The best laid plans often actually have quite an effect

written by John Nott
19/02/21

Our three sites are all very different. In fact, that’s the point. More than anyone else in the MCS team, I’ve had the opportunity to linger in and wander around all of our medical schools—to absorb these differences. This was a happier time, pre-coronavirus, when lingering and wandering and idle conversation were all possible, and even encouraged as part of a thorough ethnographic inquiry. That all three sites are materially and pedagogically distinct is, again, at the heart of our project.  But material distinction is not limited to the models, manikins and textbooks which are used to confer anatomical knowledge or learn clinical skills. A more expansive reflection on the material environment might also consider the stately, fin-de-siècle architecture of Semmelweis’ Anatomy Department, or the utilitarian, simulated consultation rooms in Maastricht’s Skillslab. These material surroundings contribute to an abstract sense of place which is difficult to define. It is individual and experiential, a semi-conscious processing of the sensory queues we used to receive when we were allowed out of the house, to linger and wander and engage in idle conversation.

Theorists from a range of disciplines have defined this phenomenon in a range of ways. Personally, I like the term ‘affect.’ To me, at least, it suggests some active, agential force which somehow exerts lasting influence. As I sit in my flat in Maastricht, it is the affective experience of these three medical schools which has remained with me and, undoubtedly, with the generations of students that have had much more affecting experiences in these schools than I did. The affective influence of medical schools is perhaps because of their oddness, replete with cadavers, skeletons and manikins used to simulate prostate exams. Foucault might have described them as ‘heterotopias’, Edward Casey would likely say they’re ‘thick places.’ In any case, I’ve been thinking about the relationship between the histories of these schools and their individual, affective natures. In particular, how much, if any, of this was planned?  And what does this mean for students’ understanding of medicine?

Debates around the construction of the University of Ghana Medical School (UGMS) offer some insight. Plans for a purpose-built medical school and later also a teaching hospital have been in the works since the 1920s, but it was only in the mid-2010s that construction began on the University of Ghana campus in Legon, on the outskirts of Accra.

In the 1920s, Accra was one of the sites considered for the construction of a medical school in British-colonial West Africa. A 1928 Colonial Office report even included detailed blueprints [1]. Appended to the city’s main hospital, the school would have consisted of long, low-rise buildings, each containing individual departments, as well as on-site dormitory accommodation for students. The report also made clear that this university would not teach students to the same level as a British school, nor would its degrees be equivalent to those granted by metropolitan universities. Here, students were to be cloistered away from the city proper, transposed into well-planned, quarantined areas defined by European architecture. Under British government, the spatial distinction of the university was intended to promote the development of a professional class employed in the interest of empire. As one educationalist in Accra noted in the 1940s, university education was intended to provide ‘a higher appreciation of British life and civilisation.’ It might be said that, in these plans, we see the origins of what Ann Laura Stoler has described as ‘imperial debris’, the affective material and spatial remnants of empire.

This school was never built. Instead, following independence from Britain in 1957, a medical school was quickly established, in an ad-hoc fashion, around repurposed hospital buildings. Through the 1960s and early 1970s, several plans were made and then shelved for the construction of an integrated medical school and teaching hospital. This was intended to consist of a group of modernist, high-rise buildings which, like the emergent nation, were based on the ideals of self-determination, ‘designed … [to] encourage patients to help themselves as soon as possible, as a therapeutic measure.’ Architectural and communications technologies were to be employed as a means to integrate teaching and treatment as part of a ‘continuous and harmonious’ system. Buildings were to be linked by covered walkways and telephone lines, closed-circuit television would be employed to link teaching with the clinic. Sadly, most of the architectural drawings are missing, but what does exist reflects the political economy of the Ghanaian 1960s, the influence of modernisation theory and faith technological advancement as a route to rapid social and economic development [2].

The spaces of medical education materialise ideas, ideals and assumptions regarding medicine and education, they emphasise the expectations which are made of medical students and corral them in shared experience. These assumptions and expectations are, necessarily, historical, drawing from the specific context in which plans were first drawn up. So, as a result, is student experience. Affect is moulded by historied materials and spaces. The new teaching hospital at Legon was finally inaugurated in 2018. As is often the case with the most recent past, understanding the circumstances of its construction is muddied by its closeness and our lack of perspective. These plans haven’t yet made it into the archive and I haven’t yet visited, but I look forward to wandering around and to seeing what stays with me after I do.

 

These plans can be found at the Public Records and Archives Administration Department (PRAAD) in Accra. My thanks to the staff at PRAAD for their assistance over the course of this project, it is always an enjoyable experience.

[1] PRAAD, Accra, ADM/5/3/26, ‘Report of the committee appointed by the secretary of state for the colonies to formulate a scheme for the establishment in British West African of a college for the training of medical practitioners and the creation and training of an auxiliary service of medical assistants, 1928’

[2] PRAAD, Accra, RG/3/6/1095, ‘Medical school and medical centre complex, 1974’

Learning the lamp of the body: normality and pathology in the technologies of medical education

That pathology and normality exist on a complex spectrum of bodily manifestation is an enduring question which lies at the heart of the philosophy of medicine (Canguillem, 1943, trans. 1991). Insights from STS and medical anthropology have suggested that this may be because the body—in both health and disease—does not exist as a single entity but is enacted in many ways, and in various spaces and times, through practices which make bodies visible, audible, tangible and knowable (Mol, 2002). As the primary locus for the reproduction of medical practice and epistemology, medical schools are important sites for the cultivation and disciplining of sensory attention in medicine. Often, students are taught to know the sight, sound, smell and feel of ‘the normal’ before learning to sense deviations from it. However, access to a requisite range of bodies is not so easily obtained; nor is it readily reproduced in simulations, photographs and films, which tend towards assuredness and fixity in their representations. Drawing on ethnographic and historical fieldwork in medical faculties at Semmelweis University (Hungary), Maastricht University (the Netherlands), and the University for Development Studies (Ghana), this article considers how historical and spatial variations in the teaching of ophthalmology constructs ideas of normalcy and pathology in conjunction with the educative technologies which populate these sites. In doing so, we argue that, although the pathologisation of bodies in biomedicine may derive from technoscientific developments in the clinical sciences, it is promoted by those epistemic technologies which reify and reproduce specific constructions of pathology and normality. We go on to suggest that the application of decolonial and postcolonial critiques of education and epistemology to medicine invites an alternative philosophy of normality in medicine while also offering a means to challenge the ontological assuredness of biomedicine around the world.

The map here shows where and when doctors registered to practice in Ghana in 1984 received their first degree. This data excludes the temporary, expatriate register, so only Ghanaian doctors are shown. Although unable to show the full provision of medical education in the earlier years, due to doctors having retired or passed away before 1984, this map still outlines the movement of educative centres over a period of dramatic political change.

Britain was the primary space for training under empire, but Colonial Office concerns around the destabilising effect of educated Africans meant that African access to professional medicine was extremely limited. With independence in 1957, universities in Western Europe began accepting more students and, following the extension of scholarships to Ghanaian students, significant numbers of doctors travelled to the Soviet Union, some even attending Moscow’s Patrice Lumumba University. Named for the murdered Congolese independence leader and martyr to African nonalignment, Patrice Lumumba University was the most explicit Soviet attempt to develop pro-socialist African and Asian elites through the provision of higher education. Even though Soviet-educated students learnt their craft in Russian or Polish or Serbo-Croatian, they usually had a second copy of English-language textbooks which they used alongside vernacular editions.

With the establishment of the University of Ghana Medical School in 1963, Ghana gained considerably more agency over medical education. Although UGMS was high on Nkrumah’s agenda for Ghanaian self-determination–localising the production of doctors in much the same way as the Akosombo Dam sought to nationalise electricity generation–textbooks were still primarily drawn from Britain, as were many of the early professors, the x-ray machines and the glasswear needed for basic science instruction. As with the movement of students to the Soviet Union, shifting the educative centre does not, it seems, always move the epistemic centre at the same time.

An outbreak of ‘apollo’ recently spread through my friend’s family and their acquaintances in Accra. I didn’t ask who started the whole thing, that could never be polite, but it must have been the baby that spread it to his nanny, and it was surely the nanny who spread it to her unsuspecting family. A little while after this particular outbreak, I happened across the first recorded discussion of epidemic apollo in the March 1970 edition of the Ghana Medical Journal. In the parlance of such a publication—established in the 1960s as an outlet for Ghana’s nascent medical academy—appolo is explained as acute haemorrhagic conjunctivitis. For many other people, however, the causative agents of apollo were germs which had only recently arrived from the moon. This association is still commonly invoked, at least in Accra.

Today appolo is a recurring, seasonal epidemic which usually coincides with the dry air and dust of the Harmattan– the trade wind blowing south from the Sahara—but the first recorded outbreak came in the middle of 1969, the very same time that Neil Armstrong’s cabal first exposed humanity to those virulent moon germs. This should be understood as a fairly significant event in Accra. At the highest ebb of the initial epidemic, the ophthalmology department at Korle Bu, Accra’s primary hospital, registered 1,115 appolo patients in a single day. Somewhat spoiling the moon germ narrative, the Ghana Medical Journal claimed that the first cases were seen in late June, a month before the Apollo XI mission had returned any germs to earth. That said, the epidemic only really took hold in August, so I’m reluctant to entirely dismiss the influence of moon germs in its overall aetiology.

It is difficult to say where rumour ends and humour begins in the history of appolo, I imagine that both elements have contributed to its emergence and endurance in the Ghanaian vernacular. Appolo’s etymology also speaks to the localisation of disease, as well as localised discourses regarding illness. Such specificity is, however, not well catered for in the increasingly international field of medical education. This is something which has come up, time and again, in discussions with doctors in training and in practice in Ghana. The need for translation is an everyday occurrence in the larger hospitals of teeming, multi-ethnic cities like Tamale, where a dozen or more languages might be heard in the waiting rooms on any given day. It is often only by shanghaiing other hospital residents–doctors, nurses, orderlies, other patients or other patient’s visitors—that clinicians at the Tamale Teaching Hospital are able to exchange words with their patients. But effectively understanding symptoms and histories should transcend the workaday translation of words to embrace the coy turns of phrase and anxious untruths which can impede frank discussions of our fragile selves. One doctor recently told me that, in his opinion at least, two thirds of diagnoses can be made solely from a well-taken history. Effective translation is, of course, central to the practice of medicine in multi-lingual environments, how medical students might prepare to meet such challenges is a rather more complex matter.

Our study considers English-language medical training in three countries which are not, predominantly, English speaking. While we have been focussing on the material technologies by which students learn about the body, biology, illness and health, languages might also be understood as pervasive, albeit somewhat conceptual, technologies which lie at the heart of medical education. As has been outlined in postcolonial histories of biomedicine in African contexts, an eagerness to translate complex, socialised understandings of health into a scientific lexicon can actually betray the insights which might have been gleaned from a truer translation. While this has been explored, to some extent, with a mind to twentieth century medicine, these questions should also be asked of contemporary trends. To what degree, for instance, does learning medicine in English promote the development of a medical profession whose use of an English-scientific lexicon jars with the primary language of the patient public? While medical practice grows ever-more global, patient understanding of medicine does not necessarily keep pace. At the same time, although not necessarily in the same places, a growing number of patients are using the internet to research their symptoms and histories prior to any formal interaction with health professionals. The nature or soundness of patient knowledge is largely beside the point here, what is relevant to the training of doctors is that patient experience remains a central part of clinical assessment at the same time as patient knowledge is growing increasingly irregular.

It is probably no surprise that I see the solutions to these questions in clinical engagement with the social study of medicine. Perhaps, one day, recognising the role of moon germs in the popular aetiology of conjunctivitis will bear some relevance to a differential diagnosis. Who knows, it might even have been moon germs all along.

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