The two books under review here make a useful contribution to understanding the changing public health sector in Africa. The edited volume by Prince and Marsland is a critical reflection on new forms of public and global health. The economic recession during the 1980s and the aggravated AIDS crisis in many African states led to the massive influx of Western NGOs, the privatization of hospitals and medical services, and the engagement of international research funds such as PEPFAR (the US President's Emergency Plan for AIDS Relief) and other humanitarian institutions. This situation is the starting point for the editors to discuss the influence of markets, biotechnologies and pharmaceutical companies on social relations, medical care and new forms of citizenship. The volume by Johanna T. Crane ties in with these problems. She offers a detailed case study of a transnational research centre and clinic in Western Uganda under similar socio-economic conditions.
In her knowledgeable introduction, Ruth Prince brings to the fore the difficult trajectory of African healing from precolonial times to the neoliberal twenty-first century. The great merit of this introduction lies not only in the richness of its historical data and its socio-economic contextualization but also in the analytical gaze that discerns the entanglement of public medicine with historically different hierarchies of power and wealth. All three parts of the volume shed light on different aspects of public health, its dynamics of change and deep entanglement with foreign donors. The first part deals with the relationship between public health and the postcolonial state. Whereas government officials in Northern Nigeria try to profit politically from the presence of public health centres (see the chapter by Last), in Tanzania, officials challenge seemingly irrational and backward traditions at funerals and other social events by imposing rational by-laws (Marsland). Both chapters emphasize the existence of very different, if not antagonistic, conceptualizations of the public and of public health. Historically, public health was part of the religious and moral order of African societies, being firmly rooted in collective social and political relationships. These ideas contradict the present emphasis on individual responsibility for one's health and explain why a great majority of the population remains rather sceptical about modern forms of biopolitics. That these attitudes, however, do not lead to passive or just observant behaviour but can generate constructive recommendations by self-conscious citizens is the tenor of Tousignant's chapter. Because of the increase in pharmacy thefts, linked to illicit markets and outsourcing of production, Senegalese pharmacists reminded the government of its duty to uphold standards and control for the public good. Their enactment of a ‘citizenship of quality’ (p. 97) underlines their professional responsibility in times of the illicit trading of drugs and is interpreted as a renewal of the contract between the state and its professional elites.
The second part of the book is characterized by detailed case studies of care whose difference in quality is related to the influx of foreign-dominated home-based AIDS care institutions (HBAC) in comparison to government services. The free distribution of ARVs (antiretroviral medicines) has tremendously improved the life of AIDS patients, who, in return, have to follow strict regulations of drug taking and food control. In her case study, Meinert describes the tension that results from the social role of being a patient and the wish to become a full person again. A different perspective of home-based care is conveyed by Brown's chapter on community public health projects in Nyanza Province. She draws attention to the older history of this institution in Kenya and the contradictory role of women in such care. Against this multi-layered experience, Brown argues that home-based care is not necessarily connected to the withdrawal of the state from public health; rather, it allows women to position themselves as actors in relation to the state. They engage themselves for the public good and turn private care not into an exploitative enterprise, but into a successful community concern. In contrast to internationally sponsored care and private clinics, Mulemi deals with the desolate situation of cancer patients in government hospitals. The author vividly describes the hopes of patients for healing and their increasing disappointment due to technical failures, lack of medicine or uncertain diagnoses. Despite many shortcomings, doctors, nurses and other staff try to uphold the image of the hospital as a symbol of hope, either by recommending alternative therapies or by shortening unnecessary suffering through early discharge.
Like cancer, the causes of other non-communicable diseases (high blood pressure, diabetes, being overweight, or obesity) are of global concern. Whyte's findings (in Part 3) regarding rural and urban populations are quite explicit in that there are no great distinctions by class, gender or lifestyle. However, the responses of her informants vary according to their own life conditions and reflect ideas about aesthetics and body shapes.
The juxtaposition between government hospitals and the new HIV clinics built with international donor money is taken up again in the last two chapters. Prince analyses the new ‘landscape of global health’ in Kisumu, which – sponsored by international donor money – is marked by better infrastructures and enlarged networks as well as access to new kinds of knowledge, job opportunities and self-empowerment. She draws attention to the hope of youth for a better life but also points to the fragility of the system and its dependency on time limits, which generate anxieties about the future of the projects. The last chapter of the volume stresses the nodal function of international research centres and clinics. Despite their close-knit integration in global networks, they are unable to integrate their surroundings into a functional whole but remain isolated islands in impoverished territories. Nevertheless, their financial and intellectual capacity turns them into dream points for the Kenyan youth hoping for a career or at least some remuneration for volunteer work. Geissler describes the employees' dreams and desires, and, by exploring their daily struggles in luxurious but ephemeral working conditions, allows the reader nuanced insights into the working of high-tech medical centres and the inequalities they generate.
Crane's sensible case study of the Immune Wellness Clinic in Mbarara, Western Uganda ties in with Geissler's analysis of a similar institution in Western Kenya. Crane familiarizes the reader with a world of international research relations with all their opportunities and ambiguities, inclusion and exclusion. Several months of fieldwork and interviews with researchers, doctors and administrators, as well as reports on conferences, workshops and occasional conversations, are the solid foundation of the book.
Her case study delivers insights into everyday practices in the clinic, laboratories and pharmacies, discusses the pros and cons of capacity building for Ugandan doctors and researchers, and analyses the relationship between administrative competences, the control of money, and racial prejudice. Despite the fundamental changes ARVs have brought to the life of the patients, the practice of ‘global health’ is not free of problems. The many rifts and conflicts generated by these kinds of transnational cooperation are vividly illustrated through the biographies of the researchers and the personnel of the clinic.
What makes this book an interesting and rewarding reading experience is the combination of scientific analysis and social criticism. Her description of the ‘molecularization’ of HIV treatment, European stereotypes of African behaviour and the growing distance between clinicians and researchers problematizes this form of knowledge production under conditions of unequal transnational relations. While the focus of the book lies in the organization of international research agendas, it is a pity that Crane abstained from asking patients about their evaluation of this high-tech world. The integration of their perceptions would have rounded up an otherwise balanced analysis sustained by a very refreshing self-reflexivity.
Making and Unmaking Public Health offers interesting reading. Its historical contextualization of public health practices under different relations of power, economic dependencies and conditions of change confronts the reader with one of the most important transformations Africa has gone through. Written by renowned specialists, the chapters are well informed and rich in data and critical evaluations. But, as in many edited volumes, the chapters rarely speak to one another, which leads to some doubling of arguments (see Prince and Geissler). Although the term ‘public and global health’ looms throughout, its theoretical discussion is quite short (Marsland, Prince and Whyte). Marsland's interpretation is rather empirical and remains unsatisfactory, especially as the reference to Habermas lacks deeper analysis. But apart from these minor deficiencies, the volume sums up admirably the problems of public health and its transformation into a world of global medical institutions.
