Post-Foucauldian Governmentality and African Healthcare

The thought-provoking book Para-States and Medical Science draws on anthropology and history to fruitfully engage with the concept of the ‘para-state’ in its analyses of transfigurations in the production, management and social relations of scientific research and public health in various sub-Saharan African countries. The para-statal organizations discussed in the book adopt some of the work of the nation-state and form when portions of it have been parceled out and segmented off. Justifications for and the perceived validity of para-statal organizations are based on and affirmed by their connection to the nation-state, which persists as their point of reference even where these organizations challenge the institutions of the nation-state. The para-state, shaped by market forces, evolves next to and around the nation-state rather than being part of or equivalent to it (pp.9-10). African statehood is not discussed in the book as weak or disappearing, but rather as present in the state’s workforce, its buildings, infrastructure, and bureaucracy. The state is palpable in foreign donors’ emphasis on working through state “partners” as well as in people’s claims for care, memories of past government services, and imaginings of future improvements. The para prefix helps reveal, the book’s editor P. Wenzel Geissler explains, conflations between original and copy while highlighting the sense of things changing but not losing their form (p.1,4). The book’s focus on the para-state provides fascinating and productive insights into ways of thinking about governmentality.

The para prefix in para-state is further used in the book to allude to the relationship between the state and new biopolitical forms, where “the state’s place in biopolitical order has changed, not diminished” (p.9). This emergence of new biopolitical forms through para-statal organizations arises in a variety of ways and contexts analyzed by the book’s contributors. Guillaume Lachenal, for example, discusses the 1994 discovery of the HIV-1 O strain in Cameroon, which led to the privatization but also revitalization of Cameroonian medical research when the University of Yaoundé and the underfunded governmental Centre Pasteur du Cameroun agreed to give patient blood samples to commercial German and French laboratories in exchange for HIV testing kits. Rene Gerrets explores a malaria research and control partnership formed between the Tanzanian Ifkara Health Research and Development Centre and US Centers for Disease Control that shifts in perception from clearly distinct to barely distinguishable from the state. Another contributor, Branwyn Poleykett, examines a Senegalese state clinic that registers female sex workers, placing them into a pool of potential HIV research subjects in a collaborative project between the Université Cheikh Anta Diop in Dakar, Harvard University, and the Universities of Tours and Limoges in France. Each of the book’s chapters unearths compelling insights into African healthcare and/or medical research.

The chapter structure of Para-States and Medical Science emphasizes points of rupture, pasts and possible futures, the persistence and struggles of the nation-state, and the ways in which para-states impact and are impacted by relations between people as members of the public. The book begins with a chapter by Vinh-Kim Nguyen considering how para-states produce a kind of “experimental society” with the clinical trial as a technology of rule. The following chapter by John Manton questions the newness of para-statal configurations by drawing on early post-colonial leprosy research in Nigeria. Guillaume Lachenal and P. Wenzel Geissler’s chapters explore the relationships between para-states, neoliberalization and biopolitics. Rene Gerrets and Reynolds Whyte’s chapters reveal the persistent experienced presence of the state in people’s lives. Branwyn Poleykett and Lotte Meinert engage with the role of emotion and personal connection in HIV research conducted by para-statal organizations. Finally, Ulrike Beisel, Ann H. Kelly and Didier Fassin deal with issues of territory between nation-states, para-statal organizations and scientific research, with Fassin’s chapter highlighting points of disjuncture between scientific knowledge and policy positions of the South African government. All but one of the book’s eleven chapters handle para-statal organizations heavily centered in some way on HIV/AIDS or malaria. This reflects a strong focus on these diseases within African medical science and healthcare. Other diverse health and health-related issues, however, such as cancer, diabetes, disability, female genital cutting, maternal mortality, or mental health may be associated with very different biopolitical regimes.

Geissler et al. steer away from simplified discussions of neoliberalism and 1980s style medical anthropology critiques that position biomedicine as a tool of domination or discipline, the state as the agent of biomedical technologies in opposition to the public, or biomedicine as one form of knowledge among many. The book’s contributors instead consider the possibilities and responsibilities of biomedical science and the state to public health, while paying close attention to space, place and historical trajectories as well as the unequal scientific partnerships that emerge in para-statal organizations. As Geissler notes, this shift stems from a theoretical move to post-Foucauldian and post-Marxist analyses and the contributors problematize the idea of biopower as an increasing and expanding disciplinary mechanism (p.24,35). The book points to ways in which national citizens can be understood as assemblages of illnesses and bodies with rights and claims, holding mercurial identities that position them in roles such as peer group member or community representative in relation to the para-state. Out of this, temporary multiple publics are formed and governed under often short-term projects, mirroring the fetishization of randomized controlled trials in public health research. Through this, the book points to innovative ways of thinking about African biological citizenship.

Several chapters critically engage with African scientists’ work-lives and visions of public health, but it would be interesting to read more specifically about African scientists’ perspectives on the logic, value and outcomes of research they participate in. Nguyen notes that randomized controlled trials can only reliably measure relatively simple interventions across brief periods of time and do not measure what might happen outside of trial conditions. Interventions such as the social and economic empowerment of women do not fit easily into this randomized controlled trial framework and would require researchers to engage with complex issues of human behavior, gender identity and social constraint (p.52,57). What discourses do African scientists use to frame, highlight or obscure the shortcomings of randomized controlled trials and the social consequences of the interventions these trials? It would be valuable to also hear more about how discourses produced by local and national media interact with broader international discourses that include transnational scientists and organizations, as Fassin does in his chapter on Nevirapine.

Para-States and Medical Science is an exceptional and engaging book that will be of interest to anthropologists, Africanists and historians as well as those interested in science and technology, post-colonial and development studies.

Mary-Anne Decatur is a PhD candidate in anthropology at SOAS, University of London. Her research examines Maasai and Chagga people’s conceptualizations of female genital cutting on social, cultural, historical and medical grounds in the Kilimanjaro region of Tanzania. She explores how these differing understandings of the practice shape predominantly Chagga NGO and healthcare employees’ strategies and messages for ending female genital cutting in comparatively less affluent Maasai communities, and in turn influence Maasai interpretations of these strategies and messages. Mary-Anne is also the FGM country of origin expert for Tanzania for the Rights in Exile Programme and the editor of Popular Anthropology Magazine.

© 2015 Mary-Anne Decatur
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