Edited by Anna Greenwood, Beyond the State: The Colonial Medical Service in British Africa explores the role of non-state actors in shaping and providing medical services during the colonial period. The work demonstrates that many stakeholders, including missionaries, local elites, and private business interests, helped direct, create, and enforce policy. By widening the scope and paying attention to the influence of non-state actors and their interaction with state officials and institutions, Beyond the State provides a fuller, more developed picture of medicine in the colonies.

Beyond the State joins the growing list of studies that question the degree of control wielded by authorities in London over day-to-day operations in the colonies. Anna Greenwood and Harshad Topiwala's examination of recruitment policies in Kenya demonstrates that while the Colonial Office wished to appear in control, realities on the ground forced them to assent to practices that directly contradicted their own policies. For instance, officially the Colonial Office stated that it recruited only European doctors for service in Africa; however, Greenwood and Topiwala demonstrate that for every European doctor there were two Indian doctors employed in Kenya. Clearly, medical expediency could be, and indeed often was, at odds with official policy. The willingness to ignore official policy and to bend to local needs shifted power to the periphery, where colonial doctors and administrators could, and often did, operate with much independence from metropolitan authorities. Greenwood and Topiwala's insights into the recruitment, experiences, and careers of Indian doctors in Kenya adds depth to our understanding of colonial medicine and the people who helped manage and sustain it. It also reminds historians of the importance of scrutinizing official narratives, which should not be confused with the actual realities on the ground.

Yolanda Pringle's contribution examines the relationship between the Church Missionary Society and the Colonial Medical Service in Uganda before 1940. Pringle determines that the short-term and reactionary measures that characterized the earliest days of colonial medicine in Uganda were replaced by a more formalized, fluid, and responsive system that incorporated and gained strength from an alliance between state and non-state actors. Crucially, although missionaries and the Church Missionary Society were an important component of medicine in Uganda, she asserts that few patients would have realized the distinction between state and non-state medical care.

Markku Hokkanen further explores the intersection of government medical services and missionaries with his study of colonial Malawi, 1891–1940. Hokkanen demonstrates that while cooperation did occur, much tension existed between the missionaries and the British medical services. According to Hokkanen, this history should serve as a reminder that colonial medicine was neither monolithic nor organized around simple binaries such as state and missionaries or religious and secular. Completing the strand on medicine and missions, Mike Jennings's chapter argues that by the 1940s medical departments and missionaries began working together to improve local health conditions in Tanganyika. While there were tensions, for the parties did not always share the same aims, missions became a central aspect of colonial medicine. Jennings concludes that, as the first extra-governmental bodies to have a significant say on state policies, mission organizations laid the groundwork for later nongovernmental organizations.

While most contributions in Beyond the State highlight the importance of state and non-state actors' collaboration, Greenwood's examination of Zanzibar demonstrates that cooperation could not be achieved in all colonies. In this case, the British government actively distanced itself and discouraged the growth of a local institution, the Zanzibar Maternity Association, which the British perceived to be a competitor rather than an ally. Greenwood argues that the failure to cooperate originated from the British need to be in control. Collaboration and cooperation were valued, but only when non-state actors did not challenge British authority or expectations.

Shane Doyle's contribution, a study of medical departments in Uganda and Tanganyika, demonstrates not only that colonial medical departments looked to cooperate with other groups, but also that they actively sought advice and medical opinion from outside their own borders. Aligning his work with wider trends in the field, including emphasizing transnational cooperation and consultation while highlighting the importance of epistemic communities in shaping and maintaining the Empire, Doyle argues that colonial officials and administrators employed a vast array of scholarship to buttress the assumptions and position of colonial medical departments.

Matthew Heaton explores the role of private interests by analyzing the degree to which colonial officials cooperated with business in repatriating to Nigeria Africans deemed to be mentally unwell. Heaton explains that hundreds of Nigerians suffered mental disorders while abroad and that for many of these individuals it was judged best to repatriate them to Africa to aid in their recovery. Studying the processes of repatriation allows insights into the role played by the government in London, the shipping company responsible for transporting patients deemed mentally unwell, and the colonial government.

In sum, Beyond the State demonstrates the degree to which collaboration between local interests and medical authorities shaped medicine in the colonies. The work demonstrates that colonial medical departments worked towards consensus with non-state actors so long as cooperation reinforced their own interests. This account offers a correction to studies that seek only to highlight force and resistance and privilege the imperial center as the single driving force in shaping the development of colonial medicine. Rather, Beyond the State convincingly asks scholars to set aside the blunt colonizer/colonized model and to consider local policies and collaboration as important factors in shaping colonial medicine.