The starkly visible interplay between infectious and non-communicable disease is a hallmark of a range of emerging threats to human health in contemporary sub-Saharan Africa. The recent prominence of cancers as an object of epidemiological and social concern warrants precisely the keen, detailed scholarly focus offered in this remarkable book, skilfully blending historical and ethnographic modes of enquiry and presentation. Julie Livingston reflects on the experience of carers, clinicians, communities and patients grappling with cancer at a hospital in Botswana's capital, Gaborone, in the wake of the country's destabilizing HIV epidemic and the consequent resource crisis in universal healthcare provision.
Livingston reminds us that ill and debilitated Batswana, at home and as migrants, inhabit a curious juncture amid southern African histories of state racism and the post-independence promises of the Botswana state, centred on universal rights vested in citizenship. This juncture conditions both the phenomenology of pain and the expectation of palliation, which converge in the hospital locus of Livingston's ethnographic work. The oncology ward of Gaborone's principal referral hospital draws together clinical and nursing expertise from across the globe in a new techno-scientific venture. German, Egyptian, Batswana, South Asian, Cuban and North American workers wield and ration drugs and equipment, in order to contend with cancers bursting into public visibility on the shoulders of improved prognoses for people living with HIV – prognoses contingent in large part on pharmaceutical philanthropy.
The irony is not lost on the author. As a historiographical undertaking, the book traces a history of bodies and a society grappling with the unexpected consequences – manifested as a rapidly increasing prevalence of cancers – of a fracturing experience of colonial disruption, a convergence of crises in economy and health occasioned by the HIV pandemic, the regional and local growth of corporate capitalism, and a succession of developmental and philanthropic rationalities that occasionally and catastrophically magnify disruptive outcomes. Livingston's account is rooted in, and contributes greatly to, a nuanced understanding of the interplay between temporal discontinuity and conceptual sedimentation at play in embodied histories and politics.
At the heart of the ethnographic enterprise is an attention to the experience of pain, forbearance and laughter. This experience informs the social and historically constructed mechanics of care, in a context where resources are subject to habitual rationing and triage. Relationships between patients, families, clinicians and nurses (and the visiting ethnographer – never rendered absent in the account), constituted around logics of pain and prognosis, provide rhetorical and temporal strategies for negotiating a trajectory through the brutal and violent deployment of oncological technique and apparatus. The range of trajectories is shown to be social and personal, anchored in a contingent and shifting relation to resources and patient outcomes; oncology, the social relations thus constituted, and the right to draw on hospital resources are rationed to a particular temporal phase in the course of cancer.
The text is often confrontational and graphic, evoking and invoking a debilitated presence around which ideas of the social must be recomposed and supplemented on the ward. Livingston's presentation is tightly composed, dense with contending poetics of pain and palliation. It proceeds by means of restatement and reiteration, thickening and enriching historical context, revisiting field notes, destabilizing the ethnographic encounter with reference to the author's physical implication in care, and counterpointing silence (as forbearance, concealment, misunderstanding) and visibility (as wounds and lesions, and as cues in the communication of pain). In doing so, it continually revisits oncology's contingent, local and particular resolution of hope, death, pain and social peace in the context of a broader political economy of techno-medicine, where family and patient hopes transcend the particularities of individual cases to become vested in imperfectly translatable ‘powerful’ North American modalities of cancer care.
Together with the author's previous monograph, Debility and the Moral Imagination in Botswana, this book traces an essential journey through landscapes of impairment in recent historical and contemporary Africa. In its consistent dramatization of the ethnographic encounter, as gaze and as commitment, and its invocation of the contours of hope linking experiences of techno-medicine in southern Africa with North America and Western Europe – and the gradients of opportunity that divide them – it claims relevance beyond the anthropology and history of health and medicine, and indeed beyond African studies. This book places us at the heart of an unfolding drama in global health, and brings the fraught, fragile and inherently destabilizing bodily experience of illness and care centre stage. Marrying the temporalities of living and dying with the contingencies of history, Livingston's account issues an insistent call to scholars and activists engaged in welfare, development and global health, in Africa and across the globe, to remain attentive to the poetics, sensibilities and entanglements arising among shifting political economies and institutional contexts of care. The book's astonishing epilogue, detailing the cyclical, entangled insecurities and fragilities of institutional medicine across southern Africa, offers a chastening reminder of the improvised, provisional bases of care and hope in Africa's cancer epidemic.
