The Wedding Goes On Without Us (review)

The Wedding Goes On Without Us is a chronicle of Raymond Downing's life as a specialist in "poverty medicine," ranging over his work in the Bronx, Appalachia, Sudan, Tanzania, and Kenya. The book is divided into two related parts. The first part describes the Downing's professional odyssey in poverty medicine. The second part, subtitled Bury Me Naked, is a collection of stories about patients, families, and co-workers in Africa. The whole book is a collection of stories within stories not only about Downing himself but also about his wife (physician Janice Armstrong) and their patients and communities, families and cultures. The individual stories are engaging and, taken together, evoke certain themes like recurring melodies in a symphony.

The most readily apparent theme that is that of poverty medicine, a term Downing adopts from David Hilfiker's book, Not All of Us Are Saints.¹ Like the ubiquitous "needs assessment," poverty medicine defines people by what they do not have. Downing's wife, speaking for many others, objects to the term as being derogatory, but Downing defends it by explaining, "Poverty medicine refers not to just what our patients lack but what we lack in trying to treat them." Downing's professional experiences are chronically a matter of making do and never having enough but, as his stories unfold, we discover that poverty medicine does not necessarily mean an impoverished professional life for Downing or an impoverished personal life for his patients.

Downing continues to elaborate the difference between experiencing poverty and being impoverished by telling us a story about a 5-day wedding that he begins to attend in Tanzania. He only begins to attend it because he arrives exhausted and slightly ill from a journey just completed and, fighting the feeling that he is obliged to stay in order not to discompose his hosts, Downing retires to his home for rest and recuperation. Concluding, he notes, that the wedding went on all the same. In the following chapter, he draws an analogy between this series of events and his own role in them and the practice of poverty medicine. In places without technology, expectations of cure, lawsuits, and interventions of Western medicine, much of the true healing that occurs takes place in family, culture, and faith in divine forces. The people Downing describes are poor but not impoverished, arriving at the allegorical wedding of their lives joyously. Those who practice poverty medicine have an invitation to this wedding but their presence is not essential to its success.

The second theme of the book is the tension between what Downing labels primary health care (PHC) or community-oriented primary care (COPC) and clinical care. Whether in Appalachia or Africa, Downing and his wife are torn between the attractive features of PHC and the limitations of such a system. Downing's questions about PHC began in Appalachia with "the problem of figuring out who the community was." As his journey in poverty medicine continued in Africa, he struggled to reconcile PHC with African culture. He writes, "I was convinced that primary health care was good for Africa, that Africa had a chance to build a kind of bottom-up health-care system that was no longer possible in the West." But an African colleague reminded him that, "Primary health care is a Western system. You brought it to Africa, it's not our system."

Many of the narratives from Africa reflect Downing's confusion and frustration in reconciling this conflict. Would PHC work if there were more communication? Coordination? Community involvement? Money? What keeps PHC from working? Downing never fully resolves this conflict. He recalls a conversation with an African colleague in which he expressed despair about PHC in Africa by means of a metaphor of swimming upstream never succeeding in changing the direction of the river. His colleague, Magiri, responded by noting that anything floating downstream is dead, suggesting in this way that swimming upstream, struggling for survival, is a centuries-old component of African life...