Medicine in the Meantime: The Work of Care in Mozambique
Duke University Press, 2018, 256 pages
The study of medical humanitarianism has grown tremendously in the last decade. Notable work has analyzed the debated ethical practice of Médecins sans Frontières (Redfield 2013), state uses of illness diagnosis as a pathway to citizenship (Ticktin 2010) and the way medical aid programs provide mechanisms to enact new identity claims among aid recipients (Nguyen 2010; James 2010). Recent studies have turned their attention to the complex, diverse historical practices informing current aid programs, and the wider relational and political basis for humanitarian action in African communities (Scherz 2014; Halvorson 2018). Among them, Ramah McKay’s book Medicine in the Meantime is a well-researched and insightful contribution.
The book describes the pursuit of health care in two different sites in Mozambique: 1) Global Children’s Fund (GCF) activities in Morrumbala District, Zambézia Province, and 2) “Clínica 2,” a small public health center in the capital Maputo that received support from the International Center for Health Care. Drawing on ethnographic research among patients, clinicians, aid workers, and volunteers, McKay’s account carefully examines the subtle political, historical, and relational negotiations that take place over community health care provision. Individual chapters focus on the work of GCF volunteer community health activists, tasked with caring for chronically ill patients; workshops and meetings as contested spaces of knowledge production within NGO offices; historically-rooted practices of food aid distribution and relational care; elite professional activities of interviewing and counseling that intertwine moral and therapeutic labor; and bureaucratic paperwork like forms and prescriptions that present separate, at times conflicting, notions of treatment effectiveness and patient compliance. Across these diverse locations and practices, McKay introduces the term multiplicity to depict the varying claims, pursuits, and understandings of medicine itself that underpin each dimension of health care provision. She rightfully points out that, while this multiplicity characterizes much African medical provision today, health in African communities has long been a practice of moving among diverse modalities. Multiplicity as a term of art seeks not only to recognize the pluralism in transnational medicine but also the various relations and forms of care drawn into and produced by medical practice yet formally “rendered external to it” (10).
One of the greatest theoretical contributions of Medicine in the Meantime is its persuasive rethinking of the relationship between public institutions and health care NGOs in Mozambique. It is commonly argued that health care NGOs in African states channel resources away from public medical institutions like state-funded hospitals. This argument has nurtured a view of public institutions and transnational medicine as opposed in the pursuit of resources or, in the least, distinct in their aims. While McKay does not dispute the idea that publicly-run hospitals and clinics often lose programs and qualified professionals to better-funded health care NGOs, she also traces several ways NGO work and public health care are complexly intertwined. First, she shows that, among Mozambican and expatriate NGO workers, the socialist-era public health care of late 1970s Mozambique sometimes operated as an ideal or model for their programs, a “nostalgic echo and future horizon” (22). Thus the kind of medicine they pursued was produced “in the meantime,” or betwixt and between these “nostalgic echoes and future horizons” of what public health care could look like (22).
Additionally, in Chapters 1-3, McKay convincingly demonstrates how the work of GCF volunteer community health activists in Mozambique was entangled with past and present forms of state governance. Seasoned volunteers expertly cobbled together services for the chronically ill from a running list of publicly and privately funded health care programs. Individual health care staff, such as Violeta, followed a common trajectory of moving from jobs in public clinics to NGOs. Aid organizations’ participatory methods, such as the mapping of distinct communities and vulnerable subjects eligible for aid, quietly replicated forms of rural governance under Portuguese colonialism and later under the socialist state that relied on identifying “communities” as salient political units. Furthermore, the state registration of children and other vulnerable populations by GCF strengthened the interrelationship between NGO programs and older and ongoing forms of state biopolitics by identifying populations for future humanitarian care and state management.
Through these and other examples, McKay develops the point that NGOs deploy and rework many different political concepts and practices as they pursue community health in Mozambique. Her work raises interesting and important questions about precisely what is political (or perhaps even more, what is not political) in transnationally- and publicly-funded health care provision. McKay’s collective answer to these questions prompts readers to consider the biopolitical dimensions of numerous practices. These include NGOs’ definition of legitimate, financially supported “care” (e.g., which often divided affective care from material and medical support), the making of “fields” of health care intervention in meetings and workshops; and the historical practices of care and support that people use to evaluate their ongoing relationships with Mozambican NGOs. The result is an approach that deeply contextualizes medical humanitarian activities in the wider historical, political and relational practices through which they gain selective traction. Through her careful attention to the far-reaching cultural histories of biopolitical governance that inform and are selectively remade through aid practices, McKay’s ethnography puts the metaphorical nail in the coffin on the notion that medical aid constitutes a set of encapsulated programs and resources, only cultural insofar as they influence patienthood, treatment, and care. By tracing the way aid programs tap into and refashion political notions of community, gendered labor, and more, the book challenges the idea that the political dimensions of humanitarian action are primarily limited to their mechanisms of resource allocation and accountability.
In addition to this important contribution, McKay’s ethnography of volunteer community health activists is particularly memorable, insightful, and well-written. Many studies of medical humanitarian work have focused on administrators, professional aid brokers, and physicians, leaving aside the clerks, nurses, volunteers, and aides that often make medical operations possible on a daily basis. McKay’s attention to Mozambican volunteers who perform home visits to the chronically ill is thus a rare and welcome addition to the literature. Her richly described ethnography with GCF volunteers vividly brings to life their training, varying visions of the work they do, disagreements with NGO staffers, and the substantial experience many have amassed from prior involvement with government agencies and church organizations. The book importantly critiques GCF’s dominant narrative that volunteers view their work as an expression of social solidarity. Rather, McKay documents how volunteers rely on the per diem compensation, lunches, and the cultural capital of organizational certificates that they receive from their volunteerism. This ethnography also diverges in important ways from recent accounts of volunteerism in Italy (Muehlebach 2012) and Russia (Caldwell 2017), where faith-based volunteers more readily voice a moral discourse of love, compassion, and solidarity as a critique of and practice intertwined with the neoliberal market. Likewise, while it has not often been explored, McKay’s account shows how health care NGOs depend on volunteer labor to pursue their operations in African contexts, such as through medical scouts and community health workers, furthering the economic inequalities and power relations among those involved in medical humanitarian activities.
Another ethnographic strength of the book is its rich analysis of the strategies of care practiced by Mozambican women and the contrasting, often paternalistic views of those practices among GCF aid workers. McKay shows how Mozambican women who received food aid baskets practiced a variety of strategies for dividing their contents, interweaving their households with wider networks of exchange and support. Though GCF staffers often portrayed women as potential victims of romantic relationships with Mozambican male migrants recruited to work in South African mines, McKay contends that women’s relations with migrant men can be understood in the wider context of care practices that women pursue to shore up potential future support. This argument builds on a critique in African ethnography of one culturally particular yet pervasive notion of romantic love that divides affect from material support (Cole & Thomas 2009). While food aid baskets have been significant components of local distributive economies, McKay points out that this form of aid has become increasingly more restricted and difficult to obtain. Part of the problem lay in NGOs’ futile and arbitrary efforts to separate poverty and illness. In order to mandate common standards for aid distribution, GCF established metabolic benchmarks as criteria for food aid eligibility. Additionally, GCF policies imagined food insecurity as a short-term problem rather than an ongoing issue. In addition to critiquing these problematic assumptions, McKay’s effective ethnography underscores how care is already understood and practiced by Mozambicans through long, ongoing and gendered strategies of nurturance and support, activities that chafe against the restrictive logics used by NGOs to establish need and eligibility.
Though this book is a sharply observed, carefully analyzed ethnography with numerous insights for the reader, some components of the overarching theoretical framework could have been further developed. For instance, multiplicity is an interesting unifying concept, but the varying meanings of multiplicity and the differences between multiply coexisting practices of care and food aid distribution, on the one hand, and multiplicity in the bureaucratic footprints produced by aid agencies, on the other hand, could receive greater attention. In other words, does the term multiplicity theorize varying cultural forces that might be teased apart further? How do varying forms of multiplicity have diverse cultural effects and implications for different people? Additionally, as someone interested in the temporalities of aid initiatives, McKay’s title sparked several questions: How is “the meantime” of contemporary Mozambican medical initiatives made and experienced as a cultural reality by variously positioned individuals? For whom is Mozambican transnational medicine practiced “in the meantime” and for whom is it less so, and why? The author traces in the introduction how humanitarian aid happens in and of time through, for instance, the ongoing comparisons NGO workers and Mozambican aid recipients make to other kinds of prior or potential future assistance. Yet the felt instability and cultural making of the present—a meantime—could be analyzed more explicitly. In the book’s closing lines, McKay eloquently writes of how people “work anyway” in a critical space between pragmatic demands and what could be (198). This beautiful point could be threaded more through the book to examine how a present orientation to medicine exists in the many accommodations that people make at the level of daily practice.
Medicine in the Meantime effectively draws together critical literatures on global health, medical humanitarianism, and African health care provision. The book will be of great interest to scholars and students of global health, African health care practices, Mozambican and Lusophone histories, transnational medicine, and humanitarian aid. The writing is appropriate for upper-level undergraduates, graduate students, and specialists in those fields and could be an attractive adoption for courses in Global Health, Humanitarianism and Development, and Medical Anthropology. Above all, Medicine in the Meantime brings much-needed theoretical attention to the diverse relational, political and historical basis of contemporary humanitarian action, demonstrating superb ethnography, and for that reason is a valuable, highly recommended contribution to the field of medical aid.
Caldwell, Melissa. 2017. Living Faithfully in an Unjust World: Compassionate Care in Russia. Berkeley: University of California Press.
Cole, Jennifer & Lynn Thomas, eds. 2009. Love in Africa. Chicago: University of Chicago Press.
Halvorson, Britt. 2018. Conversionary Sites: Transforming Medical Aid and Global Christianity from Madagascar to Minnesota. Chicago: University of Chicago Press.
James, Erica. 2010. Democratic Insecurities: Violence, Trauma, and Intervention in Haiti. Berkeley: University of California Press.
Muehlebach, Andrea. 2012. The Moral Neoliberal: Welfare and Citizenship in Italy. Chicago: University of Chicago Press.
Nguyen, Vinh-Kim. 2010. The Republic of Therapy: Triage and Sovereignty in West Africa’s Time of AIDS. Durham, NC: Duke University Press.
Redfield, Peter. 2013. Life in Crisis: The Ethical Journey of Doctors without Borders. Berkeley: University of California Press.
Scherz, China. 2014. Having People, Having Heart: Charity, Sustainable Development, and Problems of Dependence in Central Uganda. Chicago: University of Chicago Press.
Ticktin, Miriam. 2011. Casualties of Care: Immigration and the Politics of Humanitarianism in France. Berkeley: University of California Press.
Britt Halvorson is a faculty fellow in Global Studies at Colby College in Maine. Her research examines religious, historical, and market practices of valuation within faith-based medical aid. She has also published work on medical waste economies, African Christian communities in the Midwest U.S., and therapeutic practices that combine prayer healing and biomedicine. Her book, Conversionary Sites: Transforming Medical Aid and Global Christianity from Madagascar to Minnesota (University of Chicago Press, 2018), examines faith-based medicine as a renewed yet also deeply historical site of religious engagement linking evangelical Christians in the United States and Madagascar.