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

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Review

“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"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“This book will find a ready readership among Africanists and medical anthropologists. I envision its wider use in g'lobal health' courses, where it will challenge aspiring health workers accustomed to locating hope for medical development in scalable technical interventions... Cancer care, Livingston shows us—like medicine, like development—often requires starting over, usually entails improvisation, and always calls for hard labor by particular individuals in the face of destructive political and economic forces. Improvising Medicine reminds us effectively, sometimes devastatingly, how intractably human this thing called 'health care' is.” (Claire Wendland American Ethnologist)“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…. 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.” (Johanna Crane African Studies Review)“Improvising Medicine is best suited to those who are interested in global health or who provide medical care across cultures. While its primary subject is cancer, the points the author makes regarding the view of medical care priorities in resource-poor countries, as well as the culture-dependent experience of disease, are well taken and can be applied to work in other areas of the world.” (Holly Salzman Family Medicine)“In Improvising Medicine, Julie Livingston presents a vivid ethnography of cancer management in an African hospital ward...This book is rich in textual and visual data and is theoretically well informed. It is a model of ethnographic work and an excellent monograph in global medicine and health systems research.” (Benson Mulemi Social History of Medicine)“Although this scholarly work explores a harsh and distressing reality, it is well written, with a warmth and compassion that will make it accessible and appealing to a broad readership… This book will have a direct and sustained impact across fields of social sciences and medical humanities – as it can provide an important perspective often lacking within the paternalistic global health debates.” (Karen Barnes Journal of Southern African Studies)“Improvising Medicine is an exquisite ethnography, replete with both specific, richly observed encounters at a cancer ward in Botswana and broader, urgent arguments for anthropology and global health. . . . Drawing on beautifully rendered ethnographic evidence, Improvising Medicine tells a compelling story that is relevant for anthropology and beyond.” (Anne Pollock Journal of Anthropological Research)“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.” (Neil Kodesh Journal of African History)"Improvising Medicine is a brilliant and groundbreaking hospital ethnography, one that grips the reader with its narratives of an institution characterized by constant precarity, where supplies, medications, procedures, and staff are never assured.... Improvising Medicine should interest diverse audiences. These include medical anthropologists, sociologists, social historians of Africa, public health specialists, and scholars across disciplines with interest in the cultures and practices of biomedicine, the morality of care, and the comparative analysis of medical ethics." (Carolyn Sargent Medical Anthropology Quarterly 2016-06-14)

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About the Author

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.

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Product details

Paperback: 248 pages

Publisher: Duke University Press; 1st edition (August 29, 2012)

Language: English

ISBN-10: 0822353423

ISBN-13: 978-0822353423

Product Dimensions:

6.2 x 0.8 x 9.2 inches

Shipping Weight: 12.8 ounces (View shipping rates and policies)

Average Customer Review:

4.2 out of 5 stars

10 customer reviews

Amazon Best Sellers Rank:

#111,152 in Books (See Top 100 in Books)

In "Improvising Medicine: An African Oncology Ward in an Emerging Cancer Epidemic", Julie Livingston argues, “First, improvisation is a defining feature of biomedicine in Africa…Second, though cancer produces moments and states of profound loneliness for patients, serious illness, pain, disfigurement, and even death are deeply social experiences…Third, cancer in Africa is an epidemic that will profoundly shape the future of global health, raising fundamental policy, scientific, and care-giving challenges for Africans and the international community alike” (pg. 6-7).Livingston’s analysis provides for an interesting comparison between Botswana and the global north/Western world. She writes, “Healthcare (including oncology) is provided as a public good for citizens under a program of universal care. Most notably, Botswana has not accrued foreign debt, and so has been spared the predations of structural adjustment” (pg. 17). Despite this, Livingston cautions her readers against reading any utopian vision into oncology in Botswana. She writes, “Botswana’s position as an African nation that against all odds on the continent prioritizes universal healthcare and corporate capitalism simultaneously, and as a place where the cancer epidemic itself is in some part an outgrowth of a philanthropic project by Merck pharmaceuticals to extend the lives of those with HIV through the provision of antiretrovirals suggests a somewhat different, but not less compelling politics afoot” (pg. 171). Livingston contrasts this with Annemarie Mol’s discussion of similar systems from her book, "The Logic of Care". Livingston writes, “In Botswana, a country with universal access to healthcare for citizens, and with a historically deep and explicit understanding of care as a densely social dynamic, we encounter a particular pragmatics and an ethos of clinical medicine that at least partially diverges from what the philosopher Annemarie Mol calls ‘the choice model’ of healthcare” (pg. 153). Even with guaranteed healthcare, limited resources, physical distance to sites of treatment, and cultural views of medicine and pain management create a dynamically different situation than the one Mol described in "The Body Multiple", in which Dutch patients seek cutting-edge treatment for atherosclerosis at all stages of the disease and have a variety of options open to them, as well as a different cultural understanding of disease itself.A final interesting point Livingston makes deals with patient’s autonomy in the social culture of Botswana. Livingston writes, “There are several problems with fetishizing autonomy as progress, as some would do. First, there is a temporality to prognostic desire, even in places that privilege autonomy…Second, deeming autonomy as progress implies a uniformity of desire by patients within a particular national culture and historical epoch” (pg. 166). The social networks of Botswana only recently allowed the medical autonomy Americans expect in their doctor-patient interactions. Doctors in Botswana deprive patients of their autonomy in cases of terminal disease, instead socially distributing “to their kin through customs of prognostication that allow for frank, if brief, discussions with relatives, but not with patients” (pg. 159). Western patients expect medical control over the manner of their death in cases of terminal diagnosis, but this expectation does not exist in Botswana.

Anyone interested in medical anthropology can use this thoughtful and observant book. Livingston is the daughter of an oncologist and she states in the introduction: "In the face of many deaths I have witnessed since childhood, I have also questioned oncology's rituals, its liturgy, and the excesses to which blind faith and desperation can lead. . . . [In Botswana] I came to understand that while cancer with oncology was awful, cancer without oncology could be obscene."She puts the things she observes in the context of rising cancer rates in Africa and general unavailability of treatment, especially given forced-by-IMF privatization and expensive cancer drug patents. In a still-public hospital in Botswana which at least has an ethos of caring and an excellent oncologist, Livingston is, as she realizes, in one of the better possible settings in the environment, but the hospital staff struggles mightily with limited resources, hordes of patients, lack of treatment drugs and palliative drugs, and in general tremendous difficulties. How the patients and the staff manage and conceptualize things is astutely observed.Yet at the end the book leaves me touched, yes, but also angry about the marginalization of African health care and disease and about the drug patent system, as well as somewhat frustrated at how ephemeral any local gains can be without any sort of steady or rational progress, but grateful for people who are willing to deal with things as best they can regardless of that. And grateful for this fine book.

This is the last book for my graduate class reading. The story is very moving how it gave accounts of people's experiences going through cancer in Botswana in the late 90s to early 2000s. The epilogue also describes the cancer hospital in Zimbabwe. This book is about how doctors adapt their delivery of services under the constraints of lesser resources as cancer became an epidemia in Botswana. Truly, cancer has received lesser attention as HIV/AIDS became the center of attention worldwide although some form of the former is a complication of the latter. Some accounts are more morbid and horrific than others but all are equally hopeless and realistic. It is a documentation of reality when the poor struggle through cancer and lose their battle against it in the end. Sad, yet informative and not for the faint of heart. Now, I want to learn and read more about ethnography. On another note, I love that the pages of the hard copy resembles that of the Kindle version. What is exciting in the kindle version is the easy access to definition when some words are part of the medical jargon. I easily understood the meaning and appreciated more the context.

I read this book for my anthropology class and really enjoyed it. It was very well written and descriptive. This is a good read for entry-level college students.

This is an amazing, fascinating, heart wrenching book. A colleague recommended it to me for a class I'm teaching on Global Health and Development. Since I have tended to focus on general development more than health studies, I got a copy of this and was totally blown away when I read it. Great book for anyone interested in these issues!

A must read. Just read it. You won't regret it.

The book arrived promptly and in good condition. Livingston makes a valuable contribution to the literature on health care, sickness, and variability within human practices and experiences

I just didn't like the way the author thinks that screening for HIV is useless if you cannot pay for treatment. I think its very important. If we know, then perhaps we can take precautions to further spread it. Prevention is key.

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