Para-states and medical science – making African global health

Para-States and Medical Science is an impressive volume and a welcome addition to work on critical global health in Africa. The collection provides a much needed re-reading of contemporary biopolitical regimes in Africa, which neither fit old models of biopower nor conform to neoliberal forms found elsewhere. The work shows the global health movement in Africa to be less a “biopolitical project of ‘empire’” (Nichter 2008, 152), an image which has dominated previous development critiques, and more a fragmented system orchestrated by a diverse set of actors (including both stagnant and novel versions of the state). Playing on the notion of the para-statal, the contributors to this volume situate the state as para, a productive move that illustrates the nation state's durable, lingering and lasting imprints, as well as its mediated residues, in African global health today. This new set of configurations is illustrated across 11 chapters, divided into 5 parts concerned with the central themes of experimentality, temporality, collaboration, relation and nation. Careful ethnographic work offers a fine-grained appraisal of enduring and novel forms of citizenship, kinship, health-seeking and navigation of shifting epidemiological, political and treatment borders. Theoretically, the volume is situated between critical medical anthropology, science and technology studies (STS) and postcolonial theory, and demonstrates the longstanding synergy between histories and anthropologies of Africa.

HIV science is a prominent concern of this volume, with six chapters documenting the emergent networks of researchers, trial communities, state governance structures, NGOs and pharmaceuticals that constellate around the human immunodeficiency viruses. Vinh-Kim Nguyen poses experimentality as a new form of governmentality in his chapter on treatment-as-prevention strategies, which inform new sets of social organization through large-scale trials that produce “experimental societies”. This speaks readily to Branwyn Polykett's chapter on the regulation of Senegalese sex workers, for whom mandatory official registration is often also an induction into clinical trials on the natural history of HIV. Guillaume Lachenal's chapter on Cameroon's HIV pandemic underscores the need to assess the forms of nihilism and non-intervention deployed by state and other actors in African global health governance, where what is not done is often instructive, a logic also employed in P. Wenzel Geissler's ethnography of a trial site where global health rhetoric and practice has done little to transform local structures. In contrast, Susan Reynolds Whyte, in her chapter on “working and surviving”, shows how the state, as a reliable and desirable employer for Ugandans, remains a central link in the chain of access to antiretroviral therapy (ART) in this setting. This theme repeats in Lotte Meinert's ethnography of an ART project in East Africa, in which she demonstrates how networks are formed or severed via the project, with implications for ART access, employment and survival. Didier Fassin concludes the volume with his biography of Nevirapine, a skillful description of the shifting place of the South African state as this antiretroviral went from “magic bullet” to second line agent. Two chapters on malarial control reinvigorate old debates on interventions against one of the continent's old enemies. Rene Gerrets’ work on an artesunate combination therapy trial in Tanzania demonstrates that the public–private partnerships proliferating in global governance structures are not necessarily dominated by Northern partners, as critiques of new collaborations and capacity-building have put forth, whereas Uli Beisel's contribution on malaria control experiments in Ghana reiterates that attempts at malaria eradication are best viewed as ecological experiments, often with unpredictable outcomes. The only chapter by a historian in the volume (John Manton) utilizes a history of leprosy in Nigeria to outline continuity rather than novelty for themes such as collaboration, experiment and emergency, a theme echoed in Ann Kelly's contribution on articulations of public health in The Gambia, which are both stable and changing as the aims and boundaries of this project shift.

This volume is a significant addition to the body of work in anthropology on the international health and global health projects in Africa. The dominance of HIV and ART-related ethnographies in the collection may speak to the centrality of HIV in the construction of the object of global health on this continent, which begs a return to the question of “what or who must be valued in order for knowledge to count as global health science, and what or who remains subjacent or unaddressed” (Biehl and Petryna 2013, 15). The volume could have benefitted from the inclusion of work on other obvious images of African global health science, including maternal and child health and emergent non-communicable disease burdens, and a more explicit interrogation of what constitutes “health” in frameworks of “global health” in Africa. Nevertheless, this work makes an original and innovative contribution to scholarship on the shifting relations between state, public, private and corporate interests in health care in Africa, and makes inroads for anthropologists, historians and STS scholars to move beyond standard narratives of “development” and “neoliberalism” in African contexts.