The value of this edited volume, which should interest anthropologists, historians, and science studies scholars working on and within global health institutions in Africa, lies in the convincing and ethnographically-informed challenges it poses to favored theoretical frames in the critical scholarship on health and medicine in Africa. The guiding analytic of the volume – the ‘para-state’ – troubles normative understandings of the state in Africa as weak or retreating. Across eight geographic case studies, eleven authors show that amid a global health boom, the state still matters. The volume disrupts theoretical orthodoxies – surveyed in P. Wenzel Geissler's ‘Introduction’ – that have dominated critical scholarship in recent years; the contributors draw attention to social relations and transactions beyond regulation, exploitation, weak states, strong transnational institutions, and biopolitical surveillance.
It is fitting that Vinh-Kim Nguyen's contribution kicks off the collection, as his theoretical investment in the rise of ‘experimental societies’ is productively challenged by other contributors. Nguyen's para-state ‘shape[s] and discipline[s] the world’ through ever-expanding forms of biopolitical surveillance like those associated with new prevention technologies, such as pre- and post-exposure prophylaxis (73). This doomsday reading is engaged by subsequent authors who suggest that the rupture associated with contemporary global health in Africa is less striking than it may seem; their accounts temper scholars’ enthusiastic uptake of Nguyen's therapeutic citizenship by foregrounding multiple and competing interests, networks, and actors – in addition to bodily states and survival techniques – that mediate social relations in the era of global health.
John Manton's chapter periodizes research and therapeutic networks in leprosy control in Nigeria (1948–67), showing that state power was bolstered by transnational research partnerships that reflected interests of ‘missionaries, adventurers, and capitalists’ (96). His prehistory of postcolonial science features the hybridization of colonial government, humanitarian-missionary, and local administrative responses to leprosy in the mid-twentieth century, countering the epochal shift we associate with global health. Ann Kelly, meanwhile, traces the evolving sociopolitical significance of research and its effects in the Gambia since the late colonial period. She illustrates how the present-day biopolitical regime no longer favors long-term commitment to a place, but adheres to deterritorialized experimental networks. Yet, paradoxically, as transnational projects abandon the Gambia, ‘health’ has become political currency for antiscientific nationalist projects.
Geissler's chapter analyzes the diverse temporalities of the National Clinical Research Organization (NCRO) in a sub-Saharan African country to move away from teleologies that characterize interpretations of global health in Africa. In comfortable offices that staff view as ‘out of Africa’, researchers analyze data and oversee trials (147). It is tempting to read NCRO's activities through the lens of Western extraction of raw material from African bodies, but Geissler suggests NCRO is rich with ‘ongoing engagements between pasts, presents, and futures’ (145). Employing an ethnographic history and spatial analysis of NCRO, he considers the present as ‘process rather than … outcome of global transformative causalities operating shifts between states’ (170). Didier Fassin's chapter, as well, temporalizes the stories people have told about nevirapine, hailed as a magic bullet when it arrived in South Africa in 1999. A cheap and simple protocol for preventing mother to child transmission, this beacon of hope soon engendered hot debate: was nevirapine an easy way to treat the country's most vulnerable populations or a suboptimal treatment adding salt to post-apartheid wounds? For Fassin, two truths and two ethics were at stake. A ‘wonder drug’ became legible against a landscape devoid of technologies for preventing mother to child transmission, but later became a ‘suboptimal’ drug amid a field of blooming medical possibilities and breakthroughs. Fassin exposes how truths become ‘certain’ not because they are scientifically sound, but because they enter into social and political projects that provide scaffolding for success or failure.
Guillaume Lachenal encourages us to move beyond denunciations of transnational research as exploitation and extraction. He proposes that the Global Viral Forecast Initiative in Cameroon became a site of public critique not because its scientists were greedy or profit-seeking, but because they were viewed as absurd figures staging fictive interventions against imaginary public health threats. Branwyn Poleykett shows how Senegalese sex workers who participate in epidemiological mapping projects forge relations of care, obligation, and reciprocity. Rather than viewing the project that collects their blood as vampiric, they express trust and loyalty toward researchers and clinicians. Lotte Meinert, too, moves beyond science's menacing discipline and regulation of bodies by illustrating how it produces (and cuts) novel kinds of social relations, networks, and subjectivities in the context of the history of ART in rural East Africa.
Rene Gerrets usefully challenges the assumption that private public partnerships (PPPs) in post-1990s Tanzania have weakened a highly aid-dependent state by showing how a transnational malaria research and control partnership bolstered state influence in health governance. Amid cynicism about north/south collaboration, he reminds us that partnership can be appropriated and parasitized. Ulrike Beisel also discusses a malaria control PPP between a mining company, the Global Fund and the Ministry of Health in Ghana, tracing how a corporate health project transformed into a national-level insecticide spraying initiative.
Finally, Susan Reynolds Whyte's brilliant contribution boldly challenges the theoretical investments in Foucauldian biopolitics. Engaging directly Nguyen's argument that mastering ‘confessional technologies’ ensure some a new lease on life via access to ART, she shows that in Uganda the most important predictor of positive life chances was earned income. Her chapter moves beyond a limited bioscientific (bare life) understanding of survival in the age of strong biopolitical interventions, highlighting two paradoxes that complicate therapeutic citizenship. In Uganda, remaining healthy on ART entails not confessing one's ‘positive’ bioidentity, but hiding it to maintain government jobs. Amid deterritorialization and international institutions, the state remains the most stable provider of income: ‘a reliable salary’, she writes, ‘[is] evident in body size’ (221).
The collection overwhelmingly focuses on AIDS and malaria, mirroring perhaps global health's own gaze. The authors might have more explicitly addressed their own roles in global health's visions and stories and, in the spirit of caution against narratives of historical rupture, considered the continuities and sociopolitical stakes of anthropological and historical critique itself in Africa's pasts and presents. Nonetheless, this well-curated and compelling volume invites us to update our theoretical toolkits to reflect on-the-ground realities that defy, almost as often as they confirm, received interpretive frameworks.
