Improvising Medicine is both a very easy and an extremely difficult book to read. As with any good ethnography, Julie Livingston’s deft and careful storytelling draws you in and holds you. But the stories she tells so well are often those of gangrenous tumors, unmedicated pain, and death. Thus it is all the more remarkable that her account of Botswana’s only cancer ward ultimately serves as a testament to the profoundly humanizing potential of public oncological care, even as it chronicles the burning, cutting, and poisoning that constitute the primary means of cancer treatment available to patients at Gabarone’s Princess Marina Hospital.

Africa, Livingston argues, is facing a cancer crisis. In Botswana, increased cancer awareness plus the proliferation of AIDS-related cancers are giving rise to a growing epidemic. But cancer is not “new” to Africa. Contrary to the traditional global health imaginary of African publics as “biologically simple” (plagued mainly by infection, excess fertility, and malnutrition), Livingston’s careful historical work shows that cancer has long been a health problem in Africa. Fifty years ago, researchers in eastern and southern Africa were making significant contributions to oncological knowledge as they studied the relationship between cancer and infectious disease. But this work diminished as structural adjustment policies and political instability in the 1980s crippled some of the most promising African research sites and as the AIDS epidemic refocused global health priorities on HIV. Currently, Livingston argues, “Africans are living in a carcinogenic time and place” structured by a combination of infectious disease, environmental pollution, and the multinational tobacco industry (51). But African cancer has remained largely invisible.

In Botswana this imbalance is apparent in the contrast between AIDS treatment, which is available nationwide and is supported by a transnational public–private partnership, and oncological care, which is funded solely by the government and limited to the single ward that is the subject of Livingston’s ethnography. In accordance with Botswana’s system of universal health care, the ward provides citizens with free cancer care—a characteristic that distinguishes Botswana from poorer African countries (and also the United States). The ward is staffed by Batswana nurses and a handful of foreign doctors (Botswana has no medical school), and led by “Dr. P”—an irascible and impassioned German oncologist whom Livingston portrays with both warmth and honesty. A fiercely dedicated but sometimes difficult man, he offers a welcome departure from the cliché of the heroic expatriate doctor in Africa. The care provided by Dr. P is “improvised” by necessity, as he must constantly adapt oncological knowledge and standards of care produced elsewhere to the “technical, biological, and social conditions of medical care in Botswana” (20). Cancer patients may be co-infected with TB or HIV, many drugs and diagnostic technologies standard to Western care are unavailable or unreliable, and patients often arrive with late-stage tumors. Dr. P and his colleagues must also work to translate cancer from biomedical terms into the Setswana language and “vernacular forms of embodiment”(77) that make sense to patients under their care: an ontological project in which illness is localized into tumors that can then, they hope, be destroyed.

In her focus on a single oncology ward, Livingston manages to convey both the specificity of cancer in a particular time and place—its “local biology,” to invoke Margaret Lock’s term—while at the same time speaking to much broader questions of human suffering, dignity, and care. In particular, her “interlude” (a sort of a mini-chapter) on amputation and the following chapter on the “moral intimacies of care” bring the reader face to face with the healing-through-harming that is perhaps universal to cancer treatment, but which the underfunded, “improvised” conditions at Princess Marina hospital throw into particularly sharp relief. Patients, families, and providers cry, yell, and—miraculously—laugh as they negotiate decisions (“You must choose! Leg or life!”) which are both routine (for ward staff) but also push at the boundaries of human identity and survival.

Amidst the deformity of advanced cancer and the violence of oncological treatment, Livingston reveals an ethic of care and social healing that manages to humanize patients whose bodily decomposition has left them in profound physical, and often social, pain. While Dr. P remains a central figure, it is really the nurses of the ward who make this possible. In a chapter intended to balance negative accounts of African nursing, Livingston directs us to the indispensible physical and emotional work that the ward’s nurses do. They begin each day with song and prayer, filling the ward with Tswana choral music and appeals to Jesus to heal their patients and bless their work. In doing so, Livingston argues, they mark the ward as a “moral space” and an “intensely social world” in which God is present and nurses pray for their patients (105). It is from this starting point that they embark on the day’s difficult and deeply intimate work of carefully cleaning necrotic, foul-smelling wounds, bathing patients, and changing diapers. In doing so, they embody both the state’s commitment to care for its citizens and the “humanistic promise of medicine” by humanizing patients whose bodies are literally rotting (107). Despite the profound importance of this kind of nursing care, we later learn that the ward’s limited bed space means that patients not explicitly in need of a doctor’s care are often discharged—sometimes against the wishes of nurses, who are all too aware of the difficulty and pain that may await their dying patients at home, where relatives may be unequipped or unprepared to care for them.

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. But where this book is most needed is in the burgeoning field of “global health” where, at least in the United States, oncology is still figured as a “first world” practice and health care in Africa is most often rendered either in the abstract, acontextual language of “DALYs” (disability-adjusted life years) or trite, depoliticized narratives of scientific heroism. Instead of—or at least in addition to—these vehicles, 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.