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Making and Unmaking Public Health in Africa: Ethnographic And Ethnographic and Historical Perspectives Making and Unmaking Public Health in Africa Edited by Ruth J. Prince and Rebecca Marsland Ohio University Press • Athens Contents vii ACKNOWLEDGMENTS Situating Health and the Public in Africa Historical andINTRODUCTION Anthropological Perspectives RUTH J. PRINCE 1 ThePART Peculiarly I: WHOSE Political PUBLIC Problem HEALTH? behind Nigeria’s Primary HealthONE Care Provision MURRAY LAST 55 Who Are the “Public” in Public Health? Debating Crowds, Populations,TWO and Publics in Tanzania REBECCA MARSLAND 75 The Qualities of Citizenship Private Pharmacists andTHREE the State in Senegal after Independence and Alternance NOÉMI TOUSIGNANT 96 PART II:Regimes REGIMES of Homework AND RELATIONS in AIDS CareOF CARE Questions of Responsibility andFOUR the Imagination of Lives in Uganda LOTTE MEINERT 119 v Contents “Home-Based Care Is Not a New Thing” Legacies of Domestic GovernmentalityFIVE in Western Kenya HANNAH BROWN 140 Technologies of Hope Managing Cancer SIXin a Kenyan Hospital BENSON A. MULEMI 162 PART III: EMERGINGThe Publics LANDSCAPES of the New Public OF PUBLICHealth HEALTH Life Conditions and “LifestyleSEVEN Diseases” in Uganda SUSAN REYNOLDS WHYTE 187 Navigating “Global Health” in an East African City RUTHEIGHT J. PRINCE 208 The Archipelago of Public Health Comments on the LandscapeNINE of Medical Research in Twenty-First-Century Africa P. WENZEL GEISSLER 231 Bibliography 257 Contributors 285 Index 289 vi INTRODUCTION Situating Health and the Public in Africa Historical and Anthropological Perspectives RUTH J. PRINCE decay of government-controlled health services and a corresponding SINCE THE 1980S, MANY AFRICAN COUNTRIES HAVE WITNESSED THE proliferation of nongovernmental, transnational, private, and humani- tarian organizations that target specific health-care needs, treat dis- eases, support service provision, or combine research with provision of health care—often through geographically and temporally limited projects. Since the turn of the twenty-first century, the language of health “emergencies” in Africa has gained increasing purchase in inter- national concerns about security, conflict, and the spread of disease and is being linked to moral agendas and discourses of human rights. Africa has emerged as a prime arena of “global health” interventions focusing on the control of particular diseases. These high-profile interventions are reshaping social and political landscapes as well as infrastructures of health. Yet they exist alongside more mundane and persistent condi- tions and concerns. While global attention is focused on HIV activ- ism and the terrain of antiretroviral provision, most African doctors, nurses, and health-care workers struggle with the day-to-day challenge of providing a reasonable standard of care in underresourced public health facilities. This volume rethinks public health and what it means in Africa. The term public health implies the duty of government to provide for the health of its citizens, yet this situation has never been fully implemented on the continent. Attending to the legacies of earlier ameliorative drives 1 to provide health care to nationalRUTH J. publics,PRINCE to neoliberal structural ad- justment, and to novel transnational interventions and biopolitical configurations, the volume assesses the uneven terrain of public health in Africa. It offers a critical analysis of widening global and national inequalities and the emptying out of the public as an inclusive terrain, as health-care provision is shifted towards the arena of the market and of nongovernmental and transnational organizations. At the same time, less visible engagements with the health of the public and with a public good open up new perspectives on the present and future. The book thus casts a critical eye on both the radical shifts in health-care provi- sion and the less visible concerns and practices that connect the realm of “health” with that of the “public” (or publics) in Africa today. It presents ethnographic and historical perspectives on landscapes of what can be broadly termed “public health” in Africa, as well as on the regimes, rela- tions, and tensions that animate them. Contributors to the volume analyze the place of public health within emerging global “biopolitical” formations of political institutions, mar- kets, human populations, and health, and explore how African profes- sionals and citizens approach questions of responsibility for public health as they navigate contemporary landscapes of NGOs and transnational projects, faltering state services, and expanding privatization. The au- thors also attend to the broad range of moral and political practices that Africans have drawn upon to intervene on the health of a collective, practices that have a long history going back to the precolonial period. Individual chapters explore confrontations of official versions of public health with indigenous concerns about collective well-being in Tanza- nia; tensions between private and public spheres of responsibility for health and welfare in northern Nigeria; and attempts by pharmacists in Senegal to mediate public and private health sectors, state responsibili- ties, and citizenship. Other chapters follow how medical professionals, patients, “community-based organizations,” and “volunteer” health work- ers navigate new regimes of HIV treatment in East Africa; negotiations of care for cancer patients in an underresourced public hospital ward; the struggles of people with diabetes within a disparate and uncoordinated landscape of health promotion, advice, and therapy in Uganda; and the interweaving of transnational medical research trials with health-care provision. Together, the chapters offer insights into widening global and national inequalities as well as present and future trajectories of public health in Africa. 2 Introduction: Situating Health and the Public in Africa The term public health conventionally refers to the duties of the modern state concerning the protection and care of the health of its citizens, through the application of modern, scientific medicine and rational administration—providing health-care services, preventive medicine, and environmental sanitation, as well as protective legislation concerning exposure to industrial, agricultural, or environmental haz- ards.1 A vision of amelioration guides this drive toward public health, which applies biomedicine and bureaucratic procedures to state inter- vention and control, financed by national systems of taxation and health insurance. This vision, and the unity between “state” and “society” that it both assumes and strives for, was embodied most fully in the socialist and welfare regimes that were established in western European states during the mid-twentieth century.2 It was exported to Africa in the halfhearted attempts of some colonial administrations in the 1940s to extend health and welfare services to broader segments of the population and was more enthusiastically pursued by some independent African govern- ments in the “developmentalist” era of the 1960s and 1970s.3 This vision of public health appears anachronistic when we consider contemporary landscapes of health-care provision, whether in Africa or in Europe. Yet it is one that should be taken seriously. The appeal of biomedicine to inclusive and expansive visions of progress and development and as- sociated ideas about government responsibility, public service, and the public good are concepts that are now rarely associated with African states, yet they did play a part in the hopes and expectations many Afri- cans had for development and for a national future.4 In many countries after independence, especially those that appear in this book—Senegal and Nigeria in West Africa, and Uganda, Kenya, and Tanzania in East Africa—the extension of public health to an expectant citizenry became a nationalist project. It was pursued by governments and backed up by foreign aid and by the World Health Organization (WHO), and it had some success: hospitals and clinics were built in rural and urban centers; medical schools were set up; and primary health-care programs, vacci- nation and immunization campaigns, and maternal health services were extended. These visions were not, of course, shared across African coun- tries (some of which were still fighting white supremacist regimes while others faced civil war, backed up by foreign political interference). They were also often tied to authoritarian and paternalistic regimes; they had to contend with, and were often deflected by, the very different con- cerns of what Rebecca Marsland in her chapter refers to as “indigenous” 3 public health; and they wereRUTH undermined J. PRINCE by scarce resources. Still, their legacy is apparent today in the material and human infrastructure of government health services, even if much of this is currently in a state of disrepair and even ruin.5 The first objective of the book is to take these histories and legacies of biomedical modernization and associated public health initiatives seriously in our attention to how African publics—including medical professionals, scientists, government officials, staff of nongovernmental organizations (NGOs), community health workers, “volunteers,” pa- tients and their families, and clinical trial subjects—seek to provide or receive medical care. In doing so, we try to understand both why these initiatives often failed and how these actors navigate within contem- porary landscapes of NGOs and transnational projects, faltering
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