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“Not Here”: Making the Spaces and Subjects of “Global Health” in Botswana

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Abstract

This essay argues that what makes “global health” “global” has more to do with configurations of space and time, and the claims to expertise and moral stances these configurations make possible, than with the geographical distribution of medical experts or the universal, if also uneven, distribution of threats to health. Drawing on a study of public–private partnerships supporting Botswana’s HIV/AIDS treatment program, this essay demonstrates ethnographically the processes by which “global health” and its quintessential spaces, namely “resource-limited” or “resource-poor settings,” are constituted, reinforced, and contested in the context of medical education and medical practice in Botswana’s largest hospital. Using Silverstein’s work on orders of indexicality, I argue that the terms of “global health” are best understood as chronotopic, and demonstrate how actors orient themselves and others spatio-temporally, morally, and professionally by using or refuting those terms. I conclude by arguing that taking “global health” on its own terms obscures the powerful forces by which it becomes intelligible. At stake are the frames within which medical anthropologists understand their objects of study, as well as the potential for the spaces of “global health” intervention to expand ever outward as American medical personnel attempt to calibrate their experiences to their expectations.

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Notes

  1. This is the case across schools and specializations (see: Evert et al. 2007; Grudzen et al. 2007; Haq et al. 2000; Houpt et al. 2007; Nelson et al. 2008). Panosian and Coates note that, “in 2003, at least 20% of students graduating from U.S. medical schools had participated in overseas activities related to international health during medical school, as compared with 6% of 1984 graduates” (2006, p. 1772).

  2. This is not to assert that health inequalities do not exist and should not be taken seriously, but to ask how some places, people, and health inequalities fall under the purview of “global health” while others do not, and to interrogate the effects of this delineation. Thanks to an anonymous reviewer for drawing my attention to this point.

  3. Other authors have also called for an interrogation of the terms by which global health is framed, e.g., Pfeiffer & Nichter 2008; Gaines 2011.

  4. Referral Hospital is a pseudonym, as are the names of all persons and institutions mentioned in this paper.

  5. Notable exceptions include: Cicourel 1995; Lingard et al. 2003; Macdonald 2002; Sinclair 2000.

  6. The “culture of no culture” is from Traweek (1988); on the turn toward “cultural competence” in American medical education, see (Taylor 2003b).

  7. Such partnerships have tended to focus on the donation of treatments for specific diseases, such as onchocerciasis (river blindness), childhood immunizations, and vaccine research (Collins 2004; Frost et al. 2002; Reich 2002).

  8. The term Batswana (sing. Motswana) describes the citizenry of the Republic of Botswana; it may also designate membership in a Tswana morafe (ethnic group or tribe).

  9. A former British Protectorate, Botswana declared itself an independent republic in 1966. Botswana’s medical system has much more in common with those of former British colonies than it does with the American system. Furthermore, most Batswana who study medicine do so in countries with Commonwealth-style educational systems. Formal medical education in these contexts begins after the completion of secondary school, rather than after a Bachelors degree. The degree is often a 6-year process consisting of 2 years of pre-clinical training in what are called “basic sciences,” and 4 years of training in a clinical environment. Holders of such an undergraduate medical degree are often required to serve a 1- or 2-year internship after which they are qualified as medical officers (i.e., non-specialist physicians). Doctors with specialized training beyond the medical degree (i.e., residency) are called “attendings” or “specialists.” Batswana returning from medical training abroad must serve a 1-year internship at one of the country’s referral hospitals. Physicians trained abroad must be vetted by the Botswana Health Professions Council before they begin to practice in the country.

  10. Festus Gontebanye Mogae was President of the Republic of Botswana from 1998 to 2008, and is widely credited both within and beyond Botswana for exerting the political will necessary to create a free public HIV treatment program at a time when international health institutions and policymakers showed little support for such an idea.

  11. See Acemoglu et al. (2003), Maipose (2009), Samatar (1999). See Good (1992, 2008) for vehement disagreement with Botswana’s supposed “exceptionality.” Parsons (1993) provides a more balanced account, while Livingston (2009) offers a subtle and nuanced portrait of the ambivalence of everyday life in the “African miracle.”

  12. On shifters and social meaning, see: Benveniste 1971/1956; Jakobson 1971; Johnstone, et al. 2006.

  13. I am thus less concerned with arguing how “global health” fits into other analytical forms, such as assemblages and immutable mobiles, than with analyzing how such a thing as “global health” is made coherent in the first place.

  14. This circular temporality reflects the logic of the “war on terror” inasmuch as it emphasizes an infinite loop of unpreparedness (Lakoff 2008). Thanks to Joe Masco for this point.

  15. 6 weeks is the length of many elective rotations, particularly those overseas, for advanced medical students, though some “global health” rotations are as short as 4 weeks. Many American medical students, having completed their pre-clinical (i.e., “basic science”) courses in the first 2 years, will complete their required clinical rotations in their 3rd year, leaving more time for elective rotations, often of shorter duration, in their 4th year. EUMS students coming to Botswana were required to have completed their sub-internship, in which students (alone or in pairs) perform the duties of an intern (i.e., a doctor in his or her first year of residency). EUMS covered the cost of the flight and provided room and board in a set of apartments near the hospital.

  16. PEPFAR is the President's Emergency Plan For AIDS Relief, a U.S. government program launched in 2003 to provide US $15 billion over 5 years targeted toward 15 “focus countries,” of which Botswana is one.

  17. Students sometimes asked the nurses, most of whom are Batswana, or me about these matters, and later groups took some advantage of lessons in Setswana, the most widely spoken indigenous language, but these topics were, I argue, generally regarded as tangential to the “real” task of learning and practicing medicine.

  18. Thanks to Summerson Carr for drawing my attention to this.

  19. It should be noted that this comparison also renders invisible any variation in medical practice in the U.S.

  20. Silverstein reminds us of the improvisational nature of this process: “such a dynamic or processual figuration of participants’ contextually created and transformed ‘groupness’ characteristics—in short a real social act—happens improvisationally each time there is discursive interaction” (1997, p. 282).

  21. American EUMS doctors modeled the further marking of in-group and out-group membership in “global health” when drawing comparisons in medical practice. When teaching only EUMS students, they explicitly compared “here” with “the U.S.” When “local” doctors were present, by contrast, EUMS doctors shifted terms, comparing to “here” to an unspecified “elsewhere” or “other parts of the world”.

  22. In this sense, the pedagogy of “global health” bears a resemblance to ethnographic fieldwork. To the extent that I was mistaken for a “native” of these practices, the Batswana nursing staff of the medical ward, upon finding me circulating with a newly arrived cohort of students, would exclaim with some surprise, “You’re still here?”.

  23. That said, while the task of sorting the “inadequate” from the different-but-adequate from one context to another is partly a matter of hierarchically organized expertise, it also rests partly on the need for certain EUMS personnel, such as Drs. Rosen and Matheson, to maintain long-term relationships with “local” doctors and with Referral Hospital. Students seemed to feel less responsibility for these institutional relationships, despite the efforts of the student handbook to recruit students to the role of “ambassadors” of EUMS.

  24. Even positive comparisons were uneven, such as when Drs. Rosen, Matheson, and Frank reminded their students that, whatever its faults, Referral Hospital was “not bad for an African hospital.” Here, “African hospitals” figure as places where not even Referral Hospital's standard of care is available. Like “here” and “local”, “Africa” was equally susceptible to this kind of semiotic ordering. One EUMS attending who had worked in Sudan in the 1970s voiced his surprise and pleasure at finding “anything this sophisticated in sub-Saharan Africa outside South Africa”.

  25. Only among “locals” do certain distinctions seem to matter, as when Dr. Chilube, who spoke iKalanga as a first language, expressed discomfort upon being asked to translate from Setswana, which he called his “school language,” to English for EUMS personnel. The Bakalanga are an ethnic minority within Botswana.

  26. When I discussed the matter with one American pediatrician who had worked in Botswana’s northeast, she retorted, “Referral Hospital is not ‘resource-poor!’”.

  27. We might imagine here a similar ideology operating by means of diagrammatic iconicity wherein geopolitical units (countries, districts, etc.) are assigned a color to indicate their level of HIV prevalence, e.g., blue for 10% prevalence, purple for 15%, etc., with Botswana (on the multi-country maps) always a solid block of red.

  28. Dr. Baum was “pimping” Dr. Moseki. This is a quotidian phenomenon in American medical pedagogy wherein a supervisor (e.g., attending or resident) fires a series of questions at a junior (e.g., student, intern, or some other “learner,”), usually in an aggressive manner, until the “learner” staggers under the weight of the questioning, confessing, in some manner or another, his or her ignorance with regard to a fact or set of facts about the case at hand; see Brancati (1989) and Bennett (1985). Thanks to Dan Menchik for these references.

  29. Although some “local” doctors did become narratable as “more” than “local” within the configurations of the global health chronotope, I lack the space here to discuss the conditions in which this transpired.

  30. The Superlative Clinic also operated in accordance with these national guidelines, but the relative autonomy of the Clinic vis-à-vis Botswana’s national health care system in general was an ongoing matter of contention.

  31. James was, in all likelihood, prescribing three drugs in an attempt to cover as many possible bacterial organisms in the absence of laboratory tests identifying the source of the infection. These events took place before I became familiar with Botswana’s pharmacopoeia. If James did order ciprofloxacin, that drug is reserved in Botswana for two conditions, one of which is multi-drug-resistant tuberculosis, a potential public health nightmare in a country with a large immunocompromised population.

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Acknowledgments

My largest debt remains to all the people in Botswana who took time to speak with me. The fieldwork described in this paper was generously funded by the Fulbright-Hays Doctoral Dissertation Research Abroad Fellowship program and the Wenner-Gren Foundation; further research was supported by the University of Chicago in the form of a Social Science Collegiate Division Teaching and Research Fellowship and a Mark Hanna Watkins Dissertation Fellowship. This essay began as part of a panel organized by Seth Holmes and Maya Ponte for the conference, “Medical Anthropology at the Intersections” in 2009. Subsequent versions were presented at the University of Chicago to: the U.S. Locations Workshop; the conference, “Culture and History in Eastern & Southern Africa”; and the 12th Annual Michicagoan Graduate Student Linguistic Anthropology Conference. My thanks to the organizers and participants of these events, and particularly to Summerson Carr, Molly Cunningham, Jeremy Jones, and Janelle Taylor, who served as my discussants. This paper also benefited greatly from the readings and suggestions of Claudia Gastrow, Brian Horne, Angela Jenks, Joe Masco, Marissa Mika, Aaron Seaman, China Scherz, Scott Stonington, and Anwen Tormey, as well as the thoughtful comments of two anonymous reviewers. Thanks to Seth Holms, Angela Jenks, and Scott Stonington for their support and their efforts bringing this collection together. Any omissions and errors remain my own.

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Correspondence to Betsey Brada.

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Brada, B. “Not Here”: Making the Spaces and Subjects of “Global Health” in Botswana. Cult Med Psychiatry 35, 285–312 (2011). https://doi.org/10.1007/s11013-011-9209-z

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