For many readers of Julie Livingstone's Improvising Medicine, “cancer” and “Africa” will be two words they have not thought to put together. The publics of global health in the South have for so long been envisioned as the vectors of infectious disease, the target of fertility management programs, and the victims of malnutrition that cancer has slipped insidiously under the radar of the popular imagination. Livingstone's book serves not merely as a corrective to this myopia, but as a thorough immersion in the lived experience of oncology in Botswana's only cancer ward.
In Livingstone's book, cancer, with its malignancies and indignities, is cut open before us. Accounts of biopsies, amputations and the suctioning of tracheostomies are the marrow of the book. But – for all its sharply observed empirical accounts – Livingstone's book is a deft work of interpretation and subtly woven argumentation. There are three strands to this, each hitting a discrete analytical level. First – and emblematically, given the book's title – biomedicine in Africa is characterized by improvisation. In Botswana, cancer treatment is provided by the state, as part of the social contract of universal care, but resources are thinly stretched. The hospital gets by with a sole oncologist, Dr P, whose daily work is shaped by the pragmatic negotiation of inadequate bed spaces, a lack of functioning diagnostic technology, and shortages of essential drugs. Livingstone shows how cancer in this improvised setting becomes a question of “rationing, prognostication and futility” (21), a far cry from the dominant, heroic narratives of cancer in the global north.
The book's second theoretical point is that cancer is a social phenomenon, an event which takes place between people. This is aptly illustrated throughout, but particularly in Chapters 4 and 5 on “the moral intimacies of care” and “pain and laughter.” Here, the disfiguring brutalism of cancer's tumors and the treatment to remove them are humanized through a deep concern for care. While Livingstone characterizes the care the Batswana nurses provide as “an extension of the state's commitment to care for its people” (96), the very personal tales of wound-cleaning and empathetic suffering show cancer to be a phenomenon that transcends the notion of therapeutic citizenship. The hospital is a site where an ethic of social healing suffuses care-giving practices; where pain is a silent form of call and response; and where laughter is an antidote to the threat of social rupture that pain embodies. As Livingstone aptly observes, no one laughs alone.
By the time one reaches the closing pages of Improvising Medicine, the suggestion that cancer in Africa is an epidemic which will fundamentally shape global health is one which barely needs announcing. In the final chapter – as in the first two – we are transported beyond Gabarone's Princess Marina Hospital, into the broader political economy of oncology in sub Saharan Africa. The population we have come to know ethnographically is not American oncology's “false African twin,” a primitive people exempt from cancer envisioned as a disease of civilization. And the disease we have glimpsed through the ethnographic lens is equally not the cancer of global health, compacted into the logics of infectious disease epidemiology. The implicit provocation of this book is to find ways to render cancer in the global south both visible and legible beyond these fallible logics.
Variously labeled as hospital ethnography and activist ethnography, Improvising Medicine succeeds in two areas where it might easily have fallen down. First, although Livingstone takes us deep into the intimacies of care on a single ward, exemplifying hospital ethnography at its best, she also transcends the local specificity of the Princess Marina Hospital by showing how the improvisation of the book's title is a result of both historical and geopolitical process. Second, where the book could have become an issue-based vehicle, never does it slip into easy moralizing or pathos. Livingstone shines an unflinching light on cancer, exposing both the brutalities of cut-and-burn care and the intimacies of moral labor it occasions. Visceral and arresting in its exposé of pain, death, need, and inequality, it neither needs nor resorts to proscriptive or explicitly normative statements.
While the book deserves high praise, it occasions a lingering sense of disquiet, that perhaps it contributes to what Lawrence Dritsas has referred to as the “hagiographies of Great White Men” in Africa (also in a book review, for Science, Technology, & Human Values). This is a criticism Livingstone pre-empts early on. She is explicit that the book should not be read as a “tale of white physicians come to save the poor Africans” (Preface). And yet, as we follow Dr P, the German oncologist, through the wards of the hospital and from one hospital to another, it is hard not to see him as the hero of the story. Indeed, he is the figurehead for the kind of medicine that must be improvised, and it is he who choreographs the improvisations. When he leaves Botswana to return to a post he previously held in Zimbabwe, Livingstone follows him and so does the ethnography. Whatever our misgivings about this, it pertinently underscores a point made by the author herself about the bigger picture of global health: this huge institution “occurs on the ground through the work of specific individuals labouring in particular circumstances” (175). That the ethnography shows this so well is both its (minor) shortcoming and ultimate triumph.