So far, the twenty-first century has been a boom time for studies of health, illness, healing, and care work in Africa, and the COVID-19 pandemic has only increased attention to these issues. Yet again, current events remind us that history, politics, social relationships, and public health are inextricably linked. These five books encompass a range of approaches to the questions and sources that animate these studies from a variety of disciplinary perspectives, including anthropology, public health, gender studies, medicine, political science, and history. Each of these authors and editors is explicit about their commitment to reaching an interdisciplinary audience and, for most of them, interdisciplinary work is core to their professional identities. Paul Farmer, Luke Messac, and Simukai Chigudu all earned medical degrees as well as doctoral degrees in medical anthropology, history and sociology of science and medicine, and international development respectively; Nolwazi Mkhwanazi and Lenore Manderson describe themselves as working “at the intersections of medical anthropology, public health and gender studies” (vii). These five books reflect the wide range of authors and audiences engaging in questions about what constitutes health, how it is achieved or undermined, and how the past has contributed to present conditions on the continent.
Geographically, these volumes cover a wide range of territory. Four of the books focus on one or two countries: Malawi (Messac), South Africa (Mkhwanazi and Manderson), Sierra Leone and Liberia (Farmer), and Zimbabwe (Chigudu). Rebekah Lee attempts a more comprehensive survey of sub-Saharan Africa. All five books deal primarily with the past one hundred years, though Lee and Farmer begin their historical surveys in the nineteenth century.
The Political Life of an Epidemic by Simukai Chigudu is an extraordinary analysis of the 2008–2009 cholera outbreak, which struck Simukai’s home country of Zimbabwe while he was studying medicine in the United Kingdom. At the time, he recalls in the book’s preface, he felt as if he were “drowning, engulfed by a deluge of disaster reports, articles, opinion pieces, blogs, and analyses of the situation in Zimbabwe” (xi). Several years later, after completing his training and while working as a clinician, Chigudu made the transition to the social sciences, partly to answer some of the questions he had found himself asking as he observed the outbreak and the responses to it from a distance (xiii). Readers will be impressed by the facility with which he combines theoretical models with archival sources and interview material to tell a story about the multiple ways in which past and present regimes have failed to provide Zimbabweans with the minimum requirements for good health.
Chigudu makes three connected arguments in his book: First, “the cholera epidemic was not an isolated, ‘shocking’ moment but, in an analogous way to famine, it was the final stage of drawn-out, contingent processes rooted in questions of political economy such as the inadequate delivery of public goods, failing livelihood strategies and profound social inequalities” (29). Second, people’s experiences of the epidemic reflect “multiple ontologies,” and this multiplicity prevented the epidemic from taking on a single, shared meaning that would make it the “tipping point” for major social and political change in Zimbabwe (29). Third, those multiple ontologies of cholera are shaping the ways the epidemic is being committed to historical memory “as a health crisis, a political-economic crisis and a social crisis, as well as a crisis of expectations, history and social identity” (30).
The book is divided into five chapters plus an introduction and conclusion. The introduction provides a thorough introduction to cholera, an overview of how the book fits into the scholarship on the social and political dimensions of epidemics and the literature on statehood in Africa, an explanation of methods, and a chapter outline. Chapter One lays out the long-term and short-term history of the urban environment, starting with the establishment of Harare in the late nineteenth century, which ultimately led to the disastrous cholera epidemic in 2008–2009. Colonial efforts to exercise political control through a segregated and profoundly inequitable organization of urban spaces were never adequately remedied by the post-colonial government. Chapter Two unpacks the ubiquitous claims that the cholera epidemic was a catastrophe of health infrastructure by examining in detail the specific steps taken by the government that led to the combination of failures and disfunctions in the healthcare delivery system, the water reticulation system, and the “political economy of daily life” setting the stage for the epidemic. Chapter Three delves into the ways in which the cholera epidemic was framed as an emergency in three different frameworks: humanitarian, security, and governance. Chapter Four interrogates the “salvation agenda” which came to dominate the logic of responses to the epidemic, describing how that happened and why it ultimately undermined any possibility of a substantive “political and structural response to the epidemic” (125). Chapter Five examines the ways in which residents of the townships affected by the epidemic recount those experiences and connect them to their political subjectivities. Chigudu is adamant that these stories, while grim, are not merely a narrative of victimhood, but constitute forms of political and social claims and demonstrate “a remarkable politics of adaptation” (156). The conclusion returns to the framing questions posed at the beginning of the book, synthesizes the findings from each chapter and the book as a whole, and briefly but meaningfully reflects on the author’s own subjectivity and how academic researchers might grapple with the inevitable questions about relevance and utility.
Chigudu has packed a great deal of information and analysis into a relatively short book. The result is a text that demands slow, careful reading but rewards the effort richly. Undergraduates may struggle with the book, which connects an enormous amount of material from a wide variety of disciplinary canons and includes specialist vocabulary, but advanced undergraduates, graduate students, and scholars working on international development, global health studies, the history of Zimbabwean politics and society, and the history of disease control will find a wealth of useful material in this book. While the price point of the hardback edition would pose a significant barrier to many potential readers, there is now a much more affordable paperback edition.
Another contribution to the literature by a scholar trained in medicine and the social sciences, No More to Spend by Luke Messac is a masterful indictment of the policies and politicians that brought about Malawi’s catastrophic scarcity of medical care. The book combines sophisticated historical, ethnographic, and clinical sources and analysis. Reversing the usual assumption that neglect is natural or even inevitable and spending requires deliberate action, Messac shows “the rhetorical and political work to sustain a regime of delay in Malawi’s government medical care” (26). Like Farmer, Messac is principally concerned with the biomedical dimension of disease, health, and health care. Over the course of an introduction, seven chronological chapters, and a conclusion, Messac shows how different regimes constructed medical scarcity in Malawi and how different constellations of people and institutions contested and resisted that construction.
Each chapter begins with a “prelude” recounting an incident from Messac’s fieldwork between 2011 and 2015. In the introduction, Messac outlines the scope of the book (the economics and politics of healthcare spending in Malawi across the colonial, Federation, and postcolonial eras) and situates his inquiry with respect to a rich and thoughtful historiographic framework. Chapter One considers the experience of Africans conscripted into the service of the British war effort during WWI and nascent efforts to deliver government health care in the 1920s. Chapter Two focuses on the interwar period, with special attention to debates over the 1929 Colonial Development Act. Chapter Three examines how the Great Depression further exacerbated patterns of neglect in Nyasaland while at the same time political unrest compelled the colonial government to increase spending in other parts of the British empire. Chapter Four examines the debate about who was responsible for the welfare of colonial subjects in the period during and immediately following the Second World War. Chapter Five attributes the expansion of postwar health care services in Nyasaland to increased demands for newly developed and highly effective medical technologies. Chapter Six examines the ways in which the postcolonial government led by Hastings Kamuzu Banda failed to deliver on the promises of healthcare that were integral to his platform. Chapter Seven shows the continuity of medical neglect through the end of the twentieth century, the impact of the debt crisis and structural adjustment programs, and the power of scarcity as a construct in the context of Malawi’s AIDS epidemic. This chapter observes that a surge in global health funding in the mid-2000s appears to be an interruption to this pattern, but one which may or may not be sustained. The conclusion calls upon readers to engage critically with the rhetoric and logic of scarcity and to recognize that “scarcity is a construction that obscures unequal wealth and exploitative extraction, and by so obscuring it aims to free the powerful from social obligations” (189).
Messac’s narrative is concise and compelling, explicating complex historical dynamics with enviable clarity. His integration of documentary sources, ethnographic observation, and synthesis of related scholarship translates seamlessly into a very readable story that is both measured in tone and damning in its conclusions. Finally, the book is a pleasure to read, engaging the reader on every page with a combination of archival detail that brings the past to life and analysis that connects those details to his larger argument. This book will make a valuable addition to many syllabi on histories of Africa, medicine, and global health for upper-level undergraduates and graduate students. Like The Political Life of an Epidemic, No More to Spend is now available in paperback at a price point that should make it more accessible to students and other readers with limited resources.
Health, Healing and Illness in African History by Rebekah Lee tackles the challenge of synthesizing the large and complex field for a non-specialist audience. The introduction offers a succinct but thorough historiography of health, healing, and illness in sub-Saharan Africa since the nineteenth century and an overview of the themes explored in the rest of the book: “environmental concerns and approaches,” “global flows,” “tension between the local and the global,” “medical and healing technologies,” “African resistance to and creative adaptation of these technologies,” “medical pluralism,” and “symbolic representation of disease and the diseased.” The remainder of the book is divided into two parts: Part I, “Historical dynamics,” comprises three chapters that summarize the history of pre-colonial, colonial, and contemporary systems of understanding and managing health and disease in Africa. Part II, “Case studies over time and space,” comprises four chapters, each of which explores a particular disease or group of diseases: HIV/AIDS, mental illness, malaria and sleeping sickness, and occupational lung disease. While Part I provides the necessary background information for contextualizing the case studies, I found Part II more satisfying in its use of specific examples from different parts of the continent; its illustrations of the links between biomedical disease categories and larger social, economic, and political forces; and explicit attention to connections between the past and current issues facing healthcare providers and seekers in Africa.
Rooted in pedagogy rather than original research, Lee’s book provides a useful scaffold onto which instructors of undergraduates or students with little knowledge of the history of health and healing in Africa could append more focused secondary literature and/or additional primary sources. Lee has incorporated a variety of primary sources directly within the text, along with suggestions for analyzing and interpreting them in context. In this and other ways, the book adopts some of the tools common in textbooks, including boldface type for keywords, inset text delivering background information, informative subheadings that guide the reader through the text, and a lengthy list of suggestions for further reading at the end of each chapter. However, the book lacks a certain animation that characterizes so much of the scholarship in this field. It may not be sufficiently dynamic on its own to engage less enthusiastic students and would need to be supplemented with additional materials.
Unlike the other four books, Connected Lives, edited by Nolwazi Mkhwanazi and Lenore Manderson, eschews the biomedical gaze, privileging instead a focus on families and the relationships between individuals and groups of people that facilitate or prevent people from achieving and maintaining a state of full health. The format of the book is also significantly different from the other books and can best be read as an anthology. Mkhwanazi and Manderson collected and compiled a variety of case studies from research by other scholars which were unpublished or published for a very limited audience (such as graduate theses and “gray literature” produced for NGOs.) In so doing, they highlight the work of researchers who are not widely cited or recognized in international academic literature, especially researchers from South Africa and those at the early stages of their careers. The strength of this approach, in addition to the exposure of previously under-appreciated research, is that it incorporates a rich body of field work from a wide variety of settings in South Africa and by researchers pursuing a diverse group of questions. The cost of this approach is a loss of cohesion; it is sometimes difficult to determine exactly what aspects of the case study are most pertinent and what the authors and editors want the reader to understand through the group of case studies.
The interdisciplinarity of the book (Mkhwanazi and Manderson are anthropologists, and the case studies are written by scholars from a wide variety of disciplines, including gender and sexuality, psychology, social work, history, public health, and sociology) offers advantages and disadvantages. It is exciting to see work from such a wide array of disciplines brought together on a topic that clearly transcends disciplinary boundaries. However, there is very little reflection by the editors on the relationship between the disciplinary training and approaches of each of the authors and their findings and insufficient explicit discussion of the ways in which the different disciplines inform one another, privilege different forms of evidence, and prioritize different questions. There are some major limitations of the scope of the book, which the editors clearly identify and acknowledge: “very few case studies are concerned with white, coloured or Asian families; only one article is concerned explicitly with gay South Africans, and none is concerned with queer families” (vii). Moreover, the gender binary is presented unproblematically throughout the book. However, these shortcomings appear to reflect the limits of existing research rather than carelessness or disinterest on the part of the editors and, as they say, indicate avenues for further research.
In Chapter One, “Changing Family Structures and Everyday Relationships of Care,” Manderson and Mkhwanazi argue that families, regardless of their structure or the context in which they exist, are “the most important social support structures for all people worldwide.” Therefore, they imply, centering families in studies of health, healing, and caregiving can move scholars closer to understanding the lived experiences of South Africans than a focus on medical facilities, state agencies, or any other entities. The next five chapters comprise groups of five or six case studies linked by a thematic framework and loosely interpreted by the editors.
Chapter Two, “Making Families,” includes case studies related to reproduction, fertility, and childbirth. Chapter Three, “Family-Keeping,” explores the acts and ideas that link or separate members of families and the ways that individuals negotiate their identities and those of the people to whom they are linked. Chapter Four, “How Men Care,” explores notions of masculinity and the place of men in families in the context of marriage (or more often, in relationships that do not lead to marriage), childbirth and childrearing, and economic hardship. Chapter Five, “Everyday Care and Illness,” delves into the ways in which different arrangements of interpersonal relationships support or fail to support people experiencing illness and disease. Chapter Six, “As Families Age,” illustrates the dilemmas faced by people caring for aging relatives or dependents as well as the ways in which the infirmities of age can challenge existing relationships and foster new ones.
One of the challenges of reading the book, as well as summarizing it, is that the editors leave it to the reader to do much of the synthetic work of connecting the case studies and identifying those aspects of each case study that inform the themes they are most interested in. The editors use a light hand when analyzing and synthesizing the material from the case studies, and readers must be attentive to pick up on the many insightful and provocative claims they make almost in passing. This book will probably be most useful to scholars who are looking to enrich their understanding of the topic from a variety of angles and who have the tools and knowledge to make connections and draw conclusions that are only implicit in the text. As the editors intended, the book is more likely to serve as a starting point for a variety of new inquiries than to act as an end point to any one of them.
Paul Farmer, whose death in early 2022 shocked and grieved the global health community, left a legacy that historians of global health will spend years unpacking. In his final book, Fevers, Feuds, and Diamonds, he argues that the world needs to understand the history of the region hardest hit by the Ebola epidemic of 2014–2016 to learn the lessons of that catastrophe. Farmer’s goal is explicit and compelling: to persuade readers fortunate enough to live in parts of the world where access to the most basic forms of medical care is taken for granted that they have a moral and a practical imperative to ensure that everyone else enjoys the same access to medical care.
The book is structured in three parts separated by two “interludes.” Part I includes four chapters. Chapter One recounts the events of December 2013 to November 2014, as the Ebola epidemic spread and doctors and politicians on both sides of the Atlantic reacted. It invokes the paradigm of social medicine to encourage readers to interrogate the differential mortality rates of West Africans and the small number of Europeans and Americans who were infected as well as the institutional and popular responses provoked by each. Chapter Two describes the dilemmas faced by Farmer, the organization he represented, and other global entities as they debated whether and how to intervene in the unfolding crisis. In particular, Farmer describes his frustration with the “control-versus-care” framing, which pitted strategies for preventing further infection against interventions to treat people already infected with Ebola. Chapters Three and Four seek to convey the “lived experience of the epidemic” through the stories of two Sierra Leonean Ebola survivors who went on to volunteer with programs providing support to other survivors. These stories, Farmer suggests, offer “insight into the role armed conflict played in setting the stage for the epidemic” (148).
Part II includes four chapters that aim to answer the question, “How did West Africa become a clinical desert—a place in which the rapid human-to-human spread of Ebola was not just possible but almost inevitable?” (191). This section reads like a book within a book—a survey of five hundred years of the history of the region that is now Sierra Leone, Liberia, and Guinea in a little over two hundred pages. This historical narrative feels divorced from the rest of the book. People interested in the history of the region will find the broad overview unsatisfying, and others will probably be deterred by the volume of material which is only occasionally linked explicitly to the Ebola epidemic.
Part III includes two chapters followed by an epilogue. Chapter Nine interrogates the contradiction between the vast advances in knowledge of the pathology and structure of filoviruses and the less impressive progress in treatment and epidemiology of the outbreaks they cause. Chapter Ten, which serves as a conclusion, argues that the official end of the West African Ebola epidemic should not be mistaken for an absolute cessation of new infections or the end of the suffering the epidemic caused. Farmer returns to the most compelling message of the book: prioritizing disease control over care continues to expose people in some parts of the world to preventable suffering and death. Finally, in the epilogue, Farmer makes the same argument in the context of the burgeoning COVID-19 pandemic: “it’s wrong and invariably self-defeating for public authorities to put controlling an epidemic before caring for its victims” (517).
While I am delighted that such a towering figure as Paul Farmer championed the significance of history for global health, I couldn’t help but be disappointed by the unsophisticated and unambitious vision of history he chose to showcase. Moreover, unlike his books on Haiti, which were produced through lengthy and extensive engagement with people on the ground and thorough anthropological research, this book is the product of a time in Farmer’s career when he was responsible for projects in twelve countries on four continents; he was a highly sought-after mentor, speaker, and commentator, holding multiple major academic appointments. The book doesn’t clearly state the amount of time Farmer spent in West Africa during the Ebola epidemic, but it would be measured in days or weeks, not months or years. To compensate for this, the book features many stories of the caregivers whose constant presence on the ground was heroic and, in several cases, fatal. But the voice that predominates is Farmer’s own, and he cannot offer the same insight into the challenges facing doctors in Sierra Leone, Liberia, and Guinea that he did with Haiti, or even Peru and Rwanda.
Nonetheless, there is much to appreciate in Farmer’s account of the Ebola epidemic and its roots in historical injustice. For one thing, he makes it abundantly clear that excuses for depriving Ebola patients of basic care such as intravenous fluids (like “it’s too risky,” or “it’s futile”) are unjustifiable and founded on bad data. His descriptions of the ways in which lives were lost that could have been saved by relatively low-cost interventions are absolutely devastating and, along with similar arguments by other observers, should provoke major revisions to standard operating procedures for future epidemics. Farmer’s body of work has already had a significant impact on the next generation of scholars, including Luke Messac and Simukai Chigudu.
Each of these books marks a distinct contribution to the field of health, healing, and illness in Africa and will best serve different audiences. While I found much to critique in Farmer’s book, there is no question that his name and reputation will attract readers who would not otherwise engage in questions about the historical roots of structural health disparities in West Africa, and such engagement is critical if patterns of spending and resource allocation are to change. I will return often to the books by Messac, Chigudu, and Mkhwanazi and Manderson as I continue my own research on the history of global health research and policy, and I look forward to seeing the impact of their work on future scholarship. Rebekah Lee’s book will be a valuable tool for many instructors incorporating material and developing new classes on the history of health and medicine in Africa for students with little or no background knowledge. This collection of books is a sure sign that the wealth of quality work on these topics from a wide variety of disciplines is continuing to grow, with increasing attention to engaging diverse audiences, sources, and scholarship.
Open access
