Beyond the State: The Colonial Medical Service in British Africa ed. by Anna Greenwood (review)

Beyond the State: The Colonial Medical Service in British Africa is stimulating reading for historians of medicine working in the Canadian context. In its broadest framework, the collection provides a variety of access points for a re-examination of the place of state-run health care in the history of British imperialism in Africa. As the book's editor, Anna Greenwood, notes in her introductory discussion about historiography, "attention has moved away from triumphalist accounts of the conquest of disease in former European colonies to a more critical, less ethno-centric and more socially inclusive examination of the complex relationships between colonial states and colonised societies" (1). Taking this orientation as a starting point, the book sets out to revisit the history of the Colonial Medical Service, an institution that has long been at the centre of discussions concerning British medical engagement in Africa. While there are notable gaps in the book's coverage (most glaringly, as Greenwood acknowledges, the lack of any sustained focus on indigenous African actors), the collection provides some really interesting food for thought on colonization and health care.

Beyond the State consists of a set of case studies set in British colonial Africa from the turn of the 20^th century to 1960, together with an introductory chapter. The most substantial field of exploration in the book relates to Christian medical missionaries. Three of the seven case-study chapters focus on the relationships that were established between medical missionaries and the British Colonial Medical Service. Yolana Pringle, Markku Hokkanen, and Michael Jennings offer analyses of state-mission relations on the subject of health-care services in Uganda, Malawi, and Tanganyika, respectively. The three chapters share a temporal focus (they all span the first half of the 20^th century) and some of their most obvious findings. For example, all three authors show that these relations were neither static nor simple; state-mission dynamics varied according to location (especially rural vs. urban), political and economic timing, and the particular personalities and perspectives of key players. In the context of colonial Africa, their whiteness, their class, and their Western cultural orientations determined that many state-employed medical officers and medical missionaries would move in shared social circles. Moreover, for a variety of practical reasons, medical missionaries often served part-time or informally in the employ of the state. Yet as Pringle, Hokkanen, and Jennings show, relations between the state and missions were also frequently strained and conflict-ridden. Leading doctors within the Colonial Medical Service jealously guarded their state-vested authority, and resisted missions' efforts to collaborate when it came to making policies or deciding how funding would be allocated.

The articles on medical missionaries' associations with the colonial state in three different African contexts add some complexity to a history of health-care provision and British imperialism that has tended to acknowledge the centrality of religious organizations in this work. Shane Doyle's exploration of the roles played by academic social scientists in determining colonial state policies and practices engages with a history that is in some respects similarly familiar. Historians of British imperialism generally assume that studies undertaken by members of the colonizing society's intellectual elite would be used to help state administrators comprehend the behaviour of local populations, and to justify unpopular state policies and practices. The two case studies associated with the work of members of the East African Institute of Social Research that Doyle explores in his chapter are compelling because of the local health histories that they uncover and because of the nature of the larger contexts within which Doyle presents them. Doyle's first case study is set in Buhaya, Tanganyika, where an exceptionally high percentage of the population suffered from sexually transmitted infections. To cite just one of the statistics used to demonstrate the scale of the problem in this community, "42 per cent of all cases treated in Buhaya's...