UNIVERSITY OF AMSTERDAM
GRADUATE SCHOOL OF SOCIAL SCIENCESMSc of Medical Anthropology and Sociology
August 15th 2014
Acting Nurses in Aidland
Exchange and Professional Subjectivities in International Development
Student: Vegard Traavik Sture (10601864); vegard.sture@gmail.com Supervisor: Dr. René Gerrets
i Acknowledgments
First of all I wish to express my humble thanks to, let me call you Anja and Greta, for letting me into your lives for a brief but significant time. Were it not for your welcoming me by opening up your door and hearts, this research would be impossible to achieve from start to finish. To the staff and patients in the Cancer Clinic, I would also like to provide my deepest gratitude – it is by no means a given that nurses in a stressful work environment or patients in a vulnerable position should act as accommodating and sharing as you have. With this in mind, I do particularly thank Yolanda, Sara, Destiny, Hadjia and Matron M; all are nurses in CC who were gracious enough to spend some of their time in my company.
Second, the person who has been supervising my project from the meek startup last
September, Dr. René Gerrets, deserves my most profound respect and gratitude. Thank you for inspiration, encouragement and support throughout my times of frustration and anxieties, and thank you for all your extensive and valuable comments and ideas.
My family has always been there for me, and a few short words cannot describe my
gratefulness for your support and love. Takk søstre for å holde Johnny (litt for godt) i sjakk den siste tiden; takk Audun for rosinøl, fersk humle og Berlin; takk Øyvind og Magni for tålmodighet, trøst og redning i mine svarteste øyeblikk dette året. Takk alle for fine små stunder i Amsterdam, Bergen og Uskedalen.
To my MAS colleagues I will say congratulations and thanks for a wonderful, though quite often nerve wrecking year. Were it not for coffee or beer induced conversation and discussion with you, Gwyneth, Sari, Mandy, Annabel, Pomelo and José, my adaptation into the strange world that is Amsterdam and UVA would not have been as easy and enjoyable as it has been.
ii Abstract
Development has since the end of the Second World War been an important framework for constituting relations between the so-called developed and underdeveloped societies of the world, with a discursive rationale of bringing the underdeveloped ‘up’ to a level of the
developed. The following is an actor focused insight into a particular development project for nurses from Haukeland University Hospital in Bergen, Norway and Cancer Clinic in Dar-es-Salaam, Tanzania. The project was facilitated by the Norwegian Peace corps (FK-Norway), and it was placed within the agency’s ideological framework. The framework is primarily based on mutual exchanges of knowledge and experience between Norwegian and ‘Global South’ based institutions, corporations and individuals. Through my study of two HUH nurses working in CC and their Tanzanian colleagues I will show that the exchange came to bear different, contradictory and opposing meanings for different actors in the project, and that the egalitarian reciprocity FK-Norway presents as fundamental for their exchanges ultimately failed to happen on a ground level. A premise for the study is the notion of nursing as a profession in which subjectivities are made, shaped and mediated from a broader
intersubjective field of experience beyond a platform of clinical knowledge. The grade of intersubjectivity between the Norwegian and Tanzanian nurses in the project was low, and their detached lifeworlds seemed to maintain and strengthen beliefs in one’s own medical (nursing) imaginaries as superior to the ones they met through the development encounter.
iii Table of contents
1 Introduction………,……1
1.1 A brief anecdote on climate and air conditioners………,…….1
1.2 Not climate – then what?...1
1.3 Methodology, challenges and ethical considerations…………..………..3
1.4 Guiding theories……….…8
2 The Players and the Project……….…10
2.1 Introduction……….…..10
2.2 Contemporary Aidland……….…….10
2.3 FK Norway……….……...12
2.4 Haukeland and Ocean Road ………,……....12
2.5 The exchange project………,……...14
2.6 What does exchange mean for the project?...,.,...15
2.7Conclusion………...………20
3 Exchange on the Ground………...……….20
3.1 Introduction……….………20
3.2 Actors in Aidland……….………21
3.2 Exchange translated………24
3.4 Exchange performed - The case of the chemo course………….………31
iv
4 Clinical Tourism, or a Phenomenology of Aidland Nursing…………..………….….38
4.1 Introduction……….………….…38
4.2 Professional subjectivities and Clinical Tourism………...…….39
4.3 Motivations and aspirations………,……40
4.4 Expat life – expat nurses?...42
4.5 Exchange equals cosmopolitanism?...45
4.6 Future nurses……….……...…49
4.7 Conclusion………,…….…..51
5 Concluding words………,……….…51
- 1 - 1. Introduction
1.1 A brief anecdote on climate and air conditioners
Dar-es-Salaam, Tanzania – February 2014
My first day of visiting Cancer Clinic (CC): I am sitting in a conference room in the new hospital building with two Norwegian nurses, where we are waiting for Yolanda and Sara, Tanzanian CC nurses, to join us. The schedule for today is discussing and planning the upcoming chemotherapy course which is to be implemented for the nursing staff of CC on different dates before May, when the Norwegians leave the hospital and Tanzania. It is a rather warm day outside and Greta, one of the Norwegian nurses, turned on the air conditioner as well as the fans in the room immediately when we entered, complaining about the
temperature. After we have waited for some time the two Tanzanians arrive, and Yolanda shows with her body language that she finds the air in the room to be cold, by crossing her arms and rubbing her shoulders. She walks towards the air conditioner and starts turning it off, but before she can finish her button pushing, Greta says in a firm voice: “no, don’t turn it
off. It is too hot today, and I can’t cope with it. If it’s absolutely necessary, you can turn off the fans, but the AC stays on”. Yolanda sends Greta a seemingly exasperated look, but she
says nothing. The AC stays on for the rest of the meeting.
I am initiating the following study with this brief anecdote for two reasons. First, it provides an introduction to one of the main activities undertaken during my months of fieldwork – attending meetings and discussions in CC. Second, the anecdote serves as an illustration of one of my core arguments to be dealt with on the journey. What the argument is will be further elucidated in what is to come, and hopefully the reader can return after carefully going through the text and say “ah, so that is why he was talking about climate and air
conditioners”.
1.2 Not climate – then what?
I am neither investigating air conditioners nor climate in Dar-es-Salaam further, but approach the development industry or Aidland as some would name it. The term ‘Aidland’ was first introduced by Raymond Apthorpe (2011) as a satirical concept, intended to illustrate how contemporary development can be dealt with as a field of social practice, or rather multiple fields, from an anthropological point of view. More specifically this short journey is about a
- 2 -
set of nurses working in a particular part of Aidland. The nurses are predominantly Anja and Greta, two Norwegian women in their mid-twenties both employed by the oncology
department of Haukeland University Hospital (HUH) in Bergen, Norway. At the time of my fieldwork, the two of them were conducting their final months of work in Cancer Clinic (CC), Dar-es-Salaam, Tanzania. Their part of Aidland was a so-called knowledge exchange project between the two hospitals, first initiated in 2004 under the umbrella of the Norwegian Peace Corps’ (FK-Norway) development initiative. The overarching goal of the initiative is an exchange of knowledge and experience between Norway and in this case Tanzania. Anja and Greta constituted the fifth group of nurses travelling from HUH to CC through the project; they were stationed in the Tanzanian hospital for two terms, amounting to just over one year in total, from April 2013 to May 2014. My study is hence an actor-focused approach to Aidland, and the approach is inspired by those in the social sciences who throughout the last decades have made investigating the insides of development organizations and projects through their actors a field of interest (e.g. Long & Long 1992; Long 2001; Mosse 2005; 2011; 2013)
Nurses working in international development are important actors in Apthorpe’s Aidland(s), but even though cross-cultural nursing as a phenomenon has been a subject of study for several decades (Leininger 2000), questions regarding nurses’ understandings and
performances of their profession in Aidland have gained limited academic attention (Brenda & da Gloria Miotto Wright 2011). I am seeking to approach this missing piece of
development studies by dealing with two overarching themes; the two are presented
separately, but ultimately they will also be seen as intimately interlinked. First I address the question of how ideals and goals related to the ‘exchange’ concept came to be conceptualised and performed within the exchange project between HUH and CC. In the second section, I turn to a phenomenological dimension of the exchange, and intend to situate nursing practices and professional subjectivities within the context of Aidland. A major premise for this part of the study is the notion that professionals do not merely constitute their subjectivity from a foundation of professional (in this case, clinical) knowledge. By dealing with nursing as a discipline in which subjects are shaped through a broader field of lived experience, I address the question of whether and how staying in Dar-es-Salaam and working in the exchange project made an impact on the nurses’ professional subjectivities.
- 3 -
The research questions informing my study are thus formulated as follows:
1. How was the exchange conceptualized and performed by different actors in the project between CC and HUH?
2. How were the nurses’ professional subjectivities brought into and shaped by the knowledge exchange?
In chapter 2 I provide an introduction to FK-Norway, HUH and CC and I dedicate significant attention to the institutional designs of ‘exchange’. Here I intend to situate the project within a contemporary development discourse – a discourse which is heavily reliant on tropes of egalitarianism, as opposed to previous ‘vertical’ development principles. Chapter 3 digs further into the exchange of nurses between CC and HUH. I look into what the project meant for the different nurses and how they performed the exchange. Finally, in chapter 4, I situate Anja and Greta within a broader field of lived experience in Dar-es-Salaam, and analyze how the social space they were part of contributed to how they perceived the Tanzanian society, its health-care system, CC as well as how they perceived themselves as professional subjects in Aidland.
1.3 Methodology, challenges and ethical considerations
In order to ethnographically explore their roles and activities in Aidland, I spent ten weeks with Anja and Greta in Dar-es-Salaam and CC. My entering the field was their exit, as I was with them during their last months in the project. Throughout the fieldwork I followed the two nurses closely, both inside and outside the Tanzanian hospital. We attended meetings with nurses, doctors and administrators in CC; we walked around the hospital compound chatting with random encounters; we were eating and drinking together; from time to time I slept in their apartment. In other words, my work relied profoundly on participant observation as a method of data collection, conducted through what Renato Rosaldo famously termed a ‘deep hanging out’ (Rosaldo in Clifford 1997: 188). An important part of my hanging out was additionally done in CC without the Norwegians present. This in order for me to get a sense of understanding regarding the Tanzanian nurses’ practices and to discuss the project with those involved on the CC end.
Initially my intention was to draw upon my own nursing background by working clinically alongside Anja, Greta and their Tanzanian colleagues. I planned for this in order to gain a
- 4 -
deeper understanding of the nurses’ practices and professional subjectivities beyond what I assumed accessible through interviews. Perhaps observant participation is a better fit term for the approach than participant observation. Working clinically was, however, not feasible for two reasons. First, due to circumstances which will be further elaborated on in chapter 3, the Norwegian nurses had already quit their clinical work when I arrived. They had turned their focus explicitly towards teaching the nursing staff in CC their ideas about a proper handling of cytostatic drugs1, as well as initiating other pedagogic measures. Second, because of the limited time I had to plan and conduct the fieldwork, I was unable to go through the administrative procedures needed to obtain proper official Tanzanian clearances (national work permit and license from the Tanzanian nurses’ association). I had formal access to the knowledge exchange project through the Norwegian institutional end, but they could not facilitate the administrative procedures since I was not an employee in HUH at the time of my fieldwork.
Although my plans to work clinically in CC fell through, my nursing background and
experiences were valuable for the fieldwork. Possessing a (medical) language which I have in common with the different hospital actors made the process of understanding what went on in the project easier than it would have been if I did not have a background in the profession. My nursing background also proved itself valuable in terms of getting access to Anja and Greta’s lifeworld2. By enabling a sharing of similar work experiences, my background was helpful in terms of me being accepted into the nurses’ lives to the extent that I was. We have worked in the same institution (HUH), and we know several of the same people in the hospital. We have shared similar work routines, and we have had similar funny, sad and generally emotional experiences within the hospital walls. Throughout the fieldwork we shared stories about strange patients and even stranger colleagues.
In addition to hanging out with Anja and Greta, I conducted life history interviews and a series of semi-structured discussions regarding different aspects of their lives and work. During a time when Anja and Greta were away on a short holiday I went to Stone Town,
1 The literal translation of ‘cytostatic’ is ‘cells stoppage’. Cytostatic drugs are hence drugs used in oncology
medicine to inhibit cancer cells from reproducing and/or killing them.
2 ‘Lifeworld’ for Habermas (e.g. 1987) represents sets of shared norms, values, mutual understandings and
- 5 -
Zanzibar to interview three HUH nurses working six months in the Mnazi Mmoja hospital through the FK Norway facilitated exchange program. In Zanzibar I also interviewed Kari, a Norwegian anthropologist who has been working a decade for FK-Norway; now a HUH coordinator for the Tanzanian/Zanzibari branch of the hospital’s Department for International Collaboration. The interviews and discussions serve more as supplements to my engaged observations with Anja and Greta than as individual data, and my data collection in general was conducted through a process similar to the hermeneutic circle, or an interpretive
movement between a larger picture and its parts (e.g. Gadamer 1975). Through participating in their broader lived realities of Dar-es-Salaam I was able to pick out aspects which seemed more important for the nurses than others, and thus bring these parts into an interview context. An instrumental challenge regarding my data collection entails my discussions about Anja and Greta with their Tanzanian colleagues. Early in the fieldwork I experienced that the Tanzanian nursing staff seemed reluctant to talk to me about the Norwegians. I hung around the wards and nursing stations in CC either with or without Anja and Greta to have small chats with whoever was present at the time. My presence was welcomed both by the hospital administration and the CC nurses themselves, but every time I touched upon the Norwegians complete silence arose, my questions were politely laughed away or I was asked to talk about such matters with someone senior in the hospital hierarchy. The social tensions between Anja and Greta and their Tanzanian colleagues will be dealt with specifically in chapter 3, but I will mention here that the ‘silence’ was also something experienced by the Norwegian nurses themselves. Given the tensions between the Tanzanians and Norwegians, I was quite
understandably identified as part of the ‘Norwegian group’, and I suspect this to be a reason for the difficulties I encountered. The following is paraphrased from a European
microbiologist (and friend of the Norwegian nurses) working in an international malaria vaccine project, telling me about advice she was given from a Tanzanian colleague regarding an ongoing conflict with another coworker: “Here in Tanzania we will not shout at you or
talk badly about you if we don’t like you. Rather, we will kill you slowly by ignoring you and stop talking about you at all”. Without falling into the trap of making deterministic and
generalized assumptions regarding Tanzanian conflict management, I will say that this statement made sense for me given the ‘silence’ towards and regarding Anja and Greta. The challenge was partly overcome during the months of my fieldwork. After spending some time actively distancing myself from the Norwegians by going to CC alone, and by letting people
- 6 -
know that I was there mainly to conduct a study on Anja and Greta’s adapting into the CC setup, some nurses shared their thoughts about the exchange more freely.
Studying ‘up’ or ‘your own’ has been problematized increasingly in anthropology throughout the last decades (e.g. Forsythe 1999). Since the 1980s the world in general has experienced an enhanced accessibility to academic knowledge through the expansion of information
technologies. A general shift of research interest has also occurred within the discipline towards studies of “[those] with power to exclude themselves from the realm of the
discussable” (Cooper & Packard 1997: 5). In an Aidland context this can mean studies of
development professionals rather than the groups of people affected by development initiatives or birds-eye view studies of (global) power dynamics. The two processes have contributed to anthropologists entering into an era of critical self-reflection, and the reflection is related to methodology and knowledge production alike (e.g. Mosse 2013). The subjects of your study have the opportunity to read, understand and disagree with your findings, and a broader social space might be shared with your informants beyond fieldwork. The closeness between research subjects and produced knowledge constitutes a dilemma which, perhaps unfortunately, were largely absent in earlier anthropology. The ‘strong voices’ might have the power to discredit or invalidate results they do not agree with, and informants might read critical analysis as personal attacks (e.g. Mosse 2005; Harper 2011). Rottenburg (2009) goes as far as fictionalizing a development organization in an imaginary African country in order to make his analysis on Aidland actors. By circumventing the dilemma of dealing with
recognizable people and institutions he argues that his monograph is better equipped to be read and understood unbiased by development professionals.
The dilemma I sketch out in the paragraph above is one which I had to deal with throughout the fieldwork, and one which I continue to struggle with in text. My shared background with Anja and Greta did help me get access to their lives in an intimate way, but meanwhile, the critical foci of my analysis lays the ground for the Norwegian nurses to disagree with my findings, and for them to potentially feel like my writings are personal attacks on their
characters. This, of course, is their prerogative, but hopefully the text is written in such a way that the nurses can recognize their own voices, and my analysis can hopefully provide a tool for reflection rather than produce feelings of disgruntlement. The dilemma of my critical foci is not only of a relational character, and it might also bear analytical implications. Through my recurrent stays on the African continent I had prior to the fieldwork already positioned
- 7 -
myself as critical regarding much of what can be seen practiced in international aid and development. As such I have to acknowledge my own baggage of notions as potentially shaping the ways in which I experienced and continue to experience the exchange project. I fail to provide single tracked solutions as to how the dilemmas are best dealt with, but again I will emphasize my intention of letting the actors’ voices speak for themselves.
Anthropology, ‘up’ or otherwise, is an academic discipline in which considerations regarding ethics of methodology and representation are of crucial importance. Through close and often intimate studies of people’s lived realities, the researcher has the potential of making
significant impacts on said lives. According to the American Anthropological Association’s (AAA) code of ethics, the:
“researcher[s] should obtain in advance the informed consent of persons being studied, providing information, owning or controlling access to material being studied, or otherwise identified as having interests which might be impacted by the research” (AAA 1998: 3).
On accordance with this principle, I consciously and continuously made explicit my role as a social researcher and presented the intentions of my study to all who were part of my
fieldwork and affected by my presence in CC and Dar-es-Salaam. Furthermore, I exclusively use pseudonyms for all individuals presented throughout the study, and although the actors hopefully recognize themselves it should be difficult for outsiders to identify them. Since my formal admission into the exchange project was provided by HUH and not the Tanzanian hospital I have additionally decided to keep the name ‘Cancer Clinic’ as a pseudonym. Due to the nature of my fieldwork, few occasions opened up for the utilization of recording devices. Moving around the hospital compound with an audio recorder would potentially entail a serious breach of ethics regarding information security for patients and constitute a barrier between me and the hospital staff, since most of our conversations happened while they were working. Given the closeness between me, Anja and Greta, it also felt staged and contrived to bring a recorder into our relations. Quotes throughout the thesis are thus combinations of direct citations I wrote down during conversations and interviews, and paraphrases, written down as accurately as possible retrospectively to the observations I made.
- 8 -
1.4 Guiding theories
The headline for this section says guiding theories. This is a deliberate choice of words. My intention is not to let the study be driven forward by a set of theories carved in stone, and the framework laid out here rather provides a backdrop to the voices of the actors.
I partly consider the exchange project from the perspective of Actor-Network Theory (ANT). Originating from science and technology studies, ANT was initially developed as a
framework for understanding how knowledge systems are allowed their existence, through inter-human relations and relations between humans and non-human entities. A premise for the development of the framework was the ambition to pose an alternative to ways in which the social sciences largely operated according to dichotomies such as micro – macro; subject - object; agency - structure; local – global (e.g. Latour 1999; 2005). According to an ANT perspective, actors mediate meaning and constitute networks through modes of interaction rather than being constructed by, or constructing themselves according to said dichotomies. There is no fixed scale, to the extent that questions of whether structure constitutes actors or actors constitute structure make little sense. In other words, objective meaning never exists a priori in an actor-network, but is constantly produced, mediated and performed through multiple semiotic processes, called ‘translations’ (e.g. Callon 1986; Law 1992). A common concept within ANT is ‘black boxes’; through investigations of how notions become taken-for-granted, classifications and ontologies can be picked apart in order to see that what may have been considered as universal truths from one angle can in fact bear different truths for different actors and different networks. When conducting research from an ANT perspective, ontologies should furthermore be considered as methodologically flat, meaning that all actors have an equal opportunity to express their understandings of reality, and that all
understandings are of equal value for the researcher (e.g. Latour 1993; Law & Hassard 1999). Aidland can be said to have evolved into an ‘unruly mélange’ (e.g. Walt & Buse 1997;
Pfeiffer 2003); complex and varied networks with a vast range of actors who through action and interaction construct meanings to the networks as well as to themselves (e.g. Mosse 2005; Lewis & Mosse 2005; Mosse 2013). Hence it is possible to think of ideological frameworks, strategy papers and nurses as actors in the network that is the exchange project between CC and HUH. The ANT approach allows for an opening up of ‘exchange’; for analysing different understandings and meanings related to the concept.
- 9 -
By further adding a phenomenological layer to the analysis of nursing within the exchange, I will address the question of how Anja and Greta’s professional subjectivities were shaped through their participation in the project. Nursing philosopher Patricia Benner (e.g. Benner & Wrubel 1989; Benner 2011) has for several decades considered the profession and its
practices from a phenomenological point of view. Following Charles Taylor’s Heideggerian approach to constructions of the self (e.g. Taylor 1989), Benner considers health
professionals’ practices to exist within the realm of, but also beyond, what Michel Foucault (2003 [1963]) termed the clinical gaze; the ways through which biomedicine and its aligned actors observe and control the human body in society through modes of categorization, diagnostics and treatment. The nurse operates as a clinical practitioner, but will
simultaneously conduct his or her practice based on fundamental and often unarticulated understandings of lived reality; in other words, nursing from Benner’s point of view exists as part of the practitioners’ habitus3
, where notions and knowledge to a large extent are constructed and renegotiated through processes of embodied experience both inside and outside a work environment (Benner 2011). How one cares is reflected in what one cares about, and what one cares about is very much shaped by ones contextual lived experience. One of the main concepts preoccupying Alfred Schutz in his venture to bring phenomenology into the social sciences was that of intersubjectivity (e.g. Zaner 1961). Our understandings of the world are constructed through our lived social experience, and in the thinking of Schutz there are grades of how social subjects relate to each other. The closer subjects are to each other in terms of experience, the closer and more related will their understandings of the world be (e.g. Schutz 1972 [1932]; Wagner 1970). Through investigating how perceptions of proper knowledge and practice were shaped and employed in the exchange project, I will link the concept of intersubjectivity up to medical imaginaries. The concept ‘medical imaginaries’ was first introduced by Mary-Jo Delvecchio Good (2007) in order to provide an account of how biomedicine produces an array of images in terms of what the field can accomplish as well as how accomplishments could best be made. Actors’ (e.g. professionals; patients; relatives) practical experiences within the field are, however, often incongruous to mapped out imaginaries. By combining the two concepts it is possible to provide an insight into how
3 According to Pierre Bourdieu’s definition, the habitus represents acquired dispositions a person has for acting
in the world. An individual’s habitus is shaped by lived experience within particular social and historical fields (e.g. Bourdieu 1977).
- 10 -
the Norwegian nurses’ imaginaries of good nursing practice were shaped and constituted through shared experience throughout their year in Dar-es-Salaam. When bringing intersubjectivity and medical imaginaries into the exchange project, I argue that I am equipped to investigate the epistemological and practical interplay between the Norwegian nurses working in their Aidland position and their Tanzanian counterparts in CC. In short, how the actors constituted their imaginaries of a proper nursing practice within the project, which experiences shaped them and how certain imaginaries were valued higher than others.
2. The Players and the Project
“We are convinced that the world becomes a little more just when people get to know each other better and create values together” (Webpage – FK-Norway 2013)
2.1 Introduction
In order to start making sense of the knowledge exchange between CC and HUH, I will here present the institutions involved in the project. The chapter starts out with a brief
anthropological clarification of discourses paving the ground on which I am walking when engaging in institutional parts of Aidland. The development industry has undergone significant changes throughout the last twenty years, and to start moving forward with my arguments, I present the core of these changes. Further I sketch out the frameworks of FK-Norway, HUH and CC. Finally I provide an introduction to the partnership between HUH and CC, and situate the knowledge exchange project within a contemporary Aidland discourse. 2.2 Contemporary Aidland
For more than six decades, development has existed globally as a stable framework regarding relations between so-called developed and underdeveloped4 societies, discursively driven by an intention of bringing the underdeveloped ‘up’ to a modernization level of the developed (e.g. Escobar 1995; Cooper & Packard 1997; Rottenburg 2009). The practical approaches in-, and organizational structures of Aidland have, however, undergone changes. Since the 1990s,
4 These terms have changed over the years. One could speak of the ‘first-’ and the ‘third world’, ‘developed’ and
‘developing’, or as in more recent times, ‘Global South’ and ‘- North’. In the language of FK Norway, ‘developed’ and ‘underdeveloped’ have largely been changed to the ‘Global North’ and the ‘Global South’.
- 11 -
an enhanced focus on participation, empowerment, partnerships, local ownerships, reciprocity and similar tropes of egalitarianism and mutuality gained ground at the expense of previous approaches, where singular technical solutions were the standards. So-called ‘magic bullets’ (e.g. Cueto 2013), expert knowledge and verticality used to constitute primary approaches to development, and ideas of proper development/modernization were ideally flowing in a unidirectional line from the ‘developed’ above to the ‘underdeveloped’ below. Where western institutions previously sought to implement technologies and policies constructed from
perceived universal standardizations, a discursive shift was made towards contextualizing problems, finding value in- and employing local knowledge (e.g. Stirrat & Henkel 1997; Crewe & Harrison 1999; Cramer, Stein & Weeks 2006; Cooke & Kothari 2001). As I will show with regards to FK-Norway’s development model, the notion of a unidirectional epistemological flow has been rhetorically replaced in the agency’s ideological framework, especially through employment of the exchange concept. The framework challenges the idea of a ‘developed’ part exclusively providing something for an ‘underdeveloped’ part; the agency presents reciprocal and egalitarian relations to be emerging from their platform of exchange.
Stirrat and Henkel (1997) scrutinize the emerging orthodoxy of egalitarianism within development. Drawing from Mauss’ (1966 [1950]) classic work on gift economies of so- called archaic societies, they question the possibilities of constituting genuinely egalitarian structures in the development industry. Mauss considered gifts to be an integral part of social life in the societies he studied, acting beyond the purely material transactions they represent. The gift can never be separated from neither the giving nor the receiving person, and it enacts a social power. There are inevitably certain obligations linked up to the gift process, not in the least for the receiver. Through the analogy of the gift, Stirrat and Henkel scrutinize the notion of ‘partnership’ between donor and receiver in development relations. Although ideals of egalitarianism and mutual identification can be made possible from a charity perspective (the western, Christian ideal of the unreciprocated gift), the gift (of donor transactions) will
inevitably change meaning when reaching the receiving end, and may for that end constitute a reaffirmation of differences instead of identification (you are rich, I am poor and unable to reciprocate in an equal manner). The authors do not claim the impossibility of making the partnership model work, but they problematize the language of egalitarianism as potentially hiding inherently unequal power structures through rhetorical measures (Stirrat & Henkel
- 12 -
1997). The authors make a significant point which will be further investigated through the lives of Anja and Greta in Dar es Salaam, but I will remain careful in terms of assuming inequalities to be a priori inherent and all defining in the relations between HUH and CC and the two Norwegians and their Tanzanian colleagues.
2.3 FK-Norway
The Norwegian Peace Corps, FK-Norway, is the primary facilitator and funder of the knowledge exchange between CC and HUH. The agency was established in 1963 with the intention of sending young Norwegians to developing countries in order to teach ‘locals’ different skills assumed to be needed in particular societies/communities. FK-Norway initially based its development model on that of the American Peace Corps, but has since the
beginning operated independently. Throughout the following decades the agency has grown exponentially, become increasingly professionalized and in 2010 FK-Norway was placed administratively under the Norwegian Foreign Ministry. The agency is hence responsible for adhering to- and maintaining the national Norwegian strategies for development (FK-Norway 2011). FK-Norway is continuously supporting and facilitating a wide range of multi-sector exchange projects between institutions, organizations and corporations in Norway and the ‘Global South’. According to the 2010 instructions as formulated by the Foreign Ministry, the three core functions of the agency, informing all their projects are as follows:
1. [To] facilitate development programs and administrate funds to a diverse range of organizations, institutions and corporations in Norway and developing countries.
2. [To] stimulate and organize the exchange of experience and knowledge, and contribute to the return of knowledge to one’s own society.
3. [To] contribute to the development and strengthening of civil society in developing countries (FK-Norway 2010: 1).
2.4 Haukeland University Hospital and Cancer Clinic
Even though biomedicine has evolved to be the common denominator in dealing with health related issues on a global level, one cannot easily treat the field as a homogenous system of knowledge and practices (e.g. Mol 1999; 2002; Van der Geest & Finkler 2001). Medical ontologies are understood and performed differently in different spaces (Mol 1999) and the hospital institution is not a universal island of knowledge and practices that can be detached
- 13 -
from the larger society it exists in (Van der Geest & Finkler 2001). These notions will be informing my study, and in this section I briefly present the two hospitals involved in the knowledge exchange project. There is a large gap between the two in terms of available funding, technology and the load of patients relative to health care professionals. These factors do naturally play a part in the institutional relations between CC and HUH (we are dealing with a development project), and as I will be investigating further in the coming chapters, the material and technological gaps between the two also seemed to play significant parts in how the different actors understood and performed the exchange project.
HUH is one of the leading hospitals in Norway, and celebrated in 2012 its 100th anniversary. The hospital is located in the city of Bergen, and serves the population of Norway’s western region as a specialist health care institution. Hence, the hospital potentially provides services to approximately 1.2 million people, and a yearly number of above 600000 patients are treated in said institution. HUH is furthermore the largest employer in the Bergen region, and provides jobs to over 11800 people (Helse Bergen 2014). The oncology department of HUH was opened in 1972, and has over the years expanded to be one of the largest in the hospital. The department is an up to date oncology facility by international standards and provides diagnostics, treatment, follow-up and care. Additionally HUH serves as an international research facility on cancer (Helse Bergen 2012).
CC was founded in 1981, and is the only specialized oncology hospital in Tanzania. The prevalence of diagnosed cancer disease is rapidly on the rise in Africa, and an increasing attention within the global health discourse is focused on cancer on the continent. The increased attention largely results from a biomedical linking between cervical and uterus cancers and the already massive discourse on STIs in Africa, particularly HIV (e.g.
Livingston 2012). Hence, CC is obligated to provide services for vast amounts of potential patients relative to its earlier years, not only coming from Tanzania, but also neighboring countries such as Burundi and Malawi. Due to the extensive flow into the institution, reliable statistics regarding patient load and follow-up of the individual patient are hard to obtain in the CC setup (Dr. N in personal conversation).
The hospital setup in CC can superficially be compared to that of the oncology department of HUH. It consists of an outpatient clinic for diagnostics and follow ups, an outpatient
- 14 -
and treatment and a palliative care unit with a bed ward and an ambulant home-based care team. The facilities and technology in CC are, however not comparable to the HUH setup. Radiology and laboratory equipment are the equivalents of outdated equipment in HUH; technology tends to break down at a larger rate, often without the right engineers available to do maintenance; the pharmacy is often missing appropriate drugs.
Julie Livingston (2012) shows how oncology medicine in a Botswana hospital is constituted by performances of improvisations. The hospital she studies entails a differing techno- material environment compared to the institutions in (and in ways for) which the epistemological and practical standards of the field are produced. A result of the (often lacking) available resources is the need for health personnel to work outside the box, so to speak, by drawing more from lived experience than from structural guidelines when making decisions. Similar acts of improvisation can be seen in the CC set up from a nursing
perspective, and decisions are often made ad hoc rather than planned and structured to the extent that the HUH setup requires. For instance, the lack of staff often results in the necessity for assistants to perform nursing duties such as chemotherapy administration and other tasks related to the handling of hospital drugs, or nurses might send relatives to nearby pharmacies to fetch drugs missing in the hospital.
2.5 The knowledge exchange project
The Department for International Collaboration (AiS) in HUH is the coordinating section for all development/exchange projects between the hospital and health care institutions outside of Norway. The department was opened in 2003, and throughout the last decade it has grown to be the largest of its kind in all Norwegian hospitals. In 2014, AiS is coordinating
approximately twenty exchange projects with so-called southern institutions, a majority of them on the African continent (Helse Bergen 2014).
The exchange between CC and HUH was initiated in 2004, and is one of the AiS coordinated projects solely based on FK Norway’s development principles. Preceding Anja and Greta, four Norwegian groups of nurses have been working in CC through the project. The two of them stayed for one year, but the standard has been six months. Similarly, four groups of Tanzanian nurses have been in Norway throughout this period, and they spent six to eight months in the oncologic bed wards of HUH, observing the Norwegian nurses’ practices.
- 15 -
Anja and Greta started their exchange with a two week Kiswahili course facilitated by FK-Norway in Stone Town, Zanzibar, before they went to Dar-es-Salaam and overlapped for a week with a preceding Norwegian participant.
Apart from being a primary facilitator and funder of development projects, FK-Norway’s main instrumental function in the exchange between CC and HUH is to hold a two week course for participants in different projects. The course is meant to prepare the participants for cultural exchange, and involves lectures and seminars with titles such as ‘Global forces – Local issues’, ‘Intercultural Communication’ and ‘The Communicative Participant’. After Anja and Greta had spent their first week in Dar-es-Salaam, the initiation course was arranged in Addis Ababa, Ethiopia. Throughout the two weeks they met with people of different
nationalities about to exchange between ‘North’ and ‘South’, as well as preceding participants who were returning to their home countries. Following the course, the two Norwegian nurses returned to Dar-es-Salaam in order to properly initiate their exchange in CC.
2.6 What does ‘exchange’ mean for the project?
By 1999, the so-called vertical way of doing development was considered by FK-Norway as
backwards and ignorant5; no longer should we think that ‘our’ (technical) solutions are the best solutions to any problem anywhere. So the former FK-Norway was shut down, and reopened in 2000 with a new vision of how development through the agency is to be implemented. The new FK-Norway constituted its framework from ideals of reciprocal exchange instead of the previous top–down model. Rather than sending Norwegians to developing countries in order to implement perceived universal systems of knowledge, the agency set out to make programs which could facilitate exchange meetings between people and institutions coming from different socio-cultural backgrounds. The ‘new’ FK-Norway thus operates according to this overarching Mission Statement:
FK Norway promotes reciprocal exchanges between a diverse range of institutions and organizations globally. This fosters mutual learning, development of capacity and change for the common good (FK-Norway 2011: 1).
- 16 -
The sentence “We are convinced that the world becomes a little more just when people get to
know each other better and create values together” (FK-Norway 2013) is posted in bold
letters on the front page of FK-Norway’s about us website, and further illustrates that ‘exchange’ is conceptualized by the agency as something beyond a material exchange of personnel and technologies. The exchange process is fronted as fostering a social space where people, institutions and organizations come together from different backgrounds to blend experiences and knowledge in ways benefitting all involved parties. The ideals of mutual learning and creativity are strengthened by these words from the agency’s director general in the 2012 annual FK-Norway report:
“Given the interrelatedness of global concerns, FK-Norway helps promote partnerships for development which are challenging the traditional notions of North and South. In our reciprocal exchanges, everyone has something to contribute and something to learn. (…) An international exchange builds capacity, knowledge and experience – both of the individual travelling abroad, and within the organizations or institutions sending and hosting an international professional or volunteer. (…) Furthermore, an exchange can also be a practical school, not only for increased social responsibility, but also for trouble-shooting and problem-solving, to learn how to think outside the box, to challenge assumptions, inspire creativity and foster entrepreneurship” (FK-Norway 2012: 2).
The following is a quote from the previously mentioned course for coming participants in FK-Norway facilitated exchange projects. All lectures were according to Anja and Greta focused on creating a platform for mutual understanding and respect between people of different socio-cultural backgrounds, and the explicit renouncement of ethnocentrism in the quote illustrates this well:
“When communicating with people across cultures, participants must abandon any
sentiments of ethnocentrism—the tendency of individuals to judge other groups according to their own group’s standards, behaviors, and customs” (Presentation on intercultural
interaction – FK-Norway 2013).
In the preceding paragraphs I present an ideological framework which is (rhetorically) fronted by FK-Norway as constitutive of their development model. Hence, the ways in which
‘exchange’ is designed by the agency can be read as correlating with the concept of
- 17 -
According to his definition, cosmopolitan subjects are symbolically borderless people, capable of immersing themselves in, adapting to and blending with situated cultures outside of their own (Hannerz 2005). Given the strong emphasis on cultural meetings based on mutual respect, understanding and learning in FK-Norway’s development rhetoric, I intend to further utilize the concept of cosmopolitanism through an analytical lens when investigating Anja and Greta’s participation in the exchange project; particularly in chapter 4, where I analyze the nurses’ lived experiences throughout a broader social field in Dar-es-Salaam.
AiS’ overarching strategy papers adhere to the rhetoric of reciprocity as a fundamental framework for all the department’s exchange projects, and their primary goal is as stated:
To enhance global health for all, through:
- Emphasizing better quality health-care services for the people affected by HUH’s southern partner institutions.
- Enhancing the quality of HUH’s health-care services (Helse Bergen 2010: 2).
Though emphasizing reciprocity the AiS strategies are, as opposed to FK-Norway’s rhetoric, explicit in presenting the notion that Norway (and HUH) possesses something valuable - medical knowledge and competence, which needs to be transferred to hospital setups of the ‘Global South’. The third secondary goal in the department strategies states that:
“Norwegian health competence is internationally acknowledged, and the partner hospitals of HUH have a great need for access to the competence available in Norway. (…) HUH has an extensive experience in transfer of medical knowledge, something which provides a good starting point for the training of health personnel within a range of medical areas in the global South” (Ibid: 4).
Emphasis is also put on addressing the so-called global health personnel crisis, and the fourth secondary goal states that:
“The lack of health personnel in our partner institutions is severely acute. (…) The personnel crisis in developing countries is a problem addressed by many health related development organizations, and it has been acknowledged that the best and probably only short term solution is the recruitment of western health care workers. On accordance with this
- 18 -
acknowledgement, HUH will contribute to a relief of the personnel crisis by recruiting health care workers who can serve terms in our partner institutions” (Ibid: 4 - 5).
FK-Norway does not provide project-specific strategies for the exchange projects they facilitate, and it is up to each ‘partnership’ to define the specificities of their exchange while adhering to the agency’s frameworks. Anja and Greta were not initially given formal
instructions regarding how they should go about their work in CC, but they eventually got hold of the previous Norwegian group’s strategy papers. The papers were written as a joint effort between HUH and CC, and they briefly sketch out the goals for the nursing exchange between the two hospitals. The specified tasks for the Norwegian nurses in CC are according to the strategy papers to:
- Participate in work at the Chemotherapy section at [CC]. - Participate in routine work at [CC].
- Assist in on-going training programmes for nurses and doctors.
- [Conduct] Follow up of previous group task (the previous exchange) (FK-Norway 2012: 7)
Regarding goals for the Tanzanian end of the project, priorities are directed primarily towards competence enhancement in CC. Particularly related to the handling of cytostatic drugs and general hygienic principles for nurses:
“Chemotherapy is the main priority, but a new area of focus the next three years will be an increased attention to hospital hygiene, patient information and supporting local program in training of nursing and clinical oncology” (Ibid: 3).
Hence, the primary achievement goal for the CC setup is as follows:
“Increased competence in administration and preparation of safe handling of chemotherapy/chemotherapeutic agents, in order to provide a more secure working environment for [CC] staff members” (Ibid).
On the Norwegian end, to make mutuality in the knowledge exchange a reality, there are also goals. The primary goal presented for the Norwegian nurses deals with so-called multi-culturalism, and the rationale behind the goal is related to an increased flow of international
- 19 -
patients into Norwegian health care institutions. The papers state that the exchange is supposed to provide the Norwegian nurses with:
“practical experience in communicating with cancer patients/relatives in a developing country, in order to provide cancer patients at HUH with multi-cultural background, better follow-up of patients and their relatives” (Ibid: 3).
And further:
“(…) experience from handling cancer patients of different race and culture than what is prevalent at HUH (important lesson to learn as our home society in Bergen is becoming more multi-ethnic and multi cultural)” (Ibid: 7).
The goal seems to presuppose a generic ‘multi-culture’, applicable to people with a
background from any given developing country living in Norway. If Norwegian nurses are provided with the opportunity to practice communication with representatives for this multi-culture in a developing country, the papers assume them to be better equipped for taking care of said patients6. This notion can be scrutinized from the perspective of a long running anthropological critique of how culture has been, and in many ways continues to be, widely conceptualized. The dichotomy between ‘us’ possessing (western) culture and ‘them’ being homogenized products of (non-western) culture has been a way of describing a western understanding of non-western societies (e.g. Said 1978). In the strategy papers,
communication practice is presented as a goal, but specifically how the goal is to be achieved and what the enhanced skills are assumed to entail are not made explicit.
In the previous paragraphs we can see how the ideological framework of FK-Norway
correlates with a broader contemporary discourse of egalitarianism in Aidland (e.g. Stirrat & Henkel 1997; Crewe & Harrison 1999; Cooke & Kothari 2001). There are, however,
potential ambiguities to be read from the exchange ideals fronted rhetorically by FK Norway and the hospitals’ strategy papers. The more specific the papers are in stating their exchange goals the more emphasis is put on a transfer of medical knowledge and competence from the Norwegian HUH setup to Tanzania and CC. The transfer of this type of knowledge is
6 It will be mentioned here that the amount of people living in Norway with a Tanzanian background is marginal
to the extent that Tanzanians fall outside national statistics on immigrants or Norwegians with an immigration background (SSB 2012).
- 20 -
presented as unidirectional, not reciprocal. This notion has, as I will investigate further, the potential to compromise FK-Norway’s ideological framework for actors in the exchange project. Although not explicitly contradictory, the ambiguities regarding institutional design of the exchange contributed to an opening for contradictory interpretations of what the process should entail for the nurses.
2.7 Conclusion
This chapter has served as an introduction to the exchange project between HUH and CC. Thus, the stage of my study has been set. Investigations into the project ideals and strategies have unveiled a potential ambiguousness in design regarding the exchange concept. While FK-Norway’s ideological framework implies equality and identification to be inherent in their exchanges, the hospital strategies understate differences between Norway and the ‘global south’, and introduce the notion that HUH is in possession of medical knowledge and
competence needed in an Aidland context. Throughout the next chapter I intend to continue in the preceding trajectory, and will investigate how Anja, Greta and their Tanzanian colleagues made translations in the exchange project as well as how translations were performed.
3 Exchange on the ground
“The point of the project is knowledge exchange (…). We [Anja and Greta] have already seen many areas [in CC] in demand of improvement. We only hope that we will be able to make some of the changes we want to make.” (Blog post - Anja, April 2013)
3.1 Introduction
By the time I came to Dar-es-Salaam and met with Anja and Greta, the term
‘utveksling’7
quickly stuck with me – not only did the project utilize and put emphasis on the exchange concept in all strategy papers; utveksling also became one of the topics we most frequently discussed when we were getting to know each other, and one of the words the Norwegian nurses emphasized when discussing their understandings of the project. What the
- 21 -
utveksling meant for them as persons and as professionals when they were working in CC
was, in other words, my point of entrance into their part of Aidland.
The following chapter investigates how the exchange project made sense to different actors in different parts of the network, as well as how voices were spoken and heard. The above quote is taken from the final words of a blog post, written by Anja during the first month of the Norwegians’ stay in CC. There is a contradictory tone in the quote regarding her presentation of ‘exchange’, which correlates well with how I came to understand the ways in which she and Greta approached the project. While emphasis was put on exchange, the ways in which the Norwegian nurses spoke about it also implied that they not necessarily understood
exchange as a relation of reciprocity. In the previous chapter I was looking at how the process of exchange is designed slightly different by different institutions and strategies; by dealing with how translations in the network were articulated and performed by the nurses, I will argue that the different designs become more elucidated and emphasized.
I initiate the chapter by providing a brief anthropological account of how Aidland can be approached through the actors participating in the field(s). Next, I investigate the ways in which Anja, Greta and their Tanzanian colleagues spoke about their understandings of the exchange project. The case of the chemo course will finally provide an illustration of how the inequalities and differences between Anja, Greta and their colleagues were performed, and further, the case shows how meaning was mediated and power inequalities resisted. 3.2 Actors in Aidland
Development has grown both in size and heterogeneity and I previously mentioned that some have come to view the industry, or Aidland, as an ‘unruly mélange’ (e.g. Buse & Walt 1997; Pfeiffer 2003). Aidland consists of complex and intricate fields of practice inherent with an array of different intentions, hopes and modes of action. Increasingly, anthropologists have taken the complexities of Aidland into account, and since the 1990s an actor-focused
approach to development has gained academic ground (e.g. Long & Long 1992; Long 2001). Along the lines of dealing with development as complex and heterogeneous fields, Pieter de
- 22 -
Vries (2006) does a re-reading of James Ferguson’s anti-politics machine8 with a Deleuzian twist, turning the machine of anti-politics into a machine of desires. His argument is that development as a concept produces desires for all parts/actors within the field, and that one ought not undermine the possibility that people (of the developing world) might desire images produced by the development industry, and that desires can be further driven forward by project failures (de Vries 2006).
De Vries’ desiring machine is a positive critique of Ferguson’s post-structuralist approach to development. He acknowledges that inequalities in power (and resources) are driving forces behind desiring machines, and considers “the development industry [to be] parasitic on the
beliefs and dreams of the subjects it creates” (de Vries 2006: 30). Others have questioned the
very fundaments of such an approach in today’s Aidland. It has been argued that not only does the approach produce inaccurate and simplistic accounts of development in terms of what it does and means for people; it might even contribute to building or maintaining the structures it intends to criticize. Thomas Yarrow (2008) argues that in assuming a priori power inequalities to be an integral part of development structures, one runs the risk of actually employing and empowering dualisms. His suggestion is that we ought to go beyond using categories such as ‘global’ – ‘local’ and rather look at what categories actually mean for the people operating within-, and those affected by, particular development projects (Yarrow 2008). Development should hence not be seen as a set of coherent practices but a set of practices producing coherence (Yarrow 2011; Mosse 2013).
David Mosse (e.g. 2005; Mosse and Lewis 2005; Mosse 2011) is in the front lines of contemporary anthropologists applying an ANT approach to development studies, and he does in particular utilize the concept of ‘translation’ borrowed from the framework.
Translation in an ANT fashion represents the modes in which meaning is mediated in
8 James Ferguson’s ‘The Anti-politics Machine’ (1992) is, along with Arturo Escobar’s ‘Encountering
Development’ (1995) one of the most influential contributions made to critical development anthropology. Both contributions take post-structuralist positions in the field and both are influenced by Michel Foucault’s theories on power and knowledge (e.g. Foucault 1967). Ferguson (1992) shows how development initiatives, though they might be explicitly non-political in their ideological frameworks, still have a potential to bear unintended instrumental effects which ultimately serve political means of control and surveillance. Escobar (1995) considers development as an institution through which western governments produce knowledge about a so-called third world, and the knowledge ultimately serves the interests of the developer. ‘Poverty’ was largely an invention of the west, and development is a discourse through which an affluent west was (is) able to enact surveillance and control over an increasingly dependent third world.
- 23 -
networks. Actors reinterpret or displace the interests of other actors in order to realign them with her/his own, and successful mediations between different and potentially opposing translations are needed for an actor-network to stabilize (e.g. Callon 1986; Law 1992). In his most impactful work, Mosse (2005) explores the relationship between practice and policy in a British development organization operating in Rajasthan, India. Through his long running employment in the organization, he picks apart its utilized concepts, and argues that policy does not necessarily precede the practices within the organization. The two coexist in a dynamic relationship, and oftentimes processes move the other way around. In other words, policy is meant to guide practice, but in practice it rarely does. The development organization survives according to Mosse through interaction and mediation of meaning on all levels of the organization, rather than strictly by human actors non-reflexively performing what the
policies tell them to. Furthermore, he considers the mediation processes to ultimately serve the purpose of reaffirming existing (political) discourses rather than that of helping those the organization sets out to ‘develop’.
The previously mentioned ideals of egalitarianism have similarly been put under scrutiny with an ANT approach. Rebecca Marsland (2006) shows through a study conducted in Tanzania how the participation concept comes to bear differing and even contradictory meanings for different actors within a development project. While participation within the discourse of international development implies notions of empowerment and employment of local knowledge, it comes to bear meaning through the post-independence political landscape of Julius Nyerere from the perspective of the Tanzanian government. Following the socialist ideals defining this era, participation is conceptualized as people having an obligation to contribute to the collective good, and not that people as individuals should be enabled to empower themselves. Still, in line with Mosse (2005), Marsland comes to see that the tensions between differing modes of meaning are being negotiated out of necessity in order for
projects to survive; compromises are made and middle grounds are figured out through processes of mediation.
In the following I intend to adapt an ANT approach to the exchange project between HUH and CC. In the previous chapter we have seen that FK-Norway’s ideological framework and the hospital strategies open for different interpretations of the exchange concept. As I will show here, translations in the network opposed and constituted tensions between the groups of nurses.
- 24 -
3.3 The project translated
‘Exchange’ the way it is fronted by FK-Norway did in certain contexts seem to have a strong value for Anja and Greta. When discussing the agency’s way of doing development with me in more formalized settings, the two of them expressed pride in being part of the organization. They considered the model of exchange and mutuality as unique and something to emphasize and cherish. The first time we talked about the matters while I had my notebook ready, such notions were presented by the Norwegian nurses. Greta explained her thoughts about the exchange project like this:
“While most development organizations only work in one direction, FK-Norway lets the development go both ways. By also allowing Tanzanians to come to Norway, they open up for a better understanding between us and them, and both sides can learn from each other”
The Norwegian nurse expressed notions of FK-Norway’s development model as less demeaning and more morally sound than a top-down model, and she had no ambitions or intentions of being a lone savior of Tanzania:
“I didn’t come here thinking that I could save the Tanzanian society or even make a
significant impact in [CC]. Those ideas [in development] are somewhat arrogant. They [CC nurses] are nurses just like us, and they are not stupid. In many ways they know better than me what is needed here” (Conversation with Anja and Greta February 25th
2014).
Further, when discussing the FK-Norway facilitated introduction course in Addis Ababa, Anja and Greta presented similar positive sentiments towards a development model of mutual respect and understanding:
V: How do you feel about the [FK-Norway] initiation course? Did it have any value for you? G: The course is made for us to challenge our own presumptions about other cultures and we were forced to engage in discussions which sometimes were uncomfortable but necessary. All in all I think it’s a good thing that they arrange this kind of preparation.
A: Actually, most of the things we learned were quite obvious for us [Anja and Greta], but I think especially the [participating] Africans could benefit from learning about openness towards different [cultural] ways of thinking (Conversation with Anja and Greta, February
- 25 -
The quote from Anja shows another side of the Norwegian nurses’ approach to Tanzania and the exchange project. In some contexts they emphasized and made value judgments regarding differences between them and their Tanzanian counterparts, rather than cherishing and
emphasizing mutuality and identification. As will be dealt with more in-depth throughout the next chapter, Anja and Greta’s social realities in Dar-es-Salaam were largely constituted by their existence in what I will call an expat social field. The stories Anja and Greta shared with other expatriates9 and travelers in this field tended to vary from being mundane or humoristic accounts of how their (Tanzanian) taxi driver failed to understand where he should pick them up or how the (Tanzanian) waiter needed to be reminded three times before she was able to bring them their order, to stories about robberies or examples of how they perceived the Tanzanian health care system to be inefficient, immoral or dangerous. As my following field notes suggest, the two Norwegians often shared frustrations originating from their experiences in CC:
“Went out to eat and drink on the [Msasani] peninsula with Anja and Greta and a group of [expat] people yesterday. When [a European friend] asked them how their work is going, Anja, in what has become a common fashion for me to observe in this [expat] context, made frustrated remarks regarding the way she perceives the Tanzanian society and CC. Yesterday her frustrations were directed towards the department of accounting [in CC]. She considers the process of preparing the [chemotherapy] course as moving too slowly, and talks a lot about how the ‘African’ ways of doing things are inefficient and incomprehensible for her”
(Field notes March 15th 2014).
In the above paragraphs we can see that there were certain incoherencies regarding how the Norwegians approached their relations to Tanzania and CC through the exchange project. The ways Anja and Greta spoke on their ideas about the project and the country in different contexts is in ways relatable to Goffman’s (1956) notion of stages in his dramaturgical theory on social life. Where the ‘front stage’ represents the ways in which actors present themselves in front of an audience, ‘back stage’ represents the self when no, or a very limited audience is present. On certain social stages the language of identification and reciprocity was
emphasized by Anja and Greta, and on others they emphasized the perceived differences
9 Expatriate or the shortened ‘expat’ refers to people temporarily or permanently living outside their country of
- 26 -
between them and Tanzania. However, rather than sticking to the limiting borders of different stages, I will argue that the two nurses maneuvered on a continuum of stages. In other words, the metaphor of the stage might imply that Anja and Greta had a more ‘black-and-white’ approach to Tanzania and the exchange than what was the case.
One notion that Anja and Greta emphasized when talking to me about their understandings of the exchange was that of being left alone to make sense of the project. It was thus difficult for them to present a clear vision of their primary functions and goals in CC. This difficulty seemed related to the potential ambiguousness in design of ‘exchange’ I sketched out in the previous chapter. The design constituted a set of paradoxes for the nurses regarding their perceptions of expectations in the project. On one hand they were (perceiving themselves as) expected to make a change in the CC setup, related in particular to the handling of cytostatic drugs. Meanwhile they were (perceiving themselves as) expected to share and develop ideas with the Tanzanians through sentiments of mutual respect and understanding. Anja and Greta expressed notions that made possible fulfillments of the expectations mutually excluding - in order to make change, they felt that they had to implement practices they were accustomed to from Norway regarding safety measures and hygiene in CC, and in order to live up to the expectations of mutual understanding and creativity they felt that they had to (at least to a certain extent) abandon said practices:
V: “What have you been considering as your main goals [in the exchange] so far?”
G: “We didn’t get any specific instructions and everybody has basically told us that we are free to do whatever we want. I actually had to ask for the [joint hospital] strategies before we got them. In the end it hasn’t made much sense to work according to them anyways, and we’ve had to figure things out for ourselves. There is of course the chemotherapy part that has been a focus all along [for all Norwegian groups in the project], and this has been our main concern as well.”
V: “So, what about the ideals of mutuality presented by FK-Norway?”
G: “Well, it’s difficult to ignore the differences between them [CC nurses] and us. We come from a much more resourceful and well functioning hospital, and it is unavoidable that this plays a part [in the inter-professional relations between the Norwegian and Tanzanian nurses]. I can’t keep working in a certain way when I know it’s wrong. In the end I guess it has to be more about us bringing our knowledge down here, and not the other way around.”
