Bradford, ON: Demeter Press, 2016. ix, 317 pp. (Tables, figures, map, B&W photos.) US$34.95, paper. ISBN 978-1-77258-004-4.
The United Nations published the eight millennium development goals (MDGs) in June 2013 with a thousand-day deadline of September 2015. Though these goals have now expired and been replaced by the “sustainable development goals 2015–2030,” or SDGs, the issues remain relevant even as the acronyms and programs change, because development and human rights goals like the MDGs are never actually finished. The articles in this important collection focus on MDG 3, “promote gender equality and empower women,” and MDG 5, “improve maternal health.” The volume discusses these goals by focusing on in-depth ethnographic cases in both Africa and Oceania. In various ways the chapters examine the impact of cultural challenges, resource scarcity, and gender-based, structural inequality on women’s health issues, showing how the MDG goals made or missed the mark (spoiler alert: as the title implies, it’s mostly the latter). The contributions in Missing the Mark offer deep ethnographic context for women’s health care, setting this context against the culturally flattened superficiality of the millennium goals themselves. The volume adds to editor McPherson’s important career contributions on Melanesian health and gender issues and her introduction stresses how the solutions of cosmopolitan medicine fail to account for the diversity of challenges in Melanesia and Africa.
It comes as no surprise that reproductive health is especially complicated for women in the Global South. Often women cannot make the individual and free reproductive choices that are engendered in policies like the millennium development goals. Some of the challenges to achieving the MDGs appear to be resource-related and infrastructural: access to medicine, access to clinics, availability of health providers, and affordability of health care are among many such factors. In the volume’s introduction McPherson tells us that a Marshallese woman wanting to give birth in a hospital must plan to be away from her family for six months due to the distance between islands and transportation costs. But even structural and logistical challenges are not simply about resources: cultural values, religious practices, and social relationships are always an important part of the picture. Cosmopolitan medicine is based on the assumption that patients have individualized control over decision-making, but for women in Melanesia and Africa, decision-making is embedded in kinship, and male kin often exert control over women’s reproductive health. Such decision making is often most complicated with contraception. Family planning is frequently stigmatized due to pro-natalist cultural, and religious beliefs found widely in Africa and Melanesia and addressed at length in this collection, most thoroughly in Nicole Hayes’ excellent article on condom use in southern Malawi. The volume underscores how gender empowerment and equality (MDG 3) are necessary for women to achieve better health outcomes (MDG 5).
McPherson rightly asserts in the introduction that the global breadth of the MDGs make them oblivious to local issues of “cultural safety,” a concept referring to the need to empower cultural identities, originally developed by Brascoupé and Waters in their studies of health care delivery to the Maori. Responding to this need, the articles in the collection bring detailed ethnographic focus to the importance of cultural safety in the improvement of maternal health. Along with the volume’s excellent introduction, several articles stand out. Stephanie Hobbis’ contribution on kastom and changes in women’s status at Malaita, Solomon Islands draws on the rich ethnographic literature from there, updating it and framing it in terms of women’s health. She ties together many relevant themes: kastom and its transformation (she calls its current form “muddled”), the relevance of transformed pollution beliefs about women’s bodies, the gendering of witchcraft, women’s labour, the impact of development, and ultimately health services as an institutional nexus where these strands come together in a detailed case study.
Barlow’s article on a Lower Sepik mission-based maternity clinic is another stand-out. She offers a case study of successful care based on cultural safety. From 1981 to 1997 at the Marienberg Catholic Mission station, Sister Marianna built a maternity clinic for pregnant, birthing, and post-partum women. Knowledge of local practices is an important form a cultural safety and one which is made possible if birth attendants and other maternity clinic personnel are members of the community, a point also stressed by Chelsea Wentworth in her contribution on breastfeeding in Vanuatu. Because of Sister Marianna’s Catholic affiliation, the clinic did not provide family planning services or contraception and there were some customary practices that Sister Marianna worked to overcome, including the ideal for unassisted birth. Yet the clinic’s success resulted from Sister Marianna’s sensitivity to local needs and understandings, precisely what is underemphasized in policies like the MDGs.
Overall, Missing the Mark is a first-rate collection, a medical anthropological antidote to universalist policies. Volumes premised on grouping disparate geographic regions have largely fallen out of favour in anthropology, but Missing the Mark works due to the global nature of the MDGs and the consistent set of challenges faced across the Global South with respect to women’s health. Thus, the African entries in the collection should appeal to Pacific scholars. For example, Hayes’ descriptions of Malawian churches’ impact on matrilineal institutions discuss the displacement of sibling solidarity and extended family with the Pauline emphasis on conjugally based nuclear families with male heads of household. This will ring familiar to scholars based in the Melanesian islands, where these effects on matrilineal groups are also felt. The book’s strength lies in the diversity of case studies, field sites, and contributors, one of whom, Winnie William (Nipa, Southern Highlands), is an indigenous Melanesian scholar of note. The copyediting has some minor problems and unfortunately the book lacks an index. Nevertheless, this is an important group of papers and Missing the Mark is recommended for those interested in medical anthropology, women’s health, development, and human rights. Due to the emphasis on ethnographic context and lack of obfuscating theory or jargon, the book (or selections from it) would be suitable for undergraduate introductory courses as well as more advanced topical seminars and graduate classes. It is a recommended acquisition for libraries maintaining collections in Melanesian anthropology, medical anthropology, and gender and health. The volume showcases contemporary research in this much-needed area and points the way toward additional scholarship. The MDGs have ended but the relevance of this volume outlives them.
Derek Milne
Pasadena City College, Pasadena, USA