Public health systems across much of Africa are struggling. That will come as no surprise to anyone who followed the recent Ebola outbreak in West Africa, where understaffed and understocked hospitals were quickly overrun by needs that exceeded their capacity. For those who study health in Africa, the Ebola outbreak is a spectacular demonstration of what is unfortunately a quotidian reality: the chronic incapacity of African public health systems.
The fragility of African health care delivery systems stands in sharp contrast with the productivity of transnational medical science—now called global health—on the continent. In Para-states and Medical Science: Making African Global Health, edited by P. Wenzel Geissler, anthropologists and historians of biomedicine in Africa explain how and why this is so. To date, much scholarship on global health in Africa has emphasized the disappearance of the African state and the growing role of foreign NGOs, foundations, universities, and corporations in global health governance. While not disputing the weakness of African public health systems or the huge role played by international institutions, this collection makes the provocative argument that the state not only continues to exist but also continues to matter in African medical science. It does so through the concept of the “para-state.”
In his thoughtful introduction, Geissler defines para-state as “a chunk of the original nation-state that is parceled out and run differently, shaped by market operations” and notes that the volume’s use of the term is derived from the para-statal scientific institutes established across Africa in the late 1970s (pp. 9–10). These institutes represented a “new institutional form of the life sciences” that arose following the decline of national universities. African scientific para-statals were linked to national governments but were not integrated into them or funded by them; rather, they were designed as “collaborators,” intended to take advantage of foreign funding (p. 11).
Drawing from ethnographic and archival work on biomedical science in at least eight sub-Saharan countries, the book’s 11 chapters provide a diverse array of case studies from which to understand African medical science (Geissler and Meinert’s sites are anonymized, while Nguyen’s argument speaks to research across Africa).
Vinh Kim Nguyen’s initial chapter serves as something of a foil for many of the subsequent authors. Nguyen uses the case of HIV treatment as prevention (or TasP) to argue that medical research is ushering in an era of “experimental societies” in Africa, which he describes as “large-scale forms of social organization assembled on biopolitical terrains left fallow by retreating states” (p. 48). He speculates that TasP, in its authorization of mass HIV treatment and monitoring in the name of prevention, “furnishes a model for how global health programs may be able to use disease-specific programs to launch population-wide forms of biopolitical regulation and surveillance” (p. 72). For Nguyen, the para-state represents a new experimental disciplinary regime (“experimentality”), in which “the clinical trial has become a technology of rule” (p. 71).
While acknowledging the importance of Nguyen’s contributions here and elsewhere, many of the other authors in this volume gently challenge elements of his stance. Manton’s chapter, which follows Nguyen’s, uses a historical study of leprosy research in late colonial Nigeria to show continuity between past and current social relations of science, suggesting that these formations are not new. Beisel’s account of a corporate-run malaria control project in Ghana opens up the concept of para-statal experimentality, suggesting that it may offer “opportunities for public engagement, civic negotiation, and decision making” (p. 296). Subsequent authors draw attention to the persistence of the African state in global health and describe how African agency shapes government-by-experiment. Together, they open our eyes to social relations of science beyond regulation, surveillance, and rule.
Chapter 4, authored by Geissler, provides a useful framework for understanding these competing narratives. Reflecting on the relationship between an anonymized African “National Clinical Research Organization” and a “Global Health Agency,” Geissler effectively demonstrates how differently positioned actors narrate the NCRO/GHA partnership quite differently. While Nguyen’s experimentality is one valid interpretation of the relationship between NCRO and GHA—one that sees NCRO as reduced to a para-statal field office of its international funder—Geissler argues that “it is but one story among many that emerge from this territory’s layered morphology” (p. 148).
Local scientists, by contrast, see NCRO as deeply tied to the national state, not only because it is answerable to the Ministry of Health, but because “it marks the presence of another potential future, seeded in the founding moment of the NCRO, when young scientists shed the (post)colonial yoke and took the helm of African science” (p. 154). Geissler’s chapter shows how paying attention to multiple coexisting narratives of the past, present, and imagined futures can reveal a greater range of interpretations that exist alongside and in tension with experimentality and the receding of the African state.
The other chapters provide rich examples of such alternative interpretations. Whyte’s chapter aptly demonstrates the ongoing importance of the Ugandan state as a source of reliable, if not always well-remunerated, employment. For people with HIV, she shows, this kind of secure government work and the benefits that come with it can be the key to both biological and social survival.
Other chapters bring a nuanced understanding to the relationship between the state and global health science. Poleykett argues that the relationship between state-run sex worker medical registries in Senegal and international health research is evidence not only of discipline and experimentality, but also of agency, solidarity, and care; chapters by Gerrets and Kelly show how African states are able to use the opportunities, resources, and networks of international scientific partnerships to address national agendas. Fassin’s concluding chapter offers a “political biography” of the antiretroviral drug nevirapine, told through its entanglement with government, activism, and public health in South Africa.
The diversity of states in this volume is worth noting: while the problem of health care capacity spans the continent, the role of the state is not the same in post-socialist Tanzania (Gerrets) as it is, for example, in post-apartheid South Africa (Fassin); similarly, the relatively stable “microstate” of the Gambia (Kelly) has had a different relationship to international medical science than has the large and often divided state of Nigeria (Manton).
Some chapters are less explicitly tied to the volume’s theme of the persistence of the state than others. Lachenal’s chapter, for example, provides a fascinating and astute analysis of virus hunting and “medical nihilism” in Cameroon but does not fully develop its argument about the importance of Cameroonian state actors. Meinert offers an engaging account of one family’s complex social intertwinement with an international HIV project, but speaks to the role of the state only in passing. Nonetheless, these chapters provide valuable insights into the politics of international research in Africa and the social relations they engender.
I highly recommend this volume for anyone interested in the social relations of biomedicine, and particularly biomedical research, in Africa. As an interdisciplinary anthropologist who works on this topic, I found the book’s provocation to pay attention to the persistence of the African state extremely useful—suddenly, I am seeing the state in places in my work that I had formerly overlooked. I also appreciated this volume’s empirical documentation of the numerous ways in which, despite persistent inequalities, African actors—states, institutions, and individuals—shape global health partnerships and the knowledge they produce.