1852

SAC15110.1177/1206331211421852Street and ColemanSpace and Culture

Articles

Introduction: Real and

Imagined Spaces

Space and Culture

15(1) 417
The Author(s) 2012
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DOI: 10.1177/1206331211421852
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Alice Street1 and Simon Coleman2

Abstract
The hospitals ambiguous relationship to everyday social space has long been a central theme
of hospital ethnography. Often, hospitals are presented either as isolated islands defined by
biomedical regulation of space (and time) or as continuations and reflections of everyday social
space that are very much a part of the mainland. This polarization of the debate overlooks
hospitals paradoxical capacity to be simultaneously bounded and permeable, both sites of social
control and spaces where alternative and transgressive social orders emerge and are contested.
We suggest that Foucaults concept of heterotopia usefully captures the complex relationships
between order and disorder, stability and instability that define the hospital as a modernist
institution of knowledge, governance, and improvement. We expand Foucaults focus on the disciplinary, heterotopic qualities of the hospital to explore the heterotopia as a space of multiple
orderings. These orderings are not only biomedical. Rather, hospitals are notable for the intensity and heterogeneity of the ongoing spatial ordering processes, both biomedical and other, that
produce them.We outline an approach to heterotopias that traces the contingent configuration
of hospital space through relationships between the physical environment, technologies, and
persons, while simultaneously considering the kinds of spatial imaginings, hopes for the future,
and emotional responses that are rendered possible by those configurations. We provide three
thematic frameworks through which the heterotopic and contingent qualities of hospital spaces
might be explored: boundary work, generating scale, and layered space.
Keywords
Hospital ethnography, heterotopia, biomedicine, STS, medical anthropology

The backdrop for a coup and its bloody aftermath in Ethiopia (Verghese, 2010), the site where
postapartheid tensions ferment and erupt in South Africa (Galgut, 2003), a vantage point for
exploring changing masculinities and the morality of war in early-20th-century Britain (Barker,
1991). The hospital has emerged as a quintessential setting for contemporary fiction; a stage
where dramatic historical events, social and cultural divisions, and moral dilemmas are played
out against the backdrop of modern medicines battlefield between life and death.

1
2

University of Sussex, Brighton, UK

University of Toronto, Toronto, Ontario, Canada

Corresponding Author:
Alice Street, Department of Anthropology, University of Sussex, Brighton, East Sussex, UK BN1 9RH
Email: a.street@sussex.ac.uk

Street and Coleman

Why does the hospital prove to be such a valuable literary device? Of course, the hospital is a
place of high drama, where the stakes involved in attempts to diagnose, treat, cure, care, and save
lives are frequently articulated through the idiom of warfare (Martin, 2001), and where patients
and doctorsfaced with the possibility of their own or others physical transformation and
deathare prompted to reflect on the core issues of life (Long, Hunter, & van der Geest,
2008). But in this special issue we argue that the metaphorical persuasions of hospital space
further derive from an intrinsic ambiguity in the relationship between the hospital and everyday
social space. In its fictional versions, this spatial ambiguity has three simultaneous modes of
representation.
First, the hospital is represented as a place set off and isolated from everyday social space. The
highly ordered and ritualized spaces of the medical ward or the operating theater, full of material
implements and technologies that symbolize the mystery and magic of scientific knowledge,
where trained doctors and nurses do war with unruly nature, are simultaneously uncanny and
depict the hospital as a world governed by its own complex systems of social control and order.
The hospital appears to become a foreign, unfamiliar place of medicine analogous to the other
exotic locations that regularly serve as settings for fictional escapades.
Second, and in contrast to this image of the hospital as a place apart, the hospitals ordered
isolation is nearly always shown in its fictional versions to be incomplete. The events taking
place in the hospitals wider spatial arena transgress its boundaries, transported by patients,
soldiers, politicians, or missionaries, who intrude on the tightly structured and ordered world of
the hospital, introducing new social rules and cultural values, raising the stakes for those who
inhabit the institution and driving the plot forward.
Last, the hospitals simultaneously bounded and permeable status facilitates its literary
purpose as a metaphor for the wider regional, national, or global space in which it is located. The
hospital appears as a microcosm of society. The conflicts, love affairs, and struggles that play out
in its operating theaters, medical wards, and labor units stand for those wider historical and
social transitions from one social order to another. The changes undergone by the hospital and its
inhabitants represent the threat of transformation to the social order as a whole.
A concern with the hospitals boundaries and the relationship between hospital space and
other external spaces has equally preoccupied hospital ethnographers. However, as we outline
below, in hospital ethnography the question of boundedness has tended to be framed as an
either/or issue. Hospitals are presented either as isolated islands defined by biomedical
regulation of space (and time) or as continuations and reflections of everyday social space that
are very much a part of the mainland. This polarization of the debate overlooks what we
believe to be a significant aspect of hospital space and the reason why hospitals are deeply
important truth spots (Gieryn, 2006) for social scientists interested in the relationships between
space and culture more broadly: hospitals paradoxical capacity, readily exploited in the literary
world, to be simultaneously bounded and permeable, both sites of social control and spaces
where alternative and transgressive social orders emerge and are contested.
We suggest that Foucaults (1986) concept of heterotopia usefully captures the complex
relationships between order and disorder, stability and instability that define the hospital as a
modernist institution of knowledge, governance, and improvement. As we outline in this introduction, this special issue expands Foucaults focus on the disciplinary, heterotopic qualities of
the hospital to explore the heterotopia as a space of multiple orderings (following Hetherington,
1997). Crucially, we argue that the multiformality of the hospital, the complexity, variability,
and unpredictability inherent to the relationships that order its constituents, are often central to
its continuity and durability as an institution (Singleton, 1998)
A focus on the heterotopic qualities of hospitals draws attention away from the composition
of external boundaries and toward the heterogeneity and internal differentiation of hospital

Space and Culture 15(1)

space. Hospital ethnographies that have focused on the existence or not of boundaries around the
hospital have tended to equate those boundaries with biomedical authority, thereby reducing
hospital spatiality to an issue of biomedical control. By contrast, we propose a focus on the
multiple, layered, and contested orderings that configure hospitals as spaces of care, expertise,
and science. This is to emphasize the contingency and fragility of hospitals. The articles in this
special issue do not take the status of particular sites for granted but explore the complex everyday configurations and alignments of materialities, social practices, and representations through
which particular spaces are constituted as hospitals. The contributors do not start by asking are
hospitals bounded spaces? but by asking how are hospital spaces made up? and exploring
how answers to this question can speak to wider debates about space and culture.
To answer this question in ways that overcome simplistic binary classifications of hospitals as
either scientific or social spaces, we believe that hospital ethnography needs to look beyond
medical anthropology to draw on theoretical and methodological resources from cultural
geography and Science and Technology Studies. In our introduction, we outline an approach to
heterotopias that traces the contingent configuration of hospital space through relationships
between the physical environment, technologies, and persons, while simultaneously considering
the kinds of spatial imaginings, hopes for the future, and emotional responses that are rendered
possible by those configurations.1
We first describe the theories of space, society, and science that are implicit in established
approaches to hospital ethnography before providing a more extensive discussion of why we find
the notion of heterotopia useful for thinking through hospital spatialities.

The Three Spaces of Hospital Ethnography

The early sociology of hospitals that emerged in the 1950s and 1960s, based largely in European
and American hospitals, emphasized their separation from everyday life and focused on the
informal relationships and cultural conventions through which the hospital was maintained as a
functioning unit (Caudill, 1958; Coser, 1962; Goffman, 1961).2 The hospital was treated as a
small society whose organization, rules, and social structure were defined by its medical functions.
This interest in the isolated order of the hospital was related to the changes that the institution
had undergone in the late 19th and early 20th century with the professionalization of nursing and
medicine and rapid advances in technology that transformed the hospital into a space of medical
specialization and expert authority (Porter, 2002; Rothman, 1991; Starr, 1982). Arguably, by
focusing on the particularities of hospital space it also helped define medical sociology as a
subfield in its own right.
Such early ethnographies focused on the experience of patients, whose abrupt removal from
the homes and workplaces associated with their everyday relationships and social identities best
exemplified the closed order of the hospital. They described patients collective experience of
ward life and the social relationships and cultural norms that they established with one another
in response to the hospitals alien, closed, and highly regimented social order. Moreover, it was
argued that the patient subculture in the hospital and the highly structured relationships between
patients and staff were key to the hospitals fulfillment of its medical functions (Coser, 1962;
Goffman, 1961; Zussman, 1993).
This image of the hospital as a tight little island (Coser, 1962) is replicated today in
policy demands for the democratization of medicine and the claims that social scientists
make for hospital ethnography as a tool that can open up the closed expert culture of the
hospital to public scrutiny (Finkler, Hunter, & Iedema, 2008). Such calls for democratization
and transparency, which imply that hospitals had until now been closed, elitist spaces of
medicine, have gained momentum as anxieties about the risk of infection in hospitals have

Street and Coleman

increased and as calls for medical accountability and patient rights have grown. This model
of hospital ethnography as an instrument of accountability or transparency is manifested in
arguments that hospital ethnography can provide guidance on how to negotiate contemporary
health services as a citizen of the modern world (Finkler et al., 2008, p. 250).
Despite such depictions of hospital ethnography as an instrument of transparency and
accountability, however, recent attempts to map out a new field of hospital ethnography have
been notable for their arguments that hospitals are not closed, total institutions but are continuations and condensations of society at large.3 In a 2004 special issue of Social Science &
Medicine, van der Geest and Finkler (2004) contrast new hospital ethnography with earlier
functionalist models, noting that
life in the hospital should not be regarded in contrast with life outside the hospital, the
real world, but . . . is shaped by everyday society. The hospital is not an island but an
important part, if not the capital, of the mainland. (p. 1998)
Just as historical and social events are shown in fictional depictions as flowing over hospital
boundaries, so too recent articles have emphasized the permeability of the hospital: the movement
of patients, staff, and visitors in and out of the institution and the social relationships, inequalities,
and cultural values that they carry with them (e.g., Mooney & Reinarz, 2009; Quirk, Lelliott, &
Seale, 2006). Moreover, it is argued that those social and cultural continuities are not merely
external impingements on biomedicine. Biomedical practices and diagnostic styles are themselves adapted to the social and cultural conditions of the country in which a hospital is located
(e.g., Finkler, 2004; Gibson, 2004; see also Berg & Mol, 1998).
In addition to the portrayal of hospital boundaries as permeable, hospital ethnographers have
proposed that we think of the hospital as a reflection or microcosm of the larger social domain in
which it is located. In this version, the hospital is a place where the core values and beliefs of a
culture come into view (van der Geest & Finkler, 2004, p. 1996), representing a condensation
and intensification of life in general (Long et al., 2008, p. 73). In a full-length monograph based
on fieldwork on the surgical ward of a public Bangladeshi hospital, Zaman (2005) argues,
[T]he hospital is not an isolated subculture or an island, rather it is a microcosm of the
larger society in which it is situated. A hospital ward is therefore a mirror that reflects and
reveals the core values and norms of the broader society. (p. 18)
As with their fictional equivalents, such depictions of the hospital as permeable and microcosmic present it as window onto the society where it is situated. Hospitals are recognized to be
performed in culturally and regionally variable ways.
However, while such accounts rightly contest models of a monolithic biomedical ordering
of space, their emphasis on spatial continuities risks effacing the otherness and unfamiliarity
of hospital spaces. In other words, if hospitals are simply reflections of society, what makes
them hospitals at all? The contributors to this special issue all continue to be intrigued by the
uniqueness and peculiarity of hospital spaces. However, they do not associate the otherness of
the hospital with a homogenous biomedical culture. Rather, they argue that hospitals are notable
for the intensity and heterogeneity of the ongoing spatial ordering processes, both biomedical
and other, that produce them. Furthermore, they question the easy invocation of larger society
in relation to hospital space by asking where we are to locate the boundaries of such social
influence, whether in regional, national, or transnational frames of reference.
We argue that the hospitals seemingly paradoxical status as both bounded and permeable
is crucial to its constitution as a hospital. Hospital spaces are often regulated, standardized, and

Space and Culture 15(1)

ordered according to biomedical and bureaucratic knowledges in order to align disparate

doctors, nurses, relatives, patients, technologies, and spaces in the diagnosis and treatment of
diseased bodies. At the same time, the hospital is necessarily open and permeable because
these technicalspatial arrangements do not act on isolated microbes that have been primed for
laboratory analysis but on disease as it is found in the real world; and the unpredictability
and complexity of that world enters the hospital with disease. To deal with such contingencies,
biomedical practices often develop in ways that destabilize fixed roles and afford practical
variability (Mesman, 2012; Mol, 2002; Singleton, 1998; White, Hillman, & Latimer, 2012).
Meanwhile, in places of resource shortage such as Papua New Guinea (Street, 2012), Kenya
(Brown, 2012), and Tanzania (Sullivan, 2012), the contributions to this special issue show that
biomedical orderings of space are particularly fragile (instruments break, doctors and nurses
are too expensive, there are not enough beds or metal number plates to pin to them). In such
places, hospitals often depend on other orderings, such as domestic kinship practices, to prop
up their medical functions. Permeability is shown to be a crucial asset at the same time as
incongruities between different orderings are shown to lead to potential contestation and
dispute.
The hospitals status as a simultaneously open and bounded space in the ways we have
outlined above means that it is necessarily constituted by multiple concurrent orderings of space,
both biomedical and nonbiomedical.4 It is to this issue of multiple orderings that we now turn in
relation to a discussion of the concept of heterotopia.

Hospital Heterotopias
For Foucault, the opposition of the hospital to everyday life makes it an archetypal heterotopia,
a space that is simultaneously real and imagined, constructed in relation to all other spaces. In
the few comments that Foucault made on heterotopias, in a lecture given to architects in 1967,
he argued that space is not an empty void in which individuals and things are located but rather
consists of multiple heterogeneous sites that are defined by their relationship to one another.
Heterotopias are unique sites that are both related to and defined in opposition to all other sites;
they present an alternate social order that disrupts or inverts the social relations that characterize
those other social spaces. They are a kind of effectively enacted utopia in which the real sites,
all the other real sites that can be found within the culture, are simultaneously represented,
contested, and inverted (Foucault, 1986, p. 24).
Like asylums and prisons, hospitals are what Foucault calls heterotopias of deviance
designed to deal with persons whose bodies are considered to diverge from societys norms relating to health. The hospital is the actualization of a utopian vision of scientific order, cleanliness,
and rationality, existing in opposition to and separated from the messy reality of everyday social
space (Foucault, 1986). Foucault describes how, through the exclusion of familiar everyday
space, the hospital emerges as a site (sight) of medical surveillance and discipline, a laboratorylike setting where, under the penetrating gaze of modern medicine, the symptoms of disease can
be diagnosed and treated (Foucault, 2003).
Heterotopias are, according to such a view, intrinsically ambiguous spaces. They are both
constituted by their relationship to other spaces and defined in opposition to them; they involve
a complex ordering of opening and closing that both isolates them and makes them penetrable
(Foucault, 1986, p. 26). However, it can be said that Foucault overemphasizes the efficacy of
panoptic regimes of spatial control (Elden, 2003; Gibson, 2004) and overlooks the contested
and multiple nature of hospital space even as he argues that such qualities are central to other
heterotopic sites such as the theater, cinema, or oriental garden, which are capable of juxtaposing
in a single real place several spaces, several sites that are in themselves incompatible (Foucault,

Street and Coleman

1986, p. 27). Foucaults analysis of hospitals as spaces of discipline and surveillance has been
widely taken up by social scientists interested in processes of subjectification and relationships
between space and power (e.g., Elden, 2003; Gibson, 2004; Philo, 2000; Prior, 1988; Rhodes,
1995). Rather than seeing such disciplinary orderings as totally determining of hospital space,
however, the contributions to this special issue emphasize the relational, contested, and multiple
nature of heterotopias and their capacity to change over time (Foucault, 1986).
In this regard we follow Kevin Hetheringtons (1997) definition of heterotopias as spaces
where different kinds of social ordering, which can be either transgressive or hegemonic, are
tried out. Hetherington argues that heterotopias are neither panoptic spaces of control nor
marginal spaces of freedom but are constituted by multiple and often incongruous processes of
social ordering. Hetherington describes, for example, the juxtaposition of bourgeois shopping
arcades and gardens with brothels and coffee-houses in the heterotopic Palais Royal in Paris at
the end of the 18th century. Here new bourgeois codes of behavior, modes of political mobilization
and transgression, and new economic rationalities emerged in contradistinction to the royalist
spaces of Parisian society (Hetherington, 1997). Hetherington uses the notion of orderings
rather than orders to draw attention to the incompleteness and contingency of any sociospatial
arrangement (see also Law, 1994). The alternate bourgeois social orderings of the Palais Royal
were, he suggests, performances made possible through the bringing together of physical
spaces, technologies, representations, and persons in new configurations of the social.
This focus on alternate orderings takes the contributors to this special issue beyond the
opposition of panoptic regimes of biomedical regulation and practices of resistance to consider
the multiple processes of ordering that are performed in everyday relationships between buildings, technologies, and persons. In this view hospitals are not defined by a distinction between
biomedical and nonbiomedical space but are made up of multiple internal and external spaces
whose relationships change over time with shifting configurations of actors.

Fragile Assemblages
Given our focus on contingencies in material and social orderings, we believe that an enquiry
into the spatiality of hospitals requires hospital ethnographers to look beyond medical anthropology and sociology in order to engage with theoretical and methodological approaches where
such themes have been extensively explored, such as Science and Technology Studies (STS) and
both cultural and medical geography.
Recent interest in spatial relationships in STS has highlighted the importance of the material structuring of space, not as a fixed background for social and cultural action but as an
ongoing process of alignment between different human and nonhuman entities (Gieryn, 2002).
This emphasis on associations between human and nonhuman actors draws attention to the
contingency and fragility of any spatiosocial arrangement. Laboratory studies, for example,
have demonstrated that the status of the laboratory as a place where authoritative knowledge
can be produced is not given but must be achieved through everyday material practices such
as the calibration of scientific instruments or the standardization of test tubes, lab benches, and
Petri dishes (Knorr-Cetina, 1999; Latour & Woolgar, 1986; Livingston, 2003).
In contrast with the laboratory, where spatial practices are often focused on the attempt to
eliminate contamination between laboratory and world, the hospital is constituted as a place of
biomedicine through technical and bureaucratic ordering processes and at the same time must
be made open to the alternative orderings of the world it seeks to improve, including those of
kinship, religion, or development.5 In this regard, the hospital is an intrinsically more open and
perhaps more democratic space than the scientific laboratory. Biomedical orderings of hospital
space depend on alignments with persons and things that may already be engaged in alternative

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Space and Culture 15(1)

orderings. The fragile balance of the hospital as a simultaneously bounded and permeable space
is maintained through alignments between multiple and often incongruous practices of ordering,
which might be medical, bureaucratic, religious, economic, or kinship-based.
It is perhaps for this reason that recent STS research on hospitals has challenged laboratory
studies emphasis on stability as a prerequisite for the durability of scientific networks. Those
hospital studies have shown instead how the fluidity and adaptability of biomedical practices and
knowledge can be crucial for the generation of effective care relationships in hospital spaces
(Berg, 1997; Berg & Mol, 1998; Mol, 2002, 2008; Mol & Law, 1994; Moreira, 2006; Singleton,
1998). Unstable identities, interferences between heterogeneous knowledges and productive
uncertainties, are described as crucial to the durability and workability of hospital networks.
It is notable, however, that STS studies of hospitals have tended to focus on the relationships
entailed by biomedical achievements, neglecting the nonbiomedical work and worlds that are
often incorporated into hospital space. Moreover, the STS focus on expert systems and materiality can lead to a neglect of the role of imagination and emotion in the constitution of hospital
space. As technologies of social progress, development, and modernity, hospitals are spaces of
hope that are oriented toward and anticipate a better future (Street, 2012; White et al., 2012).
They are also spaces of hope in a second sense in that both patients and relatives may invest them
with their hopes for a diagnosis, treatment, and cure (Vecchio Good, Good, Schaffer, & Lind,
1990). The fact that both social futures and individual lives are perceived to be at stake in hospital practices requires that hospital ethnographers attend to the experiential, emotive, and imagined qualities of space and explore their interrelationship with the material spatial orderings
revealed in STS approaches.
Recent developments in medical geography, which build on theoretical developments in
critical cultural geography (e.g., Massey, 2005; Soja, 2003; Thrift, 2007), have led to an
increased focus on the importance of place in the organization of health care and have
emphasized the ways in which medical institutions are invested with cultural meanings.
Scholars such as Gesler (1991) and Kearns (1993) have drawn on the tools and concepts of
cultural geography and anthropology to analyze the symbolic structuring and lived experience
of therapeutic landscapes (Gesler, 1992, 1993). Such studies have shown that hospitals are
dense with symbolic significance, repositories for individual and collective memories, and
places of sentiment and familiarity.6 Like actor network theorys examination of associations
between humans and nonhumans, the notion of therapeutic landscape moves beyond a materially determinist reading of the physical environment to emphasize the ongoing and mutually
transformative relationships between people and their environments. Unlike STS, however,
studies of landscape in anthropology and cultural geography have often framed their inquiry
in terms of the symbolic relationships between landscape and meaning, emotion, and memory
(e.g., Basu, 2001; Bender, 1993; Massey, 2005). We argue that hospital ethnography is a
particularly effective means of exploring relationships between biomedical and other kinds of
space and has the potential to draw insights from STS together with medical geographys focus
on place and landscape.
The contributions to this volume take a variety of approaches for bringing together an STS
emphasis on configurations of physical environment, technologies, and persons with medical
geographys emphasis on peoples imagined, emotional, and sensual experiences of hospital
spaces. In the remainder of this introduction, we outline three thematic frameworks through
which the articles explore these issues in relation to the heterotopic and contingent qualities of
hospital spaces: boundary work, generating scale, and layered space.

Street and Coleman

11

Boundary Work
The contingency of hospital space is best exemplified through the emphasis in several of the
articles on the ongoing boundary work (Gieryn, 1983; Star & Griesemer, 1989) through which
the hospital is established as a space that is simultaneously distinct from and related to other
social spaces. Jessica Mesman describes the huge amount of work necessary to establish the
neonatal intensive care unit (NICU) ward of a Netherlands General Hospital as a safe space.
This involves a tacit relationship of collaboration between the physical environment (air locks,
isolation rooms), mobile and immobile technologies (oxygen canisters, incubators), and
multiple team members (doctors, nurses, technicians). Mesmans piece perhaps comes closest
to an archetypal image of hospital space as isolated, tightly ordered, and populated by highly
specialized technologies and authoritative experts. However, her article demonstrates the substantial effort required by all members of the team to maintain this isolation through the proper
alignment of people, technologies, and the built environment. There is nothing given about the
boundary around the NICU; moreover, that boundary is established in spatial practices that are
diffused throughout the ward and not only through clear physical boundaries such as the air lock
at the entrance to the ward. Mesman shows that the maintenance of a safe spatial order not
only involves static regionalization and compartmentalization but also dynamic mobility work
(Bardram & Bossen, 2005) that enables the alignment of multiple care and safety practices
across different spaces. Significantly, this boundary work separates the NICU from an external,
disordered world outside the hospital; it is also necessary to set this ward apart from the other
internal spaces of the hospital and to isolate particular patients within the ward.
White, Hillman, and Latimer similarly explore the ways in which specialized spaces of care
are maintained in a Welsh hospital through practices of division that sort patients out and
determine their access to hospital resources. The authors compare the moments of access that
define the specialized arenas of A&E, intensive care, and genetics. They point out that the dual
logics of efficiency and care by which access is determined shape the actions of patients who, by
acting as responsible citizens, simultaneously determine their access to the hospital and become
complicit in the maintenance of its boundaries. Importantly, these boundaries do not map onto
the perimeter wall of the hospital but can extend into the home where genetics clinic sessions are
held, or are enacted in the corridor as consultants ascertain whether a patient can be admitted into
ICU or should be sent to the operating theater.
The importance of internal boundary work and the capacity of spaces, conceptualized as
configurations of material and discursive practices, to move in and out of the hospital are taken
up by Brown in her account of relationships between domestic and biomedical space in a
Kenyan hospital. Brown describes how Luo domestic space, with its gendered ethics of care,
is reconstituted by relatives within the hospital alongside biomedical care practices. The multiplicity of hospital space leads Brown to argue against assumptions that biomedical authority
maps neatly onto the physical boundaries of the hospital. Instead, she shows how differences
between biomedical and nonbiomedical space are established internally through discursive
and spatial practices that separate medical and familial care practices and delimit the kinds of
work relatives, nurses, and doctors are expected to do in the ward. Following a previous
special issue of this journal edited by Michael Schillmeier and Miquel Domnech (2009) on
care and the art of dwelling, we might consider care as a fragile and precarious achievement
integrally related to experiences of place and of being-at-home, which usefully cuts across
distinctions between hospital and home. Like White, Hillman, and Latimer, Brown shows how
biomedical distinctions are drawn between good/appropriate and bad/inappropriate patients,
but her analyses of boundary work are perhaps most poignantly expressed in her discussion of
the importance of the patient file in promoting desired flow in and out of ward spaces. A

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Space and Culture 15(1)

filewhich needs to be purchased by a patientbecomes a metonym for the patients identity

and embodied engagement with bureaucratic procedure.

Generating Scale
It is not only the distinctiveness of hospital space that is contingent on everyday spatial
practices. The contributions to this special issue also demonstrate the importance of the
work that goes on in hospitals for the production of national and global space. Recent
hospital ethnography has tended to depict hospitals as either reflections or microcosms of
wider cultural processes. Hospitals are sites where global cultural forces, such as those of
biomedicine, are domesticated in relation to the national and regional cultures where the
hospital is located (e.g., see van der Geest & Finkler, 2004). In this view, hospitals are hybrid
microcosms of Western and national cultures. The approach to hospital ethnography that we
have proposed above, which emphasizes the contingency and heterogeneity of hospital space,
leads to an inversion of this scalar relationship.
Rather than analyzing particular hospital spaces as instances of wider societal or global forces,
we propose that the hospital can be seen as one site among many where we can observe national,
global, and regional space in the making. In his study of the response to the potential SARS
(severe acute respiratory syndrome) epidemic in Canada, for example, Michael Schillmeier
showed the hospital to be a crucial space where precautionary systems of quarantine and
classification constituted SARS as a global risk at the same time as they sought to prevent the
globalization of the SARS virus. Global space and scale in this view are an effect of the ability
of sociotechnical networks to travel. The process of becoming global is always local
(Schillmeier 2008, p. 196; see also Law & Hetherington, 2000).
Such an approach to scale does not take the global or national status of the hospital for
granted but asks how global, regional, or national space is constituted through the enactment
of hospital assemblages in multiple places. In this view, when the assemblages of buildings,
technologies and persons travel to several locations, or, as the articles here show, when hospital
assemblages hang together precisely because of their fluid and mutable ability to change
their configuration in different places (Mol & Law, 1994), global space is established. The
contributors explore hospitals as global assemblages (Ong & Collier, 2005): institutions that
are constituted and made meaningful through their relationships with places elsewhere
(Massey, 1991).
This point is illustrated most clearly in the article by Noelle Sullivan, which shows that
producing global space in a Tanzanian hospital is no easy endeavor. Here some spaces, such
as the donor-funded HIV clinic, are established as global through processes of standardization, whereas others, like the public ward, remain resolutely local. Sullivan also notes how the
successful production of the hospital as a national space of development is dependent on the
simultaneous implementation of standardized modes of governance by the Ministry of Health
and international donor organizations. Even in the HIV clinic, however, such systems of
national and global governance depend on the efficacy of written protocols and the durability
of technologies such as computers and laboratory equipment, which remain fragile in the
Tanzanian environment. Brown similarly describes the interdependency between spaces that
we might otherwise presume to exist at different scales. She notes how relationships between
mothers, sisters, money, household objects, and food reconfigure the hospital as a domestic
Kenyan space and at the same time support and enable the hospital to operate as a global
space of biomedicine.
Meanwhile, the article by Street illustrates the importance of hospitals as technologies for the
production of national space. In Papua New Guinea, the hospital is not a reflection of the nation

Street and Coleman

13

but a site where intensive nation-building efforts are carried out. Developing physical infrastructure
is central to these efforts, but the unequal distribution of that infrastructure coupled with its rapid
deterioration lead to the indefinite postponement of stable national space.

Layered Space
Ethnographic approaches that construe the hospital as either island or mainland tend to
portray hospitals as static and ordered. By contrast, the proposed focus on contingent processes
of ordering that make up particular hospital spaces brings the historical and dynamic nature of
hospital space into view. The comparison of multiple internal and contested orderings that is
undertaken by all the contributors demonstrates the instability of any particular spatial configuration and draws attention to its propensity for transformation. Although instability can be
said to be true of any kind of space, following the approach outlined here, we suggest that it is
especially true of modernist spaces, such as hospitals, that are specifically intended to contribute
to processes of social improvement and development. If hospitals are to be successful in
improving society then they must also undergo constant development in line with the latest
expert opinions on medical intervention, organizational theory, and statesociety relations.
The historicity of space plays a central role in several of the articles. Sullivan explores the
changing shape of the hospital landscape as processes of decentralization and neoliberal reform
that have gained momentum since the 1990s make the hospital management dependent on donor
contributions from international organizations, including the World Bank and the World Health
Organization. She argues that these new alliances between local and international institutions
have enabled the flow of substantial resources into the hospital, changing the kinds of care
practices that are possible, at the same time as they have enacted the hospital as a space of
inequality through the enclaving of particular hospital spaces for donor investment.
Streets article reflects on another implication of hospital improvement: the constant redesign
and rebuilding of hospital spaces in line with changing notions of progress and biomedical
ideologies. As Streets Papua New Guinean case study shows, a hospital never corresponds to a
single, static design but consists of overlaid physical structures that must jostle and contend with
one another, generating ambivalent responses in those who inhabit them.
White, Hillman, and Latimer also explore a situation where two different rationalities of
governance, associated respectively with the postwar welfare state and post-Thatcher neoliberal
reforms, are folded into one another in practice. Neoliberal logics of efficiency come to
structure moments of access alongside the welfare logic of care. The authors argue that
patients are increasingly co-opted into bureaucratic orderings as they learn to manufacture
themselves as responsible, self-governing citizens. But bureaucratic practices of categorization
continue to be framed in the moral discourse of care. The tensions and alignments between
these two rationalities come into view with the spatial governance strategies that accompany
perpetual questions of access. Overall, then, these three articles demonstrate the value in
exploring historical processes of layering alongside the horizontal relationships between
spatial orderings that have been discussed in previous sections.

Conclusion
A volume that focuses on the multiple enactments (Mol, 2002) of hospital space is crucial
to understanding both the intrinsic spatiality of biomedical practice and its situatedness in
particular places that are never exclusively biomedical. The articles in this special issue exemplify an approach to hospital heterotopias that recognizes hospital spaces contingency rather
than panoptic qualities, and that explores such contingency ethnographically through a focus
on boundary work, the constitution of regional, national, and global space, and on hospitals

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Space and Culture 15(1)

internal multiplicities and historical layering. These aspects of hospital space are illustrated in
their comparative dimension by very different ethnographic examples drawn from Wales, the
Netherlands, Papua New Guinea, Tanzania, and Kenya.
The authors explore the connections and disconnections between these hospitals through the
flows and nonflows of capital, technology, knowledge, and persons. In their totality, the articles
reveal the hospital to be what Mol and Law (1994) call fluid space, involving relationships
between humans and nonhumans that are resilient and able to travel precisely because of their
ability to change configuration in relation to the other humans and nonhumans that they meet
along the way. Particular spatial arrangements of persons, buildings, and technologies assemble
institutions in Tanzania, the Netherlands, and the United Kingdom as hospitals, but those replications are never identical. Differences might be as stark as the presence or absence of an ICU unit,
or as subtle as the distance between beds. However, the stark spatial differences between the
NICU in the Netherlands or the Genetics clinic in Wales and the public hospital wards in Papua
New Guinea, Tanzania, and Kenya also draw attention to the important spatial inequalities that are
perpetuated through those very adaptive capacities. Paying attention to exactly what travelsis
made globaland what does not is as important a contribution to understandings of space and
power as the analysis of the disciplinary capacities of particular institutional spaces.
Rather than focusing on hospitals as bounded places the hospitals presented emerge as
translations of one another, both different from and partially connected to each other through
the global transfer and transformation of the built environment, persons, and technologies. A
hospital can be understood as a material condensation of multiple spaces, which are both contradictory and contested. The hospital is both like home and unhomely, both scientific and religious,
both isolated and permeable, a place of both visibility and invisibility. It is this intrinsic complexity of hospital space that makes the hospital both a prime setting for fictional drama and a crucial
site for exploring relationships between planned, imagined, and lived space.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The Foundation for the Sociology of Health and Illness funded the workshop on which this special issue
and introductory article are based. Alice Streets research for this article was financially supported by the
ESRC and The Nuffield Foundation. Simon Colemans research on hospital chaplains was funded by NHS
Estates.

Notes
1. The contributions to this special issue were all originally presented at a workshop held at the
University of Sussex in 2009 titled Institutions, Collaborations, Power: Workshop on Hospital
Ethnography. We are grateful to the Foundation for the Sociology of Health and Illness for their
financial support of this event. We also thank Rebecca Prentice who acted as a co-convener of the
event.
2. Many of those early ethnographies took a functionalist approach, dealing with the hospital as a complex social whole. Only one study by Duff and Hollingshead (1968) addressed the dysfunctional
aspects of hospital life, exploring the way in which hospital orders reflected and further entrenched
class and racial inequalities outside the hospital, frequently leading to misdiagnosis and poor
standards of care. Meanwhile, Foxs ethnography of an experimental cancer ward portrayed the uncertainties and ethical dilemmas experienced by both patients and doctors in the hospital when it was an
explicitly experimental space (Fox, 1974).

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15

3. An interesting conflation of political ideologies and discourses of democracy and transparency was
provided by the so-called Patients Charter, produced by the United Kingdom National Health Service
in 1991, under the conservative government of the time. Ironically, the Charter gained little visibility
among patients and was abolished after 10 years.
4. Colemans fieldwork among hospital chaplaincies has explored a further variation on such ambiguous
orderings of space, focusing on the congruities and incongruities between religious and biomedical
discourses and practices in a large hospital in the north of England (see, e.g., Macnaughten et al.,
1995).
5. Hospitals are in this sense more similar to the field trial, which requires a careful balancing act
between asserting and relinquishing scientific control (e.g., Henke, 2000).
6. A claim that is embodied in the use of the term landscape as opposed to space (see, e.g., Hirsch,
1995).

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Bios
Alice Street is a Nuffield New Career Development Fellow in the Department of Social Anthropology,
University of Sussex. Her research interests include biomedical technologies, religion, and kinship
relationships in Papua New Guinean hospitals. She is currently working on a project exploring managerial
technologies and state-building in the Papua New Guinean health system.
Simon Coleman is Jackman Chaired Professor at the Centre for the Study of Religion, University of
Toronto. His interests include the globalization of religious forms and the intersections between religion
and health. He has conducted research on hospital chaplaincies in the north of England, pilgrimage to
Walsingham in Norfolk, and discourses of health and wealth among both Swedish and Nigerian charismatic
Christians.