Health, State, and Society in Kenya: Faces of Contact and Change (review)

Academic interest in the history of medical practices in Africa during the colonial period has expanded dramatically during the last decade. With the devastating impact of aids and the reduced ability of governments to support social services in an age of structural adjustment, it is no surprise that social historians have turned to health care. Ndege's monograph on disease and state power in Kenya provides a good overview of the complicated interactions between competing notions of health within different segments of the colonial and postcolonial government bureaucracy. Though it is far from the most innovative study on medicine and health services in Africa, it is a solid and easily accessible work, useful for historians and health professionals alike.

Ndege bases his analysis on the theme of "Western biomedicine" and its evolutions in Kenya. Like Vaughan and Lyons, he contends that health care in the colonial period focused on disease as a problem to be solved through technological approaches rather than through the pursuit of indigenous knowledge and the social and cultural context of those suffering from illness.¹ The implementation of biomedicine went through several stages. At the opening of colonial rule between 1890 and World War I, colonial officials and medical personnel grappled with the violence and ecosocial disruption associated with conquest. British doctors had limited understanding of tropical diseases. Government authorities relied on coercion and older notions of public health to separate visibly ill people from others, segregating Africans from Europeans in cities to battle sleeping sickness and bubonic plague. European-trained medical professionals often criticized administrators' use of brute force as counterproductive and ineffective while disparaging local methods.

State authorities promoted health services on an uneven basis. Soldiers and workers involved in industries that colonial policymakers considered important received much more medical attention than rural people. Urbanization led to the promotion of sanitary segregation in some circles. Though some doctors opposed it, officials who argued for the physical separation of Africans and Europeans often prevailed. When the government placed the responsibility of medical expenses on local African communities in the 1920s, one consequence was that wealthier areas had much better access to clinics and Western medicine than impoverished districts. Kenyans who profited from colonial rule embraced many aspects of biomedicine and funded its expansion even as the state often lacked the ability to do so. From the 1960s until 1986, state officials ran a program that drew on public resources and international development agencies without nationalizing health-care facilities. To compound the problem of the rising aids epidemic, government revenues and health-care budgets declined after the late 1980s.

Overall, this work is a useful, if not innovative, case study of health care and state planning. Though the author makes occasional stabs at examining local understandings of health and their relationships to European views on disease and treatment, his national framework leaves little space for indigenous views on healing and illness. The scattershot nature of the evidence on African discourses of disease and cures left this reviewer wondering how much can be generalized from it. On the other hand, this work does a great service by discussing major issues related to government authority and health in language those outside the disciplines of history and anthropology can easily follow. For health-care professionals and general readers, this study will be a valuable introduction to the politics of health care in Kenya.