Health and statehood in a post-traumatic context
My doctoral research in Rwanda was born, following my first year of medical school, of a summer spent at Butaro Hospital in 2010. I was there as a volunteer for the first-ever national cervical cancer campaign, when I learned that Rwanda was gearing up to build a national cancer program. Given my interest in noncommunicable diseases in Africa, especially as they impact women’s health – motivated in large part by experiences working with African refugees in France for my BA and MA theses – I decided to make the nascent program my object of study. I proposed tracking the unfolding delivery and receipt of cancer care at what would emerge, in 2012, as the Butaro Cancer Center of Excellence. Although I had been a student of anthropology since my early undergraduate years, my initial project was couched in the language of global public health. As I refined my proposal, I came to conceptualize it more in the epistemic terms of critical medical anthropology.
I began the PhD portion of my MD/PhD program in the fall of 2012, grateful for the privilege to work with Professors Jean and John Comaroff as my mentors. Their work in historical anthropology (Comaroff and Comaroff 1987, 1991, 1992; Comaroff 1985) inspired me to investigate the Harvard University archives for primary documents on the history of cancer in Africa. Thanks to this research, I came to know of the International Agency for Research on Cancer (IARC), a subdivision of the World Health Organization, and their research initiatives in the late 1950s and 1960s that centered on cancer epidemiology and pathology in East Africa. The IARC conference reports were especially eye-opening for me, as many of the proposals for intervention – for cervical cancer screening and systems building, for instance – uncannily anticipated what I had been hearing in global health discussions (such as the constant advocacy of ‘task shifting’).
I realized that a hermeneutic of suspicion, of estrangement of commonplace assumptions so important to a critical anthropology, was required to investigate current proposals regarding public health responses to cancer in Africa. These proposals were far from new. The archival material suggested, to the contrary, that health scientists from ‘the South’ had been pointing out the need for oncology programs and systems for decades, and that the rollout I was observing was simply late in arriving, rather than innovative. I thus became dedicated to analyzing the trajectory of cancer without oncology (Livingston 2012), and to gleaning insight into the role of cancer—the conceptions, representations, and sociocultural connotations accompanying the history of malignancies—in Rwanda and the Central/East African region more generally.
In Rwanda, the challenges of implementing cancer care step by step have been enormous. Patients receive chemotherapy at Butaro but must travel to Kigali for surgery, and are sent to Mulago Hospital in Uganda for radiation therapy from an old cobalt machine (rather than the newer LINAC machine), which induces especially taxing side effects. They still tend to start treatment only after their cancer is at an advanced stage, having consulted traditional healers first, or having lacked the means and support to get to Butaro or another hospital in the network. Pediatric patients undergo chemotherapy accompanied by their mothers; these mothers are often abandoned by their husbands, who believe they are neglecting their other children or are coming to Butaro on false pretenses. All this happens in a post-genocide context in which social conditions are deeply inscribed with the residues of violence, loss, and displacement.
Rwandans are striving to ensure their familial livelihoods and well-being on a daily basis, urged by their government to cultivate a personal and collective responsibility for rebuilding a strong and healthy Rwanda. These pressures are compounded by a widespread sense that in today’s Rwanda, regardless of the endeavor at hand, failure is wholly unacceptable, both individually and as a nation. I became particularly attuned to these imperatives while in the field, thanks to my training with the Comaroffs, who urged me to think of these initiatives as part of the nation-state’s broader project of sovereignty. Indeed, I have come to think of Rwanda’s cancer program as an exercise in the construction of a new sense of sovereignty that is rendered through the politics of life, what I term ‘onco-nationhood’. This is an effort to create a postcolonial polity whose citizen body is gifted care of an international caliber, provided by a paternal state. In a critical moment of post-traumatic social reconstruction, national biomedicine is becoming the entity through which government seeks to fuse sovereign statehood and nationhood in the cause of a healthy Rwandan future.
With respect to policy and implementation in Rwanda, there is much debate: the proper sequence of steps in building the cancer program, prevention vs. treatment, and cost-effectiveness. These debates crystallize in certain events, such as the Ministry of Health negotiating with Merck to acquire Gardasil for the national vaccine schedule, or determining the location of Rwanda’s first radiation therapy facility without a plan for how to train local staff. Also, public hospitals leading a biopsy training before there is a sustainable supply of materials for clinical practice, because a pharmaceutical company has given an educational grant with a deadline. And, as Sunder Rajan (2006) notes, new biotechnologies can only be understood in relation to the global economic markets within which they materialize. This point remains crucial in analyzing the use of relatively new cancer tests, tools, and vaccines in Rwanda, a nation whose health care infrastructure has been built with extensive foreign aid. The country aims to be independent of such aid by 2020, a goal that motivates its leaders to imagine what forms of national expertise can be cultivated and exported to ensure a stable economy. Working with the Comaroffs spurred me to understand Rwanda as an experimental site in several senses: for expanding global oncology and policy, for developing local and national models, and for reconfiguring and even accelerating health development. Yet, with oncology’s tardy arrival, it also remains an anachronism, one that I’ve been privileged to observe as each ingredient is added, like watching a familiar compound being synthesized for the first time in a chemistry lab.
About the author
Darja Djordjevic is an MD-PhD (Department of Anthropology) candidate at Harvard University. She is currently finishing her fieldwork in Rwanda, which entails a multidimensional study of the national cancer program. Her scholarly interests include global oncology, the noncommunicable disease movement, the ethics of care, understandings of specialization within medicine, the history of chronic disease in Africa, and transnational public–private partnerships. She has been awarded numerous fellowships and grants including the Social Science Research Council International Dissertation Research Fellowship, The Wenner-Gren Foundation Dissertation Fieldwork Grant, the Fulbright Study/Research Grant (France), and the Augustus Clifford Tower Fellowship. She is a native of Chicago.
Comaroff, John L., and Jean Comaroff. 1987. ‘The Madman and the Migrant: Work and Labor in the Historical Consciousness of a South African People’. American Ethnologist 14, no. 2: 191-209.
Comaroff, John L., and Jean Comaroff. 1991. Of Revelation and Revolution. Chicago: University of Chicago Press.
Comaroff, John L., and Jean Comaroff. 1992. Ethnography and the Historical Imagination. Studies in the Ethnographic Imagination. Boulder, CO: Westview Press.
Comaroff, Jean. 1985. Body of Power, Spirit of Resistance: The Culture and History of a South African People. Chicago: University of Chicago Press.
Livingston, Julie. 2012. Improvising Medicine: An African Oncology Ward in an Emerging Cancer Epidemic. Durham, NC: Duke University Press.
Sunder Rajan, Kaushik. 2006. Biocapital: The Constitution of Postgenomic Life. Durham, NC: Duke University Press.