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’s interlocutor in an awkward position. The notion plays a key role in the construction of social relations, particularly between the sexes and generations. It expresses orders of precedence and who is at liberty to do what; it lays down inequalities and the distances people are expected to keep from each other (notably, distance between husband and wife); it stages those inequalities and separations by showing what happens to someone who does not comply with them (sanctions range from mockery to outright social rejection). But as the author shows, this moral system is also a means for developing a place for oneself and increasing one’s social capital: it is in meeting these moral expectations that women manage to forge a reputation for themselves, a status in the community, and a relational network they can depend upon. And the moral system is not merely coercive; women themselves can appropriate it, use it as a resource, to acquire leverage or to secure or bolster their place and that of their family in the local social world. Complying with the complex local morality code proves that one has acquired the skills needed to understand and benefit from the social game. In the end, rather than signifying passivity, it manifests a particular type of rationality, investment, and, the author stresses, genuine agency.
In her investigation of the notion of shame, Holten reveals the extremely complex relations and socially regulated decision-making that precede any move to seek therapy, any possible medical consultation, even when health care is immediately accessible and affordable. For a mother to bring her child to the clinic, it first has to be in her socially appointed power to do so, which is not usually the case. By comparing different family actors’ accounts of the same illness episodes, the author brings to light different perceptions, the different symptoms different members identify or the different ways they identify them, and the fact that there are rules about who can state a diagnosis and seek health care. Young mothers (and young fathers) cannot imagine being at liberty to say what they think about their child’s health condition or deciding what to do about it. It is the elders’ prerogative to interpret symptoms, pronounce on how serious the situation is, choose a therapeutic option in a context offering several types of medical care, mobilize the means and determine the logistics for treating (or not treating) the child. So there is manifest incongruity between the bioethical bases of health care programmes where patients’ individual responsibility is involved and local realities, where illness and therapy management is collective. Whereas mothers are the main target of health policies for children, back in the village those same mothers often remain in the background when it comes to making health care decisions for themselves and their children.
Another cause of health programme dysfunction concerns possible divergences between biomedical and local interpretations of illness. The book offers an eloquent demonstration of this in connection with malnutrition. In biomedical understanding, malnutrition is caused by nutritional deficiencies (the child is not eating enough or not eating the right foods) and requires a nutritional response (supplementing or adapting the child’s diet). International programmes for combating malnutrition are active first and foremost on food-related fronts (food security, consumption practices, representations, etc.). In local knowledge, however, malnutrition symptoms do not pertain to nutrition. In biomedical terms, they are due to premature weaning, in turn due to closely spaced births. In local knowledge terms, a pregnant woman’s “hot belly” is considered a threat to the health of her still nursing child, so that child is weaned early, taken away from the mother as soon as the family discovers the new pregnancy. Under these circumstances, treatment and prevention become difficult, first because the pregnant mother’s heat rather than nutritional deficiency is understood to be the cause of the child’s illness; second, because closely spaced pregnancies (ascribed to excessive sexuality) are socially disapproved and concealed as long as possible, including by medical professionals. Last, a sick child is seldom given a specific nutritional treatment because the understanding is that children will naturally eat when they are hungry (and should not be forced to eat) and because it would not be appropriate to treat one child differently from the others. Despite the author’s personal investment in the matter, she discovers that the measures she has taken to inform and educate the population on the causes and treatment of malnutrition have little impact with them. The extremely limited success of national and international campaigns against malnutrition is surely to be put down to the gap between biomedical and local understandings of malnutrition, and the reality of early child weaning. To be effective, the author argues, a health programme has to find some measure of common ground between its own interpretative system and the local one. For example, the women responded favourably to moves to make contraception available because it meets their need to space births.
This book will interest and engage researchers and policymakers alike. Anyone who has done fieldwork in Mali or elsewhere in West Africa will find in it several of the situations and paradoxes they were confronted with; the author’s formalization and keys for interpreting them are particularly stimulating here. One of the book’s strengths is to remain fully anchored in reality: Holten applies complex theoretical notions and frameworks (anthropology of moralities, internalization of norms and inequalities) but always to account for and better understand her own richly detailed empirical materials. Her interviews bring to light these women’s own reflexivity about their lives, actions, the constraints they are under. We are always on the side of the actors, of their rationality in coping not only with difficult socioeconomic conditions but also particularly constrictive social regulations and frameworks. The author likewise takes poverty and vulnerability thoroughly into account. As she sees it, these are what condition women’s submissive acceptance of their society’s moral injunctions: poverty and vulnerability deprive those women of alternatives for attaining material and psychological security. This thesis, highlighted throughout the work – and to which we can readily subscribe – is nonetheless rather general and not really validated empirically here. Depending on their area of specialization, some readers are likely not to feel entirely satisfied. There is little in the way of demographic statistics and those presented are rudimentary. However, Holten’s questions and findings as an anthropologist will be useful in demographic investigations of health questions, both her methodology (for example, selected statements from verbal autopsies) and analysis grids (healthcare itineraries, pluralism and comparison of therapeutic systems, family actors, etc.). While the book centres on health issues, it also discusses several other problem areas in gender relations, including the construction of distance between spouses, domestic violence, social oversight of private relations, and ideas about the body. The book is relatively short (237 p.), stimulating, sensitive, precise and extremely well written – an excellent source of inspiration for thinking on gender and health in West Africa.