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

by Julie Livingston

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.

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.

"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

“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

Genres: Anthropology, Nonfiction, Medicine, Africa, Medical, School, Health

248 pages, Paperback

First published January 1, 2012

Reviews

[WY · Rating 5 out of 5]

This was one of my favourite readings from my MPhil, from my favourite class on Global Health and Development. Reading it a second time, four years later at a different stage of life, the insights still hit hard and Livingston’s style of academic writing (effective, empathetic, making grand sense of the small quotidian minutiae in a cancer ward in Botswana) still sets a standard I can only aspire towards. This is the book that really got me thinking about global public health logics, the subconscious/implicit association of cancer as a first world disease, and how these logics have real world carcinogenic implications in the access that the developing world has to oncological and chronic health care and something as simple and humane as sheer relief from pain. Chapter 2 was still my fave for fleshing out these arguments. (And the corporeal and visceral descriptions of pain interspersed with wisps of hope felt especially poignant riding off Angels of America.)
Will read again when in need of inspiration (for writing, for ~purpose, etc)

[Liralen · Rating 4 out of 5]

Really intense, interesting look at a (the) cancer ward in Botswana. Some similar themes to A Heart for the Work, which Livingston cites -- thinking about things like inadequacy of supplies, care being sought and/or provided too late... There's a really lovely moment when a nurse talks about cleaning out a wound: I just said, 'OK, before you assign me to that I want to come and take a look, to know what to expect under that bandage.' So I looked while someone else was cleaning, and I said, 'OK, now I've seen it.' No surprises the next day, when it was my turn, Mma D assisted me, and it was fine (110). I just love how practical that is -- what a great recognition, one, that nurses and doctors are only human too, and then two, what a compassionate scene. Wendland works a lot of those in here.

I didn't take as many notes here as I did with A Heart for the Work, and those I did tended to be scenes of that sort:

Afterward, he [the three-year-old patient] is crying and screaming and lying on the table and demanding his banana [given to him by the doctor]: "Ke kopa banana ya me, banana, banana!" His mother gets up and brings it to him. Dr. P is happy that he wants to eat his banana now, feeling certain that this will calm him down, and terribly proud that he has thought to give him a piece of fruit. As Dr. P turns his back to empty the syringes onto the slides, the boy comes up behind him and throws the banana at Sr. P's bum with all his might. Everyone collapses to the ground in laughter. (146)

But there are also a lot of harder things here, like who, when resources are so limited, get those resources. Do you give a bed to the patient with terminal cancer, who is critically ill and deserves care and will die in a few months anyway -- but might survive longer, and more comfortably, in hospital? Or do you give the bed to someone whose symptoms are less severe (and who also deserves care), and who might have better support, but whose chances are better and might benefit from hospital care?

So lots of questions and few concrete answers, which seems just as it should be.

Interesting things in the references: Vita, Forgive and Remember, Stories in the Time of Cholera, When Bodies Remember, Voting with Their Feet, East African Doctors, The Quest for Therapy in Lower Zaire, And a Time to Die, Cinderella's Sisters, Divining Without Seeds, When Experiments Travel, The Story of an African Famine

[Nic · Rating 5 out of 5]

Julie Livingston writes with great sensitivity while depicting life in a cancer ward in Botswana. She brings forward the "emerging cancer epidemic" a partial effect created as ARV's allow Aids patients to live with HIV/AIDS. However, in the process, patients are acquiring AIDS related cancers (as well as other cancers like breast, HPV associated cancers) which often lead to a cruel death, especially when morphine is not available. Hopefully, with the writing of this book, morphine can become more readily available (as well as many other cancer treatments available in the global north) to patients suffering in the global south.

This statement really hit the nail on the head, Cancer is made visible once it can fit Africa's extant publichealth frameworks, in other words when it is rendered as yet another sexually transmitted disease 33

The chapter "Pain and Laughter" really offers a unique angle and had me thinking of pain and laughter and how true Livingston's observations are. For example, my daughter and I were recently helping a friend move, and when we were moving a very heavy box together we burst out in laughter. Later, while carrying a lighter box, still heavy, but not agonizingly so, we didn't laugh at all. Which made me think of this chapter, and my daughter and I agreed that we only laughed with the super heavy boxes. Anyhow, the pain in this cancer ward is horrific and often barbaric, and something needs to be done to get morphine to these places - stat!

But morphine and codeine are inexpensive drugs. Cost alone cannot explain how a health system can afford to administer complex chemotherapy to a lymphoma patient but not properly palliate a terminally ill woman whose radiation treatments for her cervical cancer have created an inoperable fistula so deep and painful that she tries by all measures to resist her own hunger - so intense is her fear of the pain of defecation. 127

This quote really captures the knowledgeable sensitivity Livingston has towards the reasons behind the actions of the people around her. This laughter was particularly cathartic for the oncologist, who spent his days inflicting pain in the name of care. 146

Loved it! An important book to get the word out for those suffering in cancer wards throughout the global south.

[K · Rating 4 out of 5]

Excellent ethnography on Bostwana's only cancer ward and the rising cancer epidemic in Africa.
Best parts:
- the chapter on nursing and care
- discussion of lack of palliation, cultural logic of how people deal with pain and suffering in Southern Africa

[Ed Summers · Rating 5 out of 5]

I read this for my Ethnographic Methods Seminar. The descriptions of the cancer epidemic in Botswana were harrowing and so gut wrenchingly sad. But Livingston does a wonderful job describing the ways in which doctors, nurses, patients and relatives work together in an overcrowded hospital in a system of universal health care and a culture of humanism (Botho) to improvise solutions that embody care in the face of overwhelming suffering. She makes a beautiful, nuanced and impassioned case for how health care embodies politics.

There are many memorable characters and moments in the book, but Dr P stands out as a unique blend of artisan, empiricist and Marxist -- and seeming tirelessness and courage. Livingston details his work habits and process which span many activities to show how improvisational medicine can be:

In PMH he works hard, and he works seven days a week. He handles all outpatient clinical oncology, seeing usually between twenty and thirty patients a day (though the worst days bring up to forty patients to the clinic), directs a twenty-bed ward (where capacity is overstretched and extra beds are often packed in), and supervises aspects of care for cancer patients housed in other wards in the hospital. He is also the hospital hematologist. He feels the contours of lumpy lymph nodes, tumors skin, and organs on the patient's body. He smells necroses, listens to whistling lungs and gurgling tracheostomies, and lays his hand on the back of each patient during ward rounds to feel for fevers. The nurses joke about his thermometer-like "magic hand". He performs fine-needle aspirations, extracting cellular material from lymph nodes and possible tumors, pressing it onto slides. He also aspirates bone marrow and performs bon-marrow biopsies by boring into the sternum or pelvis of a patient and extracting a core sample to slice, or a tube of blood and fragments, to place on slides. Since the hospital lacks a cytology lab, he is also the one to examine the slides under the microscope, actively blocking out his image of the patient's clinical presentation as he places a drop of oil on the slide, then searches for tumor cells. Cytology, as he told me, "is like trying to understand the architecture of the house from a few bricks." But he strives to make cytologically based diagnoses and to avoid requesting biopsies, because waiting times fro minor theater are long, as is the wait for histological results, which can take weeks. He also tries to avoid the need for histological confirmation because there are numerous errors and inconsistencies in the reporting of histology.
...

This oncologist continually tacks back and forth between different kinds of firsthand knowledge, creating cancer and the cancer patient in multiple registers simultaneously (visually, tactilely, socially, microscopically, clinically, economically, bureaucratically), rather than in a series of disconnected or abstracted parts, as is the case in a larger oncology setting, with a more complex division of labor.

Along the way there are some useful theoretical pointers, one which I noted down was the idea of bracketing from Dutch ethnographer/philosopher Annemarie Mol. Bracketing, or really its counterpart unbracketing is the ability to evaluate and question information in context. The concept seems like a key ingredient in Livingston's portrayal of improvisation, and draws heavily from Mol's The Body Multiple. Which could be a useful book to follow up on.

[Dan · Rating 5 out of 5]

Very impressive book from Prof. Livingston here, who took her field work in Botswana in an African hospital and managed to craft a great book about the context for health in modern southern Africa. I loved how Livingston weaved the (recent) history into the text, though I would say that this is more of an anthropological study than a history.

A couple of things stand out from this book:

- "Hope" springs from context. Batswana were, by and large, very pessimistic about technological medicine in the 90s, but the success of ARVs in mitigating the worst effects of HIV seem to have caused a change in attitude. So people are more likely to see the hospital as a place that can help them, rather than a place where friends and relatives go to die.
- Prof. Livingston seemed very willing to bend to the facts on the ground. She brings up a standard critique of paternalism in medicine, and even challenges the head oncologist, the German "Dr. P," but seems to countenance some of his aggressively paternalistic conduct, after examining the circumstances. This may or may not be the right decision, but I respect that she engaged with the specifics of the situation. Such an approach comes out of the incomparable research.
- Paternalism aside, to do what he does in Botswana and Zimbabwe, "Dr. P" must be some sort of saint.

I highly recommend this book.

Addendum: Prof. Livingston teaches at Rutgers. It is hard for me to fathom what it must be like to go from assisting a harried staff at a hospital in Botswana to listening to a student explain why they couldn't complete their 5-page paper on time.

[Justin Abraham · Rating 5 out of 5]

"A whole new, robustly signified entity created and embedded in the human body"
The ontological question of biomedical objects. Biomedical objects in new contexts.
Knowledge which has to be assimilated but can only be assimilated through the limitations on that knowledge. A restricted field of epistemology.
Collective experiences of pain.
Patient autonomy might be less important when cancer is social.

[Diana · Rating 5 out of 5]

I rarely give star five star reviews, but this book certainly deserves it.

[Evie Davidson · Rating 3 out of 5]

5/10
Very informative but could have been condensed

[Etienne RP · Rating 4 out of 5]

Lord of the Crabs

Improvising Medicine describes everyday life in a small oncology ward in Botswana, a Southern African country that has been decimated by HIV/AIDS and that now faces a rising cancer epidemic. AIDS, disease, heat, stench, misery, overcrowding, scarcity, death: the picture seems familiar, even cliché. But Julie Livingston warns (or reassures) her reader at the outset: this is not the book on Africa one has learned to expect (or to dread). As she notes, “the problems of pain, death, illness, disfigurement, and care that lie at the heart of this book are basic human ones.” This is, in essence, a book about human nature in the face of insufferable circumstances. It is told in the way anthropologists tell a story: with a concern for the local, the mundane, the quotidian. Improvising Medicine is based on an extended period of participant observation and hundreds of pages of research notes jotted down after long hours of assisting care workers in their daily chores. The particularities of ethnographic observation are reflected in the excerpts of the research diary that are inserted in the book, with the names and proclivities of each patient and coworker who, in the end, become familiar figures to the reader as they were for the fieldworker. And yet, between the localized setting and the universalist message, there are some conditions and lessons that pertain to Africa as a whole. The cancer ward in Princess Marina Hospital in Gaborone, Botswana’s capital, is referred to as an African oncology ward in an African hospital. The author routinely writes about an African ethic of care, about the defining features of biomedicine in Africa, or about the articulation between African practice and global health.

The local, the regional, and the global

Of these three overlapping planes of observation, the local that characterizes a specific cancer ward, the regional that makes it distinctly African, and the universal that is common to all humanity, let’s start with what is specific to Botswana. In the early 2000s, at the time of the book’s writing, the country had only one hospital ward dealing with cancer patients, with twenty beds and few medical equipments—radiotherapy had to be practiced in a private clinic nearby. It had no medical faculty or university hospital, and doctors had to be trained abroad or brought in as foreign experts. Botswana’s inhabitants looked up to neighboring South Africa as a place with more sophisticated and powerful medicine than was available in their country. On the other hand, Zimbabwe, Botswana’s eastern neighbor, was spiraling into a crisis of dramatic proportions, and patients or doctors who had previously relied on its health system were forced to look abroad. Unlike apartheid South Africa or dictatorial Zimbabwe, Botswana was and still is characterized by a robust social contract that has sustained a stable democratic life and steady economic growth. For over four decades, Botswana’s political leadership has proven remarkably adept, patient, and forward thinking in charting the course of development, stability, and peace under challenging circumstances. Botswana is the untold success story in a continent that is often associated with civil wars, military dictatorships, and continuous economic decline.

These characteristics of Botswana translate in the country’s health system. Healthcare is provided as a public good for citizens under a program of universal care. Most people rely on the public health system and pay only a minimal fee for its services, although the cost of transportation and hospitalization falls heavily on the poorest households’ budgets. Botswana’s democratic regime and relatively equalitarian society ensure that “Bushmen from the Kalahari lie in beds next to the siblings of cabinet ministers, and village grandmothers sit on chemo drips tethered to the same pole as those of young women studying at the university.” Its small population and dense communal life also ensures that “everybody knows each other,” and this familiarity among patients and with caregivers humanizes the illness experience. A day at the cancer ward usually starts with prayers in Setswana, the national language, as most of the nurses are devout Christians. Nursing in the oncology ward is an extension of the state’s commitment to care for its people, a manifestation of a national ethos of care and compassion, and nurses are expected to embody these deeply ingrained values. Unlike other places where nurses might look down on their poorest patients, in Botswana social differences are mediated by an equalitarian ideology, and many nurses make a point of resisting claims for extra resources (more bed space, time with the doctor, nursing attention, preferential treatment) made by the most elite patients.

Living with HIV/AIDS, dying from cancer

Of course, this picture of Botswana’s health situation wouldn’t be complete without mentioning AIDS. Botswana lives in the shadow of the HIV/AIDS epidemic. Nearly a quarter of the adult population is HIV-positive, which means everyone has intimate knowledge of AIDS and its suffering. Antiretroviral therapies, distributed free of charge by an arm of the national healthcare program, have transformed HIV/AIDS from a deadly predicament into a chronic disease. People have learned to live with HIV; new terms have entered the local vocabulary, such are mogare (worm) to designate the virus or masole (soldiers) to refer to the CD4 count. Immunodeficiency increases the risk of co-infections by hepatitis, tuberculosis, but also certain forms of cancer. Co-infection with HIV renders cancer more aggressive and prognoses more ominous and uncertain. Before ARVs were available, many of Botswana’s patients died with a cancer, but from other AIDS-related infections. Since 2001, when Botswana’s ARV program began, however, many patients have survived HIV only to grapple wth virus-associated cancers made all the more aggressive and difficult to treat by HIV co-infection.The experience of cancer (kankere) has been grafted onto an already complex health situation. “If only I just had AIDS” was the ironic refrain the author heard repeated many times by the cancer ward’s patients.

Whereas HIV/AIDS originated in Africa and is often associated with the continent, popular opinion rarely associates cancer with Africa. According to Julie Livingston, many factors contribute to make cancer in Africa invisible: statistics are scarce, detection equipments are lacking, patented drugs are expensive and tailored for rich countries’ markets, and clinical knowledge is often ill-suited to African contexts. In addition, powerful interests conspire in perpetuating scientific ignorance about cancer in Africa: the mining industry often denies occupational exposure to uranium radiation or asbestos, and the African continent is targeted as the new growth market by tobacco companies. Cancers often go undetected until they have reached terminal stage, and then again they are not reflected in mortality data due to poor registry infrastructure. The paradoxical result is the shocking visibility of cancer among African patients. Readers are reminded that “while cancer with oncology was awful, cancer without oncology could be obscene.” A visit to the oncology ward conveys a vision from hell: the author’s fieldwork notes include descriptions such as “a friable mass of bleeding tissue eating its way into the vaginal wall and the bladder,” “a black swelling on the sole of her foot which had begun to ulcerate,” “throats blocked by esophageal tumors,” or “the necrotic stench of tumors that have broken through the skin and exposed rotting flesh.” It is this rot, and its accompanying stink and sight that in earlier decades made cancer an obscenity in North America and Western Europe. Very often, at this late stage, the only solution is brutal surgery: too many breasts, legs, feet, and testicles to be removed in a single day makes the author note in her diary, with grim humor: “It’s amputation day at Princess Marina Hospital.”

Invisible pain

Cancer in Africa is made invisible; similarly, pain among African patients is negated and marginalized. Pain is what propels many patients into clinics because they can no longer endure it on their own, yet many clinical staff are reluctant to use opioids and palliative care even for patients who are dying, despite long-standing WHO protocols encouraging their use and low-cost availability of morphine, codeine, and pethidine produced by the generics industry. This economy of pain is not only limited to Africa: the Global South, which represents about 80 percent of the world’s population, accounts for only about 6 percent of global consumption of therapeutic morphine. But the invisibility of pain in Africa takes on a particular racist twist: it is widely believed that Africans are less sensitive to pain, that they are more forbearing than whites and thus bear their pain in silence, and that they even smile under duress, laugh at pain’s expression, and make it a matter of ridicule. Racial ideas about pain are inherited from the colonial period and the slave trade, with its long history of forced labor, corporal punishment, and dehumanizing psychology. But African reluctance to perform pain loudly is also understood as a function of culture, as when African women laugh at the foolishness of white women moaning and screaming during childbirth, or in reference to initiation ceremonies when young adolescents had to endure beatings and suffering in silence in order to cross the threshold to adulthood. In the cancer ward observed by Julie Livingston, pain may be spoken of, but rarely screamed or cried over, and patient silence is interpreted as a sign of forbearance. But nurses are carefully attuned to nonverbal cues, reading facial expressions and bodily contact to gauge pain. Pain, even when it is repressed, denied, or laughed at, is a thoroughly social experience.

Efforts to socialize pain point to a wider lesson: disease is not only what happens to one person, but also between people and at the level of social interactions. Although cancer produces moments of profound loneliness and boredom for patients, serious illness, pain, disfigurement, and even death are deeply social experiences. It is sometimes said that we’re born alone, we live alone, we die alone. But from the moment we are born until we take our last breath, we are enmeshed in webs of social relations: we are never alone. This social embeddedness of life and disease that the author makes visible in Gaborone’s hospital is a defining feature of medicine beyond the African context. It is also what characterizes nursing, care work, and the ethics of therapeutics whatever its location or cultural context. Improvising Medicine is therefore a book with global relevance. Even the fact that improvisation is a defining feature of biomedicine in Africa can be generalized to other contexts. Confronted with life-or-death decisions, doctors always have to improvise in the spur of the moment, make choices under imperfect information, and even triage patients by determining who might get treatment and who might be left without medical attention. Of course, doctors are supposed to memorize procedures from books and follow rules. That’s why they attend medical school for so many years and pass stringent tests to be sure they know exactly how to handle each medical emergency according to the standard procedure. But an ordinary day in Princess Marina Hospital shows us life never goes by the book: doctors may be aware of the ideal way to deliver a certain treatment or to perform an operation, but they don’t have the equipment, staff personnel, infrastructure, or administrative support necessary to follow SOPs.

Third world conditions

Improvising Medicine reminds us that global health issues are indeed global, and that cancer, like medicine itself, is neither an exclusively African problem, nor a particularly Western one. The future of global health is shaped in large part by events and trends occurring in developing countries. The cancer epidemic is rising steadily across Africa and the Global South more broadly; it is aggravated by the fact that 40% of all cancers are associated with chronic infections. Co-infections are not limited to Africa: it is an important dimension of the current COVID-19 pandemic, as being already infected by a pathogen increases the sensitivity and morbidity to the new virus. But make no mistake: the situation in Africa is different. In a hospital that lacks a cytology lab, an MRI machine, endoscopy, and mammography, diagnosing and curing cancer is an impossible mission. The forms of cancer tumors that grow and blossom, exposing rotting flesh and necrotic stench, should never be allowed to develop. Critics sometimes claim that healthcare in North America or Western Europe has declined to third-world levels. They point to the long queues, shortage of equipment, and insufficient health coverage to denounce unequal access to medicine and rampant privatization of public services. The detailed description of an oncology ward in Africa should give them pause.

[Divya · Rating 4 out of 5]

I am humbled by the images of advanced disease and care in resource-poor settings described in this book. More than that, this book showed both the diverse range of human experience as well as the shared emotions related to cancer diagnoses.

[Henny · Rating 3 out of 5]

Unødvendig tungt og avansert skrevet, men historiene og erfaringen var usedvanlig givende.

[Julia Davies · Rating 2 out of 5]

The value of this ethnography by Julie Livingston is its detailed documentation of Botswana’s only oncology clinic during the first decade of the 21st century.
However, I found it upsetting and disappointing for Livingston to minimize what is clearly injustice, devastation, poverty and needless suffering as “improvised medicine.” I found her aim to elucidate culture from this setting to be insensitive. She is obscuring what to me is simply an injustice.
Second, Livingston applies her observations in this one Botswana clinic to representing health care in all of Africa? I found this illogical, especially because Livingston does acknowledge that Botswana is unique in offering universal healthcare. Southern Africa she describes as having heterogeneous forms of health care. To me she presented no logical reason why she could make broad assertions about Africa based on this one clinic in Botswana. All evidence points instead to this clinic being very unique and singular.
Third, she makes the unsubstantiated claim that cancer has been made invisible in Africa, as it is a ‘disease of development.’ What is the evidence of this? Also it’s unclear who she is attributing this flawed view to. I would think that most physicians, healthcare workers and people in the world of global health would anticipate that cancer is a health issue in Africa, just as it is in the rest of the world. Is she claiming that Africans are unaware of cancer? She does make it clear that for many clinic patients at the time of diagnosis they had little knowledge of cancer, that speakers of the local language rely on metaphors to describe cancer and that native healthcare workers have limited training in oncology. Again, it is not clear that the circumstances in one area in Botswana would apply to a whole continent of people. Again, Botswana is one country and we are told that unlike like other nations on the continent it lacks a medical school. I think it would be reasonable to assume that knowledge of cancer varies, especially among nations of Africa with medical schools founded on the biomedical model. Yes, international health organizations, NGOs and national and local governments may be focused on public health projects on HIV/AIDs and other communicable diseases. But it is not clear to me that a focus on infectious diseases renders cancer invisible. I think it’s wrong to assume that prioritization is evidence of ignorance. Why couldn’t it be possible that important actors in public health are concerned about infectious disease AND cancer? This is just to say that she provides little evidence for this claim, and this claim cannot be reasonably inferred from the information she does present.
Lastly, Livingston unnecessarily inserts herself in the ethnography. She seemed to want praise for having stepped in on occasion to speak to patients or have pushed those in wheelchairs, rather than just being a passive observer. To me these actions were bare minimum ethical obligations of anyone occupying space in a busy, under-resourced clinic. These actions pale in comparison to the experiences of the healthcare workers, patients and visitors. Why detract focus from them? I frankly found it annoying how much Livingston commented on what she did in the clinic.

[Alison Palumbo · Rating 4 out of 5]

Definitely an informative read for someone who is interested in cancer and global health. I realized when I started reading this that it was actually written by an ethnographer, not a medical professional, so if you’re looking for hard data and scientific evidence I would look elsewhere. That’s not to say it doesn’t have value, but I will say some of it gets a bit repetitive and I honestly found the writing style hard to get into. I think it’s because it was written by a highly academic professor of history. All the multisyllabic flourishes used in social science writing just feel clunky to read to me as a medical professional and it didn’t always flow well.

All of that aside I learned some interesting facts about the gruesome nature of caring for cancer patients in a resource poor setting. For instance, prostate cancer patients can’t afford things like Lupron injections so they literally have to be castrated in order to keep their testosterone low 0___0 definitely something we try to avoid in the US. Also culturally speaking, cancer, particularly pain and death, are treated very differently in Botswana. Patients try to suppress their sometimes intense pain experiences while simultaneously being under-treated for pain. Meanwhile, patients who are dying are not usually told of their prognosis so there is a question of ethics in limiting patient autonomy in this way. All very interesting stuff. There is definitely a lot of work still to be done to address these disparities.

[Azalia Muchransyah · Rating 3 out of 5]

This book tells a story about an oncology cancer ward in Botswana. Even though it was not primarily talking about HIV/AIDS, I find this book insightful in terms of thinking about what follows the epidemy of HIV/AIDS and its treatment in Africa, specifically in Botswana. Livingston stated that, “Cancer is a critical phase of African health after antiretroviral (ARVs)” (p. 7). This makes me think of cancer and other illnesses caused by HIV-related immunosuppression as well as those manifested as side effects of ARV. Since the government made HIV the focus of their public health attention, HIV becomes the highest threshold of endurable ilness in Botswana. Especially since the government started to provide free ARVs, the attitude of cancer patients in Botswana shows that they would rather be HIV-positive instead of having cancer, which is seen as untreatable and might end up with “amputation” of the part of their bodies affected by the illness. And when they are already diagnosed as HIV-positive, they don’t want to get cancer due on top of their HIV. This attitude is worsen by the poor way Botswana government treating their cancer patients, by giving little attentions and facilities on adequate cancer wards and often sending patients on pickup trucks to be treated abroad.

[AJ Payne · Rating 4 out of 5]

It took me a really long time to read this one, as it's one I read in small pieces on work breaks occasionally. But, every time I got into it I asked myself why it was taking me so long, since it really was so good.

This is a super niche book. It's not going to appeal to any (or probably even most), but it had such great insight into medical care in Botswana and how that compares to the rest of the world (primarily the US) and it was written so compassionately with balanced and deep observations. It truly was an ethnography (as the author set out to write).

So, it really was a great book. If you're into Botswana, public health, or providing health care in extremely resource deprived conditions (not field conditions, but in modern hospitals that don't have enough doctors, beds, equipment, or medications to appropriately treat cancer) then this is a great book to pick up to look at that.

[Laurie · Rating 5 out of 5]

I’m going to be thinking about this book for a long time. Before, I thought about “global health”, which is a cool, casual term for what she perfectly executed as an ethnography to detail the years she spent in witnessing the gritty details of human life (and death, pain, laughter, stench) in Botswana’s only cancer ward at the time. Julie Livingston thoughtfully details Botswana’s healthcare landscape as one demonstration of universal healthcare under resource constraints.

I’m still thinking about the section about the expression of pain as culture and the intricacies of sociality as pain relief.

Most of all I’m thinking about the global forces at work in orchestrating these human circumstances. How can we (USA) express and cultivate care about global health (the human experience) if we can’t just ship HIV vaccines, or we’re not worried about contagious disease contaminating our goods, or disease limiting our country’s supply of cheap labor? I’m not sure of the answer yet.

[Krys · Rating 1 out of 5]

This book was so inspiring that I feel suddenly motivated to create a new tag chronicling my reading adventures ("forced-reading" OR "i-cannot-believe-i-had-to-read-this" OR something equally synonymous), to admit I'm beginning to see ethnographies together as what makes up one of the most boring genres of literature (second only to romance), and apparently to not feel abashed using run-on sentences with improper punctuation and occasionally words that make it seem like I am overly dependent on a thesaurus to deliver a moot point in order to convey the emotion of dismay.

[Victoria Cooley · Rating 5 out of 5]

I read this years ago for a class on postcolonial Africa and decided to read it again recently. Even knowing what to expect, there were numerous passages that hit so hard I had to put the book down and take a beat to let it sink in. Livingston's writing is incredibly well-researched and emotionally powerful. Despite writing about a harsh, devastating reality, she writes with obvious warmth and compassion. This is a must-read for anyone interested in medical ethics, biomedicine, anthropology, or African history.

[Courtney · Rating 4 out of 5]

For an anthropological study, Livingston's writing offers a surprisingly approachable and deeply human look at the PMH Oncology Ward in Botswana. I was really moved by some of the scenes, examples, and ethical issues she raises, even with the difficulties also posed by her status as an outsider-researcher. Though emotionally difficult, I think this is worth reading.

[Laura · Rating 5 out of 5]

Wish I had read this sooner. It really shifted the way I think about the global cancer work I have previously done. Stuffed full of insights and historical/political context about the growing cancer burden in low-income countries, particularly those in Africa. And achingly vivid descriptions of particular patients and their experiences.

[Elsa · Rating 5 out of 5]

what we owe to each other is an attention to care, not as limiting force or something limited by biomedical approaches; but instead, in tandem. this was a heart-wrenching read that spared the reader no real comfort - I feel that this has impacted my approach to studying and understanding oncology in a brilliant way.

[Faith · Rating 5 out of 5]

My ~second~ taste of medical anthropology and it was definitely a lot more informal than I had expected, which made it more easier and pleasurable to read through. I highly recommend for those who are interested in pursuing medicine perhaps in rather different method!

[Jordan]

Read as ebook

[sofia · Rating 3 out of 5]

read for my anthropology class and it was super intriguing. the writing style was easy to read and I loved how Livingston described everything

[Robynn Ashenden · Rating 4 out of 5]

great insight, clearly links to and applies many of the quintessential medical anthropological theories. eye opening and heart wrenching.

[Thomas Kalinoski · Rating 4 out of 5]

Was informative. About what I expected from my own experience living there

[kelsie young · Rating 4 out of 5]

This book offered an eye opening ethnographical standpoint on cancer in Africa. It also touched on far more broad, urgent topics that need to be spoken about more regarding care focuses and viewpoints in the global south. While I am usually not a fan of non-fiction, the book was informative, while also being raw and entertaining. I highly recommend.

[Shahira8826 · Rating 5 out of 5]

A heart-wrenching, amazingly well-written and well-documented book, that is just as gripping a read as any novel, despite being non-fiction.
A must read for anyone working in healthcare and/or in the cooperation sector.

[Erica · Rating 3 out of 5]

3.75 stars. Engaging.