African Medical Pluralism. William C. Olsen and Carolyn Sargent, editors. Bloomington: Indiana University Press, 2017, 265 pp.
Edited volumes in anthropology often aim to do one of two things: marshal diverse ethnographic evidence to establish a broader thematic claim or knit together a set of such claims into a theoretical intervention. African Medical Pluralism is a sterling example of the former that points to the necessity of working toward the latter. Framing the idea of medical pluralism as a continuum, “a sliding scale of responses to disease [that] are not mutually exclusive” (p. 2), William Olsen and Carolyn Sargent note that the volume has three main goals: First, show that African interlocutors navigate a range of therapeutic options whose historical roots run deep; second, demonstrate that therapeutic action reflects “local cultures as well as national and global power structures” (p. 2); and third, document ethnographic realities of illness and treatment in everyday life. The book is partitioned into three sections, entitled “Biomedicine and African Healing,” “Symptoms and Therapeutic Pluralities,” and “Hospital Ethnography,” with contributions mainly from senior and non-African scholars. Benson Mulemi’s chapter on cancer care in a Kenyan hospital is a notable exception, offering one of the book’s sharper takes on uneven national and transnational distributions of (bio)medical resources and the resultant therapeutic deftness of many caregivers and clinicians.
The compilation comes across as especially keen to establish biomedicine as part and parcel of the historical and contemporary therapeutic landscape for many people in Africa. It does this quite well. In particular, the chapters by Mulemi; Ulrika Trovalla, on urban quests for healing in Nigeria; Elisha Renne, on circuitous child health care in Nigeria; Sargent and James Leslie Kennell, on the elusive, fluid nature of care in Benin; and Claire Wendland on childbirth in Malawi do an excellent job of showing pluralism in action, enabling the reader to move with interlocutors. In doing so, these authors (and the book overall) collectively offer a nuanced view of biomedicine that acknowledges its lived and systemic impacts but refuses to reduce it to a hegemony eviscerating the experiences of their interlocutors. At the volume’s open, Olsen and Sargent argue that “pluralism is a reality in medical places even when the premise of legitimacy recognizes the impact and efficacy of biomedicine” (p. 7); by its close, the reader will likely agree.
Yet the book struggles to articulate what directions anthropology could or should take after establishing this reality of biomedicine and pluralism in Africa. To be fair, Olsen and Sargent are clear in positioning the book as primarily ethnographic, not theoretical, as is Arthur Kleinman in his afterword. “[T]he empirical studies in this collection,” he writes, “call attention to the tasks of theory building in medical anthropology … we still lack a theory of medical pluralism in Africa and more broadly” (p. 263). In the absence of explicit theorizing, though, the volume is marked by implicit theorizing that suggests the need for further foregrounding and unpacking. While the compilation nicely illustrates a range of approaches to the practice and writing of medical anthropology, at times this range slips into a rehash of longstanding debates in and beyond this subfield on the primacy of culture vis-à-vis power (and the conceptual surrogates of each). In his chapter on trauma and genocide, Christopher Taylor frames ihahamuka as a “specifically Rwandan illness, one not consciously chosen” (p. 181) to argue that anthropology has strayed too far from culture toward politics and ideology—a move he sees as undeniably important but at risk of becoming both overdetermining and overdetermined. While many anthropologists working in and beyond Africa have increasingly prioritized questions of power, and while the volume itself is certainly concerned with the lived politics of pluralism, the extensive space given to discussions of meaning and culture elsewhere in the book, particularly the first section on “Biomedicine and African Healing,” partially troubles this claim. Greater explication of such dynamics, and agreements and disagreements thereof, would have strengthened the book and its interrogation of the dualisms that have often marked anthropology.
Similarly—as the section title “Biomedicine and African Healing” perhaps forecasts—the volume sometimes collapses pluralism into the relationship between biomedicine and what most of the authors encapsulate as traditional medicine. Though some chapters address Islamic and/or Christian practices of healing, religious therapeutics nevertheless come across as a secondary or even tertiary realm of patient and caregiver resort. The relative absence of Pentecostalism in particular is puzzling, given not only its explosive growth across Africa and around the world, but its tendency to castigate traditional medicine (and sometimes biomedicine) and emphasize the role of divine intervention in the timing and outcome of people’s health-seeking pursuits. Koen Stroeken’s chapter on bewitchment in Tanzania is the exception here, with his take on Pentecostal churches as “new therapeutic collectives” (p. 166) helping to show the value of pushing beyond biomedical–ethnomedical dances toward a more multidimensional concept of pluralism.
The volume’s implicit theorizing comes closest to surfacing, and is the most intriguing, in its provocative discussion of entanglements of harm and care, including iatrogenesis. In his call for increased work on care, Kleinman, for one, contends that “there has been a tendency to patronize traditional forms of healing by not addressing the same questions of quality that have become central to how medical anthropologists critically approach biomedical practitioners and their practices” (p. 262). Brooke Schoepf, for another, in a chapter framed as a professional memoir, urges anthropologists to advocate for increased funding for “quality biomedical services in Africa, free and accessible to all [such that some] people may continue to consult folk practitioners, but they will have a choice” (p. 128). Wendland offers a more robust consideration of the ethnographic and theoretical possibilities of linking harm, care, and pluralism. Distinguishing between iatrogenesis as unintentional injury caused by medical intervention, and dangerous care as “damaging practices” (p. 246) that arise between systems of medical intervention, she incisively shows how these systems’ battles for therapeutic legitimacy can amplify the already-considerable risks of childbirth. Her chapter, the book’s last, has a refreshing critical bite that suggests one possible direction for future work on the reality of biomedical and pluralist care in Africa that the volume so keenly seeks to establish.
Overall, African Medical Pluralism is an engaging and accessible collection that invites students and scholars in and beyond Africa to forge its empirical insights into new theoretical paths.