Flying low across Papua New Guinea’s (PNG’s) forested hills, fast flowing rivers, and pale squares of garden land, the rich vegetation is sporadically interrupted by bright stripes of reflective tin roofing. Many of these incongruous structures shelter rural health centers, and their disturbance of the landscape is a reminder that public health infrastructure maintains a tenuous presence in some of the remotest areas of the country. For 85% of Papua New Guineans who live in rural areas, the rural health center or aid post is their main point of access for health services, and a key site of interaction with the state, churches, and international health programs. These humble prefabricated health facilities, most of them built in the decades between World War II and the country’s independence in 1975, serve as a comprehensive hub for curative and preventative services, including emergency treatment, immunization patrols, family planning, and maternal and child health programs.
It is in the shadow of one such health center, near the banks of one of PNG’s arterial rivers, that Fraziska Herbst spent the majority of more than two years of ethnographic fieldwork, seeking to understand how the Giri people “consume,” “adapt,” “appropriate,” and “construct” biomedical knowledge, technologies, and practices in relation to indigenous conceptions of personhood and the body. Herbst followed patients on their journey through the referral hierarchy of the PNG health system, tracing the therapeutic networks that criss-cross village, health center, hospital and town, in her quest to understand how people’s lives have become entangled with biomedicine.
Herbst shows that the Giri enthusiastically engage with biomedicine. They recognize the power and efficacy of biomedical therapies for certain conditions, and their illness categories have expanded to incorporate foreign diseases such as AIDS (eds) or tuberculosis (tibi), which are not considered to have a social cause. But, for the most part, the ethnographic case studies that she presents in the body of the book show that this has not led to a reconceptualization of the body in biomedical terms. The Giri continue to understand the person and the body as relationally constituted, and theycreatively appropriate biomedical technologies and services to address the relational dimensions of illness. This pragmatic pluralism is reflected in Giri people’s enthusiasm for x-rays, discussed in Chapter 3, which they understand to penetrate the interior of the body and pictorially reveal both biomedical and social causes of illness.
In Chapter 5, Herbst shows that engagement with institutionalized biomedicine has also transformed local health-related practices. Women are traditionally expected to remain secluded for up to a month post-pregnancy, until the seva (uterine blood of menstruation and parturition), which is considered to have magical properties and potentially dangerous effects, has been fully discharged from their body. But the postnatal care that is provided at the health center and general hospital (e.g., abdominal massage, vitamin K injections, hormone injections, chloroquine, and iron folate tablets) is widely understood to expedite the expulsion of seva from the uterus. Women who give birth at the general hospital therefore feel able to forego seclusion and frequently return to everyday life immediately. Herbst argues that women “are able to create new models of seclusion” (p. 166), and proactively “create spaces in which they can draw on biomedical reproductive care without having to counterpose traditional practices connected to birthing” (p. 187).
As Herbst acknowledges, previously published ethnographies of medical pluralism in PNG, most of which appeared in the 1980s and 1990s, presented similar findings. Herbst extends these debates by emphasizing the ways in which the Giri “actively shape the biomedical realities in which they live” (p. 192), and to make a broader point about the global variability and localization of biomedicine. One issue that is not clear, however, is who would disagree with such points. Several of the arguments that are presented in the book as novel contributions (that anthropologists should examine biomedicine in addition/relation to ethnomedicine, that culture is dynamic and not fixed, and that health and illness are intricately interwoven with conceptions of personhood), are already common ground for medical anthropologists.
The more significant contribution, perhaps, is Herbst’s account of the complex social networks that span domestic and institutional space, and which are discussed in detail in Chapter 4. Through the sharing of food, for example, patients and caregivers establish reciprocal exchange relationships with other patients, but also with health workers. Food is particularly significant as its material health-giving qualities are inseparable from the personal labor and intentions of the donor. By tracing the therapy managing groups that congregate around patients during episodes of illness, and the overlaps between professional and kinship based webs of care and reciprocity, Herbst shows that biomedical institutions are incorporated into relational modes of realizing health and personhood through exchange.
The almost exclusive engagement with medical anthropology literature from Melanesia, much of it published over two decades ago, limits the contribution of this book to fairly narrow debates about Melanesian personhood and medical pluralism. This is a shame, because Herbst’s rich telling of people’s experiences at the margins of a state-led health system is a welcome departure from the focus on vertical programs in much anthropology of global public health. The reliance of rural health services on community participation and labor, which is common across PNG, raises fascinating questions about the shape the state takes at its periphery, and the role of kinship in contemporary public institutions, which might both have been explored further.
It is therefore surprising that the book does not engage substantially with the growing body of ethnographic and historical work on biomedicine and global health in PNG, including but not limited to my own ethnographic research in Modilon General Hospital (the same hospital where Herbst carried out research, and which makes similar observations the role of x-rays and food sharing), Barbara Anderson’s work at Goroka Hospital in the Eastern Highlands, Katherine Lepani’s work on responses to biomedically driven HIV control programs in the Trobriand Islands, and Warwick Anderson’s work on the Fore’s engagements with kuru medicine in the second half of the 20th century.
A conversation with contemporary anthropology of biomedicine and global public health in Melanesia and beyond might have expanded the scope of the argument from what the Giri’s engagements with biomedicine tell us about Giri conceptions of personhood, to what the relational and porous qualities of rural biomedical institutions in PNG tell us about the nature of biomedical institutions and state-led health programs everywhere. This would have enhanced and updated the discussion of biomedicine and personhood in the introduction, and expanded the scope of the historical overview of local health infrastructures that is provided in Chapter 1.
Notwithstanding these limitations, this book is an exemplary ethnography of biomedicine told from the perspective of its recipients and an excellent way of introducing students to some of the methods and approaches of medical anthropology. The vivid and detailed ethnographic description that comprises the main body of the book is both accessible and a rich scholarly resource for ethnographers of the region. The use of clearly marked case studies to build up each chapter’s key arguments and the framing of each chapter with a clear summary and synopsis are useful for classroom teaching. I very much recommend the book for use in introductory medical anthropology courses, and the quality and depth of the ethnographic material also lends itself for use in fieldwork training programs.