Mothers, Medicine and Morality in Rural Mali: An Ethnographic Study of Therapy Management of Pregnancy and Children’s Illness Episodes by Holten Lianne (review)

In matters of health and of development generally, infrastructures and awareness campaigns are expected to be factors of progress that improve the situation of local populations. Yet on the ground we sometimes observe considerable discrepancies between the programmes that are set up and how target populations use them; examples are underuse of available services and non-consultation for what may be serious medical problems. When problems are clearly not due to service organization factors (cost, quality), we readily turn for explanations to “cultural” criteria (values, representations, etc.), understood to prevent people from accepting “Western” health care practices. Lianne Holten’s book on the health-seeking behaviour of women in a village in Mali takes this analysis much further, showing that use (or non-use) of available biomedical services, while partially conditioned by local representations of illness, is also closely related to how decision-making power is distributed, especially by sex and generation. With meticulous precision, the author demonstrates throughout the book the social and family mechanics that determine women’s practices and choices while likewise limiting their maneuvering room and constraining their choices and practices by way of heavy moral requirements.

The book, derived from Holten’s thesis in anthropology, is based on her monographic study of practices in a small village in southwest Mali upon the opening of a new maternity clinic (funded by private NGOs). Given Holten’s credentials not only as an anthropologist but also a midwife – she worked several years in that profession in the Netherlands – she is particularly qualified to examine interactions between biomedicine and local therapeutic practices. She began her fieldwork (a total of eight months from 2007 to 2012) with the twofold intention of developing the activity of the new maternity clinic and studying local representations of illness and “therapy management”. Initially she considered these two objectives integral parts of an action research project: to provide access to modern medical care in a remote, isolated village where living conditions are extremely precarious, and to do so by taking into account local knowledge, as this would make it easier – so she assumed – to promote modern health care, in particular by combating what appeared to be mothers’ passivity when their children fell ill. In the course of her research the author gradually changed her viewpoint, shifting from a medical approach to illness centred on individual and biological health determinants to an approach in terms of local women’s healthcare seeking behaviour that took into account not only the various therapeutic options available but also the social system, with its inequalities, power relations, and the maneuvering room available to individuals as determined by their respective places in that system.

To understand what is involved for these women in seeking care for themselves or sick children, the author adopted an anthropology-of-moralities approach. At the core of the society and Holten’s study of it is the notion of “shame”, maloya in the local language. Any researcher who has worked in West Africa knows how important maloya is: it is omnipresent in interviews touching on such questions as the soundness of an individual action, expression of a personal viewpoint, and how to behave toward elders. The French translation, honte, fails to fully capture the meaning, as maloya encompasses more than negative connotations such as humiliation or dishonour; in fact, the word refers at a more general level to the idea of reserve, modesty, discernment, and ensuring that one’s behaviour accords well with one’s status within the social system. To “have shame” is to know how to situate oneself in relation to others and to adopt the appropriate behaviour, which varies by one’s position in relation to one’s interlocutor. It also means being attentive to others and taking care not to express an opinion or make a request that might put one...