Review of Health in a Fragile State: Science, Sorcery, and Spirit in the Lower Congo. John M. Janzen, Madison: University of Wisconsin Press, 2019, 288 pp.

U.S. government actions during the Covid-19 pandemic facilitate a reading of John M. Janzen’s recent book, Health in a Fragile State: Science, Sorcery, and Spirit in the Lower Congo, on health care in times of state atrophy and incapacity in central Africa. An April 4 article in the Washington Post notes how Trump administration delays and dysfunctional responses to the virus led to inept decisions and late responses. The results are already staggering. There are presently more American deaths by the virus than “in the wars of Korea, Vietnam, Afghanistan and Iraq combined.” In a May 10 issue of the Guardian, Robert Reich states: “With 4.25% of the world population, America has the tragic distinction of accounting for about 30% of pandemic deaths so far. … In no other advanced nation has Covid-19 forced so many average citizens into poverty so quickly.” How do such horrific results happen?   

Limited or restricted state responses to diseases and pandemics display the political and economic realities of inequality within society. State collapse, underdevelopment, and failure of social services related to health care form the focus of Janzen’s latest book on medical pluralism and political economy of health in the lower Democratic Republic of Congo. The book’s central premise is that centuries of political uncertainty and social disparities have generated unreliable distributions of health resources and access to medical care. National and provincial health policies are unable to provide reliable educational and health services, and populations encounter inconsistent resources within medical and healthcare management. Left to their own devices, local hospitals and health care workers depend on NGOs and other extra-government funding to manage health care and avoid medical crises.

Chapters 1 and 2 explain how things came to be in the Luozi (Manianga) region of Lower DRC. Janzen draws on census and demographic data from Swedish and Congolese records and maps, state archives of the Belgian government, colonial documents and ledgers, and the author’s own illness distribution surveys to construct a disease archive that shows the trajectory of certain afflictions over time and within specific communities. Luozi Health Zone records display recent disease differentials by individuals and communities: schistosomiasis, HIV/AIDS, typhoid, and tuberculosis. Survey data on various diseases from Janzen’s decades of research then supplement these figures. Within his analyses of the distribution of afflictions between and within communities, Janzen illuminates scientific and local treatments. Malaria, for example, is treated with hospital medications (quinine and synthetic pharmaceuticals), as well as “a range of local traditional products and methods that have not yet been studied systematically” (p. 80). The historical data and contemporary surveys will be of value for researchers and students of comparative medicine and public health.

Janzen’s book provides further insights in the vein of Africanist medical anthropologists such as Pfeiffer in Mozambique and Nichter in Benin, whose research on various disease topics offers foundational data for public health reviews and data-collecting. Janzen charts colonial and post-colonial demographics against histories of existing disease encounters to demonstrate the impact of state-promoted health campaigns. Longitudinal data provide a snapshot of how health initiatives, grounded in state administration, effectively arrested the spread of certain diseases. They also illustrate the impact of limited access in some areas to medical doctors and hospital care. This challenge is felt throughout Africa, especially where “the rising incidence” of some diseases “is caused by declining quality of life or inadequate public services” (p. 85). The fourth chapter covers the awful decades of state control during the time of Mabutu, whose kleptocracy and corruption greatly destabilized a nascent emerging social order, including education and medical care. During those years, the state was absent in any national responses to health care needs and demands. It is difficult to overstate the negative impact on individual and community health; this point is central to the entire volume. Political economy of health data shows the impact of tainted water and inadequate access to provisional health services within various communities. Various NGOs and the World Health Organization (WHO) eventually filled the void, creating health zones to administer hospitals, medical personnel, and pharmaceuticals more efficiently. Records also show a rise in suspicions of witchcraft and divination within populations where some members of the same community suffer while others may sufficiently get by.

Medical care is, of course, personal. Public health, on the other hand, is a political matter that involves a wider social fabric. Personal resources, ideology, and access to care affect how individuals and families create medical therapy options, and remaining chapters in the book demonstrate how such variables interact. Janzen uses Goody’s social reproduction model to argue that whenever land is the basis of production, the household remains the center for social reproduction, including health decisions. Land ownership, family and clan-integrated farming livelihoods, and the distribution of harvests engender generational sustainability in the long term. They also serve to support health (marimpi) and well-being in the here and now. Congolese responses to marimpi indicate that while health is physical preservation, it also involves moral and social well-being, cleanliness, good judgement, and peace. When the state cannot, or will not, provide health structures, local forms of governmentality “must be introduced or called to life to deliver urgent services” (p. 161). In Congolese history, prophetic churches have delivered health services, such as that of Simon Kimbangu, or Eglise de Jesus Christ sur la Terre par le Prophete Simon Kimbangu. Such modes of healing are often responses to witchcraft or ndoki. As elsewhere in Africa, sickness and disease create their own authority “from below” in that “society may require a social healing that involves empowering its marginal elements” (p. 185). Remaining chapters analyze this truth of African medical pluralism, where the power and efficacy of science are never denied in the treatment of known ailments: malaria, hypertension, stroke, anemia, diarrhea, influenza. Yet members of the same household seek alternative (nonscientific) remedies to alter the course of symptoms and to address fears of job insecurity and economic uncertainty.

Local modes of healing, private clinics, hospitals, the WHO, national and international NGOs, and medical ministries make up the basis of health care today in the DRC. HIV/AIDS, typhoid, TB, malaria, flu, schistosomiasis, polio, flu, and diarrhea are common diseases. Janzen’s foundational question is: In the absence of a functional state or state health administration, do emerging local, national, or international health structures or agencies fill the void by creating functional legitimacy in health service? Are such health services received as legitimate modes of care in towns and various communities? Unabated diseases like typhoid, schistosomiasis, TB, and levels of malaria clearly illustrate state failure in disease eradication. Such realities are expressed by people in Janzen’s surveys: “The state doesn’t take charge of people.” “Would that the government would help, but it doesn’t; we are struggling on our own.” At best, international initiatives are only partially effective. Janzen’s important work is valuable to a wide range of scholars and students. The first third of his book provides substantive data to medical historians, development economists, and scholars of the post-colony. Middle chapters display for Africanists how local modes of healing interact with international programs. Ending chapters show details of how healing practices comingle with biomedicine in hospitals and in self-treatment. Rich timeline, survey, archival, and field data provide a continuing relief on applications of health care within circumstances of a failed political apparatus.