‘Making and Unmaking Public Health in Africa: Ethnographic and Historical Perspectives’ edited by Ruth J. Prince and Rebecca Marsland (Ohio University Press, 2013).
Making and Unmaking Public Health in Africa opens with a substantive chapter by Ruth Prince that lays bare the critical perspective with which the authors approach the topic of public health in Africa. The introduction is followed by nine (case study-like) chapters that focus their historical or anthropological perspectives on, Nigeria, Tanzania, Senegal, Uganda, and Kenya. The book is certainly of interest to scholars of these five countries as each chapter contains rich description and analysis, and a fair number of them draw on the principles of ethnographic writing, which make such volumes so enjoyable to read and accessible.
For those readers interested ‘in Africa’ it is only the first chapter by Prince that captures the breadth of the book’s title, in a substantial way, through its comparative lens. I believe this chapter in and of itself makes for essential introductory reading for undergraduates and postgraduates studying public health on this diverse continent. In it Prince gives a very good overview of the ‘uneven terrain’ (p. 2) of public health and explicitly highlights and places in historical perspective concepts and actors which have characterised public health discourse, such as ‘civil society’, ‘client’, ‘bottom-up’, ‘public private partnerships’, ‘community participation’, and ‘development’. The authors seem to take very seriously the idea of leaving ‘no term unturned’ by always placing debated terminology in “quotations”. The only additional term I expected to see placed under the microscope, but which was not, was ‘Africa’ itself. A deeper reflection on what Africa is, especially in relation to a case-study based volume such as this one, could have been an interesting addition to this text.
Prince’s overview in the opening chapter demonstrates that if the goal of public health is ‘a citizenry with equitable access to public healthcare, protected by a more accountable State’ (p. 36), this goal has been repeatedly unachieved across the region. While authors examine the structural adjustment and neo-liberalistic market-based approaches that account for this reality, they also go further by asking whether public health as defined above makes sense culturally and historically. Prince’s introduction and a number of the chapters draw the reader to the understanding that there are different versions of public health and almost none meet the goal of public health as it is defined above. State-sponsored public healthcare exists in parallel and interaction with private healthcare (including pharmacies), NGO-funded and delivered healthcare (often for specific conditions), and indigenous public health systems. The take-home message is that there is no singular thing called ‘public health’ in Africa. Rather, the authors take public health as a framework for interrogating this multiplicity as well as to call into question what and who is the ‘public’ to begin with.
In this last regard, scholars engaged in debate and theory making around the elusive concepts of ‘public’ and ‘publics’ will find the chapters by Murray Last (pp. 55-74), Rebecca Marsland (pp. 75-95), and Noemi Tousignant (pp. 96-117) useful. For those interested in chronic non-communicable diseases and cancer in contexts where infectious disease claims the majority of attention and resources, the case studies by Benson Mulemi (pp. 162-185) and Susan Reynolds Whyte (pp. 187-206), will be of great interest. The book also has a number of contributions that are key reading for scholars of HIV-AIDS’s social impact, including those by Hannah Brown (pp. 140-160) and Lotte Meinart (pp. 119-139). All the chapters compliment and cross-reference each other nicely and there are a number of cross-cutting themes I found particularly helpful for refining my perspective on what ‘public health’ is and means.
One crosscutting theme was that of patron-client relationships in pre- and post-colonial society as well as in contemporary NGO-dominated public health. Last’s chapter is a good example of this. It tackles the question of why regular Nigerians have not, and are unlikely to, put pressure on the government to deliver primary health care despite the fact that it is officially the responsibility of local government. Last explains how everything from health to law to poverty alleviation in the pre-colonial period was ‘private’ and not ‘public’ (i.e. rested in the hands of big families). Last believes that suspicion of government provided healthcare (dating back to British colonialism) and a belief that life and death is controlled ultimately by Allah, together explain why Nigerians preferred to take control of their own ‘public health’. From a similar historical perspective, Meinart argues that rights-based discourse in public health require particular historical precedents. Meinart explains that unlike South Africa or Brazil, there is little history of social activism in Uganda, and therefore discourse on rights and citizenship is less prominent than discourses of patron-clientship with regards to expectations of public healthcare provision.
This brings up two other important concepts running through the book, one is ‘projectification’ (Meinart) and the other is ‘care.’ Without well-funded and well-run government systems, institutions, and responses to public health needs, especially HIV care, there has been a proliferation of NGO-funded projects for specific health issues. HIV-AIDS care is the most widespread, being delivered by NGOs with limited time frames and uncertain financial sustainability. Meinert in Chapter 4 and Prince in Chapter 9 show how the power of the NGO as a symbol of better care, opportunity, advancement, and getting ahead, plays out socially. They equally point out that the danger of NGO-provided care is that all projects eventually come to an end and patients whose health does not conform to the textbook trajectory, will fall through the cracks. In addition, Reynolds-Whyte and Mulemi remind us that for those conditions for which there are no projects, such as cancer, diabetes, or hypertension, patients’ prospects are poor. Speaking of Ugandans with non-communicable disease, Reynolds-Whyte makes the point that ‘In many ways, their situation resembles that of people with HIV before the rollout of free ART’ (p. 201).
Another point the book illustrates beautifully is that care is provided by a number of actors contributing to the public’s health. A huge amount of public health care is provided by families, and increasingly by volunteers or community-health workers (mostly women) who find employment with NGO programmes. Importantly, it is provided ‘in homes’ and as such homes have been reconfigured in important ways (see Meinert). The chapter by Brown offers a fascinating exploration of the reasons why people volunteer, and the identities and aspirations which have emerged in relation to a prosperous NGO sector, symbolic of getting ahead and developing (in as much an individual sense as a society-sense). Again, the notion of patron (NGO) and client (patient or volunteer) relationships emerges. Tousignant’s Chapter reminds us of the role of private pharmacists in ensuring the ‘public’s health’, especially with regards to supplying medication in a more dependable way than some state-run pharmacies, and by lobbying for political action vis-à-vis dangerous counterfeit and black-market drugs.
The book ends with a case study of a medical research unit by Wenzel Geissler that exemplifies a number of the themes that run throughout the book. Together, the chapters paint a picture of the public health landscape that is insightful and at the ready for additional comparison across this diverse continent.
Reviewed by Megan Wainwright PhD, who is currently a Postdoctoral Research Fellow at the Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town. Megan also holds the position of Honorary Research Associate at Durham University (UK).
Correspondence to Megan Wainwright.