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Introduction: Real and Imagined Spaces

Alice Street and Simon Coleman Space and Culture 2012 15: 4 DOI: 10.1177/1206331211421852 The online version of this article can be found at: http://sac.sagepub.com/content/15/1/4

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SAC15110.1177/1206331211421852Street and ColemanSpace and Culture

Articles

Introduction: Real and Imagined Spaces

Alice Street1 and Simon Coleman2

Space and Culture 15(1) 417 The Author(s) 2012 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1206331211421852 http://sac.sagepub.com

Abstract The hospitals ambiguous relationship to everyday social space has long been a central theme of hospital ethnography. Often, hospitals are presented either as isolated islands defined by biomedical regulation of space (and time) or as continuations and reflections of everyday social space that are very much a part of the mainland. This polarization of the debate overlooks hospitals paradoxical capacity to be simultaneously bounded and permeable, both sites of social control and spaces where alternative and transgressive social orders emerge and are contested. We suggest that Foucaults concept of heterotopia usefully captures the complex relationships between order and disorder, stability and instability that define the hospital as a modernist institution of knowledge, governance, and improvement. We expand Foucaults focus on the disciplinary, heterotopic qualities of the hospital to explore the heterotopia as a space of multiple orderings. These orderings are not only biomedical. Rather, hospitals are notable for the intensity and heterogeneity of the ongoing spatial ordering processes, both biomedical and other, that produce them.We outline an approach to heterotopias that traces the contingent configuration of hospital space through relationships between the physical environment, technologies, and persons, while simultaneously considering the kinds of spatial imaginings, hopes for the future, and emotional responses that are rendered possible by those configurations. We provide three thematic frameworks through which the heterotopic and contingent qualities of hospital spaces might be explored: boundary work, generating scale, and layered space. Keywords Hospital ethnography, heterotopia, biomedicine, STS, medical anthropology

The backdrop for a coup and its bloody aftermath in Ethiopia (Verghese, 2010), the site where postapartheid tensions ferment and erupt in South Africa (Galgut, 2003), a vantage point for exploring changing masculinities and the morality of war in early-20th-century Britain (Barker, 1991). The hospital has emerged as a quintessential setting for contemporary fiction; a stage where dramatic historical events, social and cultural divisions, and moral dilemmas are played out against the backdrop of modern medicines battlefield between life and death.

1 2

University of Sussex, Brighton, UK University of Toronto, Toronto, Ontario, Canada

Corresponding Author: Alice Street, Department of Anthropology, University of Sussex, Brighton, East Sussex, UK BN1 9RH Email: a.street@sussex.ac.uk

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Why does the hospital prove to be such a valuable literary device? Of course, the hospital is a place of high drama, where the stakes involved in attempts to diagnose, treat, cure, care, and save lives are frequently articulated through the idiom of warfare (Martin, 2001), and where patients and doctorsfaced with the possibility of their own or others physical transformation and deathare prompted to reflect on the core issues of life (Long, Hunter, & van der Geest, 2008). But in this special issue we argue that the metaphorical persuasions of hospital space further derive from an intrinsic ambiguity in the relationship between the hospital and everyday social space. In its fictional versions, this spatial ambiguity has three simultaneous modes of representation. First, the hospital is represented as a place set off and isolated from everyday social space. The highly ordered and ritualized spaces of the medical ward or the operating theater, full of material implements and technologies that symbolize the mystery and magic of scientific knowledge, where trained doctors and nurses do war with unruly nature, are simultaneously uncanny and depict the hospital as a world governed by its own complex systems of social control and order. The hospital appears to become a foreign, unfamiliar place of medicine analogous to the other exotic locations that regularly serve as settings for fictional escapades. Second, and in contrast to this image of the hospital as a place apart, the hospitals ordered isolation is nearly always shown in its fictional versions to be incomplete. The events taking place in the hospitals wider spatial arena transgress its boundaries, transported by patients, soldiers, politicians, or missionaries, who intrude on the tightly structured and ordered world of the hospital, introducing new social rules and cultural values, raising the stakes for those who inhabit the institution and driving the plot forward. Last, the hospitals simultaneously bounded and permeable status facilitates its literary purpose as a metaphor for the wider regional, national, or global space in which it is located. The hospital appears as a microcosm of society. The conflicts, love affairs, and struggles that play out in its operating theaters, medical wards, and labor units stand for those wider historical and social transitions from one social order to another. The changes undergone by the hospital and its inhabitants represent the threat of transformation to the social order as a whole. A concern with the hospitals boundaries and the relationship between hospital space and other external spaces has equally preoccupied hospital ethnographers. However, as we outline below, in hospital ethnography the question of boundedness has tended to be framed as an either/or issue. Hospitals are presented either as isolated islands defined by biomedical regulation of space (and time) or as continuations and reflections of everyday social space that are very much a part of the mainland. This polarization of the debate overlooks what we believe to be a significant aspect of hospital space and the reason why hospitals are deeply important truth spots (Gieryn, 2006) for social scientists interested in the relationships between space and culture more broadly: hospitals paradoxical capacity, readily exploited in the literary world, to be simultaneously bounded and permeable, both sites of social control and spaces where alternative and transgressive social orders emerge and are contested. We suggest that Foucaults (1986) concept of heterotopia usefully captures the complex relationships between order and disorder, stability and instability that define the hospital as a modernist institution of knowledge, governance, and improvement. As we outline in this introduction, this special issue expands Foucaults focus on the disciplinary, heterotopic qualities of the hospital to explore the heterotopia as a space of multiple orderings (following Hetherington, 1997). Crucially, we argue that the multiformality of the hospital, the complexity, variability, and unpredictability inherent to the relationships that order its constituents, are often central to its continuity and durability as an institution (Singleton, 1998) A focus on the heterotopic qualities of hospitals draws attention away from the composition of external boundaries and toward the heterogeneity and internal differentiation of hospital

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space. Hospital ethnographies that have focused on the existence or not of boundaries around the hospital have tended to equate those boundaries with biomedical authority, thereby reducing hospital spatiality to an issue of biomedical control. By contrast, we propose a focus on the multiple, layered, and contested orderings that configure hospitals as spaces of care, expertise, and science. This is to emphasize the contingency and fragility of hospitals. The articles in this special issue do not take the status of particular sites for granted but explore the complex everyday configurations and alignments of materialities, social practices, and representations through which particular spaces are constituted as hospitals. The contributors do not start by asking are hospitals bounded spaces? but by asking how are hospital spaces made up? and exploring how answers to this question can speak to wider debates about space and culture. To answer this question in ways that overcome simplistic binary classifications of hospitals as either scientific or social spaces, we believe that hospital ethnography needs to look beyond medical anthropology to draw on theoretical and methodological resources from cultural geography and Science and Technology Studies. In our introduction, we outline an approach to heterotopias that traces the contingent configuration of hospital space through relationships between the physical environment, technologies, and persons, while simultaneously considering the kinds of spatial imaginings, hopes for the future, and emotional responses that are rendered possible by those configurations.1 We first describe the theories of space, society, and science that are implicit in established approaches to hospital ethnography before providing a more extensive discussion of why we find the notion of heterotopia useful for thinking through hospital spatialities.

The Three Spaces of Hospital Ethnography

The early sociology of hospitals that emerged in the 1950s and 1960s, based largely in European and American hospitals, emphasized their separation from everyday life and focused on the informal relationships and cultural conventions through which the hospital was maintained as a functioning unit (Caudill, 1958; Coser, 1962; Goffman, 1961).2 The hospital was treated as a small society whose organization, rules, and social structure were defined by its medical functions. This interest in the isolated order of the hospital was related to the changes that the institution had undergone in the late 19th and early 20th century with the professionalization of nursing and medicine and rapid advances in technology that transformed the hospital into a space of medical specialization and expert authority (Porter, 2002; Rothman, 1991; Starr, 1982). Arguably, by focusing on the particularities of hospital space it also helped define medical sociology as a subfield in its own right. Such early ethnographies focused on the experience of patients, whose abrupt removal from the homes and workplaces associated with their everyday relationships and social identities best exemplified the closed order of the hospital. They described patients collective experience of ward life and the social relationships and cultural norms that they established with one another in response to the hospitals alien, closed, and highly regimented social order. Moreover, it was argued that the patient subculture in the hospital and the highly structured relationships between patients and staff were key to the hospitals fulfillment of its medical functions (Coser, 1962; Goffman, 1961; Zussman, 1993). This image of the hospital as a tight little island (Coser, 1962) is replicated today in policy demands for the democratization of medicine and the claims that social scientists make for hospital ethnography as a tool that can open up the closed expert culture of the hospital to public scrutiny (Finkler, Hunter, & Iedema, 2008). Such calls for democratization and transparency, which imply that hospitals had until now been closed, elitist spaces of medicine, have gained momentum as anxieties about the risk of infection in hospitals have

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increased and as calls for medical accountability and patient rights have grown. This model of hospital ethnography as an instrument of accountability or transparency is manifested in arguments that hospital ethnography can provide guidance on how to negotiate contemporary health services as a citizen of the modern world (Finkler et al., 2008, p. 250). Despite such depictions of hospital ethnography as an instrument of transparency and accountability, however, recent attempts to map out a new field of hospital ethnography have been notable for their arguments that hospitals are not closed, total institutions but are continuations and condensations of society at large.3 In a 2004 special issue of Social Science & Medicine, van der Geest and Finkler (2004) contrast new hospital ethnography with earlier functionalist models, noting that life in the hospital should not be regarded in contrast with life outside the hospital, the real world, but . . . is shaped by everyday society. The hospital is not an island but an important part, if not the capital, of the mainland. (p. 1998) Just as historical and social events are shown in fictional depictions as flowing over hospital boundaries, so too recent articles have emphasized the permeability of the hospital: the movement of patients, staff, and visitors in and out of the institution and the social relationships, inequalities, and cultural values that they carry with them (e.g., Mooney & Reinarz, 2009; Quirk, Lelliott, & Seale, 2006). Moreover, it is argued that those social and cultural continuities are not merely external impingements on biomedicine. Biomedical practices and diagnostic styles are themselves adapted to the social and cultural conditions of the country in which a hospital is located (e.g., Finkler, 2004; Gibson, 2004; see also Berg & Mol, 1998). In addition to the portrayal of hospital boundaries as permeable, hospital ethnographers have proposed that we think of the hospital as a reflection or microcosm of the larger social domain in which it is located. In this version, the hospital is a place where the core values and beliefs of a culture come into view (van der Geest & Finkler, 2004, p. 1996), representing a condensation and intensification of life in general (Long et al., 2008, p. 73). In a full-length monograph based on fieldwork on the surgical ward of a public Bangladeshi hospital, Zaman (2005) argues, [T]he hospital is not an isolated subculture or an island, rather it is a microcosm of the larger society in which it is situated. A hospital ward is therefore a mirror that reflects and reveals the core values and norms of the broader society. (p. 18) As with their fictional equivalents, such depictions of the hospital as permeable and microcosmic present it as window onto the society where it is situated. Hospitals are recognized to be performed in culturally and regionally variable ways. However, while such accounts rightly contest models of a monolithic biomedical ordering of space, their emphasis on spatial continuities risks effacing the otherness and unfamiliarity of hospital spaces. In other words, if hospitals are simply reflections of society, what makes them hospitals at all? The contributors to this special issue all continue to be intrigued by the uniqueness and peculiarity of hospital spaces. However, they do not associate the otherness of the hospital with a homogenous biomedical culture. Rather, they argue that hospitals are notable for the intensity and heterogeneity of the ongoing spatial ordering processes, both biomedical and other, that produce them. Furthermore, they question the easy invocation of larger society in relation to hospital space by asking where we are to locate the boundaries of such social influence, whether in regional, national, or transnational frames of reference. We argue that the hospitals seemingly paradoxical status as both bounded and permeable is crucial to its constitution as a hospital. Hospital spaces are often regulated, standardized, and

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ordered according to biomedical and bureaucratic knowledges in order to align disparate doctors, nurses, relatives, patients, technologies, and spaces in the diagnosis and treatment of diseased bodies. At the same time, the hospital is necessarily open and permeable because these technicalspatial arrangements do not act on isolated microbes that have been primed for laboratory analysis but on disease as it is found in the real world; and the unpredictability and complexity of that world enters the hospital with disease. To deal with such contingencies, biomedical practices often develop in ways that destabilize fixed roles and afford practical variability (Mesman, 2012; Mol, 2002; Singleton, 1998; White, Hillman, & Latimer, 2012). Meanwhile, in places of resource shortage such as Papua New Guinea (Street, 2012), Kenya (Brown, 2012), and Tanzania (Sullivan, 2012), the contributions to this special issue show that biomedical orderings of space are particularly fragile (instruments break, doctors and nurses are too expensive, there are not enough beds or metal number plates to pin to them). In such places, hospitals often depend on other orderings, such as domestic kinship practices, to prop up their medical functions. Permeability is shown to be a crucial asset at the same time as incongruities between different orderings are shown to lead to potential contestation and dispute. The hospitals status as a simultaneously open and bounded space in the ways we have outlined above means that it is necessarily constituted by multiple concurrent orderings of space, both biomedical and nonbiomedical.4 It is to this issue of multiple orderings that we now turn in relation to a discussion of the concept of heterotopia.

Hospital Heterotopias
For Foucault, the opposition of the hospital to everyday life makes it an archetypal heterotopia, a space that is simultaneously real and imagined, constructed in relation to all other spaces. In the few comments that Foucault made on heterotopias, in a lecture given to architects in 1967, he argued that space is not an empty void in which individuals and things are located but rather consists of multiple heterogeneous sites that are defined by their relationship to one another. Heterotopias are unique sites that are both related to and defined in opposition to all other sites; they present an alternate social order that disrupts or inverts the social relations that characterize those other social spaces. They are a kind of effectively enacted utopia in which the real sites, all the other real sites that can be found within the culture, are simultaneously represented, contested, and inverted (Foucault, 1986, p. 24). Like asylums and prisons, hospitals are what Foucault calls heterotopias of deviance designed to deal with persons whose bodies are considered to diverge from societys norms relating to health. The hospital is the actualization of a utopian vision of scientific order, cleanliness, and rationality, existing in opposition to and separated from the messy reality of everyday social space (Foucault, 1986). Foucault describes how, through the exclusion of familiar everyday space, the hospital emerges as a site (sight) of medical surveillance and discipline, a laboratorylike setting where, under the penetrating gaze of modern medicine, the symptoms of disease can be diagnosed and treated (Foucault, 2003). Heterotopias are, according to such a view, intrinsically ambiguous spaces. They are both constituted by their relationship to other spaces and defined in opposition to them; they involve a complex ordering of opening and closing that both isolates them and makes them penetrable (Foucault, 1986, p. 26). However, it can be said that Foucault overemphasizes the efficacy of panoptic regimes of spatial control (Elden, 2003; Gibson, 2004) and overlooks the contested and multiple nature of hospital space even as he argues that such qualities are central to other heterotopic sites such as the theater, cinema, or oriental garden, which are capable of juxtaposing in a single real place several spaces, several sites that are in themselves incompatible (Foucault,

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1986, p. 27). Foucaults analysis of hospitals as spaces of discipline and surveillance has been widely taken up by social scientists interested in processes of subjectification and relationships between space and power (e.g., Elden, 2003; Gibson, 2004; Philo, 2000; Prior, 1988; Rhodes, 1995). Rather than seeing such disciplinary orderings as totally determining of hospital space, however, the contributions to this special issue emphasize the relational, contested, and multiple nature of heterotopias and their capacity to change over time (Foucault, 1986). In this regard we follow Kevin Hetheringtons (1997) definition of heterotopias as spaces where different kinds of social ordering, which can be either transgressive or hegemonic, are tried out. Hetherington argues that heterotopias are neither panoptic spaces of control nor marginal spaces of freedom but are constituted by multiple and often incongruous processes of social ordering. Hetherington describes, for example, the juxtaposition of bourgeois shopping arcades and gardens with brothels and coffee-houses in the heterotopic Palais Royal in Paris at the end of the 18th century. Here new bourgeois codes of behavior, modes of political mobilization and transgression, and new economic rationalities emerged in contradistinction to the royalist spaces of Parisian society (Hetherington, 1997). Hetherington uses the notion of orderings rather than orders to draw attention to the incompleteness and contingency of any sociospatial arrangement (see also Law, 1994). The alternate bourgeois social orderings of the Palais Royal were, he suggests, performances made possible through the bringing together of physical spaces, technologies, representations, and persons in new configurations of the social. This focus on alternate orderings takes the contributors to this special issue beyond the opposition of panoptic regimes of biomedical regulation and practices of resistance to consider the multiple processes of ordering that are performed in everyday relationships between buildings, technologies, and persons. In this view hospitals are not defined by a distinction between biomedical and nonbiomedical space but are made up of multiple internal and external spaces whose relationships change over time with shifting configurations of actors.

Fragile Assemblages
Given our focus on contingencies in material and social orderings, we believe that an enquiry into the spatiality of hospitals requires hospital ethnographers to look beyond medical anthropology and sociology in order to engage with theoretical and methodological approaches where such themes have been extensively explored, such as Science and Technology Studies (STS) and both cultural and medical geography. Recent interest in spatial relationships in STS has highlighted the importance of the material structuring of space, not as a fixed background for social and cultural action but as an ongoing process of alignment between different human and nonhuman entities (Gieryn, 2002). This emphasis on associations between human and nonhuman actors draws attention to the contingency and fragility of any spatiosocial arrangement. Laboratory studies, for example, have demonstrated that the status of the laboratory as a place where authoritative knowledge can be produced is not given but must be achieved through everyday material practices such as the calibration of scientific instruments or the standardization of test tubes, lab benches, and Petri dishes (Knorr-Cetina, 1999; Latour & Woolgar, 1986; Livingston, 2003). In contrast with the laboratory, where spatial practices are often focused on the attempt to eliminate contamination between laboratory and world, the hospital is constituted as a place of biomedicine through technical and bureaucratic ordering processes and at the same time must be made open to the alternative orderings of the world it seeks to improve, including those of kinship, religion, or development.5 In this regard, the hospital is an intrinsically more open and perhaps more democratic space than the scientific laboratory. Biomedical orderings of hospital space depend on alignments with persons and things that may already be engaged in alternative

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orderings. The fragile balance of the hospital as a simultaneously bounded and permeable space is maintained through alignments between multiple and often incongruous practices of ordering, which might be medical, bureaucratic, religious, economic, or kinship-based. It is perhaps for this reason that recent STS research on hospitals has challenged laboratory studies emphasis on stability as a prerequisite for the durability of scientific networks. Those hospital studies have shown instead how the fluidity and adaptability of biomedical practices and knowledge can be crucial for the generation of effective care relationships in hospital spaces (Berg, 1997; Berg & Mol, 1998; Mol, 2002, 2008; Mol & Law, 1994; Moreira, 2006; Singleton, 1998). Unstable identities, interferences between heterogeneous knowledges and productive uncertainties, are described as crucial to the durability and workability of hospital networks. It is notable, however, that STS studies of hospitals have tended to focus on the relationships entailed by biomedical achievements, neglecting the nonbiomedical work and worlds that are often incorporated into hospital space. Moreover, the STS focus on expert systems and materiality can lead to a neglect of the role of imagination and emotion in the constitution of hospital space. As technologies of social progress, development, and modernity, hospitals are spaces of hope that are oriented toward and anticipate a better future (Street, 2012; White et al., 2012). They are also spaces of hope in a second sense in that both patients and relatives may invest them with their hopes for a diagnosis, treatment, and cure (Vecchio Good, Good, Schaffer, & Lind, 1990). The fact that both social futures and individual lives are perceived to be at stake in hospital practices requires that hospital ethnographers attend to the experiential, emotive, and imagined qualities of space and explore their interrelationship with the material spatial orderings revealed in STS approaches. Recent developments in medical geography, which build on theoretical developments in critical cultural geography (e.g., Massey, 2005; Soja, 2003; Thrift, 2007), have led to an increased focus on the importance of place in the organization of health care and have emphasized the ways in which medical institutions are invested with cultural meanings. Scholars such as Gesler (1991) and Kearns (1993) have drawn on the tools and concepts of cultural geography and anthropology to analyze the symbolic structuring and lived experience of therapeutic landscapes (Gesler, 1992, 1993). Such studies have shown that hospitals are dense with symbolic significance, repositories for individual and collective memories, and places of sentiment and familiarity.6 Like actor network theorys examination of associations between humans and nonhumans, the notion of therapeutic landscape moves beyond a materially determinist reading of the physical environment to emphasize the ongoing and mutually transformative relationships between people and their environments. Unlike STS, however, studies of landscape in anthropology and cultural geography have often framed their inquiry in terms of the symbolic relationships between landscape and meaning, emotion, and memory (e.g., Basu, 2001; Bender, 1993; Massey, 2005). We argue that hospital ethnography is a particularly effective means of exploring relationships between biomedical and other kinds of space and has the potential to draw insights from STS together with medical geographys focus on place and landscape. The contributions to this volume take a variety of approaches for bringing together an STS emphasis on configurations of physical environment, technologies, and persons with medical geographys emphasis on peoples imagined, emotional, and sensual experiences of hospital spaces. In the remainder of this introduction, we outline three thematic frameworks through which the articles explore these issues in relation to the heterotopic and contingent qualities of hospital spaces: boundary work, generating scale, and layered space.

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Boundary Work
The contingency of hospital space is best exemplified through the emphasis in several of the articles on the ongoing boundary work (Gieryn, 1983; Star & Griesemer, 1989) through which the hospital is established as a space that is simultaneously distinct from and related to other social spaces. Jessica Mesman describes the huge amount of work necessary to establish the neonatal intensive care unit (NICU) ward of a Netherlands General Hospital as a safe space. This involves a tacit relationship of collaboration between the physical environment (air locks, isolation rooms), mobile and immobile technologies (oxygen canisters, incubators), and multiple team members (doctors, nurses, technicians). Mesmans piece perhaps comes closest to an archetypal image of hospital space as isolated, tightly ordered, and populated by highly specialized technologies and authoritative experts. However, her article demonstrates the substantial effort required by all members of the team to maintain this isolation through the proper alignment of people, technologies, and the built environment. There is nothing given about the boundary around the NICU; moreover, that boundary is established in spatial practices that are diffused throughout the ward and not only through clear physical boundaries such as the air lock at the entrance to the ward. Mesman shows that the maintenance of a safe spatial order not only involves static regionalization and compartmentalization but also dynamic mobility work (Bardram & Bossen, 2005) that enables the alignment of multiple care and safety practices across different spaces. Significantly, this boundary work separates the NICU from an external, disordered world outside the hospital; it is also necessary to set this ward apart from the other internal spaces of the hospital and to isolate particular patients within the ward. White, Hillman, and Latimer similarly explore the ways in which specialized spaces of care are maintained in a Welsh hospital through practices of division that sort patients out and determine their access to hospital resources. The authors compare the moments of access that define the specialized arenas of A&E, intensive care, and genetics. They point out that the dual logics of efficiency and care by which access is determined shape the actions of patients who, by acting as responsible citizens, simultaneously determine their access to the hospital and become complicit in the maintenance of its boundaries. Importantly, these boundaries do not map onto the perimeter wall of the hospital but can extend into the home where genetics clinic sessions are held, or are enacted in the corridor as consultants ascertain whether a patient can be admitted into ICU or should be sent to the operating theater. The importance of internal boundary work and the capacity of spaces, conceptualized as configurations of material and discursive practices, to move in and out of the hospital are taken up by Brown in her account of relationships between domestic and biomedical space in a Kenyan hospital. Brown describes how Luo domestic space, with its gendered ethics of care, is reconstituted by relatives within the hospital alongside biomedical care practices. The multiplicity of hospital space leads Brown to argue against assumptions that biomedical authority maps neatly onto the physical boundaries of the hospital. Instead, she shows how differences between biomedical and nonbiomedical space are established internally through discursive and spatial practices that separate medical and familial care practices and delimit the kinds of work relatives, nurses, and doctors are expected to do in the ward. Following a previous special issue of this journal edited by Michael Schillmeier and Miquel Domnech (2009) on care and the art of dwelling, we might consider care as a fragile and precarious achievement integrally related to experiences of place and of being-at-home, which usefully cuts across distinctions between hospital and home. Like White, Hillman, and Latimer, Brown shows how biomedical distinctions are drawn between good/appropriate and bad/inappropriate patients, but her analyses of boundary work are perhaps most poignantly expressed in her discussion of the importance of the patient file in promoting desired flow in and out of ward spaces. A

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filewhich needs to be purchased by a patientbecomes a metonym for the patients identity and embodied engagement with bureaucratic procedure.

Generating Scale
It is not only the distinctiveness of hospital space that is contingent on everyday spatial practices. The contributions to this special issue also demonstrate the importance of the work that goes on in hospitals for the production of national and global space. Recent hospital ethnography has tended to depict hospitals as either reflections or microcosms of wider cultural processes. Hospitals are sites where global cultural forces, such as those of biomedicine, are domesticated in relation to the national and regional cultures where the hospital is located (e.g., see van der Geest & Finkler, 2004). In this view, hospitals are hybrid microcosms of Western and national cultures. The approach to hospital ethnography that we have proposed above, which emphasizes the contingency and heterogeneity of hospital space, leads to an inversion of this scalar relationship. Rather than analyzing particular hospital spaces as instances of wider societal or global forces, we propose that the hospital can be seen as one site among many where we can observe national, global, and regional space in the making. In his study of the response to the potential SARS (severe acute respiratory syndrome) epidemic in Canada, for example, Michael Schillmeier showed the hospital to be a crucial space where precautionary systems of quarantine and classification constituted SARS as a global risk at the same time as they sought to prevent the globalization of the SARS virus. Global space and scale in this view are an effect of the ability of sociotechnical networks to travel. The process of becoming global is always local (Schillmeier 2008, p. 196; see also Law & Hetherington, 2000). Such an approach to scale does not take the global or national status of the hospital for granted but asks how global, regional, or national space is constituted through the enactment of hospital assemblages in multiple places. In this view, when the assemblages of buildings, technologies and persons travel to several locations, or, as the articles here show, when hospital assemblages hang together precisely because of their fluid and mutable ability to change their configuration in different places (Mol & Law, 1994), global space is established. The contributors explore hospitals as global assemblages (Ong & Collier, 2005): institutions that are constituted and made meaningful through their relationships with places elsewhere (Massey, 1991). This point is illustrated most clearly in the article by Noelle Sullivan, which shows that producing global space in a Tanzanian hospital is no easy endeavor. Here some spaces, such as the donor-funded HIV clinic, are established as global through processes of standardization, whereas others, like the public ward, remain resolutely local. Sullivan also notes how the successful production of the hospital as a national space of development is dependent on the simultaneous implementation of standardized modes of governance by the Ministry of Health and international donor organizations. Even in the HIV clinic, however, such systems of national and global governance depend on the efficacy of written protocols and the durability of technologies such as computers and laboratory equipment, which remain fragile in the Tanzanian environment. Brown similarly describes the interdependency between spaces that we might otherwise presume to exist at different scales. She notes how relationships between mothers, sisters, money, household objects, and food reconfigure the hospital as a domestic Kenyan space and at the same time support and enable the hospital to operate as a global space of biomedicine. Meanwhile, the article by Street illustrates the importance of hospitals as technologies for the production of national space. In Papua New Guinea, the hospital is not a reflection of the nation

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but a site where intensive nation-building efforts are carried out. Developing physical infrastructure is central to these efforts, but the unequal distribution of that infrastructure coupled with its rapid deterioration lead to the indefinite postponement of stable national space.

Layered Space
Ethnographic approaches that construe the hospital as either island or mainland tend to portray hospitals as static and ordered. By contrast, the proposed focus on contingent processes of ordering that make up particular hospital spaces brings the historical and dynamic nature of hospital space into view. The comparison of multiple internal and contested orderings that is undertaken by all the contributors demonstrates the instability of any particular spatial configuration and draws attention to its propensity for transformation. Although instability can be said to be true of any kind of space, following the approach outlined here, we suggest that it is especially true of modernist spaces, such as hospitals, that are specifically intended to contribute to processes of social improvement and development. If hospitals are to be successful in improving society then they must also undergo constant development in line with the latest expert opinions on medical intervention, organizational theory, and statesociety relations. The historicity of space plays a central role in several of the articles. Sullivan explores the changing shape of the hospital landscape as processes of decentralization and neoliberal reform that have gained momentum since the 1990s make the hospital management dependent on donor contributions from international organizations, including the World Bank and the World Health Organization. She argues that these new alliances between local and international institutions have enabled the flow of substantial resources into the hospital, changing the kinds of care practices that are possible, at the same time as they have enacted the hospital as a space of inequality through the enclaving of particular hospital spaces for donor investment. Streets article reflects on another implication of hospital improvement: the constant redesign and rebuilding of hospital spaces in line with changing notions of progress and biomedical ideologies. As Streets Papua New Guinean case study shows, a hospital never corresponds to a single, static design but consists of overlaid physical structures that must jostle and contend with one another, generating ambivalent responses in those who inhabit them. White, Hillman, and Latimer also explore a situation where two different rationalities of governance, associated respectively with the postwar welfare state and post-Thatcher neoliberal reforms, are folded into one another in practice. Neoliberal logics of efficiency come to structure moments of access alongside the welfare logic of care. The authors argue that patients are increasingly co-opted into bureaucratic orderings as they learn to manufacture themselves as responsible, self-governing citizens. But bureaucratic practices of categorization continue to be framed in the moral discourse of care. The tensions and alignments between these two rationalities come into view with the spatial governance strategies that accompany perpetual questions of access. Overall, then, these three articles demonstrate the value in exploring historical processes of layering alongside the horizontal relationships between spatial orderings that have been discussed in previous sections.

Conclusion
A volume that focuses on the multiple enactments (Mol, 2002) of hospital space is crucial to understanding both the intrinsic spatiality of biomedical practice and its situatedness in particular places that are never exclusively biomedical. The articles in this special issue exemplify an approach to hospital heterotopias that recognizes hospital spaces contingency rather than panoptic qualities, and that explores such contingency ethnographically through a focus on boundary work, the constitution of regional, national, and global space, and on hospitals

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internal multiplicities and historical layering. These aspects of hospital space are illustrated in their comparative dimension by very different ethnographic examples drawn from Wales, the Netherlands, Papua New Guinea, Tanzania, and Kenya. The authors explore the connections and disconnections between these hospitals through the flows and nonflows of capital, technology, knowledge, and persons. In their totality, the articles reveal the hospital to be what Mol and Law (1994) call fluid space, involving relationships between humans and nonhumans that are resilient and able to travel precisely because of their ability to change configuration in relation to the other humans and nonhumans that they meet along the way. Particular spatial arrangements of persons, buildings, and technologies assemble institutions in Tanzania, the Netherlands, and the United Kingdom as hospitals, but those replications are never identical. Differences might be as stark as the presence or absence of an ICU unit, or as subtle as the distance between beds. However, the stark spatial differences between the NICU in the Netherlands or the Genetics clinic in Wales and the public hospital wards in Papua New Guinea, Tanzania, and Kenya also draw attention to the important spatial inequalities that are perpetuated through those very adaptive capacities. Paying attention to exactly what travelsis made globaland what does not is as important a contribution to understandings of space and power as the analysis of the disciplinary capacities of particular institutional spaces. Rather than focusing on hospitals as bounded places the hospitals presented emerge as translations of one another, both different from and partially connected to each other through the global transfer and transformation of the built environment, persons, and technologies. A hospital can be understood as a material condensation of multiple spaces, which are both contradictory and contested. The hospital is both like home and unhomely, both scientific and religious, both isolated and permeable, a place of both visibility and invisibility. It is this intrinsic complexity of hospital space that makes the hospital both a prime setting for fictional drama and a crucial site for exploring relationships between planned, imagined, and lived space. Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The Foundation for the Sociology of Health and Illness funded the workshop on which this special issue and introductory article are based. Alice Streets research for this article was financially supported by the ESRC and The Nuffield Foundation. Simon Colemans research on hospital chaplains was funded by NHS Estates.

Notes
1. The contributions to this special issue were all originally presented at a workshop held at the University of Sussex in 2009 titled Institutions, Collaborations, Power: Workshop on Hospital Ethnography. We are grateful to the Foundation for the Sociology of Health and Illness for their financial support of this event. We also thank Rebecca Prentice who acted as a co-convener of the event. 2. Many of those early ethnographies took a functionalist approach, dealing with the hospital as a complex social whole. Only one study by Duff and Hollingshead (1968) addressed the dysfunctional aspects of hospital life, exploring the way in which hospital orders reflected and further entrenched class and racial inequalities outside the hospital, frequently leading to misdiagnosis and poor standards of care. Meanwhile, Foxs ethnography of an experimental cancer ward portrayed the uncertainties and ethical dilemmas experienced by both patients and doctors in the hospital when it was an explicitly experimental space (Fox, 1974).

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3. An interesting conflation of political ideologies and discourses of democracy and transparency was provided by the so-called Patients Charter, produced by the United Kingdom National Health Service in 1991, under the conservative government of the time. Ironically, the Charter gained little visibility among patients and was abolished after 10 years. 4. Colemans fieldwork among hospital chaplaincies has explored a further variation on such ambiguous orderings of space, focusing on the congruities and incongruities between religious and biomedical discourses and practices in a large hospital in the north of England (see, e.g., Macnaughten et al., 1995). 5. Hospitals are in this sense more similar to the field trial, which requires a careful balancing act between asserting and relinquishing scientific control (e.g., Henke, 2000). 6. A claim that is embodied in the use of the term landscape as opposed to space (see, e.g., Hirsch, 1995).

References
Bardram, J. E., & Bossen, C. (2005). Mobility work: The spatial dimension of collaboration at a hospital computer. Supported Cooperative Work: The Journal of Collaborative Computing, 14, 131-160. Barker, P. (1991). Regeneration. London, England: Dutton Adult. Basu, P. (2001). Hunting down home: Reflections on homeland and the search for identity in the Scottish diaspora. In B. Bender & M. Winer (Eds.), Contested landscapes: Movement, exile and place (pp. 333-348). Oxford, England: Berg. Bender, B. (1993). Landscape: Politics and perspectives. London, England: Berg. Berg, M. (1997). Rationalizing medical work: decision-support techniques and medical practices. Cambridge, Mass.: MIT Press. Berg, M., & Mol, A. (1998). Differences in medicine: Unraveling practices, techniques, and bodies. Durham, NC: Duke University Press. Brown, H. (2012). Hospital Domestics: Care Work in a Kenyan Hospital. Space and Culture, 15(1), 18-30. Caudill, W. A. (1958). The psychiatric hospital as a small society. Cambridge, MA: Harvard University Press. Coser, R. L. (1962). Life in the ward. Ann Arbor: Michigan State University Press. Duff, R. S., & Hollingshead, A. B. (1968). Sickness and society. New York, NY: Harper. Elden, S. (2003). Plague, panopticon, police. Surveillance & Society, 1, 240-253. Finkler, K. (2004). Biomedicine globalized and localized: Western medical practices in an outpatient clinic of a Mexican hospital. Social Science & Medicine, 59, 2037-2051. Finkler, K., Hunter, C., & Iedema, R. (2008). What is going on? Ethnography in hospital spaces. Journal of Contemporary Ethnography, 37, 246-250. Foucault, M. (1986). Of other spaces (J. Miskowiec, Trans.). Diacritics, 16, 22-27. Foucault, M. (2003). The birth of the clinic. London, England: Routledge. Fox, R. C. (1974). Experiment perilous. Philadelphia: University of Pennsylvania Press. Galgut, D. (2003). The good doctor. London, England: Grove Press. Gesler, W. M. (1991). The cultural geography of health care. Pittsburg, PA: University of Pittsburgh Press. Gesler, W. M. (1992). Therapeutic landscapes: Medical issues in light of the new cultural geography. Social Science & Medicine, 34, 735-746. Gesler, W. M. (1993). Therapeutic landscapes: Theory and a case study of Epidauros, Greece. Environment and Planning D: Society and Space, 11, 171-189. Gibson, D. (2004). The gaps in the gaze in South African hospitals. Social Science & Medicine, 59, 2013-2024. Gieryn, T. F. (1983). Boundary-work and the demarcation of science from non-science: Strains and interests in professional ideologies of scientists. American Sociological Review, 48, 781-795. Gieryn, T. F. (2002). What buildings do. Theory and Society, 31, 35-74.

16

Space and Culture 15(1)

Gieryn, T. F. (2006). City as truth-spot: Laboratories and field-sites in urban studies. Social Studies of Science, 36, 5-38. Goffman, E. (1961). Asylums: Essays on the social situation of mental patients and other inmates. London, England: Anchor Books. Henke, C. R. (2000). Making a place for science: The field trial. Social Studies of Science, 30, 483-511. Hetherington, K. (1997). The badlands of modernity: Heterotopia and social ordering. London, England: Routledge. Hirsch, E. (1995). Introduction: Landscape: Between place and space. In E. Hirsch & M. OHanlon (Eds.), The anthropology of landscape: Perspectives on place and space (pp. 1-30). Oxford, England: Oxford University Press. Kearns, R. A. (1993). Place and health: Towards a reformed medical geography. The Professional Geographer, 45, 139-147. Knorr-Cetina, K. (1999). Epistemic cultures: How the sciences make knowledge. Cambridge, MA: Harvard University Press. Latour, B., & Woolgar, S. (1986). Laboratory life: The construction of scientific facts. Princeton, NJ: Princeton University Press. Law, J. (1994). Organising modernity. Oxford, England: Blackwell. Law, J., & Hetherington, K. (2000). Materialities, spatialities, globalities. In J. R. Bryson (Ed.), Knowledge, space, economy (pp. 34-49). London, England: Routledge. Livingstone, D. N. (2003). Putting science in its place: Geographies of scientific knowledge. Chicago, IL: University of Chicago Press. Long, D., Hunter, C., & van der Geest, S. (2008). When the field is a ward or a clinic: Hospital ethnography. Anthropology & Medicine, 15(2), 71-78. Macnaughten, J., Collins, P., Coleman, S., Kellett, P., Purves, G., Suokas, A., . . . Taylor, K. (2007). Designing for health: Architecture, art and design at the James Cook University Hospital (Final report to NHS Estates). Retrieved from http://www.dur.ac.uk/resources/cahhm/reports/JCUH%20 FINAL%20Feb05.pdf Martin, E. (2001). Flexible bodies: Tracking immunity in American culture; from the days of polio to the age of AIDS. New York, NY: Beacon Press. Massey, D. B. (1991). A global sense of place. Marxism Today, 35(6), 24-29. Massey, D. B. (2005). For space. London, England: Sage. Mesman, J. (2012). Moving in With Care: About Patient Safety as a Spatial Achievement. Space and Culture, 15(1), 31-43. Mol, A. (2002). The body multiple: Ontology in medical practice. Durham, NC: Duke University Press. Mol, A. (2008). The Logic of Care: Health and the Problem of Patient Choice. London: Routledge. Mol, A., & Law, J. (1994). Regions, networks and fluids: Anaemia and social topology. Social Studies of Science, 24, 641-671. Mooney, G., & Reinarz, J. (Eds.). (2009). Permeable walls: Historical perspectives on hospital and asylum visiting. Amsterdam, Netherlands: Rodopi. Moreira, T. (2006). Heterogeneity and coordination of blood pressure in neurosurgery. Social studies of science, 36(1), 69. Ong, A., & Collier, S. J. (2005). Global assemblages: Technology, politics, and ethics as anthropological problems. Oxford, England: Blackwell. Philo, C. (2000). The birth of the clinic: An unknown work of medical geography. Area, 32(1), 11-19. Porter, R. (2002). Blood and guts: A short history of medicine. London, England: Allen Lane. Prior, L. (1988). The architecture of the hospital: A study of spatial organization and medical knowledge. British Journal of Sociology, 39, 86-113. Quirk, A., Lelliott, P., & Seale, C. (2006). The permeable institution: An ethnographic study of three acute psychiatric wards in London. Social Science & Medicine, 63, 2105-2117.

Street and Coleman

17

Rhodes, L. A. (1995). Emptying beds: The work of an emergency psychiatric unit. Berkeley: University of California Press. Rothman, D. J. (1991). Strangers at the bedside. New York, NY: Basic Books. Schillmeier, M. (2008). Globalizing risksThe cosmo-politics of SARS and its impact on globalizing sociology. Mobilities, 3, 179-199. Schillmeier, M., & Domnech, M. (2009). Care and the art of dwelling: Bodies, technologies, and home. Space and Culture, 12, 288-291. Singleton, V. (1998). Stabilizing Instabilities: The role of the laboratory in the United Kingdom cervical screening programme. In M. Berg & A. Mol (Eds.), Differences in medicine: Unravelling practices, techniques and bodies (pp. 86-104). Durham: Duke. Soja, E. W. (1993). Postmodern geographies: The reassertion of space in critical social theory. London, England: Verso. Star, S. L., & Griesemer, J. (1989). Institutional ecology, translations and boundary objects: Amateurs and professionals in Berkeleys museum of vertebrate zoology, 1907-39. Social Studies of Science 19, 387-420. Starr, P. (1982). The social transformation of American medicine. New York, NY: Basic Books. Street, A. (2012). Affective Infrastructure: Hospital Landscapes of Hope and Failure. Space and Culture, 15(1), 44-56. Sullivan, N. (2012). Enacting Spaces of Inequality: Placing Global/State Governance within a Tanzanian Hospital. Space and Culture, 15(1), 57-67. Thrift, N. J. (2007). Non-representational theory: Space, politics, affect. London, England: Routledge. van der Geest, S., & Finkler, K. (2004). Hospital ethnography: Introduction. Social Science & Medicine, 59, 1995-2001. Vecchio Good, M. J., Good, B. J., Schaffer, C., & Lind, S. E. (1990). American oncology and the discourse on hope. Culture, Medicine, and Psychiatry, 14(1), 59-79. Verghese, A. (2009). Cutting for stone. New York, NY: Knopf. White, P., Hillman, A., and Latimer, J. (2012). Ordering, Enrolling, and Dismissing: Moments of Access Across Hospital Spaces. Space and Culture, 15(1), 68-87. Zaman, S. (2005). Broken limbs, broken lives: Ethnography of a hospital ward in Bangladesh. Amsterdam, Netherlands: Aksant. Zussman, R. (1993). Life in the hospital: A review. Milbank Quarterly, 71, 167-185.

Bios
Alice Street is a Nuffield New Career Development Fellow in the Department of Social Anthropology, University of Sussex. Her research interests include biomedical technologies, religion, and kinship relationships in Papua New Guinean hospitals. She is currently working on a project exploring managerial technologies and state-building in the Papua New Guinean health system. Simon Coleman is Jackman Chaired Professor at the Centre for the Study of Religion, University of Toronto. His interests include the globalization of religious forms and the intersections between religion and health. He has conducted research on hospital chaplaincies in the north of England, pilgrimage to Walsingham in Norfolk, and discourses of health and wealth among both Swedish and Nigerian charismatic Christians.