A review of Negotiating Abundance and Scarcity: Health Sector Reform, Development Aid, and Biomedical Practice in a Tanzanian Hospital, by Noelle Sullivan.
In her dissertation, Negotiating Abundance and Scarcity, Noelle Sullivan draws on a case study in northern Tanzania to provide a revealing, successful account of the complex nature of hospitals and hospital work in aid-dependent countries. Sullivan draws on insights from medical anthropology, anthropology of the state, medical history, science and technology studies, and anthropology of policy to explore the ways in which donor-sponsored health intervention projects, and the minutiae of daily biomedical and bureaucratic practice, impact both the current state and the imagined future of a Tanzanian hospital. She opens her first chapter with rich, comparative ethnographic description of her field site, the district hospital in Kiunga (a pseudonym) at her first arrival in 2004, and then at her second arrival in 2008, when she found the hospital completely transformed from a dust-laden small clinic to a landscaped, multi-ward hospital facility. She then proceeds to unpack the short history of this rapid transformation across multiple scales, including global health policy, state reforms, regional and local politics, and the values, expectations and aspirations of the individual hospital workers, from the physicians to the cleaning staff.
This rich and engaging dissertation is divided into eleven clear chapters that trace the complex evolution of the health sector in Tanzania. Following a detailed introduction and background on the dissertation and Sullivan’s experience working in this area (Chapter 1), subsequent chapters trace the historical trajectories through which biomedicine and the medical profession became entrenched in Tanzania and established in Sullivan’s specific field site (Chapters 2-3). Chapters 4-5 then move to consider how health sector reform was planned through specific donor-state collaborations, and the opportunities and limitations that came about in the hospital as a result of important transformations in aid and governance modalities within Tanzania. Chapters 6-8 then turn to an examination of the various ways in which health sector reform impact existing norms and values within the hospital and its wider community, the professional obligations and personal desires of hospital workers, and biomedical encounters within the hospital. Chapters 9-10 then takes a slightly different approach, utilizing official documents to illustrate how the contested “facts” of the Tanzanian hospital are utilized both as representations of the healthcare system to the outside world, and as powerful tools for negotiating professional recognition or to address scarcity within the institution. Finally, in Chapter 11 Sullivan reviews the significance of her findings for Tanzania, and for biomedical institutions in other aid-dependent countries.
This hospital ethnography is unique in its holistic approach to understanding the institution as a totality, and the way in which the institution in its current state has been shaped by multiple and interconnected influences. Indeed, a principal contribution of this dissertation is Sullivan’s detailed examination of the way in which the hospital is “unevenly entangled” with multiple scales of influence – local, state and global (p. 36). Sullivan’s work goes beyond a description of the way in which the powerful engine of global biomedicine is “reinterpreted” in a specific locale, to demonstrate how global, state and local influences are reshaping both the representations and realities of life in a Tanzanian hospital.
While this case study is rich in ethnographic detail, it also serves as an investigation of the ongoing transformation of the practice of biomedicine under changing modes of state and global governance regimes – a transformation that is hardly unique to Tanzania. Sullivan’s account highlights the flexibility and adaptiveness of biomedicine when applied in different contexts. However, this work illustrates the way in which this same flexibility has allowed for considerable inequalities within a single institution. Sullivan demonstrates how donor-sponsored interventions and/or state-identified priorities have led to development enclaves in which excessive resources have been made available for certain conditions, while other hospital departments lack essential infrastructure, technology and expertise. Sullivan’s provides a poignant example of the experience of the development enclave in her description of the high quality prenatal care available to pregnant women. Once the women transition to labor, however, it is as though their bodies are no longer the concern of donors or the state, and the quality of care they receive reflects their stepping outside the development enclave. Sullivan provides an in-depth, integrated approach to understanding the complexities of biomedical pluralism in the context of global aid regimes, and the ways in which these complexities impact patients’ everyday lives.
In addition to documenting the experiences of patients, Sullivan also carefully examines the impact of global aid – in the context of health sector reform in Tanzania – on the lives of the hospital workers. As a result of health sector reform and the subsequent rise of public-private partnerships and donor-sponsored programs, both the hospital administrators and health professionals began to look beyond the state to satisfy both their personal and professional aspirations. Sullivan describes how hard hospital administrators worked to secure personal relationships with donors, which they used both to expand the resources of the hospital and to position themselves politically and professionally. Health professionals also looked to outside donors for training, which they had previously sought (though mostly not received) from the state. Sullivan illustrates the ways in which health professionals also carefully nurtured their relationships with donors in order to receive both the short- and long-term financial and professional benefits of the training they offered. However, these resources were not widely available, nor were they distributed equally among staff, leading to competition, erosion of morale, and accusations of corruption and/or favouritism. In this way, Sullivan notes, the investments of donors that were intended to improve the healthcare services provided at the hospital instead undermined staff cohesion and, in many cases, led to poorer quality services. While staff were often personally dedicated to caring for their patients, the uneven distribution of resources, combined with the complex political interests at both the state and local levels, often left them with no voice, despite their often creative and resourceful ideas for improving patient care.
Overall, Noelle Sullivan’s dissertation offers a compelling ethnographic account of the way in which transnational governmentality, global health discourses and development aid have shaped both bureaucratic and biomedical practices within a government-owned Tanzanian hospital. This work illustrates the importance of considering the hospital as a simultaneously global, state and local institution, as global aid and politics, state bureaucracies, local cultural norms and individual workers’ values and desires are all present and at play within the hospital’s walls. While her investigation is focused on the institution, Sullivan also brings to life the individuals within its walls, personalizing what it means to be work, living, and sometimes dying, healing and being healed at the confluence of these multiple and often conflicting influences. Noelle Sullivan is a natural ethnographer and her insights from this innovative approach to hospital ethnography are valuable to anthropology in general, and medical anthropology in particular.
Meghan C. Halley
Department of Health Services Research
Palo Alto Medical Foundation Research Institute
Eleven months of ethnographic research at a district hospital in Tanzania.
Participant observation, qualitative interviews and life histories with hospital employees at all levels, expatriate volunteers, patients, government ministers in Dar es Salaam, and bi-lateral donor agencies.
Archival research in the National Library.
University of Florida. 2011. 447 pp. Primary Advisor: Hansjörg Dilger.
Image: Photograph by Noelle Sullivan.