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Biomedicine in an Unstable Place
Infrastructure and Personhood in a Papua New Guinean Hospital
By Alice Street Duke University Press
Copyright © 2014 Duke University Press
All rights reserved.
ISBN: 978-0-8223-7666-8
CHAPTER 1
Making a Place for Biomedicine
In Madang Hospital, Papua New Guinea, biomedical practitioners struggle amid severe resource shortages to make the diseased body visible. Bodies like that of William Gambe, described in the prologue, rarely crystallize into clear biomedical objects. Here medical devices such as X-ray machines do not work well in the hot and humid climate, pathology machines are old and difficult to calibrate, and the reagents stored in fridges are rendered unreliable by the frequent power cuts. This is the murky world of biomedicine as it is practiced in the mundane places of poverty that traverse much of the globe. In such places, weak states, structural adjustment, and extractive capital have led to the degradation of public health infrastructure, and people must strive to make biomedicine work in conditions of institutional instability and medical uncertainty.
Opened in 1962 by the Australian colonial administration, Madang Hospital was intended to be a showcase for modern medicine and a catalyst for the construction of a modern independent Papua New Guinean nation-state. Situated in the third largest town in Papua New Guinea and serving as the referral hospital for a provincial population of more than 365,000 people, Madang Hospital today embodies a paradox that runs through the public health systems of many of the world's poorest countries. On one hand, since the end of the Second World War public health professionals, policy analysts, government representatives, and development workers in Papua New Guinea have condemned the drift of health resources away from rural primary health care and toward urban centers and curative medicine. In a country where an estimated 87 percent of the population lives in rural areas that are frequently inaccessible by road, and depends largely on subsistence livelihoods, the concentration of medical professionals, technologies, drugs, and infrastructures in urban hospitals seems unjustifiable and unsustainable. On the other hand, hospitals in Papua New Guinea are derided for failing to provide the levels of care that might be expected of such "modern" institutions. Hospitals, political and media representations suggest, are simultaneously overfunded and underresourced. They divert attention and resources away from preventative and primary health care, and yet they fail to accomplish the technological feats associated with modern biomedicine. It turns out that hospitals are necessary after all and that, in Papua New Guinea, they do not do what people expect of them.
It is in institutions like Madang Hospital that most people in the world are likely to encounter biomedical doctors and specialist biomedical technologies. Here biomedicine does not follow a universal template that originated in Europe. Nor is this hospital a pale imitation of "proper" hospitals in Western countries (though this narrative is sometimes adopted by people in the institution). Rather, it is in institutions like Madang Hospital that twenty-first-century biomedicine, in constantly coming up against the limits of its own practices and technologies, is continually reinvented, imagined, and done. It is thus in these mundane spaces where funding and resources are scarce that we are most likely to gain insight into what biomedicine means for the people who create and engage with its practices, and what kinds of social and physical worlds it makes possible. To understand what hospitals are and the social relationships of contemporary biomedicine, it is to these "peripheral" institutions that we must turn.
If hospitals are places of biomedicine, however, they are never solely biomedical places. A central argument of this book is that once we take the place of biomedicine as our field of enquiry, this forces our attention toward the mutually constitutive relationships between scientific orderings of the world and other orderings, such as those entailed by kinship practices and projects of development or state building, that are crucial to the production of this place as a hospital and through which people attempt to transform and improve their lives and those of others. It is hospitals' paradoxical capacity to be at once sites of "total" biopolitical management and places where alternative and transgressive social orders emerge and are contested that makes them crucial ethnographic sites for exploring relationships between science, society, and power. The complexity of the relationships between biomedical and nonbiomedical orderings that make up hospital infrastructures becomes all the more apparent in a place like Madang Hospital, where resource shortages make it difficult to map biomedical authority onto hospital space and where the successful execution of biomedical practices may in fact require doctors and nurses to harness the kinship relationships of staff or patients as a resource: for example, when patients' kin provide much needed in-hospital care, blood donations, food, and privately purchased pharmaceuticals.
The story of how bodies, persons, and diseases are made visible or invisible in Madang Hospital is not, therefore, only a story about biomedical work. It is a story about the history of hospital infrastructures as sites of colonial and postcolonial state building. It is a story about the coproduction of Papua New Guinea as a site of global infectious disease control, medical research, and public health. And it is a story about people's encounters with urban institutions and biomedical technologies and the bodily and personal transformations that this makes possible.
In Madang Hospital, this book shows, the struggle to render the biological body visible and knowable to the clinical gaze becomes entangled with attempts by doctors, nurses, and patients to make themselves visible to external others (to clinical experts, global scientists, politicians, and international development workers) as socially recognizable and valuable persons. Here the visual operations of modern biomedicine become intertwined with the visual politics of personhood in an unstable place where the infrastructures necessary for producing knowledge and governing populations are tenuous.
What is a hospital when its bodies remain blurry? When foreign donors and international organizations label the state as fragile and the health system as failing? When its nurses are regularly on strike against a state they accuse of neglect? When its doctors are frustrated by their inability to diagnose or treat people in the manner they have been trained? When its infrastructural poverty becomes a scientific resource and the basis for the construction of well-resourced research enclaves? When its patients are caught between kin who might have made them sick in the village and doctors who seem not to see them at all? On one hand, this book argues, such a hospital is a place of deep ontological uncertainty and instability, where knowledge of oneself and others cannot be taken for granted. On the other hand, it is a place of experimentation, where technological and bureaucratic apparatuses provide opportunities for making persons visible and knowable in new, unpredictable, and powerful ways. In a place where people predominantly imagine themselves to be invisible (to the state, to doctors, to a global scientific community) the hospital becomes an intense site of visibility work where bureaucratic and biomedical technologies are engaged with as relational technologies that can make the person visible in recognizable and affectively persuasive forms.
DISTRIBUTING DIFFERENCE
The chapters that follow explore the everyday relationships between persons, bureaucracies, technologies, and spaces that transform the body and the person into recognizable entities. In doing so they attend to the spatial and temporal differences in the ways in which biomedicine is practiced and the kinds of bodies and persons it renders visible. Social science's temporal register for such "differences in medicine" takes its cue from Foucault's influential account of the historical disjuncture at the end of the eighteenth century that marked the birth of modern medicine. Although the anthropology of biomedicine and hospital ethnography have in many ways departed from a Foucauldian approach in recent years, it is worth reviewing Foucault's conception of biomedical difference and its relation to the hospital as a site of visibility as a starting point for considering how such differences might also be attended to in the context of the global hospital today.
In The Birth of the Clinic Foucault described the coemergence of a new kind of institutional clinical space and new ways of seeing and knowing disease in the body. Between the investigations of doctors working in the mid eighteenth century who, for example, divided and weighed the different portions of the brain to classify its properties and those working at the beginning of the nineteenth who saw and described the brain's qualities in order to seek out new empirical truths about disease, Foucault identified differences that are "both tiny and total" (2003, xi). Up until the early nineteenth century disease was located in the limited two-dimensional space of the nosological table and was construed as external to the body in which it became manifest. The total range of possible permutations of disease was fixed by the limited classificatory series of the table and any variations were attributed to the body of the patient and construed as an external impingement on the natural course of the disease. With the emergence of pathological anatomy came a new kind of gaze that penetrated the body and saw into its depths. Disease became localizable in and specific to the individual body. It was now conceived as part of a dynamic and inchoate field of "life," which required management through both a clinical gaze and public health governance.
According to Foucault, modern medicine emerged out of the conjuncture of pathological anatomy with its internal geography of the body and the modern clinic as a space where vision and visibility become privileged as a basis for truth. The "careful gaze" of pathological anatomy restructured clinical practice so that bodies no longer needed to be opened up on the autopsy table for doctors to locate disease in their depths. Tapping, listening, prodding now all became techniques of vision that brought the dynamic geography of individual life into view. In this new "empire of the gaze" doctors "learned how to establish dossiers, systems of marking and classifying, the integrated accountancy of individual records" (Foucault 1980, 70), such as the individual case files that rendered the individuated body knowable, facilitated medical talk about the body, and made clinical intervention possible (Foucault 2003, 131–152). What underpinned these shifts in the spatiality of medical knowledge, he argued, was a redistribution of the "visible and invisible" (Foucault 2003, xii) that represented "a whole new 'regime' in discourse and forms of knowledge ... a modification in the rules of formation of statements which are accepted as scientifically true" (Foucault 1980, 112). It was with these transformations, Foucault argued, that the individual emerged as both the subject and object of knowledge and that the human sciences were born.
Foucault was peculiarly sensitive to medicine's historical epistemic breaks, perhaps even to the extent of overstating them, nonetheless his account of the clinic ran pathology, clinical knowledge, and medical research together within a homogenous epistemic space. This book, by contrast, pays attention to the ways in which differences in medical knowledge and practice are distributed across hospital, national, and global geographies. When we attend to medicine's social and geographic diversity we might find that pathology does not always and everywhere provide the dominant way of stabilizing disease. Instead the hospital is revealed as a space of sociomaterial complexity, where differences in biomedicine, disease, and biology might coexist through their distribution in space and time (Mol 2002). The kind of body that is made visible by medical practices in Madang Hospital's private wards is different from that made visible in the hospital's public wards. The kind of clinical knowledge produced in the medical ward differs from and frequently takes priority over the knowledge of pathology produced in the hospital's laboratory. Moreover, biomedical practices in these hospital spaces do not entail the diagnosis of an underlying disease through the exercise of an authoritative gaze so much as the development of pragmatic collaborations with medical devices, professionals, patients, and relatives and experimental "tinkering" with technologies, bodies, and everyday lives in order to create solutions that people can live with.
When differences in knowledge practices, disease, and bodies are traced across global rather than institutional geographies more is at stake for everyone involved. Recent ethnographies of care in non-Western hospitals have emphasized the fluid, experimental, and improvised nature of biomedicine in contexts of institutional poverty. Oncology doctors in Botswana must "borrow, adjust, and even deny, but never simply import metropolitan knowledge," writes Julie Livingston, of their attempts to align their latest readings on advances in oncology care in wealthy countries with the possibilities of care in Botswana's cancer ward. "There are moments in the trajectories of cancer illnesses or survivorship where therapy becomes an experimental zone in which innovation and guesswork is dominant." In such spaces, "resource" becomes a verb and doctors learn to "improvise new options from the resources available—material and social." This involves cobbling together "social networks, material goods, short-term opportunities and ideas to craft ad hoc solutions to the problems they faced" (Wendland 2010, 154).
That biomedicine generates its own contexts of uncertainty and improvisation is not unique to resource-poor institutions. As Atul Gawande, the American surgeon and popular medical writer has observed, hospitals are often bewildering spaces where "the gap between what we know and what we aim for persists. And this gap complicates everything we do" (2003, 3). This means, Gawande argues, that much of the biomedical work that is done in hospitals is pursued not through the rational application of available scientific knowledge to a particular case, but through "habit, intuition, and sometimes plain old guessing" (2003, 7). Such "complications" (Gawande 2003) of biomedicine may be universal, but they are also heightened in institutions like Madang Hospital. Here murky biomedical knowledge rarely clears to reveal lucid etiologies or diagnoses. The adaptive and experimental qualities of biomedical "tinkering" in such places are vital to making sure that lives are saved.
This has implications for thinking about how the hospital, as a sociotechnical assemblage, travels and what matters to whom about differences in medicine when they are distributed across contexts of relative wealth and poverty. As the acting CEO explained to me on my first day in Madang Hospital, "Here we don't have all the resources to make diagnoses on hand ... final diagnoses are only made when the patient leaves." In Madang Hospital, as I describe in chapter 4, disease is not only enacted differently in different places; it frequently fails to appear at all. In Madang Hospital, I argue, patients' bodies are clearly diseased but do not always have specific diseases. Instead doctors must deal with bodies that they describe as "generally sick."
What kinds of capacities and futures do generally sick bodies and Papua New Guinean medical experts have? These questions are important because "improvisational medicine" (Livingston 2012) is not the only kind of biomedicine practiced in Madang Hospital. Papua New Guinea has been a site of intensive biomedical research interest since Robert Koch visited the Northeast Coast to carry out malaria research in 1901, but ongoing international investment in medical research through successive colonial and postcolonial governments has rarely overflowed into the public health system (as described in chapters 2 and 8 of this book). As global funding for infectious diseases has grown in tandem with pressures to meet the health-focused Millennium Development Goals, so do resource-poor clinical medicine and internationally funded medical research increasingly converge in Madang Hospital. Papua New Guinean doctors claim uncertainty as a locally appropriate biomedical resource in the hospital's public wards. Meanwhile foreign medical researchers' experimental apparatuses enable them to stabilize the individual diseased body as an object of knowledge, and in doing so raise questions about the validity and quality of Papua New Guinean doctors' management of "generally sick" bodies.
(Continues...)
Excerpted from Biomedicine in an Unstable Place by Alice Street. Copyright © 2014 Duke University Press. Excerpted by permission of Duke University Press.
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