Tinkering toward departure: The limits of improvisation in rural Ethiopian biomedical practices

•Unequal networks of transnational biomedicine produce disconnected clinical spaces.•Moral and scientific ideals of good doctoring are defined by biomedical imaginaries.•Limits to tinkering and improvisation result in physicians' departures.•Marginalization produces physician disenchantment and shortages in high-need areas.

This paper explores Ethiopian physicians' responses to tensions produced by gaps between ideals of biomedicine and realities of clinical practice in two rural Ethiopian hospitals. Physicians engage in creativity and improvisation, including relying on informal networks and practices and tinkering within diagnoses and procedures, to overcome constraints of lack of resources and limited opportunities to engage in “good medicine.” These courageous, but often unsuccessful attempts to mitigate professional and personal conflicts within their medical practices represent improvisation in impossible circumstances. This paper results from ethnographic research conducted in 2013-2014 and includes participant observations and qualitative interviews in two hospitals within the same community. The inherent conflicts among globalized standards, unpredictable transnational medical networks, and innovative practices produce tenuous clinical spaces and practices that rely on a mosaic of techniques and ad hoc connections. Tinkering and improvisation often fail to mediate these conflicts, contributing to physician disenchantment and departure from the community.