Medicine in the Meantime: The Work of Care in Mozambique by Ramah McKay (review)

Ramah McKay’s Medicine in the Meantime is a provocative and timely addition to the literature on global health and the multiple meanings of medical pluralism in the complex historical terrain of Mozambican health care. In this book, McKay explores how global health projects build upon long standing development projects by NGOs and transnational others. Mozambique, like many contexts in southern Africa, is one where foreign aid undergirds infrastructure in ways that have expanded medical services and created new forms of dependence. McKay examines the effects of two medical projects on the lives of patients and providers, demonstrating the possibilities for care in the midst of socio-political and economic constraints. Using ethnographic methods, Medicine in the Meantime offers an interesting comparison between two organizations: the International Center for Health Care (ICHC) that supported health care at Clínica 2 and other public sites in Maputo (the capital of Mozambique) and the Global Children’s Fund (GCF) that managed projects in the Morrumbala District of Zambézia Province.

The fundamental question that drives the research in the book is how “care is made when medical knowledge and practices are shaped by a range of interventions motivated by diverse actors, aims, and temporalities” (8). McKay focuses not on the production of care, but rather on what happens as medical aid and “care” itself are manipulated by human interaction. These interactions are at the very core of the ethnography, and in a world created and shaped by colonial desires and contemporary NGOs, McKay has put people back in the center of the analysis.

In addition, McKay offers a unique perspective on how colonial pasts continue to shape a conflicted present. This book reminds us of the myriad ways in which colonization, warfare, and cultures of care resonate beyond the bodies upon which they are enacted. Specifically, the story of Mozambique is a transnational one, driven by international financial policies and agencies (20). She tackles what she describes as the dynamics of improvement—the seemingly non-reflexive anthropological writing that focuses much of its attention on critiques of global health endeavors in Africa. Arguably the “idea” of Africa itself has long been central to the anthropological work on the continent—stories of our work there are often key to the generation and regeneration of interventionist projects that are geared toward “better health.” But as McKay reminds us, such projects have only served to recreate and reinforce an idea of “racialized misery” (196) and colonial era systems of command.

A particular strength of this book, and a methodological necessity given the emphasis on multiplicity at all levels, is how McKay looks not just at individual actors (which she does do) but at the organizations themselves. These organizations have come to represent the whole of the global health machinery that makes and unmakes health for all in particular places. McKay brings us to Mozambique with anthropological skill to focus on individuals whose lives are caught up in the relationships of care fostered by the global health processes and practices. That focus illuminates the privileged position of transnational agencies and actors and how the management of medical information helps to ensure a seemingly neo-colonial system.

But the organizational management of such information is not without its obstacles. An interesting thread throughout the book focuses on documentary processes and problems, literally the paperwork that is generated in these sites. McKay’s is not just a study of bureaucracy in that sense, but rather, of the bureaucratic processes that are actors and have agency in and of themselves. By tracing the ways in which medical documentation (processos) is manifest in everyday life and at all levels of health care (at the local clinic, between caregiver and patient, at national and transnational levels, etc.), we come to see just how documents (real or imagined) contribute to what “agency” and “multiplicity” mean today.

Hence, in these two different parts of Mozambique, individual lives are caught between local needs...