Competing Orders of Medical Care in Ethiopia: From Traditional Healers to Pharmaceutical Companies. Pino Schirripa, translated by Ciaran Durkin, London: Lexington Books, 2019, 138 pp.
Competing Orders of Medical Care in Ethiopia describes the pluralistic landscape of medicines and healing practices in Tigray, a state in northern Ethiopia that is home to Ethiopia’s long-ruling party, the Tigrayan Peoples Liberation Front. By focusing on how medicine producers, users, healers, and intermediaries operate across this landscape, Pino Schirripa traces the social and political lives of medicines, emphasizing both the materiality of medicines and their effectiveness in forging social identities, statuses, and relationships.
For Schirripa, a key point is rejecting the common division of medicines into traditional, biomedical, and religious spheres, and instead distinguishing among private, public, and charitable sectors. The latter scheme allows the ethnographer to better understand how actors “jockey for position” in an arena, using various kinds of social, economic, and symbolic capital to gain legitimacy, status, and resources, à la Pierre Bourdieu’s field theory and De Certeau’s distinction between strategies (which belong to powerful field-shapers) and tactics (the efforts of marginalized actors to get by and thrive in a field of someone else’s shaping). This framework “shift[s] the focus of attention from attitudes and cultural orientations to a more specifically social level,” highlighting possibilities of and inequalities in access to resources (p. 40).
Actors in the private category—including women selling small quantities of healing herbs in local markets, Ethiopian Orthodox church acolytes/healers known as dabtara, and Ethiopian pharmaceutical producers, wholesalers, and pharmacists—aim to earn money. The public sphere is oriented toward ensuring provision of care to the widest possible audience, and charitable organizations attempt to alleviate suffering by offering free medicines for a limited set of certain conditions (e.g., HIV/AIDS). Meanwhile, an elite minority of customers signal their wealth and high status by purchasing medicines from Europe or the United States rather than from Ethiopian pharmaceutical factories.
The book is a short read at 99 pages not including references, which would help it fit into many course syllabi. This also means a lot is missing from the book, which an instructor would therefore have to address.
Schirripa based the book on fieldwork that extended over six years, during which time he worked as director of the Italian Ethnological Mission in Tigray. But while the text includes several descriptive statements about the landscape of opportunities and constraints facing various actors in Ethiopia, there is little original ethnographic writing about the everyday lives, histories, and motivations of specific medicine producers, users, or distributors. The author makes up for this lack of actor/person-centered ethnography by citing the work of other Italian medical anthropologists in Tigray. For instance, he discusses interesting ethnographic observations of Elisa Vischetti: Some healers in Tigray claim that sought-after German medicines imported into Ethiopia are actually based on Ethiopian materials and practices because long ago, healers in the city of Aksum sold an herbal recipe book to German archaeologists. This narrative brings up the issue of Western corporations achieving profits by stealing or otherwise acquiring intellectual property that originates in various African countries, while Aksumite healers “both vindicate the effectiveness of their own products and claim a specific place in the arena of therapies” (pp. 51–52). An analysis of how consumers of medicines in Ethiopia react to these narratives, and what this means for the livelihoods and well-being of any of the actors involved, would have enriched these observations.
Another ethnographic segment of the book was based partially on the fieldwork of Aurora Massa, who (according to a footnote) introduced Schirripa to a woman who heads an urban household of low socioeconomic status, including a grandchild living with HIV/AIDS and another with physical and mental disabilities. The grandmother, Schirripa emphasizes, employs completely different tactics in seeking care for these grandchildren: antiretroviral therapies offered for free by the government and its international donors, and traditional herbs and holy water, respectively.
In this segment of the book, Schirripa aims to highlight the paradoxes of charitable intervention and care in Ethiopia, relying heavily on the theoretical concepts of humanitarian reason and biological citizenship, and citing Didier Fassin and Adriana Petryna, respectively. When governments and donors are moved to provide medicine and care for single infections like HIV/AIDS, so many other ailments and people are left out. Schirripa does a fine job of explaining these theories and how medical anthropologists make sense of the inequalities they observe around the world. Yet the unique Ethiopian political–economic context is only superficially examined, and there is no discussion about how care and support for people with HIV/AIDS have been expanded across Africa in part to avoid the virus’s capability of evolving antiretroviral-resistant strains. Schirripa emphasizes the historical fact that Ethiopia was never colonized by a European power, and thus has a “peculiar history … in which biomedicine … entered the country by the will of the imperial government at the end of the nineteenth century” (p. 4). Missing is any discussion of how, during Schirippa’s time in Tigray, the ruling party attempted to demonstrate its commitment to public health in part to divert international attention from its political repressions and state violence, or how the party’s complicity in the U.S.-led global “war on terror” has helped maintain international donor relationships. I was particularly surprised that Ethiopia’s well-known Health Extension Program was never mentioned in the book, which leaves readers without knowledge of some of the most important Ethiopian actors responsible for distributing biomedicines and biomedical ideals of “healthy behaviors,” and for connecting impoverished families to the state health system.
Schirripa offers an interesting anecdote about a pharmaceutical factory in Tigray, whose executives explained to him the logic behind their adoption of the Japanese model of Kaizen, aimed at improving quality and efficiency in production, operationalized by placing panels in various departments on which employees can write their own comments about “trouble spots” in the factory’s processes. Periodically, we’re told, the comments are discussed in staff meetings. Yet there is no ethnographic observation of such meetings. Given a repressive and highly top-down political culture in Ethiopia, Schirripa imagines that staff are unlikely to feel free to express their criticisms. But he did not investigate this, and thus admits, “I do not know to what extent such a model affects power relations inside the factory, or how much it indicates a real capacity to influence the organization of the manufacturing process” (p. 75).
Schirripa’s text would have been further enlightening if it included a discussion of how Ethiopia’s ruling party—well known for mixing state-led and neoliberal approaches to development and for lamenting the “harmful traditional practices” that supposedly keep millions of Ethiopians poor and sick—attempts to support, regulate, and benefit from the private and charitable sectors, or how actors in these sectors attempt to resist or go along with government efforts. In the end, the book provides an accessible and brief ethnographic study that uncovers, but does not answer, a number of vexing questions about the social and political lives of medicines—and thus the lives of various people—in Tigray. Students would benefit from reading the monograph alongside other recent work examining the lives and relationships of healers, medicine distributors, caregivers, officials, and medicine users in Tigray and other regions of Ethiopia.