global pharmaceutical regulation (Kuo 2009). This body of literature documents the well-established point that HPIs move with great difficulty from one context to another.⁵ HPIs migrate along frictional (Tsing 2005) paths as the universal aspirations of an HPI rub against new everyday realities (Nielsen and Jensen 2013; Nielsen and Langstrup 2014; Rogvi, Juul, and Langstrup 2016; Sariola and Simpson 2011). In the study introduced above, Rogvi et al. show how frictions arise between the global indicators of the software and the actual data that the Indonesian clinicians have access to. For example, testing for HbA1c, one such global indicator, was not locally available in most clinics (2016: 259). Importantly, however, Rogvi et al. propose that these frictions should not be seen as indicative of unsuccessful attempts to transfer but rather as encounters that form a basis for generating comparisons, thus reshaping the capacity of the software to tackle health challenges locally in Indonesia (Rogvi et al. 2016: 263–4). In the section that follows, I unfold how I perceive generative comparisons to be an essential part of the work that makes FTS travel through what I call “an ethnography of traveling comparisons.”

3 An Ethnography of Traveling Comparisons

In the past decade, the notion of comparison has received renewed attention as the focus of scholarly discussions, both methodologically and as an aspect of the empirical phenomena being studied (Candea 2019; Choy 2011; Deville, Guggenheim, and Zuzana 2016; Jensen et al. 2011; Mol 2002; Niewöhner and Scheffer 2010; Zhan 2009).⁶ In particular, the dynamic between the comparison and transportability of techno-scientific forms has become the focus of an emerging literature at the intersection of anthropology and science and technology studies (STS) (Choy 2011; Kubo 2013; Lutz 2016; Mohacsi 2013; Morita 2013; Nielsen and Jensen 2013; Rogvi, Juul, and Langstrup 2016). In this article, accounting ethnographically for how FTS is made transportable has required what I call an “ethnography of traveling comparisons” (Mohacsi and Morita 2013). I build on the work of Gergely Mohácsi and Atsuro Morita (2013), who call for renewed attention to “traveling comparisons” as a concept that can help us understand empirically what enables the movement of techno-scientific forms, arguing that “the increasing mobility of scientific ideas and technological innovations is generated by practices that accumulate comparisons and contrasts on many levels” (Mohacsi and Morita 2013: 176). In their introduction, Mohácsi and Morita present an analogy between the anthropological enterprise, of which comparison has long been the backbone–anthropologists latch on to differences and similarities almost by reflex–and techno-scientific transfer processes that similarly involve comparative practices that enable movement:

The act of comparing, we may say, is a form of anthropology as well as its content, both an explanatory resource and an achievement to be explained. The metaphor of “traveling comparisons” is designed to call attention to such relations as they manifest in the scientist’s practices of comparing outcomes of experiments and observations of distant places or in the engineer’s assessment of technical problems by contrasting them with past experiences and others’ solutions as they travel with mundane artifacts. (Mohacsi and Morita 2013: 182)

A major claim of Mohácsi and Morita’s work is that comparison must be taken seriously as both an anthropological task and an analytical object of inquiry, thus linking ethnographic fieldwork with theory (Mohacsi and Morita 2013: 182). As an analytical object of inquiry, the strength of the concept of traveling comparisons is that it takes into consideration the Danish and Chinese contexts simultaneously in considering the transportability of FTS. Thus, I want to challenge the commonly used analytical terminology of sending “origins” and receiving “destinations,” which is often conceived as involving unidirectional movement from the Global North to the Global South (Wahlberg 2018), or from west to east. Instead, I will show how the transportability of FTS involves a constant two-way dynamic between Danish and Chinese hospital settings.

As an anthropological task, my ethnography of traveling comparisons makes itself at home in motion, working between difference and sameness as I and my interlocutors move across different locations and scales in the comparative practices that surround the transportation of FTS. My ethnographic fieldwork took place in two contexts: Hvidovre Hospital (2013–2016), where I was engaged as a China consultant in the Department of Executive Management, which was collaborating with Gansu Province, and was also a PhD student (2015–16); and at hospitals in Gansu Province from December 2015 to July 2016.⁷ In Denmark, I interviewed medical staff, administrators and leaders at Hvidovre Hospital, FTS experts, Gansu delegates and staff from associated consultancies. In China, I interviewed medical staff, hospital leaders, patients and their relatives, and officials in the Gansu Public Health Administration. My insights are also based on detailed in situ observations of human action during FTS training programs and of daily clinical life in Gansu’s hospitals while engaging with medical staff, patients and their families.⁸ During the FTS training program, Chinese and Danish interlocutors continuously compared and juxtaposed the contexts of Chinese and Danish healthcare and medical practices in their answers to my questions, their own observations and their interactions with each other.

My encounters with Chinese and Danish interlocutors turned into a kind of “para-ethnographic relationship”⁹ (cf. Holmes and Marcus 2008) in which I paid attention to their reflexive loops across the differences and similarities between the Danish and Chinese health contexts and their interpretative and intellectual experience-based knowledge practices as they engaged with FTS. Importantly, I too was constantly entangled in comparative practices as I carried knowledge and embodied experiences from both the Chinese and Danish settings that in various ways had become mobilized in the travel of FTS.¹⁰

As such, my ethnography of traveling comparisons is characterized by a dual purpose in the sense that on the one hand I studied traveling comparisons as an empirical object in which my informants engaged, while on the other hand I applied the approach as a method consisting of an endless series of movements back and forth, both geographically and ontologically, between Denmark and China as an essential part of my knowledge production and my acquisition of empirical insights into the travel of FTS. Throughout the article, I thus juxtaposed moments from disparate places, taking my readers back and forth between the “home” grounds of the FTS program at Hvidovre Hospital and the clinical realities in Gansu Province in China from where delegates had traveled.

Although I use pseudonyms for the persons referred to in this article, Hvidovre Hospital is the actual Danish hospital involved in the research, which I am identifying in accordance with my agreement with it. My research project was approved by the Data Protection Agency at Hvidovre Hospital, which is affiliated to the Capital Region of Copenhagen.

4 FTS Meets Gansu

Despite four decades of unparalleled economic growth, China’s healthcare system is in crisis. Struggling to provide services to a population of nearly 1.4 billion, it faces enormous problems arising from inequality of access, a shortage of healthcare professionals and a poorly functioning primary health system (Duckett 2011). During the 1980s and 1990s, as its economy boomed, China’s health system nearly imploded under the pressure of market-oriented health reforms that mandated increasing commercialization and privatization of health services (Blumenthal and Hsiao 2005; Song 2017). As a result, public hospitals had to find their own sources of income, leading to some of them engaging in shady enterprises, while at the same time more and more people were billed directly for services that had been provided by the state (Blumenthal and Hsiao 2005; Duckett 2011; Song 2017). This period marked the beginning of deep mistrust between patients and the medical system (Milcent 2016: 40), and medical practitioners became the objects of violent outbursts and assaults from frustrated patients (Gong and Chen 2016; Nie et al. 2018; Tucker et al. 2015). Despite great advances,¹¹ such as achieving universal health insurance coverage in 2011, safety scandals (e.g. the selling of tainted milk powder and faulty vaccines injected in children) have caused further mistrust of health authorities among the Chinese population (Song 2017).

In one of China’s poorest provinces, Gansu (Wagstaff and Yu 2005; Wang et al. 2012), located in the rural western part of China and home to 25 million people, crowded hospitals, overworked staff, overwhelmed facilities and long hospitalization rates–common characteristics of many hospital visits in China–are symptoms of the health-system crisis just described. With even fewer resources than other provinces, Gansu’s struggles to attract human resources and deliver healthcare for its rural residents are particularly acute (Qian et al. 2009). Long in-hospital recovery periods exacerbate the pressures on bed capacity and staff. In recent years, influenced by a domestic situation in which Chinese hospitals have had a competitive rather than a collaborative relationship, public health administration officials have begun looking abroad for inspiration to face their immense health challenges.

An e-mail written on behalf of the Gansu Public Health Administration to the Capital Region of Denmark on 8 May 2009 explained how the Administration had recently engaged in shadow doctor programs with countries such as France and the USA to improve its health staff’s skills in the “hinterlands of Western China” (e-mail May 2009). Now, pursuing new inspiration from the Scandinavian welfare model, the Administration wanted to develop a direct “link with the medical doctors in [Danish] hospitals …” (e-mail May 2009). This Chinese initiative quickly led to an agreement¹² with Hvidovre Hospital in 2009, in which the local government administration in Gansu arranged to send medical staff to undergo shadow doctor training in Denmark. Through the shadow doctor program, Gansu health officials and hospital leaders stumbled across FTS, and when they learned that a medical condition that required an operation with two weeks of recovery time in Gansu was treated on an outpatient basis in Hvidovre, their curiosity was piqued.

The first reflections on FTS were published in the British Journal of Anesthesia in 1997, when Henrik Kehlet argued that, while “no single technique or drug regimen has been shown to eliminate postoperative morbidity and mortality, multimodal interventions may lead to a major reduction in the undesirable sequelae of surgical injury¹³ with improved recovery and reduction in postoperative morbidity and overall costs” (1997: 606).¹⁴ Two years later, the article was followed by a study in the British Journal of Surgery (Kehlet and Torben 1999) showing how applying the multi-modal FTS approach allowed patients undergoing open colonic resection to leave the hospital two to three days after the operation, in contrast to ten days or more at the outset. In the following decades, FTS was applied to most surgical and laparoscopic procedures, for example, to hip fractures (Foss et al. 2003) and total hip and knee replacements (Glassou, Pedersen, and Hansen 2014; Husted et al. 2011; Kehlet 2013). Based on a growing amount of evidence from cohort studies and randomized trials over the next decades, FTS evolved as an accepted concept to improve postoperative recovery reducing the lengths of hospital stays.

Although the development of FTS might be acclaimed as a medical breakthrough, and even as “revolutionary” (Wilmore and Kehlet 2001), right from its birth in the mid-1990s, skepticism and resistance have slowed its implementation (Kehlet et al. 2006; Kehlet and Wilmore 2005). There was initial resistance to the demand for profound changes to long-held and well-established medical practices,¹⁵ workflows, hospital structures and professional hierarchies, which often collided with the introduction of FTS. Furthermore, health staff, patients and relatives all had to break with traditional thinking about rest and fasting after surgery and accept the role of the active patient, including early mobility and a quick return to self-reliance. Despite the resistance and controversies, however, by the end of the 2000s, a period of the neoliberal transformation of healthcare in Denmark and of a consequent search for cost-effective therapies, the FTS approach gradually gained ground in Denmark. In 2013, the collaboration between Hvidovre Hospital and Gansu administration was expanded to include also specific FTS training programs for Gansu officials and hospital leaders, who had themselves decided to acquire more insights into FTS with a view to implementing it in their own hospitals.

In the following three analytical sections, I describe three settings in which traveling comparisons emerged as the Gansu delegates were guided through processes involving intentionally provoked comparisons, “seeing is believing,” and a reworking of experiences on the part of the visiting delegates. As I will show, it is precisely through the traveling comparisons that were constantly invoked that FTS as a health-promoting infrastructure is made transportable.

5 The FTS Workshop as a Site of Provoked Comparison

As the workshop begins on an autumn day in October, six delegates, a translator and I are gathered around a meeting table facing Stephan, the FTS lecturer. Shortly into the day’s proceedings, the workshop becomes heated when a Chinese doctor, Xueli Zhang, is challenged over her protocol of not letting patients eat until several days after surgery:

Stephan: And now I am asking you, why can’t they just eat after surgery?

Xueli: It’s in the textbook.

Stephan: And the textbook is always right?! … They can eat immediately after surgery. Again, I ask you why … I think it is tradition, but tradition is not good for the patient. Their condition gets so bad. How would you feel if you were not allowed to eat for three days after surgery? Would you have any energy?

Xueli: Some [patients] might be allowed to eat sooner after surgery.

Stephan: There is no scientific evidence pointing at not giving them something to eat.

Xueli: We think the patients are weak. Many patients lie in their beds for a long time.

Stephan: But why?

[Silence follows for around 10 seconds.]

Xueli: We have always done it like that. My teacher told me [everybody laughs].

Stephan: Yes exactly. You are here to see that it can be done differently.

Xueli: But we have very old patients. They are weak! [protesting tone]

Stephan: But giving them no food makes them even weaker. You keep them [a] prisoner in their bodies. They are eating from their own muscles.

This encounter between visiting delegates and Stephan can be described as a “zone of awkward engagement” (Tsing 2005) in which skepticism, frustration, disagreement and doubt are intentionally introduced into the core of the workshop. Anna Tsing uses the metaphor of friction to explain global connections that do not slot seamlessly into place and processes of awkward engagement in which different worlds meet, mix and clash (Tsing 2005: xi). In the interaction just described, awkwardness arose because of differences between the FTS principle of early food-intake and the Chinese practice of delaying food-intake for several days after surgery. Not only for Xueli Zhang but for all the delegates, the FTS principle of early food-intake breaks with everything they have ever known. They are clearly upset, as I also noticed from their bodily expressions of disbelief and skepticism, exchanges of confused glances, spontaneous outbreaks of surprise and protest, and a full ten seconds of fraught silence.

However, as an ethnographer of traveling comparisons familiar with both the Chinese and Danish sites, I am aware that the awkwardness emerges not only from the comparisons between incommensurable perspectives on post-operative recovery, but also from the different meeting formats in which Stephan’s provocations and superior attitude transgress the normative expectations of formalized social interactions in China. Recalling innumerable meetings while doing fieldwork in hospitals in Gansu Province, I am well acquainted with the hierarchical and formal meeting formats that visiting delegates were accustomed to. For example, sitting in on the weekly staff meeting of a Gansu Department of Surgery, I have no doubts as to who the department’s leaders are. Clearly separated from the staff, the chief physician stands up with the head operations nurse sitting on a chair by his side. The head operations nurse is allowed to speak if trusted to do so by the chief physician, which only happens twice, also stressing the clear hierarchy between the two of them. As the meeting goes on, no one feels free to interrupt or contradict the chief physician, nor does he either expect it or welcome it. In situations like these, the participants in the meeting who are present often attempt to avoid conflicts, disagreements, embarrassing interactions and claims of superiority that may challenge the face (miànzi 面子) or the authority of especially the more senior participants.¹⁶ Miànzi refers to the recognition by others of an individual’s social standing and position (Earley 1997). In Gansu, Stephan’s direct and confrontational style of communication, questioning the often high-ranking delegates’ authority, would be very unusual, as it is where a strong emphasis on miànzi is linked to the promotion of interpersonal harmony (Earley 1997).

My point in emphasizing the awkwardness that emerged in this and subsequent first meetings is not either to suggest or to contest whether the FTS approach is superior to other perioperative treatment regimes in China or elsewhere. That is an issue for those health professionals and researchers who engage with medical evidence as part of their responsibilities. As with all evidence-based guidelines and protocols, there are always black-boxed controversies or uncertainties which are left out of training settings. However, as a study of how the FTS approach travels, Stephan’s provocations, I suggest, are an important part of the work that makes the approach transportable, as I will elaborate in the following.

The provocations, Stephan explains, are a conscious pedagogical strategy: “My style is to provoke. I am fully aware of this, and it is completely on purpose.” He further describes his style as rooted in the effect he hopes to create:

So, my starting point is to try to present them with something that they never thought was possible, and then get them to look inwards and see some of the things they do just because they always have done them. You need to be curious. You need to question what you do.

Stephan’s training strategy must be seen in light of his teaching objective. He provokes the delegates because he wants them to learn to think critically. This suggests that the workshop is not a site for the “passive” reception of FTS scientific evidence, but for the establishment of a particular mind-set. Not only Stephan, but all the FTS experts I talked to pointed to the fact that FTS–standards and protocols aside–encourages and requires a particular mind-set on the part of the professionals who use it. FTS standards and protocols should not be applied blindly, but rather treated as a set of organizing principles that should be accompanied by a specific mind-set, that is, a way of thinking through a problem and of critical questioning driven by “a desire to challenge existing practices.” Much more than a concrete set of standards and protocols that lay down a specific way of doing FTS, the method is presented as a form of ongoing critical thinking that gives way to reflection on and the optimization of clinical practice. One FTS expert explained:

It is more a wish, you could say, to continue to optimize all these aspects of the perioperative process. So, in that sense it is also a desire to continue to challenge existing practices. … It is more a philosophy or an approach than a manual.

By aiming to instill this mind-set and by being provocative, in every FTS workshop Stephan actively compels delegates to make immediate comparisons by constantly confronting them with questions that urge them “to look inwards” and reflect upon their own practices through the lens of FTS. As such, his provocations are more than a matter of his personal style of communication or of cultural insensitivity; they are elements built into the workshop format to create a shock effect and to challenge and stir up visiting delegates’ habitual medical knowledge and practices in relation to post-operative recovery by inciting comparison and awkwardness in the process. Thus, it is not Stefan’s provocations and their possible rhetorical effect that make FTS transportable in themselves, but rather the comparisons he provokes that make FTS come into being. Without a doubt, the interactions between Stephan and the Gansu delegates could easily be read as an Othering encounter in which an authoritative persona preaches to apparently “naïve” delegates about how post-operative recovery is supposed to be done. Hvidovre Hospital has been running these FTS training programs in various forms and lengths for more than two decades with delegations from within Denmark, as well as from countries such as Belgium, Holland, Germany, Italy, France, Spain, Sweden, the United Kingdom, New Zealand and the United States, and the sessions have always followed the same script with the same provocation and “seeing is believing” sessions. In 2016, a few months after participating in the workshops with Chinese delegates, I sat in on two workshops with French and German delegations. Stephan and one other FTS expert delivered the same performance, asking critical questions and challenging current clinical practices that the delegates were familiar with and leaving the delegates with a similar sense of incredulity as the Chinese delegates displayed. However, whereas the provocation and incredulity are intended, whatever the nationality of the delegates, the comparisons they provoke were completely different in the Chinese case, as the clinical reality that the Gansu delegates were familiar with was substantially different from clinical realities in Belgium or New Zealand. I will return to this matter in the next section.

In sum, the first steps in transporting FTS to Gansu are made during the awkward engagements and traveling comparisons that emerge out of the workshop format, as visiting delegates are challenged to relate the clinical practices they are familiar with to the “radical” ideas put forth by FTS experts. For visiting delegates, this first workshop is followed by “seeing is believing” sessions in which delegates experience Danish FTS patients’ well-being after surgery in a clinical setting. As I describe in the next section, the delegates’ first contact with a Danish FTS patient is considered an important element in the work of changing delegates’ attitudes from disbelief to belief.

6 ěr tīng wéi xū，yǎn jiàn wéi shí 耳聽為虛，眼見為實 (Seeing is Believing)

On the second day of the FTS program, four Gansu delegates, together with the interpreter and myself, walk to the orthopedic ward to observe a follow-up with a 62-year-old man who has just had knee-replacement surgery three hours earlier. As we enter the patient’s room with two Danish nurses, the patient is sitting at the side of the bed emptying a glass of red lemonade. This immediately causes some surprised murmuring among the delegates. The interpreter whispers: “In China [in Gansu], you would not see a patient sitting up and feeling this good so soon after an operation.” As the two nurses begin to help the patient beyond the edge of the bed, a Chinese nurse murmurs doubtfully “He has no pain!” (Tā shēnshang méiyǒu rènhé bìngtòng 他身上沒有任何病痛). A Chinese doctor dismisses her comment by saying self-confidently, “Of course he has pain” (Bìngrén shàngwèi quányù 病人尚未痊癒). However, shortly afterward, the patient manages to stand up. “No pain?” the same doctor asks the patient in English. “I have no pain, but I feel a little dizzy,” the patient replies. After some moments of silence, the patient begins to walk slowly toward the door with the nurses by his side. This provokes a cascade of muted chatter among the delegates and a flood of questions to the nurses about the methods of pain management. One nurse replies that the patient has an epidural catheter.¹⁷ The delegates cannot believe their own eyes and, while a few of them remain skeptical and guarded, others spontaneously start clapping as the patient returns safely to the bed. Everybody starts laughing, and the patient, surprised by the massive attention he is receiving, also appears to be enjoying the moment of being, apparently, a true miracle. He agrees to having his photo taken with each of the very excited delegates. As I leave the room with one nurse, she smiles at me and says: “It is the same every single time [her emphasis].”

The two Danish nurses had experienced this excitement many times before. The Gansu delegates I had joined were no exception. However, while my Chinese informants’ reactions might have been the same as those of delegations from other countries, the clinical realities they had come from are entirely different. For the Gansu delegates, beneath the surprise and euphoria lurked disbelief and frustration as they actively worked to make sense of what they had seen. The doctor’s conviction that the Danish FTS patient must be in great pain after a knee replacement should be understood against a backdrop of expectations regarding how a patient should react and appear after such an operation. The doctor was drawing not only on medical knowledge and evidence, but also on his own twenty years of experience as a surgeon. As I experienced during my travels to Gansu Province during fieldwork, a comparative Chinese rendering of the situation described above is as follows.

In December 2015, less than two months after a group of Gansu delegates have gone through FTS training at Hvidovre Hospital, I visit their hospital in the remote fringes of Gansu Province. Late one afternoon, during a quick tour around the Department of Orthopedic Surgery, I am greeted by a young and energetic surgeon, who, anticipating my question, informs me that in this department they have not yet begun the implementation of FTS. As he accompanies me down through one of the wards, I see patients confined to their beds, immobile, in pain and hooked up to pouches of liquid medicine and monitoring machines. The doctor says, “[After surgery], our patients have a lot of pain. It is impossible [for them] to get out of bed (Wǒmen de bìngrén yǒu hěnduō tòngkǔ. Xià bùliǎo chuáng 我們的病人很痛苦，下不了床).” In one room, we see to Zhou Li, a 47-year-old patient who received a new knee three days ago. He looks pale and weak and is wound up in heart-monitoring cables, a tube to his drain and a wire providing him with intravenous fluids. He is half-asleep, half-awake, and I talk mostly with his family and friends, who have congregated to support him through the discomfort of nausea, vomiting and intense pain in the first days after the operation. As I am later told, Zhou Li begins walking on the seventh day after his operation. Juxtaposed with what the delegates witnessed on the Danish ward, we can speak of an effect that might be called a comparative “double vision” (Morita 2013), one that can only be described and analyzed through an ethnography of traveling comparisons involving fieldwork in both sites.

In his ethnography of Thai mechanics, anthropologist Atsuro Morita reports that both they and Thai farmers complained about Japanese-made rotary cultivators and their blades breaking down because they were designed for Japanese soils and weeds and are therefore more susceptible to breakdowns in the very different environment of the Thai fields where they were being used it (Morita 2013: 235–6). The machine breakdown brought about what Morita terms a “double vision” in which the weeding blades caused the Thai and Japanese ecological environments to be seen “at once through their difference” (Morita 2013: 235–6). The connections with elements in the Japanese environment that the machine embodied became visible only when they clashed with another set of connections that the machine was forced to perform in the Thai farmers’ fields. In line with Morita’s analysis, the FTS patient’s act of walking evokes a similar double vision, in which the good physical condition of the Danish post-surgery patient is transposed onto the poor condition of Chinese post-surgery patients, thus promptly revealing their significant differences. The double vision overlays the contrasting levels of well-being after surgery, or, in the words of one Chinese doctor:

What made the biggest impression on me was to see that right after the operation the patients are allowed to eat and drink, and they look like completely normal people. They do not look like patients.

Double vision invoked by the transposition of the two opposing post-operative conditions is an important mechanism in making FTS transportable. Not only does the double vision destabilize the delegates’ common-sense knowledge and open up the possibility to think differently, it also serves to verify FTS practices:

Before we came here to Copenhagen, we did not know if it [FTS] was truly good for the patients. Did the patients really feel good? We found that hard to believe. But then, we saw the patients here and that they actually recover very well. Maybe you know, in China we have this saying: “Seeing is believing” (ěr tīng wéi xū, yǎn jiàn wéi shí 耳聽為虛，眼見為實). This is really important.

Like this Chinese doctor, many delegates pointed out that they had read about FTS, discussed it with colleagues and heard rumors about it in medical circles in Gansu Province before their training in Denmark. Both the Gansu delegates and the Danish FTS experts confirmed that seeing and experiencing FTS patients in clinical practice was pivotal to the delegates’ ability to begin their work with FTS. However, a key point is that it is much more than “seeing is believing” in any kind of simplified or “rational” sense. “Seeing is believing” works as an invocation that instantiates immediate comparisons. As such, seeing in double vision is a necessary part of the work that allows the FTS approach to travel. After the delegates’ first contact with a Danish FTS patient, their own clinical realities kick in immediately, and in the coming days of shadow doctoring, the moment of “seeing is believing” is overtaken and in some ways overturned by critical questions, doubts and frustrations. Can FTS really work in the radically different context of a Gansu hospital?

7 The Reworking Begins

Because our two countries [Denmark and China] have fundamentally different social systems, medical systems, and hospital management models, we cannot completely copy this [the FTS], right?! … We can only draw on some of it and learn part of it, and we have to fit it into our own processes. (delegate, Chinese doctor)

For the remaining days of the FTS program, not only this doctor but all the delegates entered a more regularized shadow-doctoring routine that allowed ample time for thinking things through and critically questioning the applicability of FTS to the Gansu healthcare system. Far from home, and in sharp contrast to their extremely busy and overburdened working lives in Gansu, these final days of the FTS program were a necessary and welcome respite that involved a kind of translational reworking of FTS before they were due to return once again to the daily grind of hospital life in Gansu. Law and Lin (2017) reflect on how terms and theories can be detached from the practices in which they are embedded and moved elsewhere. In the translation of terms they emphasize context, writing that terms “unavoidably carry their own only partially negotiable social and intellectual baggage: that they are, in other words, more or less ‘context-sticky’” (Law and Lin 2017: 258). This context-stickiness can also be attributed to FTS, as it is embedded within this “nice little welfare state (měihǎo de xiǎo fúlì guójiā 美好的小福利國家),” as a Gansu doctor described it in one of our conversations, that provides universal health coverage to its five million people.¹⁸ Now, as the Gansu delegates visualized the implementation of FTS through the lens of a gigantic, more market-oriented and insurance-based Chinese healthcare system that serves nearly 1.4 billion people, challenges began to appear. According to Law and Lin, in any process of translation one needs to ask what to recraft, what to leave behind and why. They emphasize that reworking will be needed (Law and Lin 2017: 260). As I will show in the analysis that follows, the preliminary reworking of FTS centered mainly around the early discharge of patients after surgery.

One day, while I am carrying out fieldwork in the Department of Outpatient Surgery at Hvidovre Hospital, a Chinese nurse and a Chinese surgeon observe a Danish nurse discharging an FTS patient in accordance with certain criteria only two hours after the operation. The Chinese nurse whispers, “We are so worried. How can the patient manage at home [so soon after surgery]? What if he falls … or gets an infection?!” Her whispering catches the surgeon’s attention, and he adds, “Here [in Denmark] you have general practitioners and the municipalities to help the patients [after discharge], but if something happens to the patient [in Gansu], it is my personal responsibility if I have sent the patient home too early. It can cause conflicts … even lead to a lawsuit.” As in this example, the visiting delegates’ critical reflections unfold around traveling comparisons that highlight the institutional differences between Danish and Chinese healthcare settings. As we saw earlier, the Chinese primary health sector is considered weak, causing a fear of violent behavior by the patients and their families against the hospital staff in cases of adverse medical events. Doing fieldwork at a hospital in Gansu, I came across conflicts between health staff and patients and their families. One afternoon, as I arrived at a surgical ward for my everyday routine of visiting patients, I immediately noticed a large group of health staff and a patient’s relatives gathered around the nursing station in an aggressive exchange. With menacing gestures, eyes played out and violent outbursts, one man in particular, the patient’s husband, was beside himself with anger, as other family members tried to calm him down and grabbed his arms to pull him away from the health staff. In the exact moment that two hospital guards arrived to de-escalate the situation, the relatives managed to drag the man away from the nursing station despite his continued anger and threats. I was later told that the conflict arose because the doctors had considered the patient well enough to be discharged from the hospital that same day, a decision the family members strongly opposed. To prevent the situation from escalating, the patient was not discharged until several days later. As a doctor from the hospital explained: “But there is nothing we can do. Because we cannot expel the patients from the hospital. … He [the patient] can stay as long as he wants. Sometimes we want to discharge the patient, but it is not up to us.” Numerous studies have shown how precarious the position of medical practitioners in China is, as they are subject to violent outbursts and sometimes physical harm from families and patients. In recent years yīnǎo (醫鬧，指借炒作醫療糾紛而獲得非法利益;healthcare disturbance, violent accidents directed against healthcare staff and facilities for financial benefit) have also emerged, that is, organized criminal gangs hired by families and patients to threaten and assault hospitals and medical practitioners (Gong and Chen 2016; Nie et al. 2018; Tucker et al. 2015). Due to this tense situation between doctors and patients, many delegates had clear reservations about adopting something so radically different as FTS in Gansu’s hospitals.

The early discharge of FTS patients was also an object of critical reflections centered on comparisons between the economic structures of the two countries’ health systems, China’s insurance-based healthcare system being contrasted with Denmark’s tax-funded system. While shorter stays were applauded by hospital administrators within the public Danish healthcare system, there is no immediate economic incentive to discharge the patients early at Gansu hospitals. One nurse draws the comparison in the following way:

Look, Ān Xiǎo Xià [the ethnographer’s Chinese name], here [in Denmark] it is a public system. It is a good thing to send the patient home fast because you save money, right?! But we depend on each day the patient is at the hospital, to make a profit and to get reimbursement from medical insurance. (Chinese delegate, a nurse)

Chinese public hospitals have to earn 90% of their revenues from the services they provide, with government subsidies providing the rest (Yip and Hsiao 2014: 805). In Gansu, the hospitals receive a fixed amount from the medical insurance company for each operation only if the patient is hospitalized for at least 72 hours. The hospitals do not get any reimbursement for shorter stays. The economic downside of FTS also portended consequences for the health staff:

[If] we run fast-track, the cost of care is reduced [because the patient will stay fewer days in the hospital], and the entire medical team will have no bonus. How is everybody then going to live? … Because many people [Gansu health staff] who do not understand it … will also consider their personal economic interests. If we do this [FTS], their income might fall. (Chinese doctor)

Even though the comparisons are critical and perhaps verge on the absurd, given the vast differences in population, culture and healthcare, I argue that, on the contrary, for the majority of the delegates the traveling comparisons are productive, because they generate preliminary thoughts on how to recraft FTS to make it fit in a Gansu hospital. It is through these perceived differences that FTS is negotiated and recrafted. Hence, while preparing to return to Gansu, the delegates tried to imagine a version of FTS that could overcome the perceived incommensurability between the early discharge of FTS patients and the economic, institutional and social realities of the Gansu healthcare system:

Even though each specialization cannot completely do fast recovery (kuàisù kāngfù 快速康復) meaning hospitalization in the morning, [then] surgery, [and] home in the afternoon, they cannot achieve that. However, in the phase of recovery, all aspects of treatment can be done according to fast-track, this way of thinking, right?! … We can shorten the length of hospitalization, reduce the amount of medicine, make patients … exercise early, eat things early. All this is right. (Chinese doctor)

This doctor is contemplating a version of FTS that is focused on optimized recovery rather than fast recovery, in which the various aspects of FTS can still be performed to improve the recovery of the patients, but not within the framework of same-day surgery, and still allowing a profit to be earned that is necessary to sustain the hospital and the livelihoods of its staff. In an insurance environment that requires a three-day stay for payment, three days is a reasonable starting point for a meaningful treatment program. This is still a considerable improvement over their typical hospital stay of ten to twelve days for this category of patient.

During their time away from their hectic everyday hospital life at Gansu hospitals, the delegates indulge in a rare moment of reflection and preparation prior to returning home to China. They draw on traveling comparisons across differences between the Danish and Chinese health contexts that feed into an alternative possible version of FTS in which early discharge had to be cut out of the equation for it to travel at all. This preparative reworking lays the foundations for the actual, on the ground work of “routinizing” (Wahlberg 2018) FTS into clinical practices at hospitals in Gansu Province, processes which I analyze in another paper (Andersen forthcoming). Although, as I have argued, FTS is made to travel through a sequence of traveling comparisons induced by the activities of an FTS program, this does not in any way mean that FTS will be successfully implemented in Gansu’s Hospitals. By reorienting our perspective, different problems and interests from a Gansu vantage point may challenge the further reworking of FTS into Chinese clinical practice, and sometimes FTS may indeed fail to travel.

8 Traveling Comparisons Revisited: Final Reflections

Building on Mochási and Morita’s work, this article has explored the travel work that is required to make a health-promoting infrastructure like FTS globally transportable. I have traced the potential of traveling comparisons emerging from three sites where provocations and awkwardness, “seeing is believing” and reworking were played out, constituting a certain sequence in which the visiting delegates from Gansu province went through a process of getting to grips with FTS. It is in this way that the travel of standards, protocols and procedures is reliant on workshops, meetings and educational activities. I further argue that the transportability of FTS is a matter neither of technology transfer nor of superior evidence as such, but rather involves traveling comparisons as a constant two-way dynamic between the Danish and Chinese contexts. As I have shown, both backdrops are of equal importance for the travel work surrounding FTS. Hence, traveling comparisons are one of several possible mechanisms that allow HPIs such as FTS to travel.

In the analysis of this article, I approached comparisons both as an object of inquiry and as a method by introducing “an ethnography of traveling comparisons.” In his work on the usage of a traveling comparison in a project involving technology transfer from Japan to Thailand, Morita’s (2013) analysis was situated in one site in Thailand, as he showed how comparisons of technologies, organizations, cultures and environments between Thailand and Japan was taking place constantly, also taking into account his own ethnographic trajectory. Morita describes his ethnographic take on traveling comparisons as one of lateral comparisons in which he places his own comparison alongside his informants (Morita 2020, 42). In taking my cue from Morita’s study, I opted to design and conduct an ethnography of traveling comparisons where I spent time in both sites so that I could participate in the traveling comparisons alongside my informants, thus granting me insights into the comparative practices of my informants as well as my own. A key point is that a traveling comparisons ethnography requires the ethnographer to do fieldwork in both sites involved in the comparison so they can include both vantage points in the analysis, hence the need for a “traveling comparison ethnographer.” In proposing this new ethnographic role, I argue that, when studying the global movement of technologies, techno-scientific forms, or in this case HPIs, conducting site-based, immersive fieldwork in the sites constituting one’s field (Hvidovre and Gansu in my case) should be built into the study design.

Many “interests” might lie behind the promotion or “export” of FTS around the world (whether related to finance, medical prestige or public health objectives). However, as I have shown, for FTS to become transportable, it must be relevant for those who might seek it out and want to benefit from it. In this way, FTS was made transportable. At a time when international guidelines and operating procedures are increasingly circulating, we need more traveling comparison ethnographies that focus on the actual sites of travel work.

Additional information

Notes on contributors

Signe Lindgård Andersen

Signe Lindgård Andersen is PhD fellow at the Clinical Research Centre, Amager and Hvidovre Hospital, affiliated to the Department of Anthropology, University of Copenhagen. Her anthropological research has focused on global flows of patients and healthcare innovations with a specific interest in Danish-Chinese connections.

Notes

¹ Fast-track surgery is also known as “enhanced recovery after surgery.”

² A minimally invasive procedure involves the use of endoscopic techniques (e.g. laparoscopic or arthroscopic). It is typically considered safer than an open surgery (Kehlet and Wilmore 2002).

³ Post-operative pain management is one of the most important factors ensuring early mobilization and enhanced recovery after surgery. In FTS, the approach to post-operative pain management is multimodal, a combination of several techniques being used, including regional anesthesia (spinal or epidural nerve block) supplemented with NSAIDs and opioid analgesics (morphine)³ (Nanavati and Prabhakar 2014: 132).

⁴ In a subsequent paper, I study ethnographically what happened in Gansu province in the weeks and months after the delegations returned home (Andersen forthcoming).

⁵ Various STS studies document a similar finding (Akrich 1992; Morita 2013; Schnitzler 2013).

⁶ See, for example, Timothy Choy’s account of ecopolitics in contemporary Hong Kong (2011), Mei Zhan’s comparative study of traditional Chinese medicine in San Francisco and Shanghai in which she argues that “traditional Chinese medicine” is constantly made through various translocal encounters and entanglements (2009: 1, 22–24), or most recently, Matei Candea (2019) who maps a path through the entangled conversations of the inevitabilities and impossibility of comparison in anthropology.

⁷ This article is based on insights from a collaborative PhD project between Hvidovre Hospital in Denmark, local hospitals in Gansu province and the Department of Anthropology at the University of Copenhagen in Denmark, where I am enrolled as a PhD candidate.

⁸ The dataset consists of 89 interview transcripts, personal observations and secondary sources. All participants were aware that I was undertaking research, and I obtained verbal consent prior to interviews and participant observation.

⁹ My use of the concept of “para-ethnographic relationships” is inspired by Douglas Holmes and George Marcus’s “para-sites,” a reference to ethnographic “sites” in which some sort of knowledge or expertise is integral to a particular community, where the anthropologist collaborates with “reflexive subjects whose intellectual practices assume real or figurative interlocutors,” and where there is “a preexisting ethnographic consciousness or curiosity” (2008: 82).

¹⁰ For example, prior to the PhD project, I was employed as a social anthropologist in the Department of Orthopedic Surgery, which specializes in FTS for hip and knee patients. I thus understand FTS intimately, and this knowledge proved to be of great value during my interactions with the visiting Chinese delegates. What is more, I speak Chinese (Mandarin) and have previous experience with health research in China.

¹¹ China is renowned for being a growing hub for pharmaceutical development, medical research, and advanced high-tech solutions (Cooper 2011; Greenhalgh and Zhang 2019; Song 2017).

¹² This agreement was a nonprofit one for Hvidovre Hospital, meaning that the Gansu Public Health Administration did not pay for the training in Hvidovre. The administration covered all costs in terms of accommodation and travel expenses.

¹³ With sequelae injury, Kehlet refers to for example pain, fatigue, infective and thromboembolic complications, nausea and prolonged convalescence (1997).

¹⁴ The history of FTS and its global travel is a fascinating one and merits a study on its own. Here, it suffices to account briefly for the establishment of the FTS as a standard treatment in Denmark.

¹⁵ See, for example, the article “Traditions and myths in hip and knee arthroplasty” (Husted et al. 2014), in which the authors take a systematic approach to breaking with medical traditions, such as using drains, urinary catheters and tourniquets perioperatively, and contrasting these practices with recent FTS evidence.

¹⁶ Even though one cannot speak of a single “Chinese culture” or even use the term “Chinese” in any general sense, as it is “an endlessly ambiguous marker” (Law and Lin 2017: 1), miànzi nevertheless assumes particular importance for social interactions in China (Lockett 1988).

¹⁷ Local anesthesia and analgesia, spinal and/or epidural, is a common anesthetic and pain-management technique used in FTS. Spinal anesthesia makes the patient numb from the waist down, while epidural analgesia allows the patient to move freely without pain. These procedures, supplemented with NSAIDs, play an important role in the early mobilization of the patient after surgery (Kehlet and Dahl 2003: 1922–24). The three Chinese hospitals that are a part of this study are not familiar with this method and rely mainly on opioid analgesics and NSAID in the post-operative pain-management phase, though without achieving a tolerable pain or pain-free post-operative recovery for the patient.

¹⁸ The Danish welfare state is essentially characterized as a large, tax-based public sector that attempts to provide social security for all its citizens (Ploug, Henriksen, and Kærgård 2013).