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Affective Infrastructure: Hospital Landscapes of Hope and Failure

Alice Street Space and Culture published online 2 December 2011 DOI: 10.1177/1206331211426061 The online version of this article can be found at: http://sac.sagepub.com/content/early/2011/10/11/1206331211426061

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SACXXX10.1177/1206331211426061StreetSpace and Culture 15(1)

Affective Infrastructure: Hospital Landscapes of Hope and Failure

Alice Street1

Space and Culture XX(X) 113 The Author(s) 2011 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1206331211426061 http://sac.sagepub.com

Abstract Hospitals are designed as spaces of improvement.Yet an accumulation of infrastructural projects can lead over time to the emergence of a layered landscape made up of multiple incongruous planned spaces. This article focuses on Madang General Hospital in Papua New Guinea as one example of such a landscape. Here, deteriorating colonial buildings jostle against new gleaming constructions built with donor funds. The layered effect of the postcolonial landscape draws attention to enduring racial and class inequalities; the colonial past is rendered present in the buildings of the future. Drawing on recent work on affect in anthropology and cultural geography, the author argues that this landscape impresses affects of hope and disappointment on the people who inhabit it and shapes ambivalent attachments to national and state futures. This double movement of improvement and decay is analyzed as a process of ruination that is intrinsic to modern spaces of improvement. Keywords hospital ethnography, health inequality, affect, infrastructure, postcolonialism, ruination
Life must be lived amidst that which was made before. Meinig (1979), as quoted in Ingold (1993, p. 154)

This article explores how affective states and emotive orientations to the state and national futures are generated through peoples interactions with the institutional landscape in a Papua New Guinean public hospital. Throughout varied colonial and postcolonial histories, hospitals in developing countries have consistently been associated with projects of managed social change and improvement, whether in relation to the enhancement of national health indices, as instruments of rationalization and instruction, or as contributions to the strengthening of state infrastructures. Hospitals are, in this regard, archetypal modernist institutions (Hetherington, 1997). As a growing body of hospital ethnography has shown, the planning and construction of hospital buildings and the organization of hospital space have been crucial in this process of linking specific institutional localities, the personal transformations that take place within them, and broader national trajectories. Spatialities of knowledge and power have been shown to play a crucial role in, on one hand, medical institutions shaping of patient, colonial, and postcolonial subjectivities (Casey, 1987; Foucault, 2003; Gibson, 2004; Philo, 2000; Prior, 1988; Saris, 1999)

University of Sussex, Brighton, East Sussex, UK

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

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and, on the other hand, those institutions, transformation and modernization of urban landscapes in relation to universally imagined pathways toward development (Ferguson, 2005, chap. 7; Porter, 2004). In this article, I focus on the ways in which engineered spaces of social improvement endure into other times to explore the unpredictable species of affect that are generated as people move through those layered historical spaces in the present. Many of the hospitals currently in operation throughout the Global South were originally built and designed by colonial administrations and in subsequent eras have been repeatedly modified, redesigned, and added to by successive national governments and donor partners (see, e.g., Clyde, 1962; Denoon, 2002). Throughout Madang Hospitals 40-year history, its spaces have continually been reimagined and reconstructed as tools of development. Yet this perpetual orientation toward the future has created a landscape scarred with the physical remnants of successive interventions. In its physical constitution, the hospital landscape makes both anticipated futures and past interventions present to those who inhabit it. This article therefore draws attention to an aspect of heterotopic space that has been little discussed by Foucault and his interlocutors, but which modernist spaces of improvement, such as the hospital, bring to the fore. That is the heterotemporal quality of modernist institutions that attempt to engineer the future. If the hospital, in its multiplicity of order and disorder, is an archetypal heterotopic space, then the temporal multiplicities that reside in hospitals as institutions of improvement are an important feature of the way such heterotopic spaces are experienced by those who inhabit them. What new perspectives might be afforded on the affective politics of heterotopias when we explore medical institutions as layered superimpositions of multiple times and spaces (Reynaud, 2004)? Recent work on affect in anthropology and cultural geography has drawn attention to the capacity of spaces to elicit emotions, feelings, and prelinguistic sensibilities. In this article, I draw this work together with postcolonial studies to explore how the historically layered postcolonial infrastructure of the hospital shapes emotional attachments to the nation or the state and orientations and expectations of developmental futures in the present. I am interested in what kind of a place is produced through this historical process of successive intervention, when new spatial relationships emerge out of and coexist in the built environment alongside old ones. I use ethnographic material to illustrate peoples experience of Madang Hospitals buildings as places of enduring colonial and postcolonial inequalities that materialize deteriorating prospects for health and wealth among those who work and are cared for within them. I argue that the institution is experienced by hospital workers as at once a space of hope, offering the potential for (bodily, personal, and societal) transformation and renewal, and as a space in which workers become resigned to (personal, medical, state) failure. I suggest that the affective states of hope and resignation to failure are properties of the relationship between peoples everyday tasks in the hospital and the settings in which they struggle to complete them. Moreover, I argue that this ambivalent experiential quality of the hospital space is intrinsic to its spatial and historical role as an institution of improvement.

Spatial Manipulations and Imperial Formations

To understand the hospital as an affective technology is to draw attention to the specific historical and political interrelationships between hospital buildings and their inhabitants and to the role of hospital buildings as background in the latent production of embodied dispositions and pathways for action and interaction (Barnett, 2008, p. 190). Nigel Thrift (2007), who has put issues of affect at the center of questions of space, governance, and power in recent years, describes affect as a kind of nonrepresentational, semiconscious knowledge of our world that primes us for action (p. 221). In contrast to models of emotion that tend to focus on individual psychology, affect is conceived as an emergent property of relationships

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and encounters (between persons and between persons and things). Space is a particularly important vehicle for and transmitter of affect: Transmission is a property of particular spaces soaked with one or a combination of affects to the point where space and affect are often coincident (p. 222). Thrift is less concerned with how manufactured and planned spaces might represent cultural categories of knowledge and reproduce symbolic distinctions than with what they do (p. 222); how those spaces implicitly condition and transform bodily states to make peoples behavior disposed to desirable political and economic ends. From this perspective, material things are examined and interpreted not only as repositories of cultural meaning and representations but also as containing powerful qualities that enable them to affect and modify the worlds in which they are produced, interacted with, and consumed (Gell, 1998; Henare, Holbraad, & Wastell, 2006; Miller, 2005). As walk-through machines, buildings are artifacts that have a built in capacity to structure experience and practice at the same time as they remain open to reconfiguration through use (Gieryn, 2002, p. 41). Thrift perceives an increasing engineering of affect in the Euro-American urban environment (through visual media, new scientific knowledges, information technologies, and urban design) that amounts to a microbiopolitics in which the semiconscious domain of affect is made visible and governed for instrumental effect (Thrift, 2007, chap. 8; Thrift & French, 2002). Kearns and Barnett (1977) provide an example of this from health geography in their account of the increasing permeation of the Australian urban landscape with signs and physical structures of private medicine that draw on and deploy the psychological theories of mass advertising. Kearns and Barnett describe the proliferation of private clinics positioned alongside clothes shops and fast food outlets in shopping malls, and the new strategies of for-profit clinics and hospitals who proclaim their presence through place advertisement techniques in which a commodity laden with mythical content is enhanced with architectural imagineering (p. 173). Such strategies create seductive landscapes of consumption that imperceptibly transform attitudes and dispositions toward health provision and prime people as health consumers. In Madang Hospital, however, attempts to engineer positive public dispositions through the built environment are complicated by the historical layering of physical infrastructures and the unequal distribution of these projects across the institution. Thrift (2007) acknowledges that manufactured affective outcomes are never given, and that the nonlinguistic, semiconscious character of affective dispositions prevents their wholesale control. However, the impossibility of engineering affect through design of the hospital landscape, I show below, is not primarily due to the unpredictable actions of people in interaction with their built environment (though this is also the case) but the unplanned historicity of place that is an inexorable effect of shifting finances, politics, available materials, architectural trends, and medical knowledges. As Navaro-Yashin (2009) argues in relation to the postwar landscapes and domestic abodes of Northern Cyprus, assemblages of persons and things should not only be read horizontally in terms of lateral networks of agency but also as specific in their politics and history (p. 9). Although the landscape of Madang Hospital has at various points been meticulously planned and new buildings and interventions microdesigned and controlled, the overall outcome of this historical process is an emergent and ever-changing assortment of different buildings that have messy and incoherent relationships to one another, at varying states of newness and ruin, with contrasting and often clashing design styles and aesthetics. Rather than focusing on the unfolding social lives of discretely planned architectural objects, I am interested in how this dynamic layering of planned spaces as an integral quality of the postcolonial hospital landscape produces particular affective dispositions in the people who inhabit it. An approach that draws together theories of space as affect from critical geography with critical approaches to postcolonial theory that emphasize the material durability of colonial formations can draw attention to the ambiguous range of affects exuded by historically layered

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postcolonial institutions. Ann Stolers (2008) work on imperial debris, for example, emphasizes the continuing ability of buildings built in one era to act on people in another. Moreover, this opening for ambiguity is not always generated by the oppositional forces of power and resistance or structure and agency (Giddens, 1986; Gieryn, 2002; Gregory, 1984), but, as I suggest below, also by the repetitive, almost compulsive, attempts to engineer space that result in enduring (and declining), layered structures that overlap with the social and political worlds in which they are lived in and used. I move now to a description of two historical moments in which the physical locality of Madang Hospital has been tied to national progress and constituted as a place of improvement, before going on to describe the kinds of emotions and feelings that dwell in this layered landscape.

Moment One: Beginnings

Madang General Hospital was officially opened on April 7, 1961. The Australian Minister for Territories Paul Hasluck presided over the opening, which was also attended by the Australian Administrator of Papua New Guinea, the Australian Director of Public Health in Papua New Guinea, leaders from the local churches, and several recently appointed native representatives on local government boards. Village groups from nearby districts performed dances and songs in their traditional costume, and the local expatriate and indigenous communities were invited to attend and take the opportunity to look around their new public hospital. The whole event was filmed by ABC television in Australia and received wide coverage in the Australian and regional Pacific press. The ceremonial fervor that accompanied the opening indicates the significance of the hospital building as demonstrative of a new state presence and commitment to development in the region. The opening of Madang Hospital represented the most recent stage of an ambitious postwar hospital building program that extended across the Australian territory of Papua New Guinea and included plans to build 86 new institutions. The new monumental hospitals would replace closed and inward-looking early colonial institutions that were designed primarily around policies of protectionism, racial segregation, and quarantine (Denoon, 2002). A defining characteristic of the prewar hospitals built by successive German, British, and Australian administrations was the differentiation of permanent and Western style European Hospitals erected in the commercial centers of the colonial towns, and the temporary, bush-material, shed-like structures of the Native Hospitals that were usually built on the outskirts of town, or in the case of Madangs first native hospital, on an island in the towns harbor. In contrast with those frontier hospitals, which sought to protect isolated colonial enclaves from a perceived threatening environment of tropical diseases and peoples, the hospital building program of the 1950s was initiated in a postwar political climate when pressure from the United Nations for decolonization was intensifying, when the participation of Papua New Guineans in the Pacific War effort was forcing the Australian government to recognize its responsibility for the welfare, development, and future of the indigenous population and when the emergence of new international bodies such as the World Health Organization was aligning health with development in new ways. With this new conceptual coupling of health and development, institutional spaces of medicine and their physical structures took on new significance. Much of the criticism directed at the old native hospitals, which were now exposed to a critical public gaze by Australian citizens, policy makers and administrators focused on the dilapidated, rotting, dark, and crowded nature of those spaces.1 The accusations were not only that those spaces were inadequate and unhygienic spaces for the practice of medicine, but that they were also poor conveyors of the benefits of state governance and modern medicine.

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The administration believed that the native hospitals needed to be transformed into more visibly modern spaces to mobilize the indigenous workers and patients within them to work toward their own national development and progress. The style and organization of the buildings was considered crucial. The Australian Director of Medical Services in Papua New Guinea, John Gunther, was determined that the new institutions should be of a world standard with up-to-date medical technologies, modern building materials, and clean, spacious, and efficient use of space. It was particularly emphasized that, in contrast to the old bush-material native hospitals, the new hospitals should differ as far as possible from traditional domestic structures. The evident superiority of the hospitals buildings and technologies over those of traditional medicine would, it was hoped, educate and modernize the Papua New Guineans who were admitted to the hospitals or saw them from the outside. In contrast to the prewar period when Native Hospitals were hidden, dark, marginal spaces, they were now imagined as monuments of modernity that would transform urban landscapes and be put on display for impressionable native populations. As models for what a future, developed Papua New Guinean nation would look like, state-built, technologically advanced, and modern-style hospital buildings would mobilize the indigenous population to contribute to the future development of the nation. Where Thrift and French (2002) describe an increasing attention to feelings, affects, and emotions in the commercial generation of digital landscapes in the West; a similar concern with the relationship between physical infrastructure, feelings, and active dispositions was equally prominent among postwar administrators in Papua New Guinea. The affective states of eagerness, anticipation, and hope that would produce modern subjectivities and put the development process in motion would, it was envisaged, be transmitted by the buildings themselves. How did those imaginings and investments by hospital planners become realized in specific hospital spaces? For the new world standard hospitals to be made available to both indigenous and European communities and remain affordable to the state, the construction of racially segregated institutions was no longer sustainable. However, this did not correspond with the elimination of spatial differences and racial inequalities. The Hospital Committee report noted, Where both European and Native Hospitals are to be provided at any place, the committee, as a general policy considers that these should be combined sufficiently to allow common use of such services as operating theatre, x-ray, laboratory and, in some instances, kitchens. It would be quite uneconomical to duplicate such facilities in each case. The committee, however, considers it essential to separate European and Native accommodation sufficiently to avoid objections as to proximity and intermingling.2 This tripartite segmentation of hospital space was replicated at Madang where the new general hospital was built on the site of an old German plantation and comprised several one-storey timber buildings connected by outside walkways. The site stretched between the ocean on one side and the main road leading into the town center on the other. At the center of the site was the main block, a simple assortment of white-painted timber buildings housing administrative offices, a laboratory, an operating theater, and general service blocks that were shared by the two hospital wings. Up on the hill overlooking the sea was the European Hospital. Built on stilts with long verandas, rooms for 16 in-patients and views of the ocean, the European Hospital was an elegant colonial building and received the best of the sea breeze in the stifling tropical town. The European wing was smaller but more spacious than the Native wing, allowing greater isolation of patients in private or semiprivate rooms in line with 20th-century medical concerns about patient-to-patient contagion and the need for space and the flow of air between patients.

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The Native Hospital was built on the opposite side of the main block next to the road, and in the next months there would be much campaigning by the hospital workers to the Advisory Town Council for the road surface to be sealed owing to the substantial amounts of dust that was being thrown up into the wards. The 8 public wards housed 320 beds and were divided according to disciplinary distinctions between pediatrics, surgical, internal medicine, obstetrics, and maternity. Designed in the 19th-century Nightingale style, the wards consisted of long timber and gauze sheds with doors at each end. The beds were carefully spaced, and small windows allowed airflow in between them, while fans were suspended above. Each ward was divided into half by a nurses office, from where an observation window allowed the nurses to supervise the patients. On one hand, therefore, the new hospital was intended as a new kind of public space that would generate a new kind of public sensibility among the patients. The modern, gleaming spaces, provided for both Native and European populations alike, would be so impressive as to generate a new kind of belief in development among the indigenous population and would ready those audiences for productive contributions to national futures. On the other hand, the new hospital reproduced spatial relationships of racial hierarchy and difference, which corresponded to different kinds of care (Sullivan, 2012). The world-class facilities of the native wards were neither of the same class nor belonged to the same era of medical discourse (Prior, 1988), as those enjoyed by the European patients. As I describe in the following sections, this coincidence of modernist spaces of improvement and the spatial reproduction of inequality continues to powerfully affect the people who work in those spaces today, and produced more ambivalent responses than the enthusiasm and motivation envisaged by managers, architects, and politicians.

Moment Two: Seeing and Believing

On September 13, 2003 (2 days before National Independence Day and 42 years after the original opening ceremony), I attended a different kind of open day at Madang General Hospital. As at the hospital opening in 1961, local village groups were paid to sing and dance in their traditional costume and to decorate the hospital with colorful flowers, leaves, and coconut fronds. Again urban and nearby rural residents were invited to take the opportunity to look around their public hospital. Again local and national politicians, community leaders, and church and business representativesthis time nearly all Papua New Guineancongregated at the event. But in contrast to 1961, this open day was expressly not organized to show off the hospitals world-class facilities. In September 2003, the Papua New Guinean media was rife with stories of corruption and state failure. Problems of corruption, law and order, and the weakness of state institutions were regularly linked in the media to the incapacity of the state to provide adequate public services, such as hospitals or schools. Health played a particularly prominent role in the narratives of failure circulated both in international political circles and in everyday discussions among workers at Madang Hospital. The failures of postindependence development were, it was claimed, made most patently obvious in the poor health indicators such as an increasing maternal mortality and a growing AIDS epidemic, and were palpable in the deterioration of the countrys physical health infrastructure such as hospitals and health centers. In this tense political climate, the attempt to make the public hospital more public by holding an open day was inextricable from broader projects of state building, nation building, and development. The formal speeches, given by hospital managers and board members, emphasized the importance of opening the hospital doors for rejuvenating peoples faith in national development. The hospital development reflects the development of the nation, the board chairman declared. The hospital managers admitted that the hospital is going through a difficult time,

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but all the speakers reiterated their own belief in the hospitals ability to fulfill its potential, just as Papua New Guinea will. The hospital was presented as a crucial space where hope in development could be realized or lost. Simply by walking around the institution and witnessing the states commitment to transparency and efforts to improve health, belief in an improved future might be generated. As the Hospital CEO stated, You see and you believe, you dont believe based on nothing. Or as the Provincial Governor explained in reference to a recent sexual attack on a hospital worker and in an attempt to inspire a sense of civic responsibility among those who attended, The hospital works for the people but the public must also respect those who serve them. Like the open day of 1961, the event was intended to animate the hospital as a public space in order to have a profound affect on those who attended, transforming them into active citizens with positive orientations toward the future. But in contrast to the 1961 opening, the hospital was now caught up in an endless dialectic of hope and failure. The urgent need for hope, or belief as both the Hospital Chairman and CEO described it in their speeches, lay in the realization that an optimistic temporality of progress and improvement had already been lost. The hospital was no longer conceived as a progressive force for development but was now presented as symptomatic of a wider fragility in statesociety relationships and the failure of the state to achieve development. The open day was therefore intended to reestablish a future-oriented sensibility among its publics, to create a hospital with hope (Anderson & Holden, 2008). As with the opening of the hospital in 1961, the physical hospital buildings played an important part in this generation of affect. It is significant that the open day commemorated the opening of a new transit house for nurses on night shift, built with funds from AusAID, whereas the previous open day had taken place in 1995 to commemorate the opening of a new main block for the hospital built with donor funds from the Japanese government in 1995. In each case, public speeches were followed by public tours of both the hospitals new and old buildings. Through their ritual incorporation into the event, the presence of these new buildings, which were both gifts from donor partners and bequeathed by a state that they made visible, were expected to inspire positive dispositions toward the state and national futures in the people invited to view them. It was not, however, only an external public that was meant to be impressed by the new buildings. In 2009, following the completion of several further building projects, including the renovation of the labor ward and the construction of a new hospital laboratory, the Hospital Chairman explained the significance of the transformation of the physical landscape for the improvement of attitudes among hospital staff: Before, you saw the staff were unhappy. They were striking all the time. Complaining. Now, we have made these changes, improved the hospital, renovated the labour ward, changed the environment and their morale is improved . . . this is the important thing. The staff must believe in the hospital, that it will get better. And you have to work with them, make them feel that. It is not something that you can just impose. In the vision of the Hospital Board Chairman, the new buildings were intended not only to cure, heal, and impress an external Papua New Guinean public but were concurrently about the construction of a new institutional ethos and sense of public service among the hospitals public servants. The new buildings, it was hoped, would induce them to believe in the hospitals contribution to social progress and development, and would craft hard-working and compliant worker dispositions (Richard & Rudnyckyj, 2009) committed to a general public. In fact, as I describe in the following sections, the layered spaces of the hospital generated far more ambivalent affects in the workers who inhabited them.

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Spaces of Abandonment
After the open day ceremony, members of the public were invited to take tours, run by students from the next-door paramedical college, of the hospital grounds. In this section, I focus on two spaces that formed a central part of the tour, the private ward and the public wards. I describe how these spaces were presented to the viewers by the hospital workers, most notably the nurses, as spaces that spoke autonomously of abandonment, corruption, and selfishness by the government and the hospital managers. I argue that material differences between the private and public wards of the hospital were generative of a depressive mood of failure and helplessness that the workers conveyed to the public viewers as an aspect of the hospital environment rather than something that required further explanation and elaboration. The private ward was part of a new concrete building, established in 1995 with funds from the Japanese government. The ward had been mapped directly onto the site of the old European ward that had been moved down the hill to the main block in the late 1960s, when the separation of the European and Native wings has become politically unsustainable. This was still where the expatriate residents in the town came for their medical care, but most of the patients were now Papua New Guineans who worked in the public service or local businesses. The ward was air-conditioned, and the cool air immediately hit you as you walked in from the humid corridor outside. Patients usually had a room to themselves, but if the ward was full, each bed had a curtain rail around their bed that carved a large private space out of the room for their own use. The ward was decorated with a shiny light beige floor, glossy painted white walls, Formica surfaces, patterned soft furnishings, and fresh flowersthe decor carefully mediating between a formal, sterile, and (Western-style) domestic environment. As we entered the private ward, audience members quietly gasped and muttered to each other about the separate male and female wards, the curtains around the beds, and the personal care the patients received from the nurses. The curtains were carefully drawn around the two patients in the ward. They remained silent and invisible to the onlookers. This is where you come if you have money, announced the medical student acting as tour guide. A lot of money, said the nurse on duty, and everyone laughed. The joke established an intimacy between the medical student, the nurses, and the visitors, based on their shared sense of exclusion and detachment from ideological projects of improvement in the hospital. The medical student showed the visitors the sliding doors that separate the ward into four separate rooms, enabling the nurses to quarantine patients or separate out male and female patients. Here, he explains the patients stay on their own [stap wan wan]. One member of the audience asked how much it cost and was told 200 kina (around 40) for the first 3 days and 60 kina a day after this. Several of the visitors gasped and exhaled loudly. The nurses nodded dramatically in sympathy. The tour continued from the private ward to the public wards at the back of the hospital. These had changed little since the hospital had opened in 1961. They consisted of long timber sheds with the walls above shoulder height covered in gauze to facilitate air flow. Shielded from the sea breeze by a small incline, the wards were hot and stifling. Dust and noise from the road swept straight into the buildings, and few of the fans in any of the wards were working. The wards were connected by covered concrete walkways. Here in the shade sat patients and relatives finding respite from the heat of the wards, sometimes talking to one another, more often sitting in silence as they watched the doctors and nurses walking backward and forward between the wards. The tour group walked along the corridor and was guided by the medical student into the wards themselves. The walls of the wards were lined by a long row of beds, each with a number hanging above it. The beds were old rusted steel contraptions with plastic mattresses placed on top. Many of the patients came without bedding and had to lie directly on the plastic mattresses, their bodies sticking to the surface in the heat. As we walked down the aisle, the

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audience members stared silently at the patients receiving care in their beds. This, not the private ward, was where they knew they would come should they get sick. Behind the four working wards were four unused wards that had been closed owing to a shortage in manpower and funds. The tour participants were offered the opportunity to peer into the wards on our way past. Beds lay strewn about and mattresses piled in the corners. The floor was covered in dust, and the walls were adorned with old, ripped public health posters from an earlier era. In the building at the back of the surgical ward, several long-term patients who did not have the money to return to their far away villages were camping out. As the tour group moved through the wards, the nurses pointed out the lack of resources, indicating the dysfunctional fans, dirty walls, lack of bedding, and the shortage of nurses. In the medical ward, the nurses explained that there were not enough doctors so we have to do all this work ourselves. That is the way it is. In another ward, a nurse told us, This is how the patients live. It is not good but what can we do? As the participants looked around them, quietly whispering to each other, one nurse said simply, The government doesnt help us here, reiterating a statement I often heard in villages remote from urban services, but that might not be expected in an urban statefunded institution. In many of the public wards, the nurses and the student tour guide simply gestured to their surroundings, as though no further explanation of their pitiful situation was required. The buildings, the poor equipment, the smells, the crowded beds, all manifested the abandonment of these spaces, and the patients and nurses who inhabited them, by those who should be providing services. In contrast to the hospital opening in 1961, what was put on display to the hospital public in 2003 was not a sparkling and gleaming monument to the future, but the remnants of that modernizing project, now apparently left to deteriorate by a neglectful or weak state.

Ruination
The open day tour drew attention to the deterioration of the old postwar buildings; the rusting and peeling of surfaces; the heat, smells, dust, darkness that penetrated the public wards of the hospital; the shortage of staff inside those buildings; and the old and decrepit equipment and furnishings that were housed in those spaces. The ambivalent feelings that arose as people moved through the space were not engineered by architects or planners but emerged from the overwhelming physicality of the hospitals history. Thrifts (2007) focus on the planned and technological spaces of the Euro-American city therefore risks obviating the multilayered quality of many institutional and urban spaces, portions of which might have been carefully designed at distinct historical moments but which in practice accumulate into unplanned aggregates of multiple planned spaces. Exploring layered postcolonial institutions such as the global hospital draws attention to the significance played by those places dynamic histories, and particularly histories that trace spatial inequalities between colonized and colonizer, in the generation of affect. Scholars from postcolonial studies have drawn attention to the importance of material places and things, such as colonial graveyards, tea cups, or suitcases, as powerful conveyors of nostalgia that permit us to reexperience a positive and heroic colonial past and obliterate the destructive endeavor on which it was based (Burton, 2001; Buettner, 2006; Rosaldo, 1989). Anthropologists, meanwhile, are all too aware that the material relics of colonial rule do not only continue to exert an emotional pull and affective force on descendents of colonizers. Alongside and beyond those colonial ruins that act as repositories of nostalgia, melancholy, and desire, which are restored by the United Nations Educational, Scientific and Cultural Organization (UNESCO) and marked on tourist maps, are those more violent and destructive ongoing processes of ruination that Stoler (2008) refers to as imperial debris.

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Stoler (2008) is concerned with the persistence of imperial formations through their material debris (p. 194), the remnants of colonial governance that continue to degrade both the material environments in which people live and their sensible and moral experiences of the world. Stolers call for the study of the long duree of colonialism demands that we understand how people continue to live with and in ruins. The hospital workers at Madang Hospital constantly indicated their surroundings to explain the poor morale of the hospital employees. The dysfunctional fans, the entrenched smell of sweat and feces, the crowded wards and lack of privacy, the holes in the mosquito gauze on the ward walls, and the terrible state of the patient wash block and toilets were all pointed to as reasons why Madang Hospital was not a proper hospital like the kinds of white, clean, spacious, wellequipped hospitals that I must be used to in the West. This was a place, they told me, where a shortage of care workers meant lives were difficult to save, and where patients lived in poor hygienic conditions with no privacy or dignity. I argue that imperial debris and its constant reminder of the failures of modernity is a powerful transmitter of affect to the people who inhabit it. The affective mood generated by the tour and pervading the institution was of disappointment and dismay; disappointment with development and dismay at the everyday medical failures, death, and physical suffering that resulted. The hospital has a similar status in the town to other public institutions such as schools or the local museum, whose physical infrastructure has rapidly degraded with the lack of state funding over the years. But the high stakes involved in hospital care contributes to a visceral sense of urgency and anger that may be heightened for staff working in that institution. The private ward and new technical buildings only seemed to reinforce this raw experience of failure by exposing the comparative neglect of the public wards and drawing attention to the misdirected priorities of politicians and managers and the perpetuating inequalities of Papua New Guinean social life. In contrast to the managers and politicians who expected the new glossy buildings to invoke hope and enthusiasm among the workers and public, the hospital workers did not separate those buildings from their daily experience of other parts of the hospital, the layered landscape generating a combination of dismay and resignation to failure. It should be clear, however, that the affective qualities of imperial debris are very different from the colonial nostalgia evoked by colonial graveyards or the abandoned remains of dead civilizations. Nostalgia is generated by a far more linear reading of the process of ruination. Several long-term expatriates in Madang Town evinced such a view when they emphasized the hospitals decline since independence when it was beautiful and of an international standard. As one local businesswoman told me, When we see that hospital now we feel sad because we remember what it was like before. It was a wonderful hospital. According to such narratives, the hospital began declining after independence when the expatriate doctors and nurses fears of nationalist violence (which turned out to be unwarranted) combined with a rigorous nationalization policy in health and education led to a rapid transformation of the hospital into an institution managed and staffed entirely by Papua New Guineans. Such stories of decline reinforce racialized depictions of Papua New Guinean incompetence and create nostalgia for an Australian colonial state. They also present the newly built postwar hospital exactly as it had been imagined by the officials who designed it and presided over its construction; a world-standard hospital that provided effective caring and advanced technological medical services to the public. For hospital workers, however, the hospital wards did not elicit feelings of nostalgia for a colonial heyday. Workers were critical of the state of the public wards today but were also quick to point out that the private ward was first built as the European wing when it moved down from the hospital on the hilltop. Those who inhabit the hospital buildings today were well aware that the crowding, lack of privacy, heat, and dust, that were perceived as inadequate in the public wards today had been designed into the separation of European and public wards in 1961.

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Nurses in particular suggested that there was a direct continuity between the racial distinctions of colonialism and the emergent class-based inequalities of the present, referring to the rich patients and the managers who made money from them as like White people. Nurses traced their anger and motivation to strike against the poor conditions in the hospital today back to the nurses unions first strike against colonial management at Port Moresby hospital in the year before independence. From this perspective, ruination does not consist in a linear process of deterioration and destruction but in the dialectic between the ongoing improvement of some spaces and the simultaneous decline and abandonment of others. To think about Madang Hospital as a postcolonial ruin is not to subscribe to narratives of degeneration from a utopian starting point but to consider the ways in which institutions of improvement such as hospitals might always already be ruined insofar as differentiations, exclusions, and inequalities are built into them and create spaces of relative wreckage from the start. It is this spatial layering of inequalities that I argue generates the affective qualities of the hospital as a space of simultaneous hope and despair. While Stoler (2008) emphasizes the enduring impact of imperial formations, I therefore argue that the repetitive reconstruction of postcolonial institutions as spaces of progress is integral to imperial debris ambiguous affective power.

Conclusion
The ongoing visual manifestations of state neglect in the deteriorating old and new hospital buildings, combined with enduring spatialized differentiations of persons and distributions of medical resources, engender a pervasive mood and sensibility in the institution, which seeps, pervades, and insinuates its way into the most basic of medical and caring tasks. As inhabited space, the hospital is not simply an instrumental technology of social or medical transformation but a landscape filled with emotions, passions, and feelingsof outrage, of resigned defeat, of hopelessness, of abandonment. These emotions, I suggest, reside in the landscape itself. Following Nigel Thrift (2007), I argue that hospital spaces are affective purveyors of colonial and postcolonial power relationships. However, attention to the historical layering of hospital space also reveals the unpredictable and contested nature of its affective capacities (Navaro-Yashin, 2009) and the importance of ruination as a process that is intrinsic to the lived experience of modernist planned space. Processes of renewal, construction, and reinvestment in the hospital as a space of improvement are as much a part of this process of ruination as the durable debris of colonial projects. I have therefore suggested that ruination be considered a dynamic process of shifting spatial inequalities (between European and Native, Private and Public, and Western and Papua New Guinean) rather than a linear process of deterioration. The multiplicity of new building projects at Madang Hospital shows that the institution cannot simply be thought of as a static ruin. Instead, ruination is shown to be a dynamic ongoing process of simultaneous construction and disappointment. Ruination in Madang Hospital consists in ongoing tensions between new technical buildings and hidden spaces of decline, which reproduce and transform spatialized distinctions between persons and places. In Madang Hospital, new buildings do not ever entirely erase the deteriorating remnants of old buildings and often draw attention to them as abandoned spaces. In this layered landscape, the feelings of hope and anticipation of progress elicited by the new buildings become inextricable from the feelings of resignation to failure and hopelessness elicited by the continued presence of the old. I argue that this ambiguous range of affects emerged in peoples relationship to a changing physical landscape as they struggled to save lives amid huge discrepancies in resources. In Madang Hospital, sensibilities of hope and failure were emitted by the decrepit

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hospital buildings and transmitted to hospital workers a little like the imagined poisonous miasmas of 19th-century tropical disease. Acknowledgments
I would like to thank the Medical Research Advisory Board, the National Research Institute, and the Madang Hospital board for allowing me to conduct research, and the employees of Madang Hospital who gave me their time amid very difficult circumstances. I am grateful to Simon Coleman, Joanna Lowry, and Jamie Cross for their comments on earlier versions of this article.

Declaration of Conflicting Interests

The author declared no potential conflicts of interests with respect to the research, authorship, and/or publication of this article.

Funding
The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The fieldwork on which this article is based was carried out with funding from the William Wyse Fund, Smuts Memorial Fund, Bartle Frere Fund, Richards Fund, and St. Johns College, Cambridge. The article was written with support from the Nuffield Foundation.

Notes
1. See the following archival sources: Public Works - Papua New Guinea - Lae Hospital, series A452, 1960-1964, control symbol 1962/8031, National Archives of Australia, Canberra; Visit of Fellow of Royal College of Surgery to Papua and New Guinea for Assessment of Port Moresby Hospital, series A452, control symbol 1959/2867, 1959, National Archives of Australia, Canberra; Medical - Papua and New Guinea - Medical and hospital facilities, Madang - Complaint by Mrs Marchant, series A518, 1952-1952, control symbol AO832/1/6, National Archives of Australia, Canberra; European and Native Hospital - Madang - Papua New Guinea, series A518, 1949-1961, control symbol AO832/1/6, National Archives of Australia, Canberra. 2. Development of External Territories Committee - Papua and New Guinea - Hospital Construction Programme, series A4933, 1950, control symbol DET/1.

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Bio
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.

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