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Visions of Care in a Time of Medical Multiplicity 

Review by Emma Louise Backe 

Medicine in the Meantime: The Work of Care in Mozambique 

by Ramah McKay 

Duke University Press, 2018 

 

Ramah McKay’s ethnography opens on a demonstration—a group of doctors marching out of 

Maputo’s Central Hospital protesting low wages and government malaise in the public health sector. 

The tableau of striking doctors in Mozambique’s capital illustrates health as a fertile site of contestation 

in the country, one fraught by transnational flows of money, political instability, chronic illness, and 

differential social and economic investments in care across nongovernmental and governmental 

interventions. Medicine in the Meantime: The Work of Care in Mozambique (2018) is concerned with 

the tensions embedded in Mozambique’s health system across institutions, clinicians, volunteers, and 

patients. Yet the contestations over care negotiated and structured between nongovernmental 

organizations (NGOs) and public health platforms are rarely as visible as the picketing doctors in 

Maputo. Nor are the boundaries between transnational biomedicine and public health care easily 

parsed—instead, Medicine in the Meantime dwells in the in-between, the systems of medical 

multiplicity emblematic of 21st-century entanglements between the local and the global, and the 

shifting terrain of support amidst changing notions of governmental responsibility and humanitarian 

longevity.  

Situated around two fieldsites—Clínica 2 and the Global Children’s Health Fund (GCF)—under the 

auspices of the International Center for Health Care (ICHC), McKay’s ethnography traces the 

competing visions of care for patients in Mozambique within a health system marked by institutional 

multiplicity, complicated political legacies, and economic uncertainty. McKay’s concerns with 

changing public health and transnational medical regimes will be familiar to those acquainted with 

critical medical anthropology in Africa—the improvisational nature of medicine (Livingstone 2012); 

the contradictory temporal dimensions of international assistance and prolonged illness; and the co-



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constitution of diagnoses and patient-citizenship. The challenge and strength of McKay’s ethnography 

is situating care within such a mutable space, employing ethnographic mobility to analyze the various 

domains that health workers, clinicians, psychologists, and volunteers inhabit. Medicine in the 

Meantime is marked by edgework (Nguyen and Moyer 2017), the borders of biomedicine and care that 

bleed into one another. How does the co-existence of governmental and non-governmental health 

programming in Mozambique create alternative mandates of care which account for one another’s 

shortcomings, while reifying exclusive categories of vulnerability and dependency?  

The Introduction begins to map out the complicated history of international involvement in 

Mozambique following a long period of conflict, after which time transnational and humanitarian 

actors inhabited crucial roles in restructuring the country’s economy and health system. Mozambique’s 

status as “donor darling” helps to contextualize the out-sized presence of NGO global health 

investments in the country, as well as highlight the political legacies that continue to inform public 

health reform. The structuring force of Mozambique’s history of colonialism, socialism, and 

humanitarian intervention is woven throughout the book, a seam that pokes through most evidently in 

Chapter Three when discussing food aid for returning refugees.   

Chapter One starts at the Global Children’s Health Fund (GCF), a European development organization 

in Morrumbala working on community and child-based health issues. While the NGO provides support 

to chronic illness patients and their families, the space represents a critical site for investigating 

entanglement, “how humanitarian and public forms of government come to be at work, together but 

unequally, in projects of making community health” (McKay 2018, 31). Care in this context is 

contingent on exceptional circumstances and illness categories, a politics of inclusion and exclusion 

embodied by Paula—the widow of a patient who recently passed away from HIV complications. One 

of the GCF volunteers advocates for the organization to provide a food basket to Paula and her 

children, only to find resistance from his superiors due to the uncertainty of Paula’s HIV status. The 

justifications used to provide assistance depend on particularized forms of vulnerability, rather than 

need, within the community. This dissidence between vulnerability as a medical category, and need as 

a matter of impoverishment or socioeconomic status is continuously negotiated by volunteers 

throughout the book as they encounter the limits of NGO assistance, as well as the technologies used to 

constitute the criteria for care.  

Chapter Two goes on to explore how communities of care are established and mobilized by NGOs, 

relying on the labor of provincial volunteers. Despite NGO dependence on community health 



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volunteers, the remuneration process for home-based care replicates cycles of exclusion. While 

volunteers are encouraged to build a sense of social cohesion and responsibility within their 

“therapeutic communities,” much of their work is unpaid. Instead, volunteers are motivated by a desire 

to help their communities, learn the local landscape of aid, and develop connections that will hopefully 

lead to more professional opportunities. The system represents yet another edge in models of medical 

multiplicity, in which modes of reliance between volunteers, NGOs, and communities, are rarely 

reciprocal. The transnational exchange through finances, social capital, and medication emphasizes 

care as a relational practice routed through ambiguously positioned actors.  

Moving from the relationship between volunteers and NGOs, Chapters Three and Four address the 

ways that food baskets, as individualized aid, are instead redeployed for social and economic purposes 

within at-risk communities. Diagnostic categories of vulnerability articulate with the metabolic 

demands of anti-retroviral treatment (ARV’s), such that food assistance is available only to a select few 

who qualify under humanitarian criteria. The various indices used to determine eligibility for food 

support focus on medical hunger rather than incidents of poverty or unemployment, ignoring structural 

violence as an integral component of health. The short duration of food assistance is intended to 

decrease dependency, improve economic productivity, and reinforce the temporality of NGO support 

under a thoroughly neoliberal model of care. But McKay is careful to show how food basket recipients 

resist these restraints, elevating the importance of financial survival and collective hardship to rework 

nutritional benefits for their own needs.  

Chapters Five and Six investigate the diagnostic and documentary domains provoked by 

nongovernmental involvement. The presence of a Psychology Office at Clínica 2 further complicates 

patients’ hierarchy of needs—the practice of counselling serves as another dimension through which to 

monitor clients, improve clinic attendance, and ensure adherence. Indeed, psychosocial support in an 

African context serves as one more node to illustrate the “micropolitics” of work in the clinic—the 

professional opportunities and hierarchies between psychologists, their patients, and transnational staff. 

Psychologists and other clinicians conduct intake interviews and other documentary practices to 

standardize care and improve HIV treatment, with the result of increasing the managerial demands on 

clinical staff and complicating the treatment process for patients. While these additional administrative 

and affective armatures of care were intended to enhance transparency and surveillance, paperwork 

serves as yet another therapeutic obstacle patients have to navigate.  



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Medicine in the Meantime provides personalized insights into how individuals slip between the various 

subject positions elicited by transnational governance, exploiting moments of multiplicity while 

decrying the limitations of care such international aid provides. For all of McKay’s analytical and 

narrative artistry in the aporia of aid, the book would benefit from more careful definitional delineation 

of what is meant by public health, humanitarianism, and transnational intervention—both to highlight 

moments of slippage between the paradigms and inform readers still new to the occupational 

distinctions. The mutable landscape of health in McKay’s Mozambican networks also serves to reflect 

upon the role of ethnography in public health practices, the techniques of listening and care that 

anthropologists can provide. Ethnographic presence in global health spaces, whether through 

theoretical interventions or participant-observation, creates its own critical contours. This “social life of 

critique in the field” (McKay 2017, 197) leads to the very multiplicity, and differential production of 

knowledge Medicine in the Meantime investigates. 

Works Cited: 

Livingstone, Julie. 2012. Improvising Medicine: An African Oncology Ward in an Emerging Cancer 

Epidemic. Durham: Duke University Press.   

 McKay, Ramah. 2018. Medicine in the Meantime: The Work of Care in Mozambique. Durham: Duke 

University Press. 

 Moyer, Eileen and Vinh-Kim Nguyen. 2017. “Edgework in medical anthropology.” Medicine 

Anthropology Theory. http://www.medanthrotheory.org/read/9840/edgework-in-medical-anthropology  

 

Emma Louise Backe is a PhD student in George Washington University’s Anthropology Department. 

Specializing in medical anthropology, with a certificate in Global Gender Policy, her work focuses on 

practices of care among survivors of gender-based violence. Emma has worked in the global health 

sector, focusing on chronic illnesses like HIV/AIDS and non-communicable diseases (NCD’s), with 

organizations like USAID, the International Center for Research on Women, and the Peace Corps. 

 

 

 

© 2018 Emma Louise Backe 

http://www.medanthrotheory.org/read/9840/edgework-in-medical-anthropology

