Julie Livingston

Disgust, Bodily Aesthetics and the Ethic of Being Human in Botswana

This article explores how people in Botswana approach and navigate their own feelings of disgust and morbid curiosity towards the aesthetically impaired bodies of their fellow citizens, and the problems and opportunities these feelings present in a context where a particular humanistic ethos of respect and manners, botho, is stressed in the public discourse of nationalism. The agenda of contemporary disability and patients’ rights movements is based on the assertion that moral sentiment is neither determined nor subverted by particular bodily states or configurations. While such activism acknowledges and affirms experiences of debility and physical suffering, the political agenda largely centres on enabling persons to participate equally in rational-critical discourse in the public sphere regardless of the vagaries of any individual’s particular bodily state. Within this framework, physicality should have no power to structure relationships among citizens. And yet, in Botswana, as in other places, the messiness of the human body – manifested in diarrhoea, drool, disfigurement, and disgust – threatens to subvert humanistic efforts, and challenges the smooth enactment of rights-based politics and other liberal projects. In what follows I explore the sometimes troubling physicality of humanistic and affective life in Botswana to better grasp the messy bodily dimensions of sociality that are so often swept under the rug in discussions of citizenship, rights and community. Aesthetic efforts at bathing, bandaging and otherwise reworking the bodies in question reveal dimensions of sociality and aspects of sensory and affective interaction that are critical to the enactment of

Insights from an African History of Disability

In 1996, I traveled to Botswana seeking the histories of men disabled by accidents in the South African mines.1 I knew the mines were notoriously dangerous places, and that historically the mining industry had treated African workers as disposable, drawing in the able-bodied and farming the damaged back out to the rural communities from which they had come.2 I also knew that the mines had dominated male employment opportunities in Botswana (formerly Bechuanaland) for much of the twentieth century. When I arrived, sure enough, these men were there. Many were easy to spot, sitting in corroding wheelchairs issued by the mining companies in front of their compounds, or drinking beer with friends in the shade. I soon found, however, that these men were only the most visible segment of a much larger disabled population that encompassed women, children, and the elderly, as well as adult men. Yet as I was shocked to learn, the former miners were considered the fortunate ones. Many — though by no means all — of them had received wheelchairs, leg braces, prosthetic limbs, and perhaps even a paltry sum in “compensation” for the battering of their bodies from the ever-magnanimous mines. Nonminers with physical impairments might receive a wheelchair or other technical aids from the patchwork of NGOs and government programs that provide services to disabled persons in Botswana — or they might not. The mines themselves had the most clear-cut system for processing newly impaired persons and providing them with tools for managing their new bodily states. Perhaps this should not have surprised

Pregnant Children and Half-Dead Adults: Modern Living and the Quickening Life Cycle in Botswana

This paper utilizes ethnography and oral history to examine local perspectives on one aspect of the health transition, the female life cycle, in postcolonial Botswana. Botswana has undergone a remarkably rapid epidemiologic transition in recent decades, and it thus provides a unique context within which local actors analyze the interaction between biological and sociocultural change. Improvements in the standard of living have resulted in both an earlier onset for puberty in girls and an increased incidence of stroke among older women, thus refashioning the female life course. Local analysis and commentary on the shifting norms of womens bodies read this phenomenon alongside broader historical transformations. In the process they complicate basic assumptions in international health about the meanings of health and development.

Productive Misunderstandings and the Dynamism of Plural Medicine in Mid-century Bechuanaland*

This article explores innovation in Tswana medicine (bongaka), and examines the effects of language translation in a plural medical world. Since practitioners and patients of bongaka locate medical authority in the language of ‘tradition’, innovation is often hidden under a gloss of semantic continuity that locates knowledge as ancient and immutable; yet Tswana medicine has changed over time, as all medical systems do. Bongaka embraces a historically fluid nosology, and diagnostic logic that attends to social circumstances and bodily symptoms simultaneously. This enables local medical epistemology to incorporate novel ideas and biological events within a larger framework that reinforces the over-arching unity of the bodily, ecological, and social realms – all of which are in flux. The discussion focuses on Tswana diagnostics and epidemiology in post-Second World War southeastern Bechuanaland, where increasingly pervasive experiences of particular forms of bodily misfortune merged with trends in womens extra and pre-marital sexual activity, male labour migration, intergenerational struggles over (blood, semen, money), and collapsing public health became manifest and understood in terms of evolving disease etiologies. Rather than envisioning medical pluralisation as a process that produces hybrids, the case in question suggests that translation creates productive misunderstandings that facilitate the coexistence of distinct medical categories, while patients become adept at moving across ontologically distinct domains of medical practice.

Revealed in the Wound

DOI: 10.1200/JCO.2013.52.3837 On a cold June morning in 2009, I watched a nurse clean the fungating mass of a patient—let us call her Ellen—in a Botswana cancer ward. By this point, I had spent long periods working as an ethnographer in this, the only dedicated cancer ward in the country, located in the public tertiary hospital in the nation’s capital. I had seen the awful things unchecked cancer can do to the human body, and I had witnessed a great deal of wound care. There is a cancer epidemic rapidly emerging across southern Africa, part of the larger cancer pandemic throughout the global south, and this 20-bed ward and its associated clinic handled a relatively large volume of patients, many of whom had advanced disease. Ellen’s breast was barely recognizable amid the raw flesh, with long pieces of slough hanging from it in sheets. And it smelled. Terribly. She had been visiting her local clinic regularly to have the wound cleaned. But, given their almost total lack of training in cancer, the clinic staff had been far too timid with the task. Susan, the nurse, glanced at me and remarked somewhatrhetorically, “Howcanthey leavesomuchslough on it when they dress the wound?” And a community clinic, unlike the cancer ward, would not have stocked the pethidine (Demerol) to give Ellen to help make the cleaningmorebearable.Thepainwasunmistakable, as Susan noted. “Some things are just so unfair—how cansomeonesuffer likethis? It isclearlyquitepainful to clean.” She began by opening the sterile dressing pack, and then slicing off the long sheets of dead tissue with a razor, cutting into it bit by bit, with precision and care. Ellen,whowas inhermid50s, satwearingaheadscarf and a denim skirt, her chest bare. She sat as calmly as she could manage, but still she kept wincing. She could not decide if she should look at what Susan was doing or not. So she kept looking and then turning away again, wincing, but not crying out. This is typical in Botswana, where patients rarely vocalize severe pain unless directly asked or until the pain reaches truly unbearable proportions that begin to distort consciousness. But it was clearly uncomfortable, and throughout the procedure Susan did her job well by acknowledging the pain, saying, “Sorry Mama, sorry, sorry Mama,” apologizing to and comforting her patient all at once. Susan wiped saline into the wound, “I can’t clean too deep,” she explained to me, “but we want it clean. The smell is intense and this is not good for the patient.” Then she wrapped Ellen’s chest in betadine-soaked gauze and fashioned a bandage that also doubled as a sling to support this millstone of a tumor. Wrapped in clean bandages, Ellen would now rejoin her sister, who had accompanied her that day. They still had to wait for several hours in the queue for chemotherapy before returning home. The treatment is palliative, as is the scheduled toilet mastectomy. But, likeSusan’swork, it isvital.PalliativecarewillhelpEllen and her relatives to sustain her humanity throughout the protracted process of dying; it will blunt her pain and decay. Susan recognized this in the care she put into cleaning and dressing Ellen’s wound. She knew that thesmellofnecroticfleshposedasignificantproblem for Ellen and her family. “People try not to segregate the sick, but sometimes they are cooking in that same room or sleeping in one room together, and that is difficult.” Sometimes it is the distinctive smell of advanced cancer that prompts the initial treatment, when family members tell their loved one, “I am sorry mydear,butwecannolongereat together likethis.We must go and do something about the smell.” Ellen’s case is far from unique. Over my time working as an ethnographer in southern Africa, I have seen countless toilet mastectomies, but only two lumpectomies. And it is not only patients with breast cancer who arrive in the ward and receive their initial diagnosis when their cancer is already far advanced. Giventhe lackofbothpublichealthcampaignsaround cancerandtheattendant imaging,aswell as the laboratory services necessary to support screening and early detection—indeed, given the relative scarcity of cancer care in general—it is not surprising that so many patients arrive at an oncology setting only after their disease has already progressed to such a troubling state. Ellen was lucky to be in one of the very few countries on the continent where oncology is provided as part of a system of universal health care. Botswana is a middle-income country with only about 2 million citizens and a relatively robust system of social services. This includes an extensive network of primary care clinics and hospitals that feed into the nation’s two public referral hospitals. Across the region, as in much of the global south, most patients simply cannot afford to seek oncologic care for which they must pay out of pocket. Decisions to purchase cancer care are part of a JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 31 NUMBER 29 OCTOBER 1

Comment: On the Borderland of Medical and Disability History

Beth Linker’s essay offers a timely introduction to the borderlands of medical and disability history—a rich and wondrous place—written for historians of medicine by a well-respected scholar whose work straddles both fields. Linker claims “the two fields tend to parallel one another with few points of contact, despite the multiple ways in which the actual histories of disease and disability overlap” (p. 502). She attributes this parallel play on the one hand to an analytic antagonism toward medicine by disability history and on the other to a disease-centered focus in medical history that obscures questions of disability. These are big, wide-ranging fields, and no doubt space limitations forced Linker to steer a tight path in her essay, restricting her review to twentieth-century U.S. medicine, and mainly avoiding the history of psychiatry, hospitals, reproduction, and health policy (except as they can be fitted into a disease framework). She traces a fascinating genealogy of disease-centered historiography emerging out of the Hopkins program, beginning with Temkin and Ackerknecht. Unfortunately, this means she must drop Sigerist, and thereby his legacy within the field remains untraced in her narrative, despite its presence in our field in the work of many scholars on class, race, and gender . Given these limitations, I’d like to pick up where Linker leaves off, to probe the places of productive intersection between both fields that she does not map and to argue further for the analytic value of those existing and future intersections. My alternative mapping reveals overlapping communities of thought rather than parallel tracks. Perhaps it is not surprising to see this shared constituency, once we expand our reading of historiography beyond the twentieth-century American disease-centered model that Linker ably reviews. Many disability history scholars began their careers as historians of medicine. Beyond the important work of Linker herself, Heather Monroe Prescott, or Martin Pernick, all of whom Linker mentions in passing, the list is quite long. Catherine Kudlick first wrote a cultural history of cholera in postrevolutionary France before taking up the mantle of disability

Neoplastic Africa: Mapping Circuits of Toxicity and Knowledge

On May 20, 2009 months after the Zimbabwean government had appealed for international assistance, twenty-eight new cases of cholera, and one cholera death were reported. By then, as the epidemic began to wane nearly 100,000 people had fallen sick and over 4000 had died according to official reports. The vast majority of the country had been affected, and cholera had crossed the borders with cases reported in Botswana, Mozambique, Zambia, and South Africa. The cholera epidemic in Zimbabwe was horrifying in human terms, dangerous in its rapid, far-reaching spread, and it offered stark political testimony of just how far the Mugabe regime had allowed sanitation, water, and health care infrastructure, or any vestige of the social contract to erode. The nineteenth century narrative of cholera yet again breathed new life through the 21 century misery of Zimbabwe’s now great unwashed and the rapaciousness of the Zimbabwean political elite. For all that it was unimaginable, the epidemic was all too familiar, and a predictable global health apparatus of water purification tablets, medicines, doctors, epidemiologists, and supply trucks sputtered into action. But on that same day -the 20 of May 2009 -there was another Zimbabwean death, this one across the border in Gaborone, Botswana. It wasn’t cholera that killed Lovemore Makoni. The disease though equally appalling, was much more common. Yet ironically it seems totally foreign to our image of African health and illness. Lovemore lay in the medical ward of PMH, short of breath and wracked with pain and panic. Mr Makoni, a barman at a local club, had cancer (Kaposi’s sarcoma or KS) in his lungs. He urgently needed chemotherapy, which fortunately produces relatively rapid results in many KS patients. But he had a delay in raising funds, and so was now nearing the end of his third week in PMH still awaiting treatment. Though medical care, including oncology is provided as a public good for Botswana’s citizens (an African public for whom the term public health still has some meaning), as a Zimbabwean national Mr. Makoni had to pay. When I arrived in the crowded medical ward with Dr P, who was meeting this patient for the first time, Mr Makoni engaged us. He was quite active in explaining his situation. A private, newly diagnosed cancer patient in a public hospital, a Zimbabwean

Physical fitness and economic opportunity in the Bechuanaland Protectorate in the 1930s and 1940s.

This article explores changes in the meanings of able-bodiedness in Bechuanaland in the 1930s and 1940s from a number of vantage points. In this period, Tswana ideas about able-bodiedness were increasingly determined in relation to industrial ideas about African labour. I argue that physical fitness took on new meanings as Tswana notions of male social and economic identity became increasingly dependent upon the ability to obtain industrial employment, and as British evaluations of their Tswana subjects followed suit. The discussion focuses on mine medical examinations, which had become the principal gateway to wage employment. The new modes of determining able-bodiedness were confusing to potential recruits and their families , generating multiple and overlapping sets of meanings and values of physical fitness. Through the examination process, both Tswana men and colonial officials (including doctors) tried to comprehend the general decline in health and the effects of local economic and cultural transformations. The medical examination had become a key arena for debate and, ultimately, control over local understandings of physiology and its encoded values.