Fluid results

Sites

In this inquiry into in-hereness and out-thereness the argument of Chapter 2 was that method is productive of realities rather than merely reflecting them. And that parts of the out-there are made visible while other parts, though necessary, are pushed into invisibility. This was a first stage in the erosion of Euro-American metaphysical certainties. In Chapter 3, in a move that turns singularity into multiplicity, or better into fractionality, I explored the enactment of different realities at different sites. In Chapter 4 I extend the argument by considering a further metaphysical assumption, the idea that what is out-there necessarily has a definite form. I am going to say that there are circumstances where this is not the case: that some relevant realities are indefinite.

In this chapter I again work through case studies. The first is about the treatment of alcoholic liver disease in an area of the north of England. Vicky Singleton and I together collected the empirical materials and developed a version of the argument that follows, and I am grateful to her for her generosity in letting me rework that argument here.58The second is a study of a water pump in Zimbabwe by Marianne de Laet and Annemarie Mol.

The first case, alcoholic liver disease: I want to say that its diagnosis and treatment is similar to that of atherosclerosis because it too is located and enacted as an object in a wide range of different locations:59 the Waterside District General Hospital, the alcohol advice centre, the Samaritans, the Salvation Army, the consulting rooms of the general practitioners, the resi- dential homes – not to mention the pubs, off-licences and homes of those released from hospital back into the community. Alcoholic liver disease appears, and is enacted, in many places. However I’ll start with the account of alcoholic liver disease in a textbook which sits in the office of one of the consultant gastro- enterologists in the Waterside District General Hospital:

Over the last 20 years alcohol consumption has correlated with deaths from cirrhosis.... At the Royal Free Hospital, London, between 1959 and 1965 alcoholism accounted for only 4.3% of patients with cirrhosis, compared

with 25% between 1978 and 1983.... Not all those who abuse alcohol develop liver damage and the incidence of cirrhosis among alcoholics at autopsy is about 10–15%.... The explanation of the apparent predis- position of certain people to develop alcoholic cirrhosis is unknown.

(Sherlock 1989, 425)

The textbook tells us that the aetiology of alcoholic liver disease is complex, related (but not very directly) to: the level of alcohol intake; the duration of heavy drinking; patterns of drinking (bingeing is less dangerous than continued heavy drinking); gender (everything else being equal, women seem to be more at risk to alcoholic cirrhosis than men); histocompatibility; genetically determined enzyme polymorphism (there are at least two bodily metabolic systems for converting alcohol and how these balance off against one another can be important); exposure to hepatitis B; levels of dietary protein (malnutrition tends to exacerbate the effects of alcoholic liver disease); and to a variety of poorly understood metabolic synergies, for instance between nutrition and alcohol conversion (Sherlock 1989, 427–428). The mechanisms of liver damage are similarly complex, as are morphological changes in the liver, which come in at least three varieties: steatosis (fatty liver), alcoholic hepatitis (inflammation of the liver) and cirrhosis, which is ‘a diffuse process with fibrosis and nodule formation. It has followed hepato-cellular necrosis’ (Sherlock 1989, 410).

If we follow Latour, Woolgar and Mol, then we need to say that the textbook account of alcoholic liver disease both describes and helps to enact the condition in a particular way. Here the condition becomes a complex set of aetiological, environmental, physiological, anatomical and behavioural relations and effects which match the statements in the text. Indeed, the text uses the kind of apparatus described by Latour and Woolgar: paragraphs, figures, drawings, tables, and innumerable references. The text, then, is the in-here that belongs to and helps to enact a particular method assemblage. It crafts and is crafted in a hinterland that produces a somewhat tentative and uncertain description in-here of an alcoholic liver disease and its reality out-there.

Let’s move to a second location. Again, we’re in the office of a consultant gastro-enterologist, Dr Warrington, but this time we’re interviewing him, and a somewhat different reality is being created:

When they arrive my juniors are sat down, and I tell them how to manage liver disease. The instructions I give them are quite specific. They are told to follow a written protocol. Alcoholic liver disease can be quite easy to manage. But very few understand the basic principles.60

Dr Warrington tells us that he gets a ‘little bit annoyed’ if juniors don’t follow the protocols because alcoholics in withdrawal express symptoms that can be misleading. For instance:

One of the problems is that the condition actually worsens at first. This is because we are depriving them of alcohol, which may lead to hypo- glycaemia. Also, alcohol is a depressant. Withdrawal from alcohol leads to metabolic outpouring. They may become hypokalaemic, with potassium falling along with the blood sugar. This may lead to misdiagnosis by junior staff.61

The problem being tackled by Dr Warrington is not unrelated to that described in the textbook, but it isn’t the same either. Dr Warrington needs to treat patients, to arrange to have them withdraw from alcohol, and to deal with some of the physiological side-effects of that withdrawal. He also needs to persuade them to abstain from alcohol: ‘People have brought alcohol into the hospital, for instance, by injecting fruit. You would be amazed how much alcohol it is possible to inject into a banana.’62

Here, then, alcoholic liver disease is being enacted as a set of physiological and anatomical malfunctions. But it is also a regime of treatment, and a matter of psychology too. The similarities with lower-limb atherosclerosis are obvious. Here again treatment co-exists with medical truths. So this assemblage draws on and relates to that witnessed by the textbook, but ramifies off in other directions too – into the practicalities of treating patients, junior medical staff, and nurses.

Just down the corridor from Dr Warrington, Singleton and I interviewed a busy Ward Sister. Sister Fraser is manager of one of the gastro-enterology wards in the hospital. This is our third site. Sister Fraser has much experience of patients admitted with the diagnosis of alcoholic liver disease. She and her staff are responsible to Dr Warrington and to the other consultants for the treatment of such patients. She tells us that they are often very poorly when they arrive. In addition, many do not want to accept that they abuse alcohol. The nursing staff start by devising a care plan which includes special nutrition, they check for bed sores, and arrange for the appropriate tests. And then they start on the process of trying to dry the patients out. Alcohol is forbidden, and a sedative, heminevrin, is prescribed to ease withdrawal. Even so, ‘the majority are difficult, aggressive because they are withdrawing from alcohol on the ward. Which means that they can be disruptive of ward routine.’63

So the process can be distressing for all concerned – patient, nursing staff, and fellow patients. At the same time, the ward staff are trying to arrange appropriate after-care. Here is Sister Fraser:

Some patients have partners who are also alcoholics. We won’t be able to help them very much. Socially, we have a social worker who may offer financial advice. Not very many patients get to see the psychiatrist. But we give them information about Alcoholics Anonymous, and also about the Alcohol Information Centre, which offers counselling and support, one-to-one.64

However the nursing staff, who often see the same patients readmitted time after time, also worry about the lack of after-care. Here is a colleague of Sister Fraser, who manages the equivalent women’s ward:

I would like to see more support for alcoholics. The fact that there is no psychiatric support makes me mad. Social work support is limited. If they can’t rehouse them, can’t move them, then they are likely to be going back to the situation which made them drink in the first place. That’s distressing. If they want to get out [of the cycle of alcoholism] it would be much easier if they could have proper support.65

So the ward is a third site, and those who work on it enact another variant of alcoholic liver disease both as an object in-here, and a context out-there. Thus it becomes: a set of nutritional demands; the administration of drugs; a response in the form of special nursing care; the need for quick responses to occasional dramatic medical events; an ability to manage delusional patients; and, perhaps most interesting in the present context, the process of organising broader community support, for instance from social workers, but also from family, the community health trust, and a range of other agencies and bodies. Here, then, alcoholic liver disease and its treatment becomes some kind of composite. It relates to, and draws upon, a context that is medical, psychiatric, but also social. But both the psychiatric and the social are sources of despair for those who build the disease in this particular way.

And here is a fourth site. For only a few miles from the hospital Singleton and I visited Dr Bowland, a general practitioner on the Heathcote estate where there is a substantial problem with alcohol abuse:

Interviewer: Do you talk to patients about the consequences of drinking? Dr Bowland: This is not an issue. It isn’t really possible to talk about the physical consequences of alcohol abuse. I can’t talk about

such things to many of my clients – to do so might provoke a violent response. The issue is just not relevant to them. They aren’t interested in long-term questions, don’t take them into consideration. Most people who live in Heathcote have accepted that they will never work again and don’t aspire to a fancy car or to different and better housing.66

Dr Bowland has been trained in ways that are similar to Dr Warrington and Nurse Fraser. She knows what the textbook says about the effects of alcohol on the liver. This is being crafted as a part of the relevant hinterland. But even so, the world, and therefore the disease, are being enacted very differently. This is because the textbook knowledge and training is crafted together with other quite dissimilar elements to make up a hinterland that is substantially different. Dr Bowland makes the point quite graphically by telling us the story of one client who had been told by a consultant in the hospital that if she carried

on drinking she would kill herself. The consultant hoped and expected that this would shock the patient into abstinence. But her reaction was in fact quite different. She simply came to Dr Bowland to ask, almost matter-of-factly, how long she still had to live, how many months. Alcoholic liver disease, Dr Bowland was telling us, was the least of her problems. And to underline the point, she asked us whether we’d seen the drug dealers near the little row of shops close to the surgery. Hard drugs were widely used on the estate. ‘Frankly’, she added, ‘they’d be better off on alcohol.’

So alcoholic liver disease is a very different object here. Arising out of and producing a visible context that is very different in form, it is also being enacted very differently. It is a problem for sure. But for many it is also the least of the various available evils. And in the context of a serious attempt to deliver health care in such underprivileged circumstances to such underprivileged patients, it is rarely a matter of high priority.

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