Duke University Press, 2018. 256 pages.
Ramah McKay’s Medicine in the Meantime is the latest installment in Duke University Press’s Critical Global Health series, edited by Vincanne Adams and Joao Biehl. The Critical Global Health series interrogates global health’s geographical spaces, conflicting temporalities, and forms of care. Some of the central questions of the series include: what is “new” about global health? How are global health initiatives, driven by a new generation of techno-fix savvy, philanthropic capitalists, all that different from prior generations of international development aid and humanitarian projects? What is “global” about global health? And what are the limitations of locating global health purely in the remains of the Cold War’s Third World, what some call the “Global South”?
While many of the contributions to the Critical Global Health series locate “the global” in North American settings—the global war on terror embedded in the bodies of veterans at Walter Reed Hospital (Wool 2015), the lives of pregnant drug addicts on the streets of San Francisco (Knight 2015), biomedicine’s extraordinary measures to extend the lives of the chronically ill (Kaufman 2015)—roughly half of the volumes published in this series are situated on the African continent or draw extensively on case studies from Africa. This geographic emphasis is not surprising. “Africa” is synonymous with global health initiatives. It is the key locus of the HIV/AIDS epidemic and the grand experiment to provide antiretroviral treatment therapy access. HIV anchors much of the scholarship on global health in Africa. And the tools of ethnography have provided an up close and intimate view on how HIV and global health regimes have fundamentally altered the course of people’s lives (e.g. through therapeutic citizenship, biopolitics of treatment, the hunger of ARVs, etc.).
Medicine in the Meantime offers an intimate look at the contemporary politics of allocation in public and private healthcare in Mozambique. Mozambique is a particularly fascinating country for considering to what extent public health can still be public in a country where global health interventions dominate. For example, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) funds accounted for 60% of Mozambique’s health sector spending in 2008 (Pfeiffer 2013). Healthcare workers must navigate the complexities of what is public, what is private, and what is partnership in this culture of donor driven abundance and IMF imposed fiscal austerity in order to provide care.
HIV treatment and social support programs as well as the patients who access them and the staff who manage them are certainly present and prominent in McKay’s book. What’s deeply refreshing about the book is McKay’s careful work to situate this contemporary moment where HIV brings ARVs, food baskets, and entitlements to care within Mozambique’s deeper histories. Drawing on the memories of everyday Mozambicans from rural villages to the upper echelons of the government health service, we see how and in what ways war, structural adjustment, and humanitarian health interventions of the past shape experiences and understandings of health care, and particularly what constitutes public health in a time of global health.
To engage with these issues, McKay takes us on a deep ethnographic tour of the terrain of therapy providers, clinics, professionals and the dispensaries that make up care. “Multiplicity” is the term McKay uses to describe not only this vast quilt of sites that make up the patchiness of care, but the vast array of people who care. Reading Medicine in the Meantime, I thought quite a bit about John M. Janzen’s (1978) The quest for therapy and the different strategies patients and their therapy management groups utilized to find relief for their ailments from a variety of different practitioners and therapeutic traditions. Medicine in the Meantime takes us into the world of biomedical therapeutic pluralism from a different angle. Rather than focusing on the different therapeutics patients and families cobble together to seek relief, McKay introduces us to the wide variety of actors who care in public and private health clinics. In a place where physicians are thin on the ground, volunteers, psychologists, lab techs, administrators, and nurses make up the multiplicity of biomedical care.
This is a landscape that’s been shaped profoundly by the war—both through the hollowing of the public health system and the rise of humanitarian aid. McKay also nods to the ways in which the war and the political economy of cotton production and mining migration rewrote the politics of subsistence (and therefore of care and wellbeing) in Mozambique. McKay’s work is particularly innovative when she takes up the issue of food as care, and the necessary alchemic combination for HIV/AIDS medications to offer meaningful therapeutic benefit. Chapter 3 on “Afterlives,” for example, shows us the ways in which histories of food rations during the war continue to linger in people’s memories and shape their interpretations of the temporal horizons of food baskets for HIV care. McKay writes about Susana, who had received food aid in Malawi during the war and six months of food support after an HIV diagnosis:
“Despite similarities to past experiences of aid, then, the assistance Susana now received was not distributed along the same lines of collective need that she recalled as having governed assistance in the camps. Instead, it was calculated in diagnostic terms of CD4 counts, tuberculosis treatment, and low body mass index that governed GCF’s food program. It was distributed according to medial, individual, and time-limited understandings of need and vulnerability that left little room for considering the relations on which she relied…” (96)
The attention to hunger, the politics of the belly, and the delicate work of allocation all make this book a unique contribution to rethinking how past experiences of care and entitlement shape how individuals experience care in the present. One has the sense that negotiating access to the goods of global health is just one contemporary moment in the much longer history of how practitioners, patients, and families navigate Mozambique’s historically contingent, highly uneven, and resolutely multiple topography of (medical) care.
Janzen, John M. and William Arkinstall. The quest for therapy: medical pluralism in Lower Zaire. Berkeley: University of California Press, 1978.
Kaufman, Sharon R. Ordinary Medicine: Extraordinary Treatments, Longer Lives, and Where to Draw the Line. Durham, N.C.: Duke University Press, 2015.
Knight, Kelly Ray. addicted.pregnant.poor. , Durham, N,C.: Duke University Press, 2015
Pfeiffer J. “The struggle for a public sector.” In: Petryna A., Biehl J., editors. When people come first: Critical studies in global health. Princeton: Princeton University Press; 2013. pp. 166–181.
Wool, Zoë H. After war: the weight of life at Walter Reed. Durham, N.C.: Duke University Press, 2015
Marissa Mika is an Assistant Professor and the founding Head of Humanities and Social Sciences at University of Global Health Equity (UGHE). At UGHE, she oversees and teaches in the initial six months of the MBBS program, which provides an immersive experience in writing and communication, African history, medical anthropology, social justice theory, and critical thinking skills. She received her PhD from the History and Sociology of Science Department at the University of Pennsylvania. She is currently completing a manuscript called Africanizing Oncology, which is a historical ethnography of cancer research at the Uganda Cancer Institute.