Visions of Care in a Time of Medical Multiplicity

Review by Emma Louise Backe
July 17, 2018

Medicine in the Meantime: The Work of Care in Mozambique

by Ramah McKay
Published 2018

Duke University Press

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Ramah McKay’s ethnography opens on a demonstration—a group of doctors marching out of Maputo’s Central Hospital protesting low wages and government malaise in the public health sector. The tableau of striking doctors in Mozambique’s capital illustrates health as a fertile site of contestation in the country, one fraught by transnational flows of money, political instability, chronic illness, and differential social and economic investments in care across nongovernmental and governmental interventions. Medicine in the Meantime: The Work of Care in Mozambique (2018) is concerned with the tensions embedded in Mozambique’s health system across institutions, clinicians, volunteers, and patients. Yet the contestations over care negotiated and structured between nongovernmental organizations (NGOs) and public health platforms are rarely as visible as the picketing doctors in Maputo. Nor are the boundaries between transnational biomedicine and public health care easily parsed—instead, Medicine in the Meantime dwells in the in-between, the systems of medical multiplicity emblematic of 21st-century entanglements between the local and the global, and the shifting terrain of support amidst changing notions of governmental responsibility and humanitarian longevity.

Situated around two fieldsites—Clínica 2 and the Global Children’s Health Fund (GCF)—under the auspices of the International Center for Health Care (ICHC), McKay’s ethnography traces the competing visions of care for patients in Mozambique within a health system marked by institutional multiplicity, complicated political legacies, and economic uncertainty. McKay’s concerns with changing public health and transnational medical regimes will be familiar to those acquainted with critical medical anthropology in Africa—the improvisational nature of medicine (Livingstone 2012); the contradictory temporal dimensions of international assistance and prolonged illness; and the co-constitution of diagnoses and patient-citizenship. The challenge and strength of McKay’s ethnography is situating care within such a mutable space, employing ethnographic mobility to analyze the various domains that health workers, clinicians, psychologists, and volunteers inhabit. Medicine in the Meantime is marked by edgework (Nguyen and Moyer 2017), the borders of biomedicine and care that bleed into one another. How does the co-existence of governmental and non-governmental health programming in Mozambique create alternative mandates of care which account for one another’s shortcomings, while reifying exclusive categories of vulnerability and dependency?

The Introduction begins to map out the complicated history of international involvement in Mozambique following a long period of conflict, after which time transnational and humanitarian actors inhabited crucial roles in restructuring the country’s economy and health system. Mozambique’s status as “donor darling” helps to contextualize the out-sized presence of NGO global health investments in the country, as well as highlight the political legacies that continue to inform public health reform. The structuring force of Mozambique’s history of colonialism, socialism, and humanitarian intervention is woven throughout the book, a seam that pokes through most evidently in Chapter Three when discussing food aid for returning refugees.  

Chapter One starts at the Global Children’s Health Fund (GCF), a European development organization in Morrumbala working on community and child-based health issues. While the NGO provides support to chronic illness patients and their families, the space represents a critical site for investigating entanglement, “how humanitarian and public forms of government come to be at work, together but unequally, in projects of making community health” (McKay 2018, 31). Care in this context is contingent on exceptional circumstances and illness categories, a politics of inclusion and exclusion embodied by Paula—the widow of a patient who recently passed away from HIV complications. One of the GCF volunteers advocates for the organization to provide a food basket to Paula and her children, only to find resistance from his superiors due to the uncertainty of Paula’s HIV status. The justifications used to provide assistance depend on particularized forms of vulnerability, rather than need, within the community. This dissidence between vulnerability as a medical category, and need as a matter of impoverishment or socioeconomic status is continuously negotiated by volunteers throughout the book as they encounter the limits of NGO assistance, as well as the technologies used to constitute the criteria for care.

Chapter Two goes on to explore how communities of care are established and mobilized by NGOs, relying on the labor of provincial volunteers. Despite NGO dependence on community health volunteers, the remuneration process for home-based care replicates cycles of exclusion. While volunteers are encouraged to build a sense of social cohesion and responsibility within their “therapeutic communities,” much of their work is unpaid. Instead, volunteers are motivated by a desire to help their communities, learn the local landscape of aid, and develop connections that will hopefully lead to more professional opportunities. The system represents yet another edge in models of medical multiplicity, in which modes of reliance between volunteers, NGOs, and communities, are rarely reciprocal. The transnational exchange through finances, social capital, and medication emphasizes care as a relational practice routed through ambiguously positioned actors.

Moving from the relationship between volunteers and NGOs, Chapters Three and Four address the ways that food baskets, as individualized aid, are instead redeployed for social and economic purposes within at-risk communities. Diagnostic categories of vulnerability articulate with the metabolic demands of anti-retroviral treatment (ARV’s), such that food assistance is available only to a select few who qualify under humanitarian criteria. The various indices used to determine eligibility for food support focus on medical hunger rather than incidents of poverty or unemployment, ignoring structural violence as an integral component of health. The short duration of food assistance is intended to decrease dependency, improve economic productivity, and reinforce the temporality of NGO support under a thoroughly neoliberal model of care. But McKay is careful to show how food basket recipients resist these restraints, elevating the importance of financial survival and collective hardship to rework nutritional benefits for their own needs.

Chapters Five and Six investigate the diagnostic and documentary domains provoked by nongovernmental involvement. The presence of a Psychology Office at Clínica 2 further complicates patients’ hierarchy of needs—the practice of counselling serves as another dimension through which to monitor clients, improve clinic attendance, and ensure adherence. Indeed, psychosocial support in an African context serves as one more node to illustrate the “micropolitics” of work in the clinic—the professional opportunities and hierarchies between psychologists, their patients, and transnational staff. Psychologists and other clinicians conduct intake interviews and other documentary practices to standardize care and improve HIV treatment, with the result of increasing the managerial demands on clinical staff and complicating the treatment process for patients. While these additional administrative and affective armatures of care were intended to enhance transparency and surveillance, paperwork serves as yet another therapeutic obstacle patients have to navigate.

Medicine in the Meantime provides personalized insights into how individuals slip between the various subject positions elicited by transnational governance, exploiting moments of multiplicity while decrying the limitations of care such international aid provides. For all of McKay’s analytical and narrative artistry in the aporia of aid, the book would benefit from more careful definitional delineation of what is meant by public health, humanitarianism, and transnational intervention—both to highlight moments of slippage between the paradigms and inform readers still new to the occupational distinctions. The mutable landscape of health in McKay’s Mozambican networks also serves to reflect upon the role of ethnography in public health practices, the techniques of listening and care that anthropologists can provide. Ethnographic presence in global health spaces, whether through theoretical interventions or participant-observation, creates its own critical contours. This “social life of critique in the field” (McKay 2017, 197) leads to the very multiplicity, and differential production of knowledge Medicine in the Meantime investigates.

Works Cited:

Livingstone, Julie. 2012. Improvising Medicine: An African Oncology Ward in an Emerging Cancer Epidemic. Durham: Duke University Press.  

 McKay, Ramah. 2018. Medicine in the Meantime: The Work of Care in Mozambique. Durham: Duke University Press.

 Moyer, Eileen and Vinh-Kim Nguyen. 2017. “Edgework in medical anthropology.” Medicine Anthropology Theory. http://www.medanthrotheory.org/read/9840/edgework-in-medical-anthropology

Emma Louise Backe is a PhD student in George Washington University’s Anthropology Department. Specializing in medical anthropology, with a certificate in Global Gender Policy, her work focuses on practices of care among survivors of gender-based violence. Emma has worked in the global health sector, focusing on chronic illnesses like HIV/AIDS and non-communicable diseases (NCD’s), with organizations like USAID, the International Center for Research on Women, and the Peace Corps.

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