Biomedicine in an Unstable Place: Infrastructure and Personhood in a Papua New Guinean Hospital by Alice Street (review)

Alice Street begins her ethnography of a public hospital in the town of Madang, Papua New Guinea, with a prologue that tells the story of a young male patient named William, from the moment he arrives at the outpatient department till his death a few weeks later. This tragic story encapsulates what her book is about. The doctor is unable to "find a name" for the disease because the blood tests reveal little information and the X-ray is too blurred to read due to technical problems with the machine. The patient has swollen nodules all over his body and complains of severe back pain. A sample of the nodules is sent to the hospital in the capital for diagnosis. In the meantime, the doctor decides to treat the patient for tuberculosis, without any success. The doctor's uncertainty about William's condition turns him into a patient to be avoided. William and his sister, who keeps him company, try in vain to attract the doctor's attention. Meanwhile, William worries about who may have caused his sickness. A local diviner examines his nodules for the equivalent of 100 USD while the nurses look away. William dies a few days later. Six weeks after his death the report from the capital arrives. William had been suffering from (an unknown type of) cancer.

This story presents in a nutshell the frustration and desperation of all parties in the hospital: administrators, lab technicians, doctors, nurses, patients, and their relatives. The chapters that follow describe, contextualize, and analyze the misery in and of the hospital in infinitesimal detail. Street's central question—in my words—is what the conditions in the hospital reveal about the state of the State and vice-versa. She succeeds in doing so in an impressive way, in a lucid, non-accusatory style, occasionally interrupted by complex anthropological phrases that are likely to prevent medical and policy professionals from reading (all of) her splendid account.

The introduction outlines the theme of the study and presents the theoretical concepts that underpin the author's approach. Chapters 2 and 3 will be particularly interesting for readers of this journal; they sketch the history of the introduction and expansion of biomedicine in colonial and postcolonial Papua New Guinea. Special attention is given to its early racist and more recent state-building objectives. The next three chapters focus on medical knowledge and practice from the points of view of doctors (and in their wake, nurses), patients, and state-level actors respectively. The final three chapters address the question, "How is it possible that a place envisaged as a monument of development and progress becomes experienced by hospital workers and patients as a place of invisibility and failure?" (p. 37). The chapters focus on the politics of gift-giving regarding infrastructure and on the arrival of international researchers who "use" the hospital to further their academic ambitions. The conclusion returns to the ethnographic chapters and argues that contemporary developments in public health continue to contribute to "the creation of spaces of omission, forgetting, and failure at the heart of state institutions" (pp. 37-38).

It is impossible to do full justice to the abundance of ethnographic and theoretical observations of this study, but let me pick out two themes that in the eyes of the author (and of this reviewer) are crucial. The first is the theme of "not knowing." Biomedicine, renowned for its enormous evidence-based body of knowledge, is enacted in this overcrowded hospital as a murky and dark field of uncertainty. Doctors are often forced to act without knowing, due to lack of staff, time, and diagnostic equipment. Reality on the ground contrasts starkly with the book reality they met during their training. They have no choice other than to "improvise," an elegant euphemism for a frustrating practice.

The second theme...