Negotiating Abundance and Scarcity: Health Sector Reform, Development Aid, and Biomedical Practice in a Tanzanian Hospital
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NEGOTIATING ABUNDANCE AND SCARCITY: HEALTH SECTOR REFORM, DEVELOPMENT AID, AND BIOMEDICAL PRACTICE IN A TANZANIAN HOSPITAL By NOELLE SULLIVAN A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2011 1 © 2011 Noelle Sullivan 2 To Tracy and Flynn 3 ACKNOWLEDGMENTS Dissertations are completed only after long journeys, with the support, assistance, and encouragement of so many people. Many people in Tanzania, North America, and Europe have had a hand in helping me think through the ideas that emerge in this dissertation. I have benefitted from the gracious and unfaltering support of my advisors. Hansjörg Dilger has been my Primary Advisor and Co-Chair. He has continually pushed me to expand and further clarify my ideas, and provided continual and invaluable feedback on this project from its first conceptualizations to the form that emerges on the pages below. Brenda Chalfin, my other Co- Chair, has been a constant source of stimulating ideas, enthusiasm, and encouragement. Having this special team of Co-Chairs allowed me to imagine a project that brought together the complexities of healing with those of politics, bureaucracy, and transnational governance. They have been unfaltering and invaluable mentors, continually inspiring me to explore interconnections that have not always been obvious. Luise White has pushed me to understand specific events in their wider and comparative contexts, and fostered in me a love for ethnographies past and present. Her enthusiasm, imagination and insights continue to inspire me. Maria Stoilkova urged me to think more deeply about how globalization, neoliberalism, and politics impact my research, and enticed me to assert my ideas and arguments by challenging me with important questions. I owe a special debt to Stacey Langwick, whose provocative courses and mentorship early in my graduate career significantly shaped my intellectual approach to biomedicine, science, Africa, epistemology, and notions of modernity. Although she is not on my committee, I hope she sees her mark in the pages that follow. I am also grateful to Kendal Broad, who gave me a foundation in feminist science and methodology, and was willing to share her professional and personal perspectives on very complex issues. These mentors have been 4 fundamental to my theoretical and practical training, and any disservice I do to their careful guidance belongs to me alone. For Kiswahili training, I am thankful to Masangu Matondo, who introduced me to Kiswahili with a sense of humor, and to Rose Lugano and Charles Bwenge, who continued to nurture and strengthen my language skills while at the University of Florida (UF). Lioba Moshi first introduced me to Tanzania in 2004, and provided invaluable assistance during my return trip in 2005. Her unfailing commitment to students and dry wit made my first weeks in Tanzania incredibly rewarding. MS-Training Centre for Development Cooperation repeatedly offered me training, lodging, and support in Tanzania over the years. A special acknowledgement goes out to Yusta Mganga, Gaudentia Lwakatare, and Steven Ndosi. I would also like to thank the Chuo cha Uenye Ulimavu, whose staff and resident families continue to inspire with their tireless efforts to improve the lives of people with disabilities, and train them in skills that will allow them to be independent. In Tanzania, my most profound gratitude lies with the staff, patients, and caretakers of the hospital where I worked, whose names cannot appear here for reasons of confidentiality. I was welcomed to the place I call ‘Kiunga District Hospital’ as a researcher, but also as a member of a team. The staff worked tirelessly under adverse conditions to build hospital capacity in the name of treating the ill, and patients’ relatives were admirably involved in caring for not only their loved ones, but also other patients in need. These caretakers continually assisted hospital personnel in a way that was both remarkable and generous. I am humbled and grateful that the staff, patients and relatives shared with me their joys, aspirations, frustrations, and sorrow—only a fraction of which was able to spill out onto the pages that follow. The District Medical Officer (DMO), “Dr. Saidi,” was always a gracious host, and his commitment to building the hospital 5 was imaginative and moving. Being a researcher in the context of a hospital in Tanzania truly tested my anthropological training. Importantly, it also tested me as a person, and the staff’s pragmatism helped ease these dilemmas. Ninawakumbuka sana. I must also acknowledge the warm welcome I received from ‘Kiunga’ District Council, and all of the councilors and staff that took time out of their busy schedules to talk to a researcher and allow me to attend their meetings so I could understand the way the health department intersects with other community concerns. There were many people in Tanzania who provided my family and I with friendship, support, and laughter. First among them must be Baba and Mama Simon and their children Simon and Catherine, who invited us into their lives and provided us with daily sustenance and companionship. Tunawashukuru sana, na tunawakumbuka kila siku! Claus and Trine Heim, and their children Camilla and August, as well as Stefan and Christiane Völk and their children Nielson and Tilmann, were constant friends and playmates—they literally came to our rescue on numerous occasions, and so literally, this dissertation would not have been possible without their timely and selfless assistance. I must also thank Jesper Mogensen and Lidet Wolde, who provided us with shelter, sometimes for long periods of time—not to mention amazing meals and good company. Jesper Bosse Jønsson was always source of inspiration and humor. I am grateful I was in the right time and place to meet Charles Llewellyn, and his wife Deborah, who were constantly hospitable and entertaining hosts, and have continued to support me in my work. Bernard I. Sefu, Mama Gertrude, Joho, and Sophia Moshi provided stimulating conversation and friendship. We owe a special debt to Diamond and Diana Carvalho, and their daughter Sophie, with whom we shared many great meals and even more laughter. I am quite certain Diamond and 6 Tracy will drag each other to the top of Kili one of these days! I would also like to thank Irene Rwegalulira for her assistance in transcribing interviews. Tanzania’s Ministry of Health and Social Welfare (MoH) deserves special thanks. Due to their kind invitation, I was able to mine the MoH library as I attempted to reconstruct a history of the health sector, and many officers took time out of their very busy schedules to tell me their personal stories, and the stories of the departments within which they worked. Within the MoH, I am particularly grateful to Dr. Faustin Njau, who not only agreed to an interview and provided additional information via email, but also graciously permitted me to attend the Joint Annual Review of the Health Sector meeting in 2008. Dr. Bjarne Jensen also took out so much time to share his experiences with me, both within and outside of Tanzania. I would also like to thank Dr. Z. A. Berege, for providing me with letters of introduction to the district hospital where I worked. This research was supported by a Fulbright-Hays Doctoral Dissertation Research Abroad fellowship, for which I am very grateful. Tanzania’s Commission for Science and Technology (COSTECH) provided research clearance for this study, and Dr. A. Mvungi of the Department of Sociology at the University of Dar es Salaam was my sponsor. I must also acknowledge the support of Drs Ruth Meena and Rose Mwaipopo, as well as Mrs. Mabel Kaaya. Special thanks must also go to the American Embassy in Dar es Salaam. I presented some of the ideas contained in this study at two workshops: the first, “Institutions, Collaborations, Power: Workshop on Hospital Ethnography” at the University of Sussex, UK, and the second, “Urban Health in Sub-Saharan Africa” in Bamako, Mali. I would like to thank the organizers, as well as all of the participants for the fruitful conversations we shared, which have left important imprints on my thinking. I am also thankful to Claire Mercer, 7 Lisa Richey, and Stefano Ponte for their comments and insights at the African Studies Association meeting in 2009. Although I had been following her work for several years, I finally was able to meet Claire Wendland in 2009, and our continued exchanges to date have leave a profound impact on my thinking. Her impact on the pages that follow is clear, and I look forward to future collaborations. The foundation in anthropology I received at the University of Victoria as an undergraduate has left its mark on me. I am especially grateful to Patricia Spittal, whose work first inspired me to become an anthropologist, and to Eric Roth and Lisa M. Mitchell, who honed my interests in the intersections of health and technology. At the University at Albany, I am thankful to Iris Berger, who helped strengthen my thinking and writing while a master’s student. The University of Florida’s Department of Anthropology and its Center for African Studies (CAS) have provided me with a very happy academic home. They have been constant sources of financial, academic, intellectual and moral support. From CAS, I benefited from three Fulbright-Hays Foreign Language and Area Studies Grants (FLAS), as well as several travel grants. I am thankful for the continued support of Léonardo Villalón, Todd Leedy, Corinna Green, Ike Akinyemi, Renata Serra, and Julie Silva. The Department of Anthropology gave me numerous opportunities to teach, as well as a wonderful environment in which to learn.