Medicine and The Politics of Knowledge

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Ethnographyfrom
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Ethnography
Fritha Langerman. System of human knowledge: Reason. Linocut from the exhibition, The Knowledge
Chambers (2007), and reproduced with permission of the artist.
Fritha Langerman. System of human knowledge: Reason. 2007. Linocut.
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Free download from www.hsrcpress.ac.za
Image from the exhibition Subtle Thresholds, reproduced with permission of the artist, Fritha Langerman.
The unequal distribution of health-damaging experiences is not in any sense a natural phenomenon
but is a result of a toxic combination of poor social policies and programmes, unfair economic
arrangements, and bad politics.
Commission on Social Determinants of Health (CSDH) (2008)
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1
The rings around Jonathans eyes: HIV and AIDS medicine at the
margins of administration
Oliver Human
Since the end of Apartheid, the South African state has had to learn to deal with
the need for the equitable allocation of resources to the entire population. In the
conception of the modern nation-state adopted by the South African government,
part of what it means to be modern is based on a belief that by effectively
modelling the scenarios a state practitioner may face, the state can effectively
deal with any problem found within the population that it is governing. The
management of resources depends, in this conception, on the ability of the state
to audit and measure the performance of state actors to make sure that limited
resources are used as efficiently as possible. One way to ensure this distribution
of resources in the realm of health and medical care is through standardising
services, which is made possible by protocols based on a cognitivist view of
medical practice. In this chapter, I illustrate how doctors deal with a medical
protocol when practicing medicine in a particular context. By describing how the
act of diagnosis is based on contingent, material factors rather than universal sets
of syllogisms, I illustrate the limits of the cognitivist model upon which protocols
are based. At the same time, I explore the ethical implications of following a strict
model of standardisation, as occurs through a strict reading of protocols.
I explore the operation of a medical protocol within the daily workings of a
clinic, and illustrate how a protocol, designed to serve a population both present and
future, grates against an exceptional patient in the present and his or her particular
future. I illustrate both the impossibility of a completely successful protocol and
the impossibility of success in fighting a disease, under present conditions, without
protocols. Especially in exceptional cases, in order to diagnose disease effectively,
a doctor must often break with protocol and concede to the risk inherent in this
This chapter first appeared in Medical Anthropology: Cross-Cultural Studies in Health and
Illness 30(2): 222240. The original paper was produced for the Sawyer Seminar Series on
Knowledge and the Body held at the University of Cape Town in 2009.
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divergence from authority. By relying on traces of evidence not modelled, and by

diverging from protocols, doctors depend on a type of knowledge, an excess to that
which is considered central to thought processes. This challenges modernist ideals
of classification, upon which much of the dream of the modern state depends. Yet,
paradoxically, the modern states success rests precisely on knowledge of excess of
this sort.
To demonstrate this, I focus on two doctors, DrGous and DrMira
(pseudonyms). DrGous is the regional manager of rural HIV clinics in an
agricultural region of South Africa. The clinics which he runs and in which he
works are unusually well staffed and orderly for rural public clinics, the result of his
management skill and successful applications for outside funding that allow him
to retain extra staff. His hard work is driven by faith in the equality of all humans
and the right of all to decent living conditions. Resources are used creatively in his
clinics, and his approach is expressed in a pragmatic attitude toward medicine: any
problem can be solved, any practice improved.
DrMira was born and trained in Europe in an environment of high
healthcare standards. She has a background in medical research, in pathology
in particular, and is confident of her diagnostic ability. Her experience of South
Africa is that opportunistic infections such as tuberculosis (TB) in HIV-positive
patients often are misdiagnosed, and she gets frustrated by what she sees as
unnecessary deaths. In her view, deaths should only be the result of incurable
disease, not bad management or incorrect diagnoses. The contrast between
the clinics in which DrGous and DrMira work is immense. DrMiras clinic is
literally and figuratively on the margins of the city of Cape Town. From the clinic
one can see both the countryside and the abject poverty in which people live on
the economic and social fringes of a major urban centre. As DrMira points out,
this is a forgotten place. The clinic is understaffed and, until recently, she was
the only qualified doctor working in HIV and AIDS in the clinic. Long queues
of patients from the surrounding townships wait outside her door for their
appointment with her.
While I was sitting in on a consultation one day, a healthy looking patient
walked in. With great enthusiasm, DrMira drew my attention to the patient,
Jonathan, stating that just four months previously he was on his deathbed.
Jonathan had come into the clinic, thin and wasted, assisted by the nurse because
he did not have the strength to carry himself. Before even shaking his hand,
DrMira says she could see that he had TB; after examining him, she diagnosed
TB. However, Jonathan stated that he had been turned away from the clinic twice;
the doctors could not diagnose TB because he could not produce sputum for a
microbiological test. A microbiological test is an administrative requirement for
diagnosing TB, and is one of the key requirements of the TB protocol for diagnosis.
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Often, however, as was the case with Jonathan, the only symptom is diarrhoea,
and consequently such patients are diagnosed as suffering from gastroenteritis.
This is due to the critical state of the disease in the patients body; and the time
spent misdiagnosing patients costs them their lives. As a doctor working with AIDS
patients, DrMira knew that somebody in Jonathans condition would not be able
to produce sputum due to the workings of HIV on the immune system. DrMira
subsequently sent Jonathan to a local hospital. It took the hospital two weeks of
testing before they began Jonathan on TB medication on empirical grounds they
started with the medication just to see if he would improve. Two weeks later, when
DrMira visited the hospital, Jonathans condition had improved considerably. Yet
DrMiras initial and correct diagnosis had been applied by the hospital only as a
last resort. Her position in the clinic and her experience in HIV medicine enabled
her to defy the protocol with which the TB doctors were complying in order to save
Jonathans life. Other doctors lacked this insight.
The protocol and the logic of the machine

Protocols are important for standardisation, since they attempt to structure practice.
As Berg, quoting Eddy (1990), states:
Protocols are performed recommendations issued for the purpose of
influencing decisions about health interventions. By analyzing decisions
before the fact, they prevent the mental paralysis and chaos that would
otherwise result from having to rationally decide every time again from
scratchThrough the branching structure of the protocol, a clinician can
now, at long last, specify the flow of logic in his reasoning, [so that he] can
begin to achieve the reproducibility and standardization required for science.
(Berg 1998: 227)
By attempting to standardise decision-making, protocols introduce into medical
practice a normative framework by which one can measure the performance of
a doctor (Berg 1995). A protocol structures, rationalises and prioritises certain
ways of thinking above others and aims to make thought processes efficient.
Efficiency is created by the belief that individuals can belong to particular
categories or population groups, and doctors simply need to place individuals
into the correct group for a correct diagnosis. Thus, the doctors performance
can be measured by how accurately he or she applies the protocol. In this regard,
protocols serve a valuable function; they assist in treating major diseases in the
greatest number of people by focusing on problems of health for a population.
However, due to the administrative structure that protocols make possible and
HIV and AIDS medicine at the margins of administration
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the monotony of routine, protocols exclude the possibility of exceptional cases.

The critique of protocols derives in part from these exceptional cases. So, in order
for medicine to reach the greatest number of people, major health organisations,
such as the World Health Organisation (WHO), establish protocols that exclude
the work of exceptional cases, because, by definition, these are not cases that can
be easily classified into pre-existing populations. This results in the situation
where exceptional patients require expertise and effort to maintain their health,
thereby requiring expenditure on resources that could be used more efficiently in
non-exceptional cases.
Berg (1995) argues that before World War II, medical practice was not
described by the editorials of leading North American medical journals as a
scientific practice or endeavour to the same extent it is today. Rather, these
editorials described medical practice as the artful application of scientific
knowledge and, as such, held in high regard the intuitive nature of the
physicians practice and decision-making process. These editorials argued that
medical practice should never let this science impinge too closely lest the
artful ability to apply this science be lost (Berg 1995: 442/3). Berg illustrates
how medicine came to be conceptualised differently after World War II; and
this has affected how the problems of medicine are defined. Medicine began to
be associated increasingly with the hard sciences, implying that increasingly
it was distanced from a practice in a particular context. This was an attempt to
standardise and universalise medicine for the sake of administrative orders,
such as the state, which aim to provide healthcare for a population. The result
of this re-conceptualisation was that the problems associated with medical
practice shifted from the environment within which a physician practised to
how the physician practised. In other words, how medicine is conceptualised, for
example, as a science or not, affects how medicines problems are conceptualised,
and whether limitations are found in the physicians mind or in his or her
environment. In the conceptualisation of medicine as an art, the problems
defined were largely limited by socio-economic constraints placed on a doctors
practice. As the re-conceptualisation of medical care takes place, one can witness
diminishing concern for the socio-economic conditions under which a doctor
practises and increasing focus on a doctors decision-making ability. Therefore:
Contrary to early postwar views, many recent conceptualizations of medical
practice locate both its scientific character and the causes of its problems
in the physicians mind. This cognitivist discourse on scientific medical
practicedraws upon both the prevalent, positivist rhetoric and the notion of
the individual, autonomous physician a notion which has remained crucial
to the profession throughout the postwar era.
(Berg 1995: 439, emphasis in original)
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In its description as a cognitivescientific enterprise, the practice of medicine

has thus been estranged from the practical, contingent reality of life. This
(re)description of medicine allows various factors to come into play within medicine
that do not necessarily serve the interests of good medical practice. For instance,
indescribing
medical practice itself as a scientific activitya general explicitly normative
framework is introduced, with which this practice can now be scrutinized
and judged. It is a yardstick to measure (and find lacking) the actualization
of the science. When scientific medical practice means merely the
usage of scientific knowledge, one can scrutinize medical practice for
places where this knowledge is improperly used, or not used at all.
Standardization is then a way to guarantee optimal flow of information so
that the benefits of science reach those who need it.
The normative framework introduced is now a means by which a physicians
practice can be judged. Subsequently, the possibility of auditing is introduced into
medical practice. The state thus gains control over its practitioners, legitimised by
modernist ideals of creating a health system that is accountable to its population.
This ideal of a normative framework could also be seen to support the
propagation of evidence-based medicine, through which doctors are being
conditioned to function like a well-programmed computer that operates within
a strict binary framework (Horton 2007: 2). The use of analogies surrounding
thought processes and computers is of special interest here. The result of the
re-description of medicine discussed previously was that medicine could now be
viewed as a scientific practice and the improvement of medical care could be placed
within the decision-making realm of doctors. Thus the problems of medicine
shifted from material concerns within the environment of the doctor to his or her
attempts to make rational, scientifically based decisions. This decision-making
process has now been perfected by evidence-based medicines cognitivist approach
in order to improve the accuracy of the statistical thinking around what physicians
do (Berg 1995: 461). However,
these are not newly found solutions for pre-existing problems. With cognitive
psychology, the Mind came in on the back of the Machine. Human
judgment was described, judged and explained with models derived from
images of the scientific process and computers, and statistical decision
analytic techniques. In the same vein, these models will now overcome
the faults of medical practice. The point is to see that the tools which are
described as solutions lay at the root of the reconstruction of the problems
in the first placeThe solutions are the tools which shaped the cognitive
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perspective of medical practice. With the construction of the solutions, the

specific shapes of the problems were co-produced.
Therefore, via Berg, we can view how evidence-based medicine is the result not
only of a particular discourse surrounding medicine, but also of advancements in
technologies that shape what are considered problems and what are not.
In aiming to anchor decisions and structure practice, protocols illustrate a
particular, idealistic view of medicine. This is medicine in a perfect world, where
logic and universal circumstance determine the outcome of any experiment:
With its invariable replicability and law-like precision, this view of science
is a matter of simple logic with readily deduced details and rule-governed
consequences. What characterises the care of patients, however, is contingency. It
requires practical reasoning or phronesis, which Aristotle described as the flexible,
interpretive capacity that enables moral reasonersto determine the best action
to take when knowledge depends on circumstance.
(Montgomery 2006: 45, emphasis in original)
Phronesis is knowledge gained through practical experience in a contingent world; it
depends on, and is expressed through, practice. Its essential virtue isthat [it] enables
physicians to fit their knowledge and experience to the circumstances of each patient
(Montgomery 2006: 33). It is a general body of knowledge in combination with the
particular idiosyncrasies of the individual practitioner and his or her experiences with
different medications, diseases and patients that may divert fromorthodoxy.
Hubert Dreyfus has written extensively on the models used by cognitivists in
order to explain the decision-making techniques of experts (Dreyfus 1999; Dreyfus
& Dreyfus 1986, 2002). According to Dreyfus, the history of Western thought, since
Socrates, has defined expert decision-making as a process of following rules or sets
of syllogisms. Dreyfus argues that since the invention of the telephone switchboard,
the human mind has been conceptualised as operating like a machine, with
the model of the brain changing as our technology develops from the telephone
switchboard to the modern digital computer. This, combined with the inherent
rationalism of Western philosophy, has given rise to cognitivism:
Cognitivism is rationalism turned into a research program. It proposes
to use the computer to show how, on the rationalist account, the mind
actually worksAt this level, both the human brain and the appropriately
programmed computer can be seen as two different instantiations of a
single species of device one which generates intelligent behaviour by
manipulating symbols according to formal rules.
(Dreyfus & Dreyfus 2002: 2)
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However, the notion of phronesis provides us with a different model of human

cognition. This is a model that is based within a world of action and practice, a
knowing how rather than a knowing that (Dreyfus & Dreyfus 1986: 4, emphasis
inoriginal).
An example from the field illustrates this point nicely. On my very first
day with DrGous, I saw him interact with Louise (pseudonym). When he greeted
Louise, he asked her about the voices she was hearing. Her reply was that this
was fine. On examining her medical record, DrGous seemed very pleased by her
adherence rate to her HIV medication and her general well-being. It was a short
consultation, as they often are with patients doing well with their medication.
Afterwards, DrGous explained to me that Louise had been diagnosed as suffering
from schizophrenia, and was being treated for this as well as for HIV. Louise had
been one of the first patients DrGous had put onto antiretrovirals (ARVs) once they
began to be provided for free by the state. (Prior to this he had provided ARVs to
eligible patients with help from foreign donors.) According to psychosocial criteria
provided by the WHO, which guide doctors as to who would potentially be adherent
with ARVs, Louise was not a likely candidate. Not only was she diagnosed with
schizophrenia but, due to her mental illness, was cast out by her family, and lived
alone, without any financial or emotional support. Her mental illness, her solitary
existence, and her lack of income all indicated that Louise would be very unlikely to
maintain a healthy adherence rate. However, DrGouss experience with this patient
and others like her, his phronesis, led him to take the risk of giving Louise ARVs.
His decision so far has been vindicated: Louise, at the time of the consultation,
had maintained an adherence rate of between 95 per cent and 100 per cent. That is
anything between 142 and 150 pills a month, two in the morning and three 12 hours
later, every day, at the same time. When I asked DrGous how he knew that Louise
would be adherent, he said he could not say but that he merely got the impression
that she would be successful during his brief interactions with her and from his
previous experiences with the people who frequented his clinic. DrGous could not
formulate a syllogism, could not tell me that Louise would be successful because of
a set of factors that he identified. Rather, he had made the decision grounded in an
everyday, practical contingent reality, unable to be defined in the abstract.
Phronesis describes action related to contingency and the ability to adapt
universal rules to particular circumstance. This can be viewed as the art of
medicine, in that the outcomes of the medical decision-making process cannot be
traced to a rational decision-making trail, but rather occur in the spaces, excesses
or differences that exist in between the factors considered key to decision-making,
as defined by models such as protocols or evidence-based medicine. Doctors make
decisions rather than calculations; the proponents of a strict standardisation and
cognitivism would like us to follow, instead, calculation according to protocol. As
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Jacques Derrida (2002) notes, a decision must have an element of incalculability

within it. A decision is always a risk a space must be crossed that cannot be
explained or rationalised:
If one were sure of the calculation, it would not be an action or a decision;
it would be a programmingThere is no decision without the undecidable.
If there are no undecidables, there is no decision. There is simply
programming, calculation. There must be political, ethical decisions, but
these decisions are possible only in situations where the undecidable is a
necessary dilemma. Thus a certain undecidabilityis the condition or the
opening of a space for an ethical or political decision.
(Derrida 2002: 31)
Any decision a doctor makes concerning the life of a patient covers a gap filled
with both politics and ethics, concerning, for example, the life of an individual
versus the life of a population. It is an ethico-political decision regarding the
patients life, the doctors place within a hierarchy, broader questions concerning
the common trajectory of the disease, resistance to drugs, and the responsibility
of medicine and the patient toward the health of the population as a whole. In
making a decision, responsibility arises due to the fact that a risk was taken; a
calculation was not made in which failure could be attributed to a system; rather,
responsibility for crossing a gap is placed on the shoulders of the decision-maker.
This gap is created by the contingency that a doctor experiences when dealing
with a particular patient in a particular context. As contingency, by definition,
can never be modelled, the protocols we use in clinical settings will always be
limited and doctors will always be faced with such a gap. One can note, then, how
a protocol aims to anchor these decision moments, making them not moments
of decision but moments of calculation; but, inevitably, these are moments of
decision unless one follows the protocol in which responsibility (or ethics and
politics) is shelved on to a system of governance. In the language of cognitivism
and the standardisation it attempts to make possible, one can see neglect in the
ethics of following rules or protocols. Under the cognitivist paradigm, if we follow
the system, we will never make mistakes. However, if we follow alternative models
of how the mind works, Dreyfuss being just one, we begin to see the difficulty of
a comprehensive standardisation of medicine.
The excess of categories

As with all systems of governance, protocols and the standardisation that results
from them depend on categorising patients into particular groups. Patients are
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classified according to sets of symptoms; for example, a person with TB must have
microbiological proof of bacilli infection or must experience night-sweats and
weight loss. The reproducibility and standardisation made possible by protocols,
resulting in the categorisation of individuals, allows one to create groups through
numbers; in other words, it aids the creation of statistics that express a particular
concern for a population. Ian Harper (2005) describes how such a concern for
statistics has created the concept of statistico-tuberculosis, which is
intimately concerned with a global (and national) prevalence of the disease,
which, it is believed, will decrease when enough infective patients are found
and effectively treatedFor the tuberculosis reified as a population problem,
statistico-tuberculosis, is the one that has the spectre of multi-drug
resistance hanging over it.
(Harper 2005: 136)
In this light, there is more concern with the control of an epidemic in a population
than with the care of an individual. One can easily extend the idea of statisticotuberculosis to that of statistico-HIV or even statistico-HIV/tuberculosis XDR
(adrug-resistant form of TB). The reification of disease into a threat (real or
imagined) faced by a population, therefore, attempts to justify the treatment of a
population above an individual, for the sake of the future, forsaking the individual
present. However, such reification into statistical threat is what makes activism on a
global scale possible. Roughly two-thirds of the worlds HIV-positive population, who
live in sub-Saharan Africa, or the five million HIV-positive people living in South
Africa, are products of a standardised system relying on protocols. The difficulty for
nurses and doctors is in treating patients as individuals, while reifying their disease
as a global threat (Van der Walt & Swartz 1999).
For Jonathan and Louise, the demands of the protocols did not take
precedence over their lives. The lack of microbiological proof of infection did
not concern DrMira; Louises psychiatric diagnosis did not take precedence for
DrGous. Microbiological proof is an administrative requirement for diagnosing
TB and would allow the administrative agent to classify Jonathan as a TB patient.
Yet, due to his HIV-positive status, Jonathan was not able to produce sputum and
thus could not fulfil the administrative requirements for this particular risk group.
Nevertheless, DrMira diagnosed TB in Jonathan by looking at his body. She noted
that he was HIV-positive, was rapidly losing weight, and was having night sweats
despite not coughing up sputum. She took Jonathan as an individual, and despite
beginning her diagnosis at the same place as had the TB doctors, that is, by using
statistical data that delimit a range of risk values (such as being HIV-positive and
so susceptible to TB bacilli), she ended in a radically different place. This is not
an argument against models: the thought processes of doctors such as DrMira
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or DrGous do depend on models. However, the standardisation of models that

protocols demand differs from those used by these doctors. As Jonathans case
illustrates, the resources for testing and curing his TB were available (as was the
eventual case), but the protocols on which the TB doctors relied structured their
thought in a way that led them to misdiagnose. The models that doctors such as
DrGous and DrMira use are much looser than the rationalised and standardised
models demanded by administrative orders.
Here we can extend Mosses (2004) notion of an interpretive community to
the realm of diagnosis. A protocol depends on an interpretive community, which
ascribes symptoms to diseases, a community such as a group of experts within the
WHO, for instance. A doctor like DrMira takes the risk of running up against the
medical orthodoxy of these interpretative communities, whereas a doctor operating
under the protocols framework can play it safe even at the risk of somebodys
life. Symptoms are evidence of disease, but of which disease is a matter of the
discretion of the physician in charge; it is a matter of chance whether the physician
will diagnose correctly.1 The symptoms ascribed to disease by an administrative
network limit these chances, and the success of these protocols depends on not
being proven incorrect by an alternative diagnosis. Methods do not order the world,
but rely on evidence to the contrary to slip through unnoticed, such as TB patients
who die because their symptoms could be ascribed to other causes. Joao Biehl
(2004) coined the term technologies of invisibility for this process, whereby certain
patients slip through the cracks of the health system. Bureaucracy depends then on
complexity and messiness, not order.
The attempt to hide messiness also relies on doctors compliance with the
sets of rules laid out by the prevailing order. Strict exponents of protocols assume
that doctors all operate under the same ethic and toward the same ends, without
problematising what this ethic or these ends may be. The social or material
circumstances under which doctors operate imply that much more than clinical
decisions play a role in determining the outcome of an interaction with a
patient. In approaching a patient, a doctor needs a way in which he or she can
view or analyse the patient, a means by which to frame his or her patients. The
framing process essentially amounts to limiting options or solutions. Protocols
and evidence-based medicine attempt to create such frames. These approaches
assume that frames exist independently of the material conditions under which a
doctor finds himself or herself. In contrast, Dodier (1998: 53) argues that a person
adjusts to a situation not by using discrete resources, but through arrangements of
resources (words, rules, objects) in which past experiences are inscribed, that is,
through frames. The arrangement that people find themselves labouring under,
therefore, has past experiences, present necessities, possibilities and limitations, as
well as future expectations, inscribed into the use of resources. Multiple approaches
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and resources, and limitations, are available in any situation, and more than one
frame is available for each encounter experienced by a doctor. An active as much as
a passive choice shapes which frame will be applied to the situation at hand (Dodier
1998). Each frame, thus, relies on different points of reference according to a desired
outcome (Harper 2005), which is dependent upon a particular ethic, and the
availability of resources, both ontological and epistemological. A given frame can
conflict with, mix with or succeed another frame in a particular circumstance.
Administrative orders such as those of the state, through the propagation
of protocols, attempt to develop frames, such as evidence-based medicine, which
aim to place individual patients into formal categories according to references to
a population, consistent with categories of risk established by a central authority.
Dodier has labelled this type of framing the administrative frame:
The administrative frame depends on rules coming from the centre, as in
other bureaucratic situations, and it is the administrative frame that has
developed massively under the combined influence of scientific networks
and those of the lawDodier also highlights that this corresponds to the
diffusion of protocols deeply into the system.
(Harper 2005: 132)
In contrast to the administrative frame, the type of frame I am discussing here is
hard to classify, because it depends on an apparent absence of framework as the
decision-making process is not limited to a set of syllogisms. This does not mean
that a framework does not exist. Rather, one cannot model the frame in the same
way that evidence-based medicine hopes to. The doctor may apply the rules and
syllogisms granted by administrative frameworks, but, at the same time, may not
feel obliged to comply with these rules or need to reduce his or her decisions to
some set of laws. Such doctors operate in a field open to risk and error, if measured
by the framework of the administrative order.
However, the risk that a doctor takes is not limited to patients who are
classified as marginal to an administrative order. As an example, Janie is a middleaged man who is married, has three children and works as a policeman. He is a
bit overweight. The stresses of being a policeman in a violent country have taken
their toll on his well-being. The psychosocial criteria for ARV-eligibility state that
employment and stable family lives are good indicators for positive adherence rates,
yet Janie has defaulted once before from his medication, and currently has a poor
adherence rate. In contrast, Louise (mentioned above) is single, unemployed, lives
alone and has schizophrenia, yet she has been highly successful on ARVs. The same
doctor (DrGous) examined these two patients and decided to place both on ARVs,
with Janie, who complies perfectly with the criteria, defaulting from the medication,
and Louise, ordinarily seen to be unsuitable, successful. Therefore, the risk that
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DrGous took when he placed both patients on ARVs was not one acknowledged
by protocols but one that DrGous, in his experience with both patients,
determinedhimself.
Operating under an administrative frame requires outside support. Some
order or power must create, allow and impose categories and classes onto a complex
world. This support comes from a history of Western rationalism, the hegemonic
force of the methodology of science, and the states dependence on this method
for governance over the distribution of medicine. These phenomena are guided
by a belief in the benefits offered by modernist ideals of control over a complex
world. As discussed, the nature of a diagnosis can depend as much on intuition,
on traces found in the excess of models, as on methodological evidence.2 For
example, in the case of HIV-positive patients, especially in the more critical stages,
with CD4 counts of between 20 and 100 (as in the case of Jonathan), often the only
symptom revealing TB would be diarrhoea. A doctor such as DrMira, relying on
her experience and intuition, would diagnose TB and would often be proven correct
once TB medication had begun. However, a doctor guided strictly by protocol would
diagnose gastroenteritis, as he or she could not find any symptoms that would
reveal otherwise, yet would be confident in the decision because of the institutional
support received. Due to the critical state of many patients, the time wasted trying
to treat gastroenteritis often costs them their lives. These patients will then be said
to have died of AIDS-related complications rather than TB.
In this case study, the lack of microbiological proof of infection did not
concern DrMira and, although she could not fulfil the administrative requirements
for this particular risk group, she diagnosed Jonathan correctly. In an interview
after meeting Jonathan, DrMira stated that she could see he had TB the moment
he walked into the room, and diagnosed this by the colour of his skin or the rings
around his eyes. When interviewed, DrMira stated that she believed that
doctors have gut feeling. I know how these people look like. I know
the colour of the skin. I know everything which you cant even write in
words[Youre a photographer?]Yes, thats it, and my interior designer
said: you have a discerning eye, and I do. I do, Im telling you, there are TB
symptoms that I cant put on a list, which is in the way they walk into the
room, the way they look at you, the way theywithout even loss of weight,
that kind of chronic infection look, which seems to make these kind of very
round circles on the patient not easy to see.
(Interview, April 2008)
DrMira reveals something about diagnosis that cannot be expressed verbally,
cannot be put on a list or modelled, but is rather revealed in the excess of the
model, at the margins of what is considered central to medicine. Her experience as
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a photographer, as well as her experience practicing medicine, grants her access to

shades of skin tone unnoticeable to the inexperienced eye, the life experiences of
the doctor both inside and outside of medicine contributing toward a diagnosis.
What is important is not that she lists symptoms, but that she reveals to us the
impossibility of comprehensive lists and models. DrMira moves from the colour of
skin, to interior design, the way TB patients walk and the look in their eyes. Yet she
states, I know everything which you cant even write in words.
The assumption made by proponents of a strict standardisation or evidencebased medicine is that knowledge is disembodied and, therefore, can be modelled
into a universal protocol:
Adherents of the psychological and epistemological assumptions that human
behaviour must be formalizable in terms of a heuristic program for a digital
computer are forced to develop a theory of intelligent behaviour which makes
no appeal to the fact that a man has a body, since at this stage at least the
computer clearly hasnt one. In thinking that the body can be dispensed
with, these thinkers again follow the tradition, which from Plato to Descartes
has thought of the body as getting in the way of intelligence and reason,
rather than being in any way indispensable for it.
(Dreyfus 1999: 235)
With disregard for the material circumstances under which a doctor practised,
the human body became a hindrance to accurate decision-making. However, the
embodied nature of diagnosis is revealed in interviewing DrMira, who, while
discussing her diagnosis of TB in Jonathan, touches her face around her eyes and
says she sees something in the eyes of TB patients. She cannot describe this, but it is
revealed to us, the interviewers, in her body language. The store of knowledge she
is recollecting here is not an epistemological store in her mind, a list of symptoms
she recalls. Rather, this knowledge is embodied in moments and contexts; it is
revealed by means of body language assisted by words. So an apparent run-ofthe-mill patient on paper could have radically different problems, detected by the
physician with a touch or an answer to a question, which can only be realised in the
physical encounter between an experienced doctor and patient. There is then an act
of diagnosis, a material manifestation of symptoms invisible to the untrained eye
yet essential to what is traditionally considered thought processes. As Montgomery
(2006: 34) argues:
even if computer programs, like textbook descriptions or the protocols given
to emergency medical technicians, worked most of the time, they would
still be an inadequate substitute for clinical attention. The need for human
contact by both parties to the patientphysician encounter goes well beyond
the patients need for reassurance and supportWhat experienced clinicians
MPOK - book.indb 27
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possessis an immense and well-sorted catalogue of clinical cases and

the clinical judgment to know how to use it, and that store of knowledge is
activated by seeing, touching and questioning the patient.
Therefore, what distinguishes persons from machines, no matter how cleverly

constructed, is not a detached, universal, immaterial soul but an involved situated
material body (Dreyfus 1999: 236). As a situated, material body, not a disconnected
mind, when faced with another body (the patient), the doctor views not independent
isolated parts or symptoms of the patient, but rather what he or she considers to be
the whole. It is due to this that, by using Gestalt psychology, Dreyfus (1999: 238) has
illustrated that:
in the perception of objects there are no neutral traits. The same hazy
layer which I would see as dust if I thought I was confronting a wax apple
might appear as moisture if I thought I was seeing one that was fresh. The
significance of the details and indeed their very look is determined by my
perception of the whole.
When doctors make diagnoses, they do not take note of individual traits and work
up toward a general picture. Rather, they work the other way around. What is
defined as a trait, what stands out or is noticeable, is defined by or given weight
by what the doctor perceives to be the whole. Isolated traits or symptoms have
no inherent worth or value to the doctor; what is important is the relationship
between the different parts of the whole that define which symptoms are important
and which are not. DrMira took note of Jonathans HIV-positive status and his
complaints, but it was the traces of evidence that led her to her diagnosis: the
dull rings around his eyes, the pale colour of his skin, the way he walked into
the room. When doctors make diagnoses, they collect traces of evidence which
define the relationships between the symptoms. These traces are by their nature
erasable (Derrida 2006/1967), unrepeatable and negatively defined rather than
representations based on a formalised, systematic schematic.3 Hence, different
doctors do not necessarily view the same disease in the same patient.
Conclusion
The standardisation of medicine, and the protocols used to achieve it, is based on a
particular cognitivist view of medical practice and procedure. In this view, doctors
decision-making is limited to their ability to follow certain rules. In contrast to this,
I have illustrated how the material, day-to-day practice of doctors (both within and
outside their practices) diverges from strictly following protocols. I am not arguing
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that we do away with protocols; rather, I wish to illustrate the tensions found in the
use of protocols by doctors in the field, in contrast with their imagined or intended
uses by the experts who establish them. These tensions arise from the fact that
local, particular contexts and patients will always have more complexity than can
be modelled centrally, with the same logic applying to doctors who come with
the advantages of bodies of experience, both within and outside medical practice.
Therefore, the achievement of standardisation often is based not on perfectly
following rules, but rather on diverging from them (Craig 2000; Timmermans
& Berg 1997). There is thereby tension between a policy, created in a neutral
environment in order to govern thought, and how it grates up against the texture
of local reality. As a doctor working in the administration of the Global Fund in
SouthAfrica argues:
The management of virtually every disease is based on standardization of
treatment protocols, although to varying degrees. Those standards should
draw from international knowledge and demonstrated best practice models.
However, what is possible in different countries (and often what is possible
in different areas within a country South Africa being just one example)
varies depending on the resources that are available. Strict implementation
of international standardization is therefore seldom possible best practice
models need to be able to be adapted to local settings.
(Personal correspondence, underlining in original)
A protocol, therefore, does not arrive but is produced within local contingency.
That is, when the attempt is made to implement a protocol, it has to contend with
existing structures, sometimes destroying them, sometimes appropriating them,
but often being appropriated by them. In this regard, achieving standardisation
does not rely on a central actor but is rather a distributed activity as it moves from
one actor to the next along its path (Timmermans & Berg 1997). Furthermore,
non-docile actants may well be a sine qua non for universality in practice.
Rather than being antagonistic to it, a certain looseness in the network may be
the preferred (or only possible) way to achieve standardization (Timmermans
& Berg 1997: 275). Albeit in a different context, Farquhar has also illustrated
that everywhere and always, the transportation or globalization of powerful
languages, objects, facts, and systems has required translation, whichis always
a multifaceted transformation (Chapter 7 of this book, emphasis in original). In
this regard, a policy cannot be followed to a T or enforced in a totalitarian fashion
in order for it to be successful. Looseness is required; a policy must be open to
interpretation and adaptation. 4
Tinkering, having the leeway to adjust the protocol to unforeseen events and
repair unworkable prescriptions is a prerequisite for the protocols functioning:
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in these practices, the overall stability of the network is at the same time
challenged and dependent upon the instabilities within its configuration.
(Timmermans & Berg 1997: 293, emphasis in original)
Standardisation is predicated upon medical practitioners following protocols as
accurately as possible. However, as in the case studies explored in this chapter,
the success of this global management rests on doctors diverging from the order
as they interact with particular patients, in particular settings. The paradox,
therefore, lies in the fact that the success of a protocol sometimes relies on its
subversion. Standardisation should not be abandoned; rather what should be
abandoned is the certainty that arises from an overreliance on cognitivism and
current conceptions of medical practice. The control over resources and the
insurance provided by a strict standardisation becomes unethical, even in its
attempt to ethically provide healthcare to a population. I suggest, therefore, that
the ethical treatment of disease in a population requires a little more looseness
and deviation for standardisation to be possible, even if it implies a loss of
certainty and control over the distribution of resources.
Endnotes
1
The word symptom has the Greek sumptoma (chance) as a root (Collins English Dictionary
2006).
I use the term methodological to mean evidence based on a procedure or set method. Some
could use the term empirical evidence to contrast with intuitive evidence; however I believe
this would deny the empirical nature of intuitive decisions such as traces of evidence revealed
through touch or sight.
An interesting comparison can be made in this regard between the model of diagnosis I
am trying to develop here and that adopted in Chinese medicine. Farquhar (in Chapter 7 of
this book) argues, following her interlocutor DrLu, that a neat distinction between theory
and practice cannot be made. In fact, as DrLu points out, one must learn from the objects of
practice, while engaged in practice. The objects one engages with in practice cannot be easily
delineated. They are always excessive, due to the fact that they are relationally constituted
in the encounter between the medical practitioner and his or her patient, thus rendering an
ideal, theoretical representation of such a complex relationship impossible.
One can see this looseness in a network in much the same way that work to rule action
operates within factories. That is, as a form of strike, workers will follow the rules like
automatons and thus bring the factorys production to its knees. This is because designed or
planned social order is necessarily schematic; it always ignores essential features of any real,
functioning social order (Scott 1998: 6).
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References
Berg M (1995) Turning a practice into a science: Reconceptualizing postwar medical practice.
Social Studies of Science 25: 437476
Berg M (1998) Order(s) and disorder(s): Of protocols and medical practices. In Berg M &
MolA (eds) Differences in medicine: Unraveling practices, techniques, and bodies. Durham,
NC: Duke University Press
Biehl J (2004) The activist state: Global pharmaceuticals, AIDS and citizenship in Brazil. Social
Text 22(3): 105132
Craig D (2000) The kings law stops at the village gate: Local and global pharmacy regulation
in Vietnam. In Whiteford LM & Manderson L (eds) Global health policy, local realities: The
fallacy of the level playing field. Boulder, CO: Lynne Rienner
CSDH (Commission on Social Determinants of Health) (2008) Closing the gap in a generation:
Health equity through action on the social determinants of health. Final report of the
Commission on Social Determinants of Health. Geneva: World Health Organisation
Derrida J (2002) Negotiations: Interventions and interviews, 19712001. Rottenberg (ed. &
trans.). Stanford, CA: Stanford University Press
Derrida J (2006/1967) Writing and difference. London: Routledge
Dodier N (1998) Clinical practice and procedures in occupational medicine: A study of
the framing of individuals. In Berg M & Mol A (eds) Differences in medicine: Unraveling
practices, techniques, and bodies. Durham, NC: Duke University Press
Dreyfus HL (1999) What computers still cant do: A critique of artificial reason. Cambridge, MA:
The MIT Press
Dreyfus HL & Dreyfus SE (1986) Mind over machine: The power of human intuition and expertise
in the era of the computer. New York: The Free Press
Dreyfus HL & Dreyfus SE (2002) From Socrates to expert systems. Philosophy (24)1: 19
Eddy DM (1990) The challenge. Journal of the American Medical Association 263: 287290
Harper I (2005) Interconnected and inter-infected: DOTS and the stabilization of the
tuberculosis control programme in Nepal. In Mosse D & Lewis D (eds) The aid effect:
Giving and governing in international development. London: Pluto Press
Horton R (2007) Whats wrong with doctors. The New York Review of Books 54(9): 1620
Montgomery K (2006) How doctors think: Clinical judgment and the practice of medicine. Oxford:
Oxford University Press
Mosse D (2004) Is good policy unimplementable? Reflections on the ethnography of aid
policy and practice. Development and Change 35(4): 639671
Scott JC (1998) Seeing like a state: How certain schemes to improve the human condition have
failed. New Haven, CT: Yale University Press
Timmermans S & Berg M (1997) Standardization in action: Achieving local universality
through medical protocols. Social Studies of Science 27(2): 273305
Van der Walt H & Swartz L (1999) Isabel Menzies Lyth revisited: Institutional defences in
public health nursing in South Africa during the 1990s. Psychodynamic Counselling 5(4):
483495
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Medicine and The Politics of Knowledge - Chapter 1

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divergence from authority. By relying on traces of evidence not modelled, and by

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The protocol and the logic of the machine

HIV and AIDS medicine at the margins of administration

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the monotony of routine, protocols exclude the possibility of exceptional cases.