by Deborah Mindry, UCLA, & Kara Miller, UC Riverside
There is a long and complex history of Western aid and medical interventions in Africa dating from the colonial era to the present. Biomedicine in Africa is fairly synonymous with colonization, and neocolonial missionary medicine. By the middle of the nineteenth century, medicine became a popular component of missionary work in Africa and the majority of medical infrastructure that emerged on the continent grew largely out of religious activity (Bornstein and Redfield 2010). The complex racial politics of colonial medical interventions in Africa is most vividly captured by Bassek in his critical film on the work of Albert Schweizer in Gabon in “Le Grand Blanc de Lambarene.” The superiority and patronizing tone of Imperial power lingers in the discourse, policies and practices of health interventions in African countries today. Clinics are thresholds to the histories of medical missions rife with ideologies of piety, hygiene, and fidelity. Stacy Langwick argues that the manuals, training modules, and published protocols of the World Health Organization (WHO) and others are bearers of the supervisory and evaluative tones evident in African clinical settings today (2012). Clinical discourses, which are at best patronizing and at worst demonizing, but always disciplinary, are perpetuated by health workers and community health officials.
Our personal engagements in sexual and reproductive health research in Uganda, South Africa, Malawi and Rwanda have drawn us each into the world of global and national health interventions – their promise and their failings. Anthropologists engaged in health research witness the impact of global health politics on local health practices, policies and behaviors. In conducting ethnographic research, we are in conversation with policy makers and others who script these interventions as well as with the clients, communities and health care providers impacted by them. We are witness to the incongruence between the glossy development portfolios and the lived experiences of healthcare providers and community members. While aid efforts and medical interventions wax and wane, and eventually fade, it is local practitioners who must find ways to continue providing care. Sustainable solutions are increasingly the focus of global health interventions but in poorly resourced settings and with limited availability of suitably trained personnel these efforts frequently fail to meet their goals or the needs of the people they claim to serve. Foreigners equipped with the power of biomedical knowledge and resources operate under the guise of medical collaboration with local community leaders and health workers. The danger in these collaborations is not only that local African authorities are placed in positions of token indigenous gatekeepers, but that these global initiatives simply do not align with the everyday processes in many African towns and villages. These efforts underscore the inherent differences in health philosophies and logistics espoused by the global health community as compared with indigenous healthcare practitioners.
For a century or more, Africans have encountered colonial and neocolonial efforts to undermine indigenous health knowledge and practices. Traditional knowledge is invariably “trained” out of people and the indigenous practices are “bettered” by biomedicine. The difficulties in merging medical systems are glaring and the local provider becomes a metaphor for how indigenous medicine does not fit into models of Western biomedicine (Langwick, 2012). The biopolitics central to development projects mean there are gaps among the abstractions and particularities of healthcare services; between policy and practice; between the global and the local. Moreover, the allure of biomedicine and all that comes along with those projects (vehicles, tablets and injections, foreign visitors, gifts, etc.) eclipses the enduring services of local providers. Western biomedicine does indeed threaten local lifeways.
At times efforts to discredit African medicine and healthcare models have been welcomed but mostly they have been challenged and resisted not only by indigenous practitioners but by individuals and communities who view western medicine and global health initiatives with suspicion. Most infamous was the resistance by Thabo Mbeki, South Africa’s President from 1998-2008 (when he was removed from office by the ANC leadership), who notoriously embraced dissident theories in his refusal to accept the linkage between HIV and AIDS, failing to provide effective treatment to a population increasingly dying from the disease. At the 13th International AIDS Conference held in Durban, South Africa in 2000, international critique and support lent weight to local activist efforts to push for change in AIDS policies leading eventually to the systematic rollout of antiretroviral treatment (ART) in 2004. South Africa now has the largest number of people living with HIV of any country in the world, estimated at 6.8 million, and the largest number of people on ART at 3.5 million (UNAIDS May 2016, http://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2016/may/20160513_UTT). Idi Amin, during his reign as Ugandan President, also exiled foreigners and called upon local practitioners advocating for “African medicine”. Africanness was a central tenant of Amin’s cultural overhaul, his creed, and his mission to bring Uganda down to a concentrate of its greatest values, and this included a rejection of all non-African business and medical doctors. The long-standing interplay between global health mega-programs and local medicine in Uganda consists mostly of either harnessing indigenous knowledge or instructing health workers and local practitioners on how better to fit into biomedical models and praxes.
Global health interventions focus primarily on efficacy and outcomes rather than on understanding the social, political and health implications of these medicalized interventions. What is not well investigated are the broader health implications for individuals, families and communities of global health interventions in African settings. An important first step in this direction was investigations of colonial era medical and health interventions. Much of this research was undertaken in the late 1980s and the 1990s exemplified by the work of Megan Vaughan, Curing Their Ills: Colonial Power and African Illness (Stanford, CA: Stanford University Press, 1991) investigating the cultural differences in the approach of missionary medicine and indigenous African understandings of illness [http://www.sup.org/books/title/?id=3171]. Rita Headrick’s, Colonialism, Health, and Illness in Equatorial Africa, 1885–1935, ed. Daniel Headrick (Atlanta: African Studies Association, 1994) which examines the disastrous health consequences of colonial interventions to develop a healthy labor force and the tardy response of the colonial health service to address the demographic crisis it created. Other important contributions include Nancy Rose Hunt’s, A Colonial Lexicon of Birth Ritual, Medicalization, and Mobility in the Congo (Durham, NC: Duke University Press, 1999) [https://books.google.com/books?id=xPzMu1jheNUC&pg=PA264&lpg=PA264&dq=colonial+lexicon+of+birth&source=bl&ots=nZUp8BQgiD&sig=irOD-Jtn7_IuOEayw1wrc-GF83o&hl=en&sa=X&ved=0ahUKEwjP2Nvt6I_PAhWM6oMKHVZdCLg4FBDoAQg0MAU#v=onepage&q=colonial%20lexicon%20of%20birth&f=false]; and Maryinez Lyons, The Colonial Disease: A Social History of Sleeping Sickness in Northern Zaire, 1900–1940 (Cambridge: Cambridge University Press, 2002 [https://books.google.com/books?id=eNgZqIQ5VxkC&printsec=frontcover#v=onepage&q&f=false].
In the postcolonial era the language of development cloaked in humanitarian ideologies has played an ever increasing role informing global efforts to improve the health and wellbeing not simply of Africans but of the global community. The new global citizen invests in humanitarianism rather than politics. In her work in France, Tiktin (2006) found that humanitarianism has grown substantially beginning in the 1990’s shifting from a human rights framework to sheer humanitarianism, evidenced by Medecins Sans Frontiers’ receipt of the Nobel Peace Prize in 1999. Tiktin points out that medical humanitarianism operates through a notion of “bare life,” that is stripped of humanity, unqualified by political and social communities (2012). She argues that the biological lives of the subjects are signed with racial, political, gendered, historical, supremacist, ideological content. Created on a global stage the subjects of these global health interventions respond to layers of health campaigns from past and present.
The language of health and healing is scripted by foreign efforts, government sponsored and/or funded through international aid, with policy documents and local records that read like the pages of a European or American medical policy manual rather than reflecting the specific needs or concerns articulated by locals. Hospitals and clinics throughout Africa are full of Western volunteers, doctors, nurses, students and researchers logging practicum hours and gaining experience in the field. All too often the standard ethics of supervision go out the window; far too many unqualified students and volunteers are practicing medicine in Africa. The empowered and entitled actions of these Westerners combined with local efforts to deliver health care to communities makes for a dangerous continuation of neocolonial experimentation that, although not systematic, is often insidiously oppressive. In this way, global policy makers and project managers blaze through Africa marking clinical spaces in ways not dissimilar from missionary colonial efforts to uplift Africans, maintaining hopeful dependencies (Hansjorg Dilger 2012).
An important emerging field of global health research is critical investigations of medical trials in Africa which interrogates the global politics of medical experimentation. Two works, in particular, provide important historical background including Melissa Graboyes’, The Experiment Must Continue: Medical Research and Ethics in East Africa, 1940-2014 (Ohio U. Press, 2015) which provides a rich ethnographic history of medical experiments in East Africa from the colonial period to the present. And Helen Tilley’s, Africa as a Living Laboratory: Empire, Development, and the Problem of Scientific Knowledge, 1870–1950 (Chicago: University of Chicago Press, 2011) which investigates British use of scientific knowledge for the purposes of colonial administration [https://books.google.com/books?id=vPrBhdBOzAMC&printsec=frontcover#v=onepage&q&f=false].
Research efforts to systematically document the history of global health in Africa are also very recent. Giles-Vernick and Webb’s (2013) edited volume “Global Health in Africa” is unique in its effort to document a more comprehensive history of global health initiatives in Africa [http://www.ohioswallow.com/extras/9780821444719_chapter-five.pdf]. Their work is preceded by efforts to investigate specific disease interventions such as John Iliffe’s, The African AIDS Epidemic: A History (Athens: Ohio University Press, 2006), and Myron Echenberg’s, Africa in the Time of Cholera (New York: Cambridge University Press, 2011). Investigations into the role of the World Health Organization in responding to infectious diseases include David P. Fidler’s, “Germs, Governance, and Global Public Health in the Wake of SARS,” Journal of Clinical Investigation 113, no. 6 (2004): 799–804, and Lorna Weir and Eric Mykhalovskiy’s, Global Public Health Vigilance: Creating a World on Alert (New York: Routledge, 2010). João Biehl and Adriana Petryna’s edited volume When People Come First, is a wonderful critical collection of studies in global health and is organized into clusters of evidence, interventions, and markets (2013). Kate Dovel’s recent dissertation, Shifting Focus from Individuals to Institutions: The Role of Gendered Health Institutions on Men’s Use of HIV Services (U. of Colorado, Denver, 2016), examines the gendered effects of global and national health policies on health service delivery and institutional practices in southern Malawi.
Susan Reynolds Whyte has long-written about medical knowledge production in Uganda and her work gets at the ways in which Africans view biomedicine and its effects. In fact, much of the literature on health-based interventions and development strategies in Africa includes some critical elements of how local people and networks contest such strategies, albeit often not overtly, but rather through pragmatics and ideological distancing witnessed as expressions of selfhood and agency (Vincanne Adams and Stacy Leigh Pigg, 2005, Sex in Development: Science, Sexuality, and Morality in Global Perspective). Saethre and Stadler’s forthcoming book, Negotiating Pharmaceutical Uncertainty: Women’s Agency in a South African HIV Prevention Trial (Vanderbilt U. Press, 2017) [http://www.vanderbilt.edu/university-press/book/9780826521392] provides an important contribution to understanding the relationships between medical researchers and their subjects.
Where do we go from here to develop a critical African engagement in global health initiatives operating under the guise of humanitarianism? As a first and very basic step, we must place Africans at the center of global health conversations that impact their lives.
Deborah Mindry is a Research Anthropologist in the UCLA Center for Culture and Health. Her research interests include gender politics, NGOS and development, and HIV/AIDS. She has conducted qualitative ethnographic research in South Africa since the early 1990s. Her current research examines fertility intentions and safer conception services for HIV infected men and women in South Africa (Durban), Malawi (Lilongwe and Nkhoma), Uganda (Kampala) and USA (Los Angeles).
Kara Miller is a PhD candidate in the Department of Anthropology at University of California- Riverside. She is interested in care as a conceptual practice, as a moral compulsion, and as a form of relationality. Miller’s research looks at bodily vulnerability and formative social entanglements of care. Her dissertation project with traditional birth attendants (TBA’s) in Southern Uganda is an ethnography of risk and responsibility in relation to care. She explores a governmental ban enacted in 2011 that outlaws the services of the TBA, and she ask what the implications are of criminalized care.