Renée van der Wiel //
I have been in the global north, what is for me a relatively exotic place, while designing a social anthropology course. The course is about healthcare professionals and institutions across sub-Saharan Africa. In the past I taught students in my home city, Johannesburg, in buildings literally only a few kilometers from the strained state healthcare institutions where I did research. Due to a combination of corona-romantic-familial reasons I found myself in the Netherlands preparing this new undergraduate course at the start of 2021. The disjuncture between, on one hand, the location of my academic research and my students in South Africa, and on the other, my new home in western Europe, has given me a lot to reflect on.
I designed the course to show students that, while guided by shared scientific knowledge and global guidelines, medical work is tailored to specific contexts rather than a universal, standard practice. This is the case everywhere. But, as the research we will review in class demonstrates, this is markedly so in many healthcare facilities across Africa, and indeed across the global south[i].
This categorisation of global south is not without its problems. It can make it easy to overlook differences within the global south, and likewise differences within the global north. This south-north binary can then erase the similarities between the south and the north. This cements an image of the south as fragile and failing and the north as proper and prosperous[ii].
So, to round off the course, I was looking for material to provide students with a broader global perspective. This will hopefully help us think about the improvisation required in healthcare as being on a spectrum rather than determined by a system of binaries. Medicine is after all hands-on work in contexts that can vary drastically within a single city or country, and a degree of life-and-death crisis can exist in any hospital not just those in Africa, as part of the global south. Not surprisingly, because of the Covid-19 pandemic, there is an abundance of reports about stretched healthcare systems and the material and moral challenges that stressed healthcare practitioners face across the planet.
However, whenever I watched Dutch television coverage of the impact of the corona virus on local healthcare I was reminded that a spectrum can encompass a vast amount.[iii] One of the morning news talk shows featured a high-level healthcare administrator who was critical of healthcare managers and professionals and of politicians. She insisted that the country needed to make compromises and plot a new path forward so that healthcare did not only revolve around treating severe corona cases. People needed other forms of healthcare, and at some point lockdown needed to end and economic activities needed to resume. She suggested that to find a route forward we had to accept death. It was unclear if “we” meant the country generally or those directly working in healthcare. But, she stated, we had become used to medicine that could do the miraculous, and we had to learn that under the circumstances we cannot save everyone, “we niet iedereen kunnen redden”.
That the moral and medical compromises of healthcare and a tolerable amount of death had to be declared in this way, a year into the country’s corona crisis, was remarkable to me. It was a stunning contrast to the course literature I was rereading and my own research about “good enough practice” in conditions of “normal emergency” (Feierman, 172). This involved ongoing, exhausting levels of triage for many doctors and nurses across Africa who were frustrated by the morbidity and mortality they knew they could prevent with better resources. Also, for example, regarding death, many doctors I had interviewed who trained in the late 1990s and early 2000s were profoundly affected by the HIV treatment crisis in public health facilities and “wards that were a mass of death”, as one of them described it.
Another episode of this news show I found startling was when the host asked her guests to comment on the Netherlands lagging behind other European countries in the delivery of corona vaccinations. The guests, a politician from a conservative Christian party and a law professor, said that it was upsetting and painful that the government program was tardy. But, also, that it was tragic that many poor countries probably had to wait another two years before getting vaccines. The host, however, perhaps misapprehending their point about global inequality, seemed indignant that the Dutch should have to compare themselves to such poor countries to console themselves about the lackluster performance of their own healthcare system.
I was stunned. In this moment of culture shock I realized that in the context of this TV studio, and perhaps for most of the Netherlands, these global injustices are an abstract moral concern. These things happen far away in poor places where people apparently do not even anticipate things ever going to plan.
As I write this now in February, I am aware that I am in a country that has actually started a vaccine roll-out while the students enrolled in my course are not. As I teach virtually across two continents over the coming weeks there will no doubt be many other moments of uncomfortable disjuncture between north and south for me to confront in my new, exotic location.
Perhaps for now it might suffice to conclude by saying that – no, binaries are not the most helpful analytical tools. They can be misleading and inaccurate. But employing the concept of a scale or spectrum for assessing the improvisational nature of medical practice around the world should not belie the fact that spectrums can be broad. Very broad.
Feierman, Steven. 2011. “When Physicians Meet: Local Medical Knowledge and Global Public Goods.” In Evidence, Ethos and Experiment: The Anthropology and History of Medical Research in Africa, edited by P. Wenzel Geissler and Catherine Molyneux. 171-196: Berghahn Books.
Map of health by Odra Noel. Attribution-NonCommercial 4.0 International (CC BY-NC 4.0) Retrieved from: https://wellcomecollection.org/works/w6w7nvcg
[i] As examples see: Livingston, Julie. 2012. Improvising Medicine: An African Oncology Ward in an Emerging Cancer Epidemic. Durham: Duke University Press; Mulemi, Benson A. 2015. “Cancer Crisis and Treatment Ambiguity in Kenya.” In Anthropologies of Cancer in Transnational Worlds, Holly F. Mathews et.al. (eds) New York: Routledge; Street, Alice. 2014. Biomedicine in an Unstable Place: Infrastructure and Personhood in a Papua New Guinean Hospital. Durham: Duke University Press.
[ii] For more see, for example, Comaroff, Jean, and John L. Comaroff. 2012. Theory from the South: Or, How Euro-America Is Evolving Toward Africa. Oxon; New York: Routledge.
[iii] Segments of the broadcasts discussed here are accessible at: https://www.npostart.nl/goedemorgen-nederland/27-01-2021/POW_04917991 ; https://www.youtube.com/watch?v=1sVMWu7D0lA ; and, https://www.npostart.nl/goedemorgen-nederland/27-01-2021/POW_04917991