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At Princess Marina Hospital in Botswana, the cancer ward is vastly different from those in the Global North. It’s the country’s only public oncology unit, with limited beds, outdated machines, and frequent medicine shortages painkillers like morphine (Livingston, 2012). Many patients arrive with late stage cancer, often while also managing HIV, due to lack of early screening and stigma (Tapela et al., 2023).

In contrast, cancer wards in the U.S. or Europe have advanced imaging, multiple specialists, and consistent access to pain relief. This difference reveals how global healthcare inequality isn’t just about access but also about resources, infrastructure, and cultural context.

Princess Marina shows that even with universal healthcare, care quality depends on systems that support it like trained staff, functioning machines, and community trust.

At Princess Marina Hospital in Botswana, doctors tend to interact with cancer patients in a direct, clinical manner, often delivering difficult news bluntly due to time constraints and high patient loads. In contrast, doctors in the Global North typically follow structured, empathetic communication models like SPIKES, allowing for more patient involvement and emotional support (Livingston, 2012; Baile et al., 2000).

Nurses at Princess Marina fill that emotional and cultural gap offering comfort, spending more time with patients, and translating medical language into everyday terms. Their role is vital in a setting with limited resources and few counselors, making them the primary source of compassionate, day to day care (Livingston, 2012).

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3. Livingston argues that caregiving is a moral endeavor because it involves profound ethical considerations and responsibilities. Caregivers often face complex decisions about how to best support someone's well-being, manage their pain, and respect their autonomy. This requires a deep sense of empathy, patience, and commitment. For example, a caregiver might need to decide whether to prioritize a patient's wish to remain at home versus the need for more intensive medical care in a hospital.

4. Livingston describes cancer as a disabling or debilitating illness by highlighting how it can significantly impair a person's physical, emotional, and social functioning. Viewing cancer as a disability changes our understanding of it by shifting the focus from solely medical aspects to the broader impacts on a person's life. Through the social model of disability, cancer-related impairments are seen not just as individual health problems but as societal issues where barriers and attitudes can disable people. This perspective encourages us to create more inclusive and supportive environments for those living with cancer.

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3. Livingston arguing this means that providing care in Botswana’s care ward was not only just a technical or clinical task, but was also a deep emotional responsibility. An example of this is shown in pages 93-100, which explains how nurses have to comfort dying patients along with already dealing with resource shortages, exhaustion, and so many other things. All of the staff continued to provide the best care possible knowing that they may not survive, which all goes to show that a duty as such becomes a form of dignity and commitment.

4. Livingston describes cancer as physically and socially disabling, specifically when it causes disfigurement or loss of mobility. As explained in pages 70-73, patients with facial tumors and amputations for example face heavy social isolation and stigma, not just physical pain. Through the social model of disability Livingston shows that an individuals illness isn’t the only thing causing suffering as the lack of support and infrastructure also play a key role. Viewing cancer this way shifts the focus from an individuals pain to a larger, social responsibility.

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How does Livingston describe cancer as a disabling or debili

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1. How is the cancer ward in Princess Marina Hospital different than cancer wards in hospitals in the Global North? What does this reveal about healthcare in different global contexts?

The cancer ward at Princess Marina Hospital, in Botswana, is very different from many other cancer wards in more profitable countries like the United States and Canada. In the Global North, places like the United States and Canada, they usually use treatments like heavy machines, various doctors, a lot of different medicine choices, and different ways to relieve pain. People in the Global North usually get treated earlier on and have a better chance of surviving altogether. But in Princess Marina, things are totally different. The hospital does not have any kind of advanced technology. They ran out of medicine pretty quickly leaving some patients without chemotherapy drugs. They only had one oncologist the entire time that Julie was there visiting. The facility Is usually very overcrowded and never has enough beds for all the patients at a time. Most of the time patients only come to the hospital when their cancer is very far ahead, this makes treatment so much harder and chances of survival more slim.

2a. How do the nurses and doctors in the cancer ward interact with patients differently than nurses and doctors in the Global North?

In Princess Marina the doctors really only focus on the facts like symptoms and the test results. They have a lot more patients and very few doctors, so they are always in a rush to provide medicine and then get to their next patient. While the nurses, they do tend to have a much closer relationship with the patients. They have more time to talk with them more, help them eat when they need it, clean them up after a long day, and comfort them when nobody else is there. Nurses can become a patient's family, especially since a lot of patients are in the hospital for weeks or even months at a time and during that time people start to slow down on coming to visit them. Then all there is, is the nurse that they see everyday.  However in the Global North, doctors and nurses appear to be more distant and focused only on helping to an extent. Patients are in and out more quickly, providing less time with their physician, therefore nurses may not get to know them as well. There are a ton of pros, there’s more technology and machines, more structure and organization, and more specialists and doctors doing different parts of the same job. That allows for a better outcome of the job.

2b. How do the doctors in the cancer ward interact with patients differently than the nurses? Why are the nurses so important in this context?

Doctors mostly deal with physical illness such as the disease. They are the ones to diagnose and try to treat the cancer, although they don’t have many tools to actually heal the cancer. They don’t really have the time to sit and talk on a deeper level with each of their patients. The nurses are there all the time with their patients. They are with the patients every day, all day. They help manage pain and give out medicine when the patient needs it. They listen to the patient's fears and emotions throughout their time in the hospital. If the time comes, they are usually there when the patient passes away. Therefore nurses are very important, especially in a place where there are very few doctors and little medicine like in Botswana, emotional care can really help more than ever. They provide the hospital with energy that feels like care, and not just survival.

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5. How does Livingston position cancer as far more than a biological, individual disease? In what ways is cancer social, political, economic, and cultural?

Julie Livingston explains that cancer in Botswana is not just about the body. It is also shaped by people, money, politics and culture. Cancer care depends on family, friends, and nurses because the hospital does not have enough staff or supplies. There is only one cancer doctor, and medicine and machines often break or run out.

The government and other countries help, but there are still many limits. Hard choices will be made about who gets care, like who gets rare medicine or blood. Culture also shapes cancer Most people do not find cancer early because there are no tests like in the U.S. Many are scared to find out they have cancer, especially if they also have HIV. Livingston shows that cancer is not just a sickness in the body, but is also part of life, money and society.

3. Livingston argues that caregiving is a moral endeavor - what does she mean by this? Provide specific examples.

Julie Livingston says that caregiving is a moral act because it’s not just about giving medicine or doing treatments is also about kindness, patience, and respect for sick people. In the cancer ward, nurses and family members do much more than just help with health. They bring food, wash clothes and sit with patients so they don’t feel alone. These small acts of care show love and dignity, even when there is no cure.

One example is how families travel long distances to visit, bringing gifts like juice or bananas to comfort the patients. Nurses also joke and talk with patients to make them feel human, not just like sick bodies. The doctor brings fruit to share with the staff and patients. These actions show that care is not only about fixing the body but also about giving hope, respect, and connection even when the end is near.

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3. Livingston views caregiving as a moral endeavor because of its ethical elements, such as bedside manner and patient treatment. Livingston refers to this as a “form of critical sociality based on incommensurate experience” (p. 7). This is her way of expressing the effect of the connection care brings along and how impactful it can be.

5. Cancer is more than just a biological disease by a long shot. Livingston explains this by speaking on the arise of cancer, referring to it through “political, economic, sociocultural, technical, and biological circumstances” (p. 52). This goes hand in hand with how cancer is heavily influenced by healthcare systems as well as its politics and poverty. Cancer treatments aren’t cheap, therefore aren’t accessible to everyone. This also goes for those across cultures and countries. Livingston wrote, “Its promise is crafted out of the social, political, and demographic imperative to care for the sick that lies at the heart of Botswana’s unusually robust social contract. Its form is marked by the contingencies, grittiness, and empirical challenges of providing high- tech medicine in a public hospital where vital machines are often broken, drugs go in and out of stock, and bed-space is always at a premium” (p. 7).

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Question 2:

a: How do the nurses and doctors in the cancer ward interact with patients differently than nurses and doctors in the Global North?

In the article, it focuses on how the nurses in the oncology ward in botswana have a more personal and intimate relationship with their patients as compared to the global north it is more "medicalized". By this I mean it is more focused on treating the issue solely rather than also paying attention to the patients emotional and psychological state which I think is really sad. This highlights a lot of issues with the medicine in more "medically accelerated" countries. For example, in Botswana, they have to consistently improvise their medical practice and care due to shortages in their countries as well as other countries. This I would argue leads to a much more personalized and holistic approach to medicine. Here in the United States, it is quite rare to have shortages on medical supplies. I would use COVID-19 as an example of how a shortage in the US along with many other factors brought out a lot of emotional and physiological highlights of medicine and how improvising can be helpful sometimes as we can focus more on patients and healthcare workers mental and physical states while trying to balance the medical aspect of things.

b:How do the doctors in the cancer ward interact with patients differently than the nurses? Why are the nurses so important in this context?

Doctors in the "Botswana ward" have less contact with patients. Their part to play is often more diagnosis and and decision making for the patients so their is less contact. There are shortages on the essential tools to help diagnose and treat patients so I can imagine this leaves a cold interaction when you are treating patients in their late stages on cancer. Nurses are essential and work hard on the ward. Emotionally and physically they fight to provide daily care amongst shortages by providing emotional support. In this state, they are being treated more palliatively rather than trying to help cure the cancer due to the lack of technology and medical supply shortages.

Question 3.

Livingston argues that caregiving is a moral endeavor—what does she mean by this? Provide specific examples.

Livingston argues that caregiving is a moral endeavor because of it involves people that suffer from cancer. You are working to help them maintain their dignity and having to make some difficult ethical decisions due to shrtages on medical supplies which is super difficult because a cure may not be available or possible for the patient. She writes " care as a human moral imperative". While it is important to treat patients, often more than not, in the global north it is super difficult to find a healthcare professional or nurse to help with providing emotional care and consideration. Too much is medicalized.

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Prompt one:

One of the first differences I noticed is when they said …” sometimes with three or four patients crammed in together on makeshift seating, their intravenous lines stretching like the legs of an octopus from a pole in the center of a tiny room” (pg.3). The fact that multiple patients were receiving treatment in one room was interesting and different than how patients in the US receive treatment because they are usually in a room by themselves. Also when they mention “this is a hospital that lacks an MRI machine, mamography, and endoscopy, where the lone oncologist performs his own cytology on a donated microscope after clinic hours…” (pg. 20). When we think about our own hospitals many of our medical staff has access to cutting edge technology and have the staff to distribute work. Here its one person basically carrying the unit and making his own diagnosis. I know to be diagnosed with cancer here there is a lot of testing to confirm certain aspects of the cancer. Another thing I saw was that “nurses do not insert cannulas unless in the case of an emergency, so the oncologist dons gloves, ties tourniquets, and inserts needles to deliver tubes of chemo” (pg. 64). Doctors putting in a line is not something I’ve heard of usually nurses put in the line or give injections. There is also a lot of mentions of the equipment being old and even one thing being taken from the trash and fixed. I think the main point of sharing this is that our healthcare is so different because we have access to so much technology to assist our caregivers. We have ways to pre-screen for cancer while a lot of the patients that come into this hospital already are inoperable.

Prompt three:

The first example would be the fact that doctor P regularly spends time after clinic hours to look at samples and diagnose patients (pg. 20). There was also a part that stated “… there were often many days Dr. P would take care of the entire ward by himself, all of the outpatients, then administer chemo” (pg. 64). On the same page it also states, “ he pushes against the bureaucracy, striding in and out of the pharmacy, demanding the chemotherapy, asking the pharmacist to search for necessary supples or drugs as they go out of stock, delivering patients personally to radiology or surgical consults so that they are not set aside or delayed. He counsels the family of patients even “popping money” out of his own pocket..” (pg. 64). He technically didn’t have to do any of this for the patients, but he had to have felt some moral obligation to help these families and patients like he did.

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1. This is a two-part question. For both parts, be sure to provide specific examples.

a. How do nurses and doctors in the cancer ward interact with patients differently than nurses and doctors in the Global North? 19 &17

They interact with them differently than the Global North because they show more empathy/sympathy and are more intertwined with the patients personally. Instead of being like a ‘cold wall’ they get more in-depth of a relationship with the patient rather than just being the medical professional. Due to this, it causes “cancer to happen ‘between’ people” in the community and hospital because of. For example, on page 17 it states, “Botswana accepts advice and assistance from others, but it is also a nation that makes its own decisions and speaks its own mind when it feels it appropriate…..” (Livingston, 2013). It continues to talk about how, due to a lot of shortcomings, the public hospital faces both patients and medical professionals feel alienated and out of touch, so they humanize the cancer and rehumanize with each other, as it essentially states (Livingston, p. 19, 2013). These examples of more cultural rootedness in personal connections with the patient really sets them apart, whereas the Global North often will intellectualize the relationship between the patient and professional and not even get attached.

b. How do the doctors in the cancer ward interact with patients differently than the nurses? Why are the nurses so important in this context?

Doctors and nurses do interact with the patients differently; however, it should still be noted that doctors here still interact and have a more formed relationship with the patients than those typically in the Global North. Nonetheless, in chapter 4 it really reveals how personal the relationships between nurses and patients are. They even have a term that is ‘botho’ where it describes a fellow human being, and to which one you would care for as well, which perfectly describes how common and close these relationships occur and are (Livingston, pp. 93-94, 2013). Nurses, alongside the partner(s) of the patient help take care of them as it's described, which is common for all cancer patients to have this because nurses what to essentially be the mediator between ‘the moral boundary between harming and healing’ (Livingston, pp. 93-94, 2013). Whereas with the doctors, they often have to go to place to place and see as many patients as they can and pick up what they know during the process so their care and knowledge can get through more people, than having people sit in the hospital all day and not be seen (Livingston, p. 17, 2013). The simple fact they have a sample group of nurses to help take care of the patient alongside the partner once again showcases the intimacy they have with and for the patients (Livingston, pp. 93-94, 2013). Not to mention, although they act with professionalism,, nurses and patients alike are often Christian, so they use those practices and beliefs into the care with the patient, which has another dimension to it all and the framework of which they go about their care, but it also explains on why they are so close with the patients do to the spiritual/religious beliefs of most nurses and patients (Livingston, pp. 93-94, 2013). Once again though doctors are not noted to do the same, or to do so in such depth in comparison to the nurses, as again there are fewer of them so they can’t ‘disperse’ their resources and time to that necessarily, even though there is a shortage of nurses as well.

5. How does Livingston position cancer as far more than a biological, individual disease? In what ways is cancer social, political, economic, and cultural?

There are numerous reasons and intersections that occur within all these that have interrelated into their healthcare, and specifically with cancer. Just as in our last week’s reading even with psychiatric disabilities, there are many factors that come into play within the care people receive with their condition (Livingston, pp. 17 & 93-94, 2013). This of course includes culture, economics, and politics. Within the social realm as I described above the nurses create a community and circle with the patient and their partner to assist in their care to help with humanization, and what they refer to botho, which again showcases how deeply their culture is rooted within their care  (Livingston, pp. 17 & 93-94, 2013). Not to mention their religion also comes into play, their religion primarily being Christianity, can assist in their day-to-day care and their connectedness amongst each other on an individual level, making both the patient and nurse at ease/calmer (Livingston, pp. 17 & 93-94, 2013). With all of that being stated by Livingston, it shows how when an individual gets cancer, it occurs ‘between’ people at that level as it deeply affects others, and because that patient isn’t ‘another case’ or ‘another number’ (p 17, 2013). Having this overlap of social relationship and culture creates a special place for the nurses in these people’s lives, as they are that bridge for them  (Livingston, pp. 17 & 93-94, 2013). Nurses are often held in high regard and respected, despite most people not wanting to have to go or be in the hospital in the first place (Livingston, p. 17, 2013). Then regarding the political and economic intertwining in the same space. This is primarily due to the structure of the healthcare system attempting to do a ‘soft transition’ from what it formerly was, but also more recently, in 2011 there was a massive strike from medical workers as their conditions as medical workers were terrible (Livingston, p. 18, 2013). However, what made it an even more pressuring economic and political issue was due the extensive history and complexity. Livingston reveals, “Botswana government has prioritized the expansion and improvement of access to tertiary care in recent years. (us, new services like oncology have been developed within PMH, one of only two tertiary-care centers in the public healthcare system, as stop-gap measures while new broader institutional capacities are being developed, “ (Livingston, p. 18, 2013). This is great news; however, it shows the strain and other underlying issues of why the problems of the medical environment are occurring in the first place, due to the structural setbacks caused by economic and political issues. This, of course, is not new to healthcare, physical or mental care alike, as once again this is mirrored globally and once again in last week's reading with the cultural issues those with psychiatric disabilities face, along with legislative and even more structural issues those with mental health conditions face

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4.) Linvingston described cancer to be an illness that was debilitating or disabling. If we view it as a disability rather than an illness it changes my thoughts on it as it would restrict ones ability to do their daily tasks like walking. Labeling it as a disability may put a more negative attitude towards patients rather than giving them hope which helps the patients recover.

5.) Livingston puts cancer as more than just a biological disease. They show that cancer care in Botswana is shaped by global inequalities. A political issue in this would be from the policies through the government. Economically, poverty has limited access to diagnosis or certain treatments. A culture issue would be how certain people interpret the illness.

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2a. How do the nurses and doctors in the cancer ward interact with patients differently than nurses and doctors in the Global North?

The interactions between nurses and doctors in the cancer ward at Princess Marina Hospital (PMH) in Botswana differ significantly from those in the Global North. Healthcare providers, specifically nurses, form deep interpersonal connections with patients that profoundly impact their emotional and social well-being. This approach contrasts with the more formal and professionalized clinical practices typically observed in the Global North.

Doctors and nurses at PMH work under extreme resource constraints and face significant emotional burdens. Instead of relying heavily on technology, they focus on improvisation, warmth, and persistence in their care. For example, Dr. P is committed to seeing every patient on the day they arrive, regardless of how many patients come in. He believes that delaying care could lead to unnecessary suffering or death. He states, "I won’t save myself any work in this way unless the patient dies in the meantime while waiting for their appointment, and this is utterly unacceptable” (Livingston, 2012, p. 20). This approach contrasts more with physicians in the Global North, who typically work within tightly controlled appointment systems, supported by multiple staff members and sophisticated scheduling software.

Additionally, PMH lacks many of the technological resources commonly found in Western oncology. Patients often wait five or six hours or more for a consultation with the hospital’s sole oncologist. According to the reading, “This doctor not only manages an average of twenty-five outpatient visits each day, but also oversees the ward, completes paperwork, administers chemotherapy, and performs cytology in the evenings” (Livingston, 2012, p. 2). These challenging working conditions force clinicians to deliver care under pressure and uncertainty. As noted in the reading, “They illustrate how care proceeds amid uncertainty in the context of relative scarcity” (Livingston, 2012, p. 6).

In wealthier countries, patients generally encounter specialized systems with pre-scheduled diagnostics, advanced imaging, and comprehensive emotional and informational support. In contrast, the doctor-patient relationship in Botswana is influenced not only by medical needs but also by urgency, scarcity, and a shared sense of care born out of necessity. As Livingston highlights, “Biomedicine is a global system of knowledge and practice, but it is also a highly contextualized pursuit” (Livingston, 2012, p. 6), which is clearly reflected in the unique and deeply human ways that care is delivered in Botswana’s oncology ward.

2b. How do the doctors in the cancer ward interact with patients differently from the nurses? Why are the nurses so important in this context?

Doctors in the PMH cancer ward interact with patients differently from nurses because they have distinct roles, shaped by institutional pressures and the social context of illness in Botswana. Dr. P, for example, is responsible for diagnosis and treatment. However, due to the high volume of patients and limited resources, his interactions tend to be brief, clinically focused, and at times blunt. For instance, when a patient with esophageal cancer mentioned experiencing shoulder pain, Dr. P responded, “No! That does not matter,” quickly redirecting the conversation to the mass in the patient's neck and inquiring, “Can you swallow porridge?” (Livingston, 2012, p. 56). While his role is crucial for clinical intervention, he has limited time to address patients' emotional needs or engage with non-critical concerns.

In contrast, the nurses at PMH provide the continuous emotional and physical care that patients require. They feed patients, change beds, clean wounds, suction tracheostomies, and offer comfort through conversation. Livingston describes how a nurse playfully encouraged a patient to drink a nutritional supplement, writing, “Roger is trying with little success to drink a small carton of strawberry-flavored Ensure as Mma T encourages him in that matter-of-fact, joking way that nurses so often use to cajole their patients” (Livingston, 2012, p. 2). The nurses not only handle these repetitive and demanding tasks but also help sustain a sense of humanity and normalcy in the ward. According to the reading, “Nurses and nursing assistants must fill out endless paperwork and computer forms and must routinely translate the same basic explanations and instructions. They must suction tracheostomy after tracheostomy, change diaper after diaper, and make and remake beds” (Livingston, 2012, p. 22). Though these efforts may seem repetitive, they are important especially when providing consistent and compassionate care.

Nurses play a particularly important role in this context because they help patients understand their illness in a system where oncology is relatively new and cancer remains poorly understood. As the reading notes, “Lay expectations around the disease are still fragile, as is the vocabulary of symbols, words, and images” (2012, p. 54). Many patients arrive with little prior knowledge about cancer or its treatment. Nurses fill this educational and emotional gap, becoming trusted guides who translate complex medical processes into understandable terms. Livingston beautifully captures their cultural and emotional significance by describing the nurses as “angelic mothers with wonderful rolling laughter” (Livingston, 2012, p. x), emphasizing their important role in bridging the gap between clinical care and human connection.

Their presence not only supports the technical work of doctors but also helps patients navigate feelings of fear, confusion, and loneliness, making them vital pillars of Botswana’s cancer care system.

3. Livingston argues that caregiving is a moral endeavor - what does she mean by this? Provide specific examples.

Julie Livingston argues that caregiving in Botswana's oncology ward is not just a clinical task; it is fundamentally a moral act grounded in caring for those who are suffering. In her work, Improvising Medicine, she emphasizes that in a context marked by scarce resources and uncertain outcomes, care is evaluated not by the ability to cure, but by ethical commitment and shared humanity. She states, “Care here was not about comfort, or necessarily about cure. It was about being with another through the throes of illness” (Livingston, 2012, p. 7). In this setting, caregiving evolves into a form of moral engagement that addresses suffering when medical interventions offer limited solutions.

One example of this is the way patients, nurses, and fellow patients engage in shared acts of care. Livingston illustrates a moment when a patient named Kenosi, who is dying of esophageal cancer, is supported by another patient named Fikile. Fikile gently cradles Kenosi while he vomits, stating, “She had been holding him, cradling him... and carefully placing a pan under his chin” (p. 24). This act, though not obligatory, reflects a moral ethic of care where patients support each other out of shared vulnerability and compassion. It goes beyond formal responsibilities; it embodies a human obligation.

Another example is Mma M., a ward nurse, who continues to provide care even when it significantly impacts her personal life. After studying oncology nursing in South Africa, she returned to Botswana, leaving her family behind for an extended period to share her expertise in the heavily understaffed cancer ward at PMH. According to the reading, Mma M. “had left her children in South Africa so she could return to Botswana to work in the cancer ward, which was severely short-staffed” (Livingston, 2012, p. 3). This act of self-sacrifice is depicted not as personal ambition but as a moral obligation to serve her country and her patients, despite the toll it takes on her personal life.

Additionally, Livingston explains how caregivers engage in emotional labor, using humor and tenderness to help patients endure painful treatments. For instance, a nurse employs gentle teasing to encourage a young man with lymphoma to drink a nutritional shake, stating, “Mma T encourages him in that matter-of-fact, joking way that nurses so often use to cajole their patients” (Livingston, 2012, p. 2). These small moments serve a purpose beyond just lightening the mood; they are acts of relational care that help preserve dignity, especially when technical interventions cannot provide relief.

Livingston explains that these actions, performed by nurses, doctors, or even patients, include a form of moral witnessing. According to the reading, “It was a way of being with another in the face of pain, deterioration, and a certain sort of time” (Livingston, 2012, p. 27). In this context, caregiving means not turning away from suffering, even when no further medical interventions are possible. It is a great representation of refusing to let individuals die alone, unseen, or untouched.

Ultimately, this shows that caregiving in Botswana’s cancer ward is defined not by the possibility of a cure, but by deep commitment to help their patients. It is a response rooted in ethics, community, and love. In her words, “To care for a person is to enter into a field of moral action” (Livingston, 2012, p. 6).

In the absence of technological solutions or medical treatm, caregiving becomes a moral practice, which is a form of solidarity and presence that ensures no one suffers alone.

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3. Livingston argues that caregiving is a moral endeavor - what does she mean by this? Provide specific examples.

Throughout the book, Livingston shows through patient and doctor/nurse experiences that caregiving (especially for those with cancer) is a moral endeavor. For example, in chapter one, Dr. P uses his voice in the newspaper to call out mercenaries and corrupt leaders in Africa. This can be viewed in a political tone, but also in a moral one. By using his influence and voice, he aligns his own personal morals and ethics into patient care. Later on in the chapter, we see how caregivers have to battle with the moral and ethical aspects of giving care to patients when supplies are low, “Yet the hospital blood bank only has five units total to dispense. How is Dr. P to decide how to distribute the platelets? Should each patient receive at least one unit? Or should all units go to the neediest case?”. We can see how these moral implications affect the caregivers personally and make it difficult to manage their work, “Yet some of the medical officers were so burned out from the grueling nature of their work that they would sometimes fail to show up for work, arrive late, or call in sick”. This is expanded on in the beginning of chapter four, describing the difficulties working in oncology, “Oncology is a domain of medicine where harming continually threatens healing in disorienting ways, for oncological therapeutic practices consist of poisoning, burning, and cutting”. For those working in oncology, these techniques can prove distressing for their personal morals. This proves especially hard for those in nursing specifically, because nursing is inherently more of a care-giving profession.

5. How does Livingston position cancer as far more than a biological, individual disease? In what ways is cancer social, political, economic, and cultural?

In this book, Livingston does a good job in centering sides of cancer that aren’t often thought about/brought up in Western society. These aspects consist of social, political, economic, and cultural implications.

Social: I personally think that Livingston writes in a way that highlights cancer as a social phenomenon well. One quote that stuck with me was: “Though cancer produces moments and states of profound loneliness for patients, serious illness, pain, disfigurement, and even death are deeply social experiences. Understanding cancer as something that happens between people is critical to grasping its gravity”. This projects an important sentiment that cancer is not just an individual battle, but a battle fought by both the cancer patient themselves and their community/family. Another example of how social factors connect to cancer can be seen in chapter three, “For an American woman, breast cancer will be a profound learning process, but even this fact is something she will have reason to anticipate. She will most likely know other women who have had breast cancer, she will see fundraising appeals, she might join a support group… But for most patients this vocabulary and set of expectations, this sense of what cancer is, will develop in large part through her own illness experience”. This highlights how a significant portion of our ideas and knowledge of cancer stems from social connection and community- and how lack of access to these connections affects cancer patients negatively in terms of when they decide to receive treatment.

Political/economic: I chose to combine the political and economic aspects of cancer into one because of how Livingston describes the intersections between these aspects. In the book, Livingston highlights political aspects of cancer that Western society doesn’t shine a light on. For example, in chapter one, Livingston brings up how Dr. P uses his voice in the newspaper to call out mercenaries and corrupt leaders in Africa. In doing this, it separates cancer from this idea of it being an individual problem and instead calls out how political forces affect cancer patients. Later on in the chapter, Livingston describes how the PMH oncology was assembled and how political and economical factors played a role: “The expertise that supports PMH oncology was assembled, in part, from African and European clinicians fleeing economic and political chaos elsewhere… Its form is marked by the contingencies, grittiness, and empirical challenges of providing high-tech medicine in a public hospital where vital machines are often broken, drugs go in and out of stock, and bed-space is always at a premium”. Additionally, Livingston dives into the differences in early cancer detection that exist between the West and Africa. In chapter three, Livingston dives deeper into how screenings and diagnostic education regarding cancer is also affected by political and economic aspects: “It takes an array of technological, intellectual, social, political, and economic circumstances to perceive these entities and make them widely accepted as facts… pre- or early-stage breast cancers (BRCA1 and BRCA2 genetic markers, ductal carcinoma in situ, and lobular carcinoma in situ) do not exist in Botswana”. Economic problems exist that limit the amount of early screening patients in Africa receive, leading to higher death rates in African patients. Additionally, Livingston connects the AIDS epidemic in Africa to the cancer cases seen in the countries multiple times throughout the book. AIDS is a heavily politicized condition both throughout the world but especially in African countries.

Cultural: There are many examples that Livingston brings up that highlight the cultural aspects that exist in connection to cancer. One example I found profound was when Livingston includes a memoir from Dr. Alfred Merriweather that talks about a case of an elderly woman with cervical cancer. In this story, it is highlighted that “She had advanced cancer of the cervix, the commonest cancer in Botswana, associated with early sexual activity and large families”. This brings up an important cultural factor into cancer: how it uniquely affects minorities. This book talks about women patients in particular, who experience cancer differently to their male counterparts (due to oppression and cultural norms, such as expecting women to bring forward large families). Additionally, the book mentions that many of the nurses who take care of cancer patients at work are also expected to take care of their family/sick relatives.

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I couldn't type my responses because they have reached the character limit. Please refer to the listed PDF.

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1. How is the cancer ward in Princess Marina Hospital different than cancer wards in hospitals in the Global North? What does this reveal about healthcare in different global contexts? Provide specific examples.

The cancer ward at Princess Marina Hospital contrasts a lot with the cancer wards in the Global north in many ways, all of which are disparities in resources for healthcare, their infrastructure, and cultural context. In Princess Marina Hospital, the cancer ward is described as an improvised setting, lacks resources, is overcrowded, and few diagnostic and treatment tools are available. They do not have the necessary equipment like an MRI machine, mammography, or even air conditioning in some treatment areas; some supplies like anti-nausea medications, morphine pumps, or even platelets are not very available. (Livingston, pp. 20–21). In comparison, hospitals in the Global North have advanced infrastructure, oncology specialists, and plentiful diagnostic options and capabilities. Overall, the oncology in Botswana is often forced to be improvised as patients arrive late is the progression of the diseases, and there is typically only one oncologist, as Dr. P, is caring for a vast number of patients per day as well (Livingston, p. 2). In the Global North, early detection is quite common as widespread screening programs are available for patients and allow for cancer to be treated early. An example is in Botswana for breast cancer patients they often get “toilet mastectomies” which are meant to rid the patient of a breast now profoundly disfigured by a necrotic, suppurating, and stinking mass. This is due to the lack of early detection tools, compared to the Global North lumpectomies, which are much more common (Livingston, pp. 53-54). These differences in healthcare systems are revealed and show how they operate with pollical, economic, and social frameworks. The Botswana a public healthcare model contrasts a lot with the Global North privatized and insurance-based system. But, contrary to the limited resources available Botswana has committed to giving free care for cancer patients to its citizens, which have an ethical root in national solidarity (Livingston, p. 17).

2. This is a two-part question. For both parts, be sure to provide specific examples.

a. How do the nurses and doctors in the cancer ward interact with patients differently than nurses and doctors in the Global North?

The nurses and doctors at Princess Marina Hospital interact with patients in a way modeled by systemic constraints and cultural norms. When looking at the more bureaucratic, impersonal systems that are used more commonly in the Global North, staff at Princess Marina Hospital can be more emotionally and socially rooted in the care process. Nurses like Mma T crack a couple of jokes, some like hearted conversation with the patients that will connect them deeper so they feel more heard and are more trusting in nurses like Mma T and allows them to motivated them to eat or follow instructions or teachings this a relationship between nurse and patient not very common in the Global north (Livingston, p. 2). This is mostly due to lack of time spent with patients or time available to talk as nurses are constantly moving and only have so much time to form a connection in the Global North. But Dr. P is rushed to appointments due to overwhelming patient loads. As a result, clinical encounters are very quick and lack the long bonding relationship and sharing decision-making process that we in the Global North value as we try and focus on patient centered care (Livingston, p. 20).

b. How do the doctors in the cancer ward interact with patients differently than the nurses? Why are the nurses so important in this context?

Doctors and nurses have supportive relationships but are vastly different when caring for their patients. While Dr.P is overbooked with the diagnostics, therapeutics, and administrative work she has, nurses play the role in the line of communication, emotional support, and continued care. Nurses often step in to provide teaching, calm fears, and maintain daily contact with patients. They make a bridge that helps the doctor that is overworked. For example, it is often the nurses who spot any changes and offer comfort during chemotherapy, and they provide social and emotional support when it is needed (Livingston, p. 2). Nurses are very much needed in this situation because they translate medical care into daily life support and provide a consistent presence in a ward that is constantly changing and filled with pain and with so many questions unanswered. They give a moral support, and a humanistic backbone to oncology in Botswana, and showing the importance of “effort, engagement, and attempt” Livingston, p. 7).

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3. In the case of oncology and caregiving, Livingston argues that caregiving is a moral endeavor because oncology is a learning process that causes the no harm rule to be frequently broken in favor of progress.

"Oncology is a domain of medicine where harming continually threatens healing in disorienting ways, for oncological therapeutic practices consist of poisoning, burning, and cutting" (Improvising Medicine electronic page 70).

She's arguing that by taking on the endeavor of caring for someone else in such an intimate way, that person's individual morals will be tested because at times they will have to put their patient over themselves or put one bioethics of care over another to do what's best. What's best changes depending on the person, so the caregiver needs to take their patient into account at all times.

She also said that "Care- giving is morally pressing, second, because in a cancer ward, to follow Solzhenitsyn’s classic insight, we see clearly how health instantiates politics" (Improvising Medicine electronic page 70). Most care giving facilities depend on the government and will put governmental success first even if it means harming some of the patients because they depend on the governmental system for the funds to keep going. Often times caregivers unintentionally adapt the idea that they should do what is best for the collective rather than the individual.

"Some are dying. All of them need care. e nurses broker this terrible thing, cancer. their job is an intensely important one, and an extremely difficult one" (Improvising Medicine electronic page 72). She's also suggesting that the moral weight of watching someone due and knowing you can do nearly nothing is a heavy responsibility.

6. "And I explain [as Dr. P explained to me] how the tumor could shrink quite a bit before he experiences a change in sensation, given where it sits. His prognosis is terrible, and we don’t tell him this. I think he knows. Words can kill. But we encourage him to focus on each day rather than worrying about a future that only God knows, and to have patience" (Improvising Medicine electronic page 91).

In this case, a man has cancer in his throat and worries about his prognosis. The doctors don't tell him how bad his cancer is despite how much he asks.

On one hand telling the patient that his prognosis is bad and that he's likely to die will cause harm but not telling him and making him believe that he could get entirely better will hurt him and his family when he passes away. The duty to care and no harm is being preserved by lying, but this is breaking his freedom because he is not being told the whole truth which stops him from being able to confidently say what he would like to happen to him as a part of his care.

I would guess it would depend on how much individual freedom mattered to the patient, and how much damage telling the patient the full truth was likely to cause.

It was probably best that they didn't tell the patient. He was already depressed after knowing he has cancer. Telling him just how bad the cancer is would only make things worse and then he would be responsible for telling his family. Yes, he might have more time to say goodbye, but he might also die sooner because he's given up hope and become even more depressed and mental health can affect a person's physical health.

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Brooke Fishback’s Answers to Questions 3 & 4

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Brooke Fishback’s Answers to Questions 3 & 4

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3. Livingston argues that caregiving is a moral endeavor - what does she mean by this? Provide specific examples.

A moral endeavor is the way you are and the way you want to treat your patients. It’s almost like a moral compass that helps you do the right thing or do what is best for the patient. Livingston provides multiple ways that express how caregiving is a moral endeavor. One is that nurses spend time not only physically helping their patients and their families, but also emotionally. “I sat with one friend while she sobbed for hours about the impending death of her only son, age five, from leukemia”(Livingston, 2012 pg 13). Nurses take time out of their day to help others in times of need. It is a selfless act that is done in tough situations. Being in the cancer ward is a tough job and is said to be “a dramatic place animated by pressing existential concerns and aversive bodily experiences. But among the dramatic deaths, the arguments, the sudden crises, the curious events, and the quiet tears, it is also a tedious and boring place” (Livingston, 2012 pg 22). Livingston also said that “Nurses and nursing assistants must fill out endless paperwork and computer forms and must routinely translate the same basic explanations and instructions. They must suction tracheostomy after tracheostomy, change diaper after diaper, and make and remake beds” (Livingston, 2012 pg 22). Through these challenging times, the staff do it every day to be a light and help their patients during their darkest times. The patients love “Chatting with the nurses or the relatives visiting a patient in a neighboring bed or receiving a brief call or text on their cell phone may be their only links to the lives from which they have come” (Livingston, 2012 pg 23). By doing so, it allows the patients and staff to connect and help them maintain some source of normalcy while they are fighting for their lives. Having a moral endeavor is something that you do all the time and yearn to help others at any point. “The moral sentiments of the nurses and patients are enacted in terms of professionalism, citizenship, and religiosity. Nurses and patients alike are generally Christian. Though they actively affiliate (or don’t) with a variety of churches and denominations, on some level they share a Christian-inflected moral framework of care and spiritual strength. as a philosophy of social healing, nursing is highly contextual” (Livingston, 2012 pg 94). The moral endeavor is mainly kindness and doing good, but a lot of it can stimulate from the faith aspect and has helped caregivers with their patients. This is what Livingston has tried to establish in the writings, and hope to end till in the readers.

4. How does Livingston describe cancer as a disabling or debilitating illness? How does viewing cancer as a disability change our understanding of it? (Especially if we understand it through the social model of disability)?

Livingston describes cancer as a disabling illness by expressing the challenges that people with cancer go through. One example is availability of care. “The government continues to send Botswana cancer patients to South Africa for specialized care unavailable in Botswana” (Livingston, 2012 pg 14). Not having care near you can be challenging and puts a wall up as to being able to get treatment. Another challenge is the cost of treatments, especially for noncitizens. Often, the cancer wards erupt “…each time a noncitizen arrives for treatment and must bring cash to cover the costs of care”(Livingston, 2012 pg 17). This can be challenging for patients to get the treatments they need when they can;t pay for it on their own. Another example might be the frustration of not getting time with your doctor to express your concerns about your illness. Livingston states that “…the temporal urgency means that each patient gets a little time to discuss their problems with the doctor, and so the humanistic side of oncology is, unfortunately, greatly curtailed” (Livingston, 2012 pg 20). This can be frustrating and disabling for people as they can be thrown off by not feeling valued and decide to not get treatments. “Patients are caught between their hopes for efficacy, their need for but wariness of trusting clinical staff, and their increasing physical desperation, a position that efficacious treatment could solve” (Livingston, 2012 pg 84). By not having the support they need, it can be frustrating and debilitating to the patients and influence their decisions on getting help.

Another circumstance could be when you had cancer, and found out it has spread. This can be debilitating as you get your hopes up and now are let down. Livingston shared a story of “…an elderly man whose testicles had been amputated in an effort to halt his prostate cancer. This castration had bought him some extra two tears of life, but now we explained to his son that the disease had metastasized to his liver and gut” (Livingston, 2012 pg 85). As he was hopeful to get rid of the cancer, he was let down by hearing it had metastasized. This disease takes emotional and physical tolls on the body and can impact patients ability to function on a daily basis. This is what can cause cancer to be debilitating. By viewing cancer as a disability, it changes our understanding on how cancer patients are always on edge and waiting for the other shoe to drop. It hinders them from living life to their fullest and influences hem by being scared of what could come next. Having a support system is important and so understanding that can help us support patients with cancer more easily.

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Livingston discusses how caregiving in Botswana’s Princess Marina Hospital is an achievement. She highlights the nurses’ compassionate care, often substituting for absent family members, and their efforts to “rehumanize” patients suffering from advanced cancer. “The care and attention with which oncology nurses clean necrotic wounds and thereby rehumanize patients who have disfiguring growths is extraordinary. Each day outpatients arrive in clinic wrapped in dirty, stinking, often homemade bandages.” (Livingston 87). This approach reflects the Tswana ethic of botho, emphasizing empathy and human dignity. Livingston also examines the moral dilemmas faced by healthcare providers when patients, often in late stages of cancer, are sent home due to bed shortages. This decision reflects a utilitarian approach to resource allocation, where the immediate needs of one patient may be sacrificed for the potential benefit of others. Such practices underscore the broader challenges in global health equity, revealing how disparities in resources, infrastructure, and cultural perceptions can impact cancer care outcomes. Addressing these disparities requires a multifaceted approach, including increased funding, resource allocation, and culturally sensitive healthcare strategies.

Livingston argues that cancer is not just a biological disease but is deeply social, political, economic, and cultural. She illustrates this through her ethnographic study of Princess Marina Hospital in Botswana, where cancer care is influenced by various systemic factors. Socially, patients often present with advanced-stage cancers due to delayed diagnoses, reflecting a lack of awareness and early detection programs. For example “By the time she arrived in oncology to confirm her cancer diagnosis and begin chemotherapy, the cancer was in her lungs, covering her legs, destroying the lymphatic system, and caus- ing massive swelling in her knee. Her pain was intense—as was her dis-figurement. Two years later her KS was in remission, but her left knee had become a fixed joint, so she could walk only short distances, she had lost her job as a cashier, and she lived in chronic pain. Cancer is nothing if not insistent.”( Livingston 37). Culturally, cancer is perceived as a foreign disease, leading to delayed care and advanced-stage presentations. Economically, PMH operates under significant resource constraints, with shortages of essential medications and equipment, forcing healthcare providers to make difficult decisions. Politically, cancer has historically been underfunded and under-prioritized in African health policies, overshadowed by infectious diseases like HIV/AIDS.

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1. How is the cancer ward in Princess Marina Hospital different than cancer wards in hospitals in the Global North? What does this reveal about healthcare in different global contexts? Provide specific examples.

2. This is a two-part question. For both parts, be sure to provide specific examples.

a. How do the nurses and doctors in the cancer ward interact with patients differently than nurses and doctors in the Global North?

b. How do the doctors in the cancer ward interact with patients differently than the nurses? Why are the nurses so important in this context?

3. Livingston argues that caregiving is a moral endeavor - what does she mean by this? Provide specific examples.

4. How does Livingston describe cancer as a disabling or debilitating illness? How does viewing cancer as a disability change our understanding of it? (Especially if we understand it through the social model of disability)?

5. How does Livingston position cancer as far more than a biological, individual disease? In what ways is cancer social, political, economic, and cultural?

6. Improvising Medicine contains stories of medical practice that raise ethical questions. Select an ethical issue in the text and analyze it - was the most ethical choice made? Why or why not? Use the principles to defend your answer.