Having previously published studies on health and healing in the Lower Congo, John Janzen brings his vast knowledge of the region to the topic of the legitimation of power and knowledge in public health and health care in his recent book Health in a Fragile State: Science, Sorcery, and Spirit in the Lower Congo. In this detailed and meticulously researched volume, Janzen shows that the local population’s experience with endemic tropical scourges and healing must be understood within a political context characterized by decades of extreme stress caused by the Mobutu and Kabila dictatorships. The years of dictatorship, combined with the negative effects of the austerity measures imposed by the World Bank and the International Monetary Fund, resulted in a “fragile state” which was unable to fulfill its responsibilities. Janzen’s book focuses on the institutions and services that emerged to fill the space left vacant by the failure of the state, including churches, universities, and other non-governmental organizations (NGOs).

Health in a Fragile State begins with a well-organized introduction in which Janzen engages with studies published by scholars such as Crawford Young and Thomas Turner, who examined the “rise and decline” of the Zairean/Congolese state, Ferguson’s work on the “shadow state,” and Pfeiffer and Chapman’s study on structural adjustment programs. Janzen also provides the background for understanding the impact of the collapse of the Zairean state on public health and health care services in the Health Zone of the Territory of Luozi (located in the Manianga district in the Lower Congo). The reader will find the insights into Janzen’s lived experience in the field and his encounters with his informants, collaborators, and facilitators while he was conducting field research particularly interesting. The introduction also outlines the themes that recur throughout the book.

The book is divided into three parts. Part I (41–89) explores the history of population and contagious diseases in the Lower Congo. Unlike other anthropological works that focus on the ethnographic present, Janzen considers the longue durée, using travelers’ accounts and other secondary sources to examine the fluctuation of the population between 1700 and 2010 and to consider the historical dimensions of health. Chapter One examines the forces and conditions that aggravated these contagious diseases, including the long-distance trade within the Luso-African zone which preceded colonial conquest and Belgian colonialism.

Chapter Two explores postcolonial population and disease trends. The postcolonial period is characterized by a decline in the birthrate due to the rising cost of living and education for children, a decline in mortality caused by better maternal and child healthcare, and a reduction in the incidence of leprosy, smallpox, polio, and trypanosomiasis. This period is also characterized by the persistence of malaria, diarrheal diseases, tuberculosis, typhoid fever, flu, bilharzia, protein malnutrition, and HIV. Janzen underlines a paradoxical situation where these diseases have persisted in spite of growing medical knowledge and the availability of better treatments.

Part II (89–156) focuses on the social reproduction of health. Chapter Three uses a case study to illustrate how subsistence production and the social reproduction of health in the household, family, and clan operate against the background of colonial and global processes and flows of resources and symbols. Janzen shows how the “life cycle of the Kongo household or family involves the active exchange of goods, gifts, symbols, and bodies to constitute the new household” (94). Chapter Four analyzes the reconfiguration of public health and health care institutions, agencies, and networks in Luozi in the second decade of the twenty-first century, following the collapse of the Congolese state in the 1990s. It was these institutions “that assumed the vestigial functions of the state” (112). Chapter Five investigates the popular meanings of health and concerns with unachieved health, as rooted in Kongo tradition.

The three chapters of Part III analyze the legitimation of power and knowledge in “situations where government fails entirely or substantially”; when this happens, other agencies emerge to deliver urgent services (161) and, in the process, renew or restore legitimate power. The evidence suggests that an integration of science and religion has taken place among both the Kongo professional elites and the populace.

This thoroughly researched and well-documented book makes an important contribution to our understanding of the local and global forces and processes that have shaped health and healthcare in the Lower Congo. Janzen demonstrates that the decline of the Congolese state made it possible for nonstate institutions and organizations to play an important role in public health, thereby gaining legitimacy. He has done an excellent job of navigating between anthropology, history, political science, and linguistics. The book nicely captures the voices and health concerns of nonstate players as well as ordinary people in the Lower Congo.