Returning to Botswana in 2006 after an absence of several years, Julie Livingston noticed a marked shift in the country's health landscape. The rollout of Botswana's public antiretroviral program, which began in late 2001, had made lifesaving drugs available to an increasing number of people infected with HIV. At the same time, a rapidly growing number of people were now receiving treatment for a variety of cancers in the recently established oncology ward at Gaborone's Princess Marina Hospital. Many of these patients were suffering from new HIV-related cancers. The establishment of oncology services to assist people with virus-associated cancers, however, had also afforded Botswana the ability to diagnose a significant population of patients with cancers not related to HIV. In Improvising Medicine, Livingston offers an intimate portrait of Botswana's only oncology ward from its founding in 2001 to 2009. The ward was headed by the hospital's lone oncologist, ‘Dr P.’, who was an indefatigable, fiery German doctor who came to Botswana after practicing in Zimbabwe for 14 years. Drawing on eight months of ethnographic research, during which she observed and participated in the daily routines of the ward, Livingston examines the experiences of doctors, nurses, and patients and their relatives as a cancer epidemic emerged in Botswana. The result is a stunning look at the practice of biomedicine in twenty-first-century Africa, the provision of care in situations of pronounced uncertainty, and the future of global health.
Africans, Livingston contends, are currently living in a ‘carcinogenic time and place’ (p. 51). Resulting from a combination of environmental factors, the increasing reach of tobacco multinationals, and the emerging problem of virus-associated cancers, the African cancer epidemic is part of a growing cancer crisis in the global south. Why, then, does cancer not register in the public imagination about Africa or occupy a significant place in global health agendas? Despite the recent surge in the number of cases, cancer is not new in Africa. Instead, cancer has been rendered invisible on the continent by a ‘narrow infectious-disease model of African public health’ (p. 38). The ‘epidemiological progress narrative’ – according to which chronic illnesses would become a significant problem only with the decrease in infectious disease that accompanied other indicators of development – obscured the relationship between cancer and infectious disease recognized by researchers in East and Southern Africa in the 1960s and 1970s (p. 34). This pattern continued with the development of HIV research in the 1990s, which advanced our understanding of virus-associated cancers in the United States and other metropolitan contexts but further entrenched the infectious-disease model of public health in Africa. The results of this ‘carcinogenic invisibility’ in Africa have been profound, Livingston argues, including the development of clinical knowledge that often does not translate well into African clinical contexts.
These differences between the understanding and treatment of cancer in the global north and the realities on the ground in African hospitals and clinics inform one of Livingston's main arguments: that clinical improvisation – the process by which practitioners, patients, and relatives adapt biomedical knowledge to particular contexts – serves as a defining characteristic of biomedicine in Africa. The ethnographic chapters at the heart of Improvising Medicine take readers on an eye-opening journey that explores the ways in which the practice of biomedicine in Africa unfolds in the oncology ward of Princess Marina Hospital. In these chapters, Livingston examines the ontology of cancer in this particular clinical context, the manner in which nurses reconfigure the deeply embedded practice of social healing through their interactions with patients and their relatives, the socialization of pain, and the complex clinical ethics of a situation in which doctors, nurses, and families must negotiate between Botswana's policy of universal healthcare for citizens and the distribution of scarce resources.
The stories of Botswana's oncology ward contained in these chapters are at turns agonizing, heart wrenching, and filled with laughter. The sometimes-gruesome details offer far more than a means for capturing our attention. They help Livingston illuminate the book's broader arguments. Perhaps better than any other work to date, Livingston brings together insights from the now well-developed history of social healing in Africa with the more recent scholarly focus on African biomedicine. She draws on these stories to reveal how care, illness, pain, and death are ‘deeply social experiences’. As she eloquently writes, ‘[u]nderstanding cancer as something that happens between people is critical to grasping its gravity’. For Livingston, the stories of Botswana's oncology ward illustrate both the necessity and the limits of biomedicine in African contexts. While biomedicine provides necessary palliative care, she argues, it is ‘an incomplete solution’ and ‘there will be no quick techno-fix for African health’ (pp. 6–7).
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.
