These detailed ethnographies engage with a long tradition in the anthropology of Africa exploring the course of action taken in the event of illness, as exemplified by Janzen's (Reference Janzen1978) classic study of ‘therapy management’ in the Congo. This literature has highlighted how illness and help-seeking are embedded within social and moral worlds, even as the terrain has shifted from a focus on ‘traditional’ healing to the ‘indigenization’ of biomedicine in African settings (Etkin et al. Reference Etkin, Ross and Muazzamu1990). Based on anthropological fieldwork in rural West African communities, both volumes highlight the ways in which the use of biomedicine is governed by gender relations and access to the cash economy, both of which are in turn suffused with notions of morality.

Holten, a midwife and anthropologist, established a maternity clinic in Farabako, a village in a remote region of north-west Mali. Her monograph, drawing on several periods of fieldwork over three years, forms her doctoral thesis. Her research arises from her bewilderment at women's unwillingness to seek help, even in the event of potentially mortal illness. Holten's detailed methodology to investigate the reasons for such apparent passivity includes ‘traditional’ ethnography such as participant observation, a village census and informal conversations, as well as quantitative and qualitative methods such as verbal autopsies, free-listing and reproductive life histories. The result is a thorough and wide-ranging investigation into the nature of health-seeking in a context of extreme poverty and rural isolation. Holten's clinical interventions in episodes of childbirth and childhood illnesses, including fatal levels of malnutrition, highlight the challenges of working as both a clinician and an anthropologist in a ‘zone of awkward engagement’ with biomedicine. However, this does not compromise her methodological or theoretical rigour in seeking to understand seemingly ‘irrational’ behaviour, the age-old endeavour of the anthropologist. She carefully uncovers the ways in which women's behaviour is governed by an ‘intersubjective logic of shame’, moloya, through which they seek to manage their status and reputation in a male-dominated society. Women must obtain a husband's permission before taking action in the event of illness and ask him for money for transport or medicines. To actively seek healthcare is to expose themselves as shameless, questioning the capacity of men as providers and risking their social status and ‘ontological security’. Holten convincingly argues that women's seeming passivity in the event of illness is rather a form of agency in order to build social and symbolic capital by meeting the moral ideal of the ‘good woman’. Although some women risk shamelessness to seek help, within the discourse of moloya there is little room for manoeuvre or agency without invoking social sanction.

In contrast to Holten, Bierlich's monograph was composed over fifteen years after his doctoral fieldwork in the early 1990s. Consequently, it does not cover the impact of more recent global and local changes such as the rise in migration and the contribution of remittances to meeting health costs, and the introduction of a national health insurance scheme in Ghana. Nonetheless, his deeply contextualized investigation into the responses to illness in a Dagomba community in northern Ghana amid social and economic change accords with a body of work from the region on ‘pragmatic experimentation’ (Reynolds Whyte Reference Reynolds Whyte1997), where biomedicine forms part of an increasingly diverse healing landscape. Outwardly, Dagomba women share much of the status of women in rural Mali. Like the women of Farabako, officially they are not supposed to take individual action to obtain medicine for themselves or their children. However, Bierlich portrays Dagomba women as having greater economic and social capacity to subvert the social hierarchy and to negotiate access to healthcare, despite men's greater ritual and political power.

Both authors illustrate how, with the impact of structural adjustment and global capitalism, men in both Mali and Ghana have increasingly struggled to generate sufficient income to fulfil the official ideal as providers for their wives and children, including paying for healthcare and medicines. However, the impact appears greater on women in Farabako, who have little opportunity to access money by other means, increasing their dependence on men and their need to prioritize their reputation over the health of their children. Dagomba women, on the other hand, generate their own income through a variety of enterprises including farming, trading and selling food, enabling them to purchase medicine themselves, despite their officially lower social status. By contrasting official discourse and observed practice, Bierlich challenges a simplistic dichotomy between immoral commodification and moral gift exchange, arguing instead for the significance of context in determining morality. Paying for medicine is morally sanctioned by men since medicines should be the freely given product of social exchange and ‘money spoils the medicine’. For Dagomba women, however, the commoditization of pharmaceuticals frees healthcare from the gendered social hierarchies governing the exchange of traditional medicine, even while the moral imperative in social interactions remains significant, for example in facilitating access to credit when purchasing medicines.

These two studies repay being read side by side, as the differences and similarities illustrate the value of ethnographic methods in shedding light on health-seeking strategies as mediated by local social and moral worlds. Failing to engage with such diversity could easily lead to superficial generalizations based on apparent similarities in social structure and gendered hierarchies. Nevertheless, even the most remote communities, in ‘the middle of nowhere’ as Holten has it, are in fact somewhere on the periphery of a globalized economy. Despite her thorough analysis of moloya and its impact on women's help-seeking behaviour, Holten ultimately concludes that interventions must move ‘beyond culture’. Such moral discourses endure, less due to some inherent or mystical power of culture, as implied in many popular conceptions of ‘tradition’, than as an expression of gender inequality compounded by enduring poverty, a conclusion supported through comparison with the relative economic empowerment of the women of Bierlich's study. Although such factors are often overlooked in favour of grappling with perceived ‘traditional beliefs’ and practices, these studies highlight how it is not so much ‘culture’ or ‘tradition’ that may be the obstacle to improving women's status and access to healthcare in Africa, but the impact of wider structural inequalities, both local and global. Without addressing these, the success of any health initiative is likely to be severely constrained, particularly as such inequalities continue to increase. As these studies illustrate, most poignantly in Holten's account of the death of a malnourished child, understanding what stands in the way of equitable access to healthcare is not simply an anthropological exercise in curiosity; rather, what is at stake is the relief of human suffering.