Experimental Futures. Durham: Duke University Press, 2014. xi, 290 pp. (Illustrations, maps.) US$24.95, paper. ISBN 978-0-8223-5778-0.
Medical anthropology in Papua New Guinea (PNG) has followed a path that reflects shifts in theoretical perspectives along with the realities on the ground. The pioneering works, dating from around the time of independence in 1975 to the early 1990s, focused on rural communities. Indigenous understandings of disease etiologies and curative actions were thoroughly investigated in a handful of case studies. Different as native ideas about the spiritual and moral basis of illness were from Western biomedicine, these studies also revealed that local people had no hesitation in using the forms of Western medicine available to them. The popular term at the time, “medical pluralism,” suggested a rather easy accommodation between the two systems. In more recent years, spurred in particular by the HIV/AIDS pandemic, anthropological research has focused on the delivery of health services by the state and international agencies. This work has revealed that there is some friction between indigenous and biomedical perspectives, particularly in educational campaigns for safe sex. More significantly, they have revealed just how shoddy what passes for modern medicine is for most people in the country.
Based on ethnographic fieldwork carried out in 2003 and 2011, Biomedicine in an Unstable Placeprovides a compelling portrait of the public hospital in Madang, PNG’s third-largest city. Alice Street draws effectively on archival and government sources and her intimate observations to give a rounded picture of history, daily routines, and problems faced by the hospital. The study gains much of its power from the vivid vignettes that run through most chapters. We meet the doctors who struggle to determine patients’ ailments, ordering X-Rays which are often unreadable (when the machine works at all) and tests which can’t be carried out because of missing chemicals, leaving them to prescribe treatments requiring drugs which just as often aren’t available. We meet the nurses and lab techs, scrambling to respond to the incessant demands of the doctors for tests that can’t be carried out and patient needs which can’t be met. We meet the foreign researchers and medical trainees whose presence is necessary to fund the new infrastructure that promises to bring the hospital up to First World standards but who come primarily because the Madang Hospital has typical Third World conditions. And, not least, we meet the patients who, with the aid of a few kin who often share their beds, reside for months at a time in a sweltering, overcrowded ward on rotting mattresses subsisting on barely edible food in hopes of drawing attention from the exhausted doctors and nurses to work out what ails them.
One of Street’s key themes is that public hospitals in PNG have long served as sites for imagining the state and, beyond that, modernity. The deep roots of the Madang Hospital lie in the German colonial period, when basic medical facilities were provided primarily to protect white bodies from tropical diseases and only secondarily to serve plantation workers. Segregation continued through subsequent Australian rule and, indeed, has become re-established in response to neo-liberal pressures in the present, where patients with money enjoy considerably better treatment, including housing, than everyone else. In the late colonial period, hospitals were reimagined as demonstrations of modernity, a theme that continues to be repeated at official openings of new facilities financed by Ausaid and other foreign benefactors. Yet, “ruination; inequality, depravation, and dilapidation were built into the new hospitals from the start” (78). The harsh climate, enormous expense of biomedicine technology—all of which must be imported—and endemic corruption that siphons off funds and medications to the elite or the black market, combine to force hospital staff to constant if largely ineffectual improvisations. And thus, the appalling conditions at the hospital feed narratives among conservative politicians in Australia of the failure of the postcolonial state and a pervasive sense among ordinary Papua New Guineans of abandonment by a government which should be taking care of them in a situation where only the elites benefit from the curative technology of “white people’s knowledge” (235).
Street argues that care-givers and patients alike in the public wards experience the decrepitude and chaos of the Madang Hospital as an ontological crisis. In their various roles, they struggle to make themselves visible to others “as particular kinds of bodies or persons in the expectation of eliciting a productive relationship” (24). This formulation is drawn in equal measure from Marilyn Strathern’s influential writings on Melanesian constructions of personhood and her later studies of reproductive technology. The framework is effective, but despite Street’s extended discussion of Melanesian “dividuality” and occasional references to sorcery and Christian spirituality, by the end of the book I was stuck more by the commonalities of the Madang public hospital in an age of neo-liberalism than the cultural distinctiveness of its placement in Papua New Guinea. Even with the best of technology, diagnosing severe illnesses is an uncertain guessing game (providing the theme for the hugely popular television series, House). The experience of being a patient is often profoundly alienating and terrifying. And, increasingly, hospital priorities are dictated more by well-heeled donors, contributing funds for vanity research labs, rather than investing in patient care. This is not to claim that indigenous cultural orientations do not shape the ways workers and patients experience Madang Hospital. Indeed, Street might have done more by investigating the views of the rural folk served by the hospital, as hinted by a short vignette that concludes the book. She does a greater service by focusing on the experience of people within the hospital system. The poverty of the Madang public hospital serves to unmask fundamental truths about hospitals in general. Anyone interested in understanding the challenges faced by public hospitals will profit from the incisive, empathic, and compelling insights of this superb study.
John Barker
The University of British Columbia, Vancouver, Canada
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