Reviewed Book
The Lives of Community Health Workers: Local Labor and Global Health in Urban Ethiopia. Kenneth Maes, New York: Routledge, 2017, 171 pp.
In 2008, an Ethiopian NGO held its second annual Volunteers Day event to honor community health workers (CHWs) who spend 15–40 hours per week visiting the homes of HIV-positive people to provide multi-faceted care. These volunteers find moral satisfaction as they traverse Addis Ababa’s sprawling neighborhoods, framing their work as an obligation to fellow citizens. Maes shows how the ritualized space and pomp and circumstance of Volunteers Day betray normative imaginings of volunteerism as a sacrifice that brings mental satisfaction and valuable (nonmaterial) returns. Drawing on participant observation with CHWs, interviews, document review, and a survey of a cohort of CHWs, Maes shows how moral sentiments not only shape CHWs’ subjectivity and practices but also operate to exploit their capacities for empathy and care in the name of saving lives.
Analyses of CHW experience have largely adopted a “human resources mentality” centered on optimizing CHW performance, behaviors, and retention to improve product delivery. Maes expands this narrow approach by modeling how we might attend to the lived experiences of those “minor” actors (e.g., health workers, data collectors, peer educators, nurses) who are most overlooked, but potentially most influential on global health outcomes.
The book tracks a paradox across five chapters: While global health seeks to make the lives of the poor more just and equitable, its projects are carried out on the backs of under- or non-renumerated volunteers. Dominant assumptions suggest that renumeration might erode “intrinsic” motivations (e.g., moral duty, empathy, altruism) at the core of the “volunteer” project (p. 126). These normative sentiments of satisfaction and sacrifice obscure the political economy of global health systems in which CHWs are embedded and efficiently “extract the labor of [the least powerful]” (p. 142). Maes navigates between taking CHWs’ moral investments in their care work seriously and bringing critical attention to the depoliticizing functions of these sentiments within a “volunteer workforce” (p. 63) that is increasingly of interest to medical anthropologists embedded in global health worlds.
Chapter 1 provides an overview of the political, economic and policy context of CHW work in Ethiopia, highlighting how the global sustainability doctrine produces a niche for the global health volunteer who will keep things going when outside projects depart. A sacrifice of wages for services rendered, so this story goes, maximizes lives saved and ensures authentic participation. Chapter 2 narrates the biography of a CHW named Eskinder alongside a history of institutions, neighborhoods, and epidemics in Addis. “Becoming a CHW” is not a straightforward path, but one that meanders through ephemeral stints, in Eskinder’s case, as a taxi tout, cement factory worker, and welder. HIV-positive Eskinder credits his transformation from sick to healthy not only to ART, but also to neighbors and health professionals who cared for him selflessly: He returns the favor as a CHW with “ARVs in [his] pocket” (p. 56).
Chapter 3, the most ethnographically rich chapter in the book, draws on participant observation to analyze ceremonies; recruitment interviews and training sessions are sites of socialization where CHWs learn to embody the kinds of emotions, expectations, and motivation that make them legible to global health systems and their communities as “good.” The chapter features an initiation ceremony for recruits rife with ritual accoutrements such as oaths, candles, and shifts in dress. Rituals such as this, Maes suggests, “pump up CHWs with [the] positive emotion” that is the motor of global health volunteerism (p. 137). The chapter highlights gatekeeping around who is a morally acceptable volunteer, showing how assessments of character (Does he drink or smoke?) and motivations (Is he in it for the money?) inform recruitment. Maes frames CHW training rituals as hierarchical sites of depoliticization where producing “happy” and empathic volunteers trumps discussion of political and economic justice issues (pp. 80–87). This recalls Harri Englund’s (2006) analysis of human rights activists in a Malawian NGO training session shouting down villagers who, frustrated with abstract talk of “freedoms,” raised concerns about material needs that fell conveniently outside the pre-packaged scripts for civic education (pp. 99–122).
In Chapter 4, Maes tracks how CHWs enact care for fellow citizens who, even as they may be strangers, are recast in clan or familial idioms. CHWs monitor biological conditions, but they also mediate biosocial problems between relatives, provide “better deaths” for patients, share their own food or money, and even take HIV-positive clients into their homes. CHWs experience psychosocial stress amid stark confrontations with death, feel shame at their inability to meaningfully help those who are suffering and endure critiques from family members who may not understand why CHWs become “addicted” to volunteer work that consumes their time and energy without material benefit (p. 104). Amid a lack of jobs, CHWs perform care work that suspends them in liminality, thwarting their ability to progress through life stages contingent on wealth accumulation. Chapter 5 shows that even though Ethiopia’s political situation and crackdown on NGOs and civil society organizations blocks CHWs’ ability to collectively bargain, CHWs employ weapons of the weak—namely, complaining and keeping their eye on other (paid) opportunities—to take more control over their lives amid constant reductions in benefits and lack of support from superiors (who may even refuse to provide recommendations for future jobs when CHW contracts end).
This ethnography calls on anthropologists to produce policy-relevant work, embodying this commitment in its clear and jargon-free style and in a final chapter that compiles a set of recommendations for those who seek to build better CHW programs. This effort to provide useful data to public health professionals and policy makers models how anthropologists of global health might surrender some of their normative commitment to negative critique, but I was left wondering how the anthropologist might transcend dialogue-based models for engagement and reform that, considering the proliferation of conferences, workshops, task forces, and committees across global health’s empire, continue to reproduce, rather than challenge, normative hierarchies of knowledge production.
I had a few lingering questions after finishing the book. First, Ethiopian CHWs are one blip in Africa’s growing cadre of low- or non-renumerated volunteers who labor every day for NGOs, governments, and other institutions whose supposedly good intentions often make them invulnerable to critique. In this regard, the insights of Chapters 4 and 5 might have been interwoven to more deeply consider how a paradoxical “volunteer workforce” sheds new theoretical light on the emerging meanings and politics assigned to “work” and care amid complicated circuits of resource distribution across Africa. Second, while Chapter 5 illustrates how CHW efforts to organize are constrained by political context, Maes might have done more justice to the creative ways in which people build habitable worlds in the absence of possibilities for collective organizing.
Whereas global health policy makers tend to cast CHWs as resources that must be carefully monitored and disciplined, Maes portrays them in their full complexity, showing how their identities, aspirations, and motivations are co-constituted by their precarious yet fulfilling place in a global health economy. While anthropologists need not be convinced of the value of the ethnographic to global health, the book should find a wide audience among those who work with and manage a range of frontline workers across development, human rights, global health, and other projects in Africa. Maes’s book is a conscious and laudable attempt to build meaningful bridges between medical anthropology and global health.
Reference Cited
Englund, H. 2006. Prisoners of Freedom: Human Rights and the African Poor. Berkeley: University of California Press.