Africanizing Oncology is a historical ethnography of the Uganda Cancer Institute (UCI). In the 1960s, the UCI was a small chemotherapy clinical trials facility. Today it serves a population catchment of over 40 million and is a centre of oncology excellence. What is unique and different about the UCI is that it is a fifty-year-old institution that had long used collaborative medical research as a resource for expanding cancer services for the broader Ugandan public. Many international partners have come to Uganda since the 1950s to study and treat cancers. But international collaborators come and international collaborators go. It was and is ultimately Ugandans who keep experiments going and freezers operating. They provide care to patients on the wards of the UCI long after expatriate colleagues leave, research results are published, and funding cycles end. A collective commitment to keeping things going explains the remarkable durability of this institution over the past fifty years. Rather than a case of unilateral extraction, cancer research in Uganda was and continues to be generative for creating long-lasting cancer care infrastructures for Ugandan publics. The book is both a history of the UCI and a history of Uganda since independence. It situates Africans at the centre of biomedical research stories as knowledge producers, rather than simply bodies for experimentation and extraction by white Western scientists. It pays keen attention to the stories of physicians, nurses, laboratory technicians, administrators, patients, families and even the occasional politician who have lived and died on the wards of the UCI over four generations from the 1950s onwards.

I greatly appreciate the thoughtful and generous reviews of Africanizing Oncology by Jonathan Shaffer and Johanna Crane. In particular, I appreciate the ways in which both Shaffer and Crane ask what lessons the UCI’s long history might offer for contemporary calls among practitioners to ‘decolonize’ the global health industry. Is equity in global health partnerships ever possible, or will the political economy of biomedical knowledge production continue to be characterized by pernicious inequalities? How much of an anomaly, really, is the UCI when compared with other research collaborations on the continent?

These are all terrific questions. My short answers: I think the UCI is a largely anomalous and exceptional case. There were so many historical contingencies that led to the establishment of the UCI and the profoundly resilient and savvy individuals who kept this site alive for decades that it is not generalizable. And I think inequity is a feature rather than a bug in most global health partnerships. However, most partnerships come to an end. And the UCI’s story offers a critical window into what happens to biomedical research partnerships between the global North and the global South after they officially come to a close. In particular, we have much to learn from the ways in which African physician-researchers keep things going despite massive oscillations of national fortune and cycles of international research investment and disinvestment.

The questions and preoccupations animating this book were not so much about decolonizing global health as they were about how to write with sensitivity, honesty and integrity about the history of biomedical research and care in Eastern Africa. When the research for Africanizing Oncology began in 2010, it was in conversation with a broader trend in African health histories to take biomedicine seriously. Over the past decade, there has been a rise in scholarship that interrogates the materiality, the practices, the spaces and the practitioners of biomedicine in African health spaces. The theoretical architecture of the book was informed by discussions of experiments travellingFootnote ¹ and the promises and shortcomings of the antiretroviral technofix for HIV.Footnote ² I also engaged with scholars writing about the material realities of biomedicine in Africa, including debris,Footnote ³ traces,Footnote ⁴ improvisation,Footnote ⁵ capacity,Footnote ⁶ scrambling for Africa,Footnote ⁷ and Africa as a living laboratory.Footnote ⁸ ‘Decolonization’ was not on my radar. Indeed, I was more concerned with the political and practical work of ‘Ugandanization’ in the 1960s at Makerere and ‘Africanization’ in the 1970s in the context of Idi Amin’s economic war.

I don’t think it is possible to separate this biomedical turn in African health histories over the past decade from the broader historical context of the HIV epidemic in Africa. Indeed, I would argue that the HIV epidemic in Africa compelled me (and many other Americans in particular who are currently working this field) to get serious about histories of health on the continent. I became interested in the history and anthropology of biomedicine in Africa because of prior experiences in applied global health that felt profoundly ethically fraught. I can only speak for myself, but I was also drawn to working on histories of biomedicine in Uganda because of how high and literal the life and death stakes were. And continue to be.

In order to really get at these life and death stakes, many of us turned to reckoning with the hospital, the clinic, the lab, the physical spaces of biomedical care. And ethnographers and historians alike had to come face to face with the material realities of biomedical tertiary care in the wake of structural adjustment and the HIV epidemic. Spaces that Kristin Peterson would call a hollowed state. What Paul Farmer would call a clinical desert. And what my colleague Dr Z at Mulago’s radiotherapy unit would simply call ‘where we are working at’.

In my writing and research, I wrestled with the question of audience and how to strike a balance between creativity and crisis, repair and destruction, hope and despair. I wanted to move beyond accounts of failure, exploitation, technocratic bumbling and untimely death in contemporary African health settings. I also wanted to draw you into the heart-breaking yet totally quotidian stakes of what it is like to work day after day on a paediatric cancer ward.

I am not sure if this constitutes a ‘decolonial’ research and writing praxis. During the work I was constantly asking myself: am I doing justice to this situation? Am I just simply recapitulating suffering strangers? Am I being overly celebratory of the work that medical colleagues are doing in these settings? Have I managed to give you a sense of where we are working at? Have I been able to move beyond the fetishization of scarcity? Have I been able to add complexity and nuance to what is not working? Have I done right by the charismatic heroes who are acting creatively in times of crisis to make ends meet? Have I adequately metabolized Nolwazi Mkhwanazi’s excellent critique of this whole genre into which she goes in her discussion of single stories in writing about African medical contexts?Footnote ⁹

In some ways, I feel that the theoretical architecture of the book is already being unravelled by new conversations about global health equity, decolonizing global health, and, of course, the uneven fallout of the Covid-19 pandemic, especially as it relates to global vaccination inequities.

It has taken this field over ten years to embrace the fact that biomedicine is something we can legitimately write about and historicize. I imagine it is going to take us at least another ten to come to a reckoning of what we’re talking about when we’re talking about decolonizing global health. No doubt many of these conversations will be about the politics of representation and identity, including a much-needed critique of the subject position of the muzungu (white) scholar of African biomedicine. Obviously, an American outsider muzungu whose Luganda is patchy is going to understand things differently from a Ugandan patient caretaker or expatriate oncologist. But I think that’s a bit beside the point. A far more interesting question to ask is why not one of the many Ugandan colleagues who made this book possible over the years had the time or the funding or the resources or indeed the training that I had in order to do this work.

The current calls to decolonize global health in the Twitterverse and beyond strike me as a largely contemporary project that is divorced from engaging with the broader histories and stakes of the decolonization of biomedicine across the globe half a century and more ago.Footnote ¹⁰ And even if it is not the explicit project of the book, I cannot think of a more powerful story of the everyday stakes of decolonizing biomedicine and global health than the story of the UCI.

In the book, I write that we have ‘so much to learn from how Ugandan physician intellectuals, fieldworkers savvy in forging friendships, resilient patients, and invested caretakers keep things going: be they buildings, bodies, experiments, kitchens, therapeutics, blood banks, or optimism’ (p. 24). I hope that you are moved and inspired as I am by the many stories of life and living at the Uganda Cancer Institute.