Olsen, W.C. and Sargent, C. (eds) African Medical Pluralism. Indiana University Press, Bloomington. 2017. 265 pp. ISBN: 978‐0‐253‐02491‐6

This edited collection brings together ethnographic research from diverse African settings in order to better understand the practice of medical pluralism. Invoking a continuum, the editors position medical pluralism as the practice of drawing on multiple medical modalities or practitioners, whether simultaneously or sequentially. Whilst the language preferred varies, the essential tension is between a reliance on traditional healing and on clinical medicine. Other visual metaphors include a kaleidoscope, evocative of the shifting range of possible combinations and unexpected juxtapositions that are in fact explored herein. The book is divided into three sections: Biomedicine and African Healing; Symptoms and Therapeutic Pluralities, and; Hospital Ethnography. This last section is an important contribution for exploring how, beyond being ‘extensions of the West and modern science’ (p. 10), hospitals also vary in quality and availability of adequate care, and are themselves often sites for medical pluralism. For instance, Mulemi writes about ‘the grim picture of cancer care in a resource-poor African health system [Kenya] with insufficient responsiveness to the patients’ needs’ (p. 208). The medical pluralism described here relies on improvisation under difficult conditions, and calls to mind Julie Livingston’s ethnography of a Botswana cancer ward, Improvising Medicine (2012). The introduction identifies three objectives for the collection, all of which are essentially descriptive. Olsen and Sargent write that ‘while theory helps to frame details and data, we believe the biggest contribution of the volume is to document the ethnographic realities of suffering and therapy in everyday life’ (p. 2). Overall, the authors draw upon rich and diverse ethnographic accounts that raise more questions about the place of medical pluralism than they answer. However, the lack of a coherent, or even contested, theoretical contribution is also frustrating, and perhaps amounts to a missed opportunity. At stake in medical pluralism are epistemic and cosmological considerations on the one hand, and material and empirical considerations on the other. Janzen's chapter – Science in the Moral Space of Health and Healing Paradigms in Western Equatorial Africa – highlights that the concern over epistemologies and cosmologies of health, and the body at play in the medical pluralism label, stems from broader shifts in anthropology. As the discipline has moved away from the privileging of Western knowledge as the rational, objective truth against which other forms of knowledge are marginalised as superstition or folk knowledge, medical pluralism becomes a lens for understanding competing understandings of health and illness. On a material note, the editors point to a predicament: ‘The contemporary realities of biomedicine vary in relation to uncertainties associated with the quality of medical care available in many African institutions, undermined by global political and economic policies’ (p. 3). At times, the explorations of medical pluralism lose sight of the lack of adequate primary care as a central consideration in most African settings. The strongest chapters, including Janzen's as well as those discussed below, are able to address both epistemic and material questions at play. Wendland's chapter balances the empirical question of cause of death with the epistemological and cosmological question of whose care is appropriate in an exploration of how safe maternity care is compromised by struggles over legitimacy. In her reading of the events surrounding two maternal deaths, rather than attributing blame to the traditional or clinical practitioners involved, she identifies that blame lies with the struggle over legitimacy itself, such as when a prior diagnosis is ignored because of its source. The material conditions for dangerous care are discursively produced when systems ‘legitimise themselves in opposition’ to each other (p. 256) alongside more widely examined factors such as the discontinuation of safe supplies to Traditional Birth Attendants and the lack of training among some clinical staff. [T]he human right to health is better served by anthropologists and others advocating for monetary contributions by national governments and international donors in aid of establishing and maintaining quality biomedical services in Africa, free and accessible to all. Some people may continue to consult folk practitioners, but they will have a choice. More frank assessments such as this, even if contradictory, would have strengthened the contribution of this collection. Returning to Wendland, she reminds us that ‘the anthropology of care redirects attention away from amorphous institutions to the intimate practices between people’ (p. 254), and it is such a focus on care itself that Kleinman endorses in his Afterword. A focus on care relationships is necessary, yet oftentimes it is ‘amorphous institutions’ that create the material conditions for care and suffering, and their activities are not beyond the sight of medical anthropologists. Kleinman suggests that we can build ‘generalisable social theories’ on a platform of ‘detailed empirical research’, and that such theories can guide not only research, but also improve health services (p. 263). However, he finds at the close of this volume that ‘we still lack a theory of medical pluralism in Africa’ (p. 263). If this is a deficit of African Medical Pluralism, creating the ground for clearer theories of medical pluralism is also its central contribution.

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