Mapping the sites?

I could multiply the sites, but I’ll stop with four, the enactment of four versions of alcoholic liver disease and the production of four different contexts. For yes, here again we face the problem of difference or multiplicity. So as with atherosclerosis, we can say that alcoholic liver disease is fractional, that it is more than one and less than many. And then we can look at the strategies for relating these. Many of the items on the list for atherosclerosis are at work here too:

• There is layering: a continuing faith, admittedly more relevant in some contexts than in others, that the body contains or is a single reality out there, with particular and quite specific attributes, even if those attributes are not necessarily clear either in the ward or the medical textbook.

• Alongside this there is a single smooth narrative – most clearly, perhaps, from Dr Warrington and the textbook, which can account for the various versions and manifestations of alcoholic liver disease by locating it as attributes of, and pathways in, the body, and noting that these express themselves in various visible ways.

• There are translations between different ‘indicators’ of alcoholic liver disease too, though I have not illustrated these in the brief account above. But for instance, there are translations in the hospital for comparing the results of different tests, for converting one to another.

• Then there are hierarchies between the tests. In particular contexts some are taken more seriously than others. Dr Warrington, for instance, mentioned that he had introduced a set of new tests for liver function. These are tests, he told us, that have since become the ‘gold standard’ at certain diagnostic moments, and are better than the older tests.

• There are also rationalisations and explanations for apparent discrepancies. For instance, it is a cliché that there are almost always differences between

liver-function test results and the patients’ own more optimistic accounts of their level of intake of alcohol. But almost always it is the test results that are treated as the gold standard: those dependent on alcohol are taken to have systematic reasons for concealing the level of their intake.

These are the perspectival strategies that work to produce singularity out there, in the face of difference in here. At the same time, there are also several non- perspectival strategies at work:

• There are sites, and therefore realities, that are mutually exclusive in space, time, or both. For instance, some of the tests for cirrhosis described in the textbook are only possible on dead livers, while liver-function tests are only possible on living organs, and patient stories about drinking also come from live people (though not necessarily the person who is drinking).

• Some incompatibilities are simply kept apart. This, for instance, is generally the case for the world inhabited and enacted by Dr Bowland, and her clients on the one hand, and the routines of the hospital ward and the practices of consultants such as Dr Warrington on the other. Very fre- quently these different versions of alcoholic liver disease don’t go together, and overlap may, as we have seen, look like tragicomedy.

• Some differences are effaced by being added together. What, for instance, counts as an improvement? The hospital says that this is abstinence. Such is one possibility, one reality. Or is it an improved life-style and a reduction in alcohol intake – a second reality? Dr Nixon, a community consultant whom we also interviewed, went for the latter version. But this is not only inconsistent with the general view in the hospital (which would suggest that these realities need to be kept apart) but is also, and in itself, additive (quality of life and reduced intake).

• Finally, and related to this, it is possible to create different objects – an issue or a strategy of considerable importance to which I will return in the next section.

Obviously many of the strategies for handling difference listed by Mol are also at work here. This means that alcoholic liver disease may be understood as a fractional object. Differently enacted in the different practices in the different sites, those differences are managed in a way that also secures the continued possibility of the singularity of alcoholic liver disease at each particular location. This in turn opens up the possibility of an ontological politics.

One example. As I earlier indicated, many of the professionals believed that after-care was both inadequate and poorly co-ordinated: that far too often, when patients were discharged they were left to fend for themselves – which meant that they returned to their old circumstances, failed, rapidly returned to drinking, and were readmitted to hospital after a few months. This was distressing from both a medical and a human point of view. However, it was

also an economic and management problem for the hospital. Patients with alcoholic liver disease kept on returning and occupying costly hospital beds.

But, though the professionals would never put it in these terms, this also implies a version of ontological politics. This is because it is not only about organisational failure (though this was one common way of talking about it), but also about the relations between two realities, two different alcoholic liver diseases. There is one, produced by medicine as this is enacted in the textbooks, practised in the wards and in particular in the consulting rooms. This is an alcoholic liver disease that is overwhelmingly medical in character. It is located in the body and in particular in the liver of the patient. To the extent that it reaches beyond the body of the patient, its relevant visible context out-there, it is likely to relate to the patient’s personal or character problems: we were told, for instance, by one consultant that alcoholics are ‘devious’ because they try to conceal their drinking. The second alcoholic liver disease is partly medical too, but it is less sharply bounded, extending into the psychiatric and (even more) the social relations of the patient. In this version, alcoholic liver disease changes its shape. Yes, it has to do with the body and the liver, but it also reaches into culture and milieu, with the ready availability of alcohol, with the likely ties between alcohol and social life, with life events (stress, loss, and their possible consequence in depression are sometimes said to lead to alcohol abuse), and on occasion with psychiatric illness. It is located both within and beyond the body. And its context is similarly diffuse and heterogeneous.67

This is ontological politics. Which of these two realities is to be preferred? Or, perhaps more appropriately, how might a satisfactory balance between the two realities be enacted? How should they be related? Indeed, this was precisely the problem that Singleton and I were being asked to think about when we were commissioned to do the study, and it was one that turned out to be quite intractable. It was difficult to handle because of the organisational, professional, and economic distinctions between acute medicine, community medicine, social work, counselling, welfare agencies, and a range of voluntary organisations. An ontological politics, then, here implied an attempt to reorder organisational and professional relations. Or, to turn this round, the particular version of organisational and professional relations in the location we studied produced a powerful and narrowly medical version of alcoholic liver disease – and as a part of this, a strong distinction between the medical on the one hand and the social on the other. The social was being pushed out of the medical context into invisibility. At the same time it also, but much more tenuously and tentatively, enacted the alternative version of the disease in which the medical, psychiatric and social were taken to be interwoven both in the patient and her condition, but also in the context out-there that was taken to be relevant. So there were two objects, and two contexts, one strong, and the other weaker – but the stronger reality with its distinction between medical and social found it difficult to cope with the continual return to drinking by those dried out in the hospital and discharged.68

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