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Modernizing Medicine in Zimbabwe
HIV/AIDS and Traditional Healers
By David S. Simmons Vanderbilt University Press
Copyright © 2012 Vanderbilt University Press
All rights reserved.
ISBN: 978-0-8265-1809-5
CHAPTER 1
Maladies of Modernity
Economic Structural Adjustment, HIV/AIDS, and the State of Health
It's very worrying. They've been educated, and they have something they can give back to the country. But just when they reach that point, they depart this life. —Dr. Timothy Stamps, Zimbabwean minister of Health and Child Welfare
Harare, also known as Sunshine City, is the capital of Zimbabwe, located on the Highveld or watershed plateau between the Limpopo and Zambezi Rivers. A city of profound contradictions, it is a place where glittering glass and steel high-rises stand side by side with shelters made of discarded wood and sheets of plastic, where cybercafes and the latest model Nokia and Sony Ericsson cell phones proliferate while the majority of the population of 1.5 million cannot afford even an in-house phone. The jacaranda-shaded streets of the low-density suburbs, which are situated mainly in the northern part of town and were formerly majority white, stand in stark contrast to the crowded usually treeless former (mainly black) townships or high-density suburbs of the city's southern borders. It is in these latter areas that one gets the sense of the pulsating life of older African cities (see Rakodi 1995)—raucous backstreet beer halls, bustling streets, markets, backyard shacks, crowded buses, taxis, and emergency taxis, or ETs. Located along the railway line east and west of the city center, the industrial areas are the buffer zone for both these sectors. It is tempting to see this buffer zone as the dividing line between African and European, poor and rich, disease and health. While this would be an oversimplification of the social geography of the city, such a depiction would have some basis in truth, particularly during colonial times when "black slums sprang up all over, constructed of the simplest and cheapest materials: poles and dagga, grass and tins, tied and nailed together to form some sort of shelter."
In this thoroughly modern city, it is common to hear accusations of witchcraft, and many people live in fear of being bewitched, of being objects of persecution by tokoloshis (invisible creatures said to possess magical powers) and other supernatural agents or phenomena. Living in and traveling around Harare, one is aware of moving through a "heterogeneous modernity," to use Clifford's term, where the staccato rhythms of mbira mix with the bold sounds of African American R&B and hip-hop, where affluent teenagers, most often nose brigade, wear the latest urban gear of Fubu and Cross Colours and debate whether or not Tupac is really alive or dead while sipping cappuccino at the trendy Book Cafe, while their less affluent age mates beg for "a dollar please, Boss," on the streets outside. In Harare, one gets the sense that linear history is broken, "the present constantly shadowed by a past that is also a desired, but obstructed future: a renewed, painful yearning" (Clifford 1997, 264).
Harare's shadowed past includes its establishment by European settlers initially drawn by rumors of the legendary riches of Ophir (Phimister 1988), a chimerical gold reef reportedly similar to that of South Africa's Witwatersrand. Through the machinations of the British South Africa Company, De Beers, and Gold Fields of South Africa, plans were quickly developed to facilitate the accumulation of capital, much of the control of which was in foreign hands, and domination of the surrounding territory. Infrastructure provision, land use planning, and the implementation of measures necessary to ensure a low-cost pliable workforce ensured the maintenance of a comfortable lifestyle for European residents at the expense of local black Africans (Rakodi 1995, 256; see also Phimister 1988). Such infrastructure provided the internal scaffolding, the template, upon which postcolonial Harare, the seat of government, has fashioned itself and its relations with the rest of the country.
Many travelers to other African countries are struck by the level of development as witnessed in Harare's apparently sound infrastructure, which includes twenty-four-hour electricity, decent roads, modern architecture and urban planning, and general cleanliness. People used to say that Harare was not really Africa but a good place to visit as an introduction to the continent—Africa lite, as it were. As many Hararians will testify, though, things are worse today and the city is falling apart. "It's bad, man, I tell you!" were the first words uttered by a friend of mine, Isaiah, when I returned in March 1999. Harare, it seemed, was full of angry citizens complaining about the deteriorating standards of the city, the country, and by extension the very promise of modernity itself. The lack of timely and systematic refuse collection, the fast demise of the city's roads—a local newspaper recently featured a photo of a flower someone had planted in a particularly large pothole on a well-traveled road—intermittent water shortages, and faulty streetlights that contributed to increased muggings and robberies in many suburbs collectively pointed to the hasty retreat of modernity, indeed its inversion. The unhindered feeling of existential security many people used to enjoy was now being replaced by a feeling of suspicion of strangers and neighbors alike, particularly as the economy worsened.
Everyone, it seemed, was more susceptible to misfortune. Diseases once thought to be safely under control—malaria, cholera, and tuberculosis—had resurfaced with a vengeance. In March 1999, Harare was in the midst of a cholera epidemic (with an allegedly lethal strain said to kill within a few hours), ostensibly facilitated by a breakdown in City Council facilities and heavy rains that made septic tanks overflow with raw effluent. The outbreak of cholera, at least in part, had its roots in the city's decaying infrastructure, incapable of absorbing the tremendous population growth of recent years, and poor city management. In the high-density suburbs in particular, shanty structures mushroomed amid officially built houses, resulting in overcrowding and the increase of backyard settlements such as Porta Farm, Dzvaresekwa Extension, the Public Works Department compound in Highfield, and Hatcliffe Extension. Such settlements pose serious public health threats because of a lack of adequate sanitary facilities and are often singled out by the media and government as scapegoats for the city's chronic malaise.
Related to the cholera outbreak—and the social and economic roots of its spread—was a surge in tuberculosis, accounting for some 14.7 percent of total deaths in the city in 1998 (in 1997, TB accounted for 13.1 percent of total deaths in the city). From 1996 to 1997, the number of reported new cases almost doubled, from 4,774 to 7,013, with poor housing conditions, malnutrition, and concurrent HIV infection largely contributing to the increase. Pneumonia, however, continues to be the leading killer disease in Harare, accounting for 23 percent of the 14,421 deaths recorded at the Harare district office in 1998, as reported in the June 27, 1999, Sunday Mail article "Pneumonia the Leading Cause Killer Disease in Harare." As Scheper-Hughes (1992, 31) points out in a different context, though we tend to think of these maladies as endemic to the tropics and arising from a confluence of "natural" climatological, geographical, and human ecological interactions, "we might do better to think of them as poverty diseases or as diseases of 'disorderly development' (to use Doyal and Pennell's 1981 term) in which the social relations that produce rural to urban migrations (and vice versa), unemployment, ... and malnutrition are the primary culprits behind the epidemics."
Colonialism and Its Implications for African Health
The ability of Europeans to tap into the wealth of tropical areas was contingent on their ability to survive in tropical climates, as Packard reminds us (1997, 94). Efforts at overcoming Europeans' health challenges in the exploitation of African resources facilitated research into the etiology of diseases associated with the tropics, and led to the development of schools of tropical medicine in Europe and the United States at the turn of the last century. Early successes of these schools in treating malaria and yellow fever helped extend the tendrils of European control into the tropics. As Europe consolidated its holdings in Africa, the health of Europeans continued to generate interest in tropical health (ibid.).
Under colonialism, rural-to-urban migration—and the demand for cheap labor pools that created it—had particular consequences for the health of Africans in the city (and, by extension, their rural counterparts). Forced to live in highly unsanitary locations and compounds, Africans suffered heavily from hookworm and other intestinal diseases. These diseases also reflect the health practices imposed by a British colonial power ostensibly intent on insuring the health of European settlers at the expense of the health of black Africans. As elsewhere in Anglophone Africa, from the late 1800s to the 1920s, health provision focused narrowly on the wellbeing of Europeans, health being viewed as a requisite condition to further the development of the colony (Gilmurray, Riddell, and Sanders 1979). In 1899, for example, a troubled Native Commissioner confessed: "I should like to point out the utter want of foresight, or more properly speaking callousness on the part of the Director of Mines. There are no medical appliances or comforts of any description, neither splints, bandages, or the many articles that might relieve pain in the event of an accident. The Mine Managers cast the blame on the Directors. Whoever the delinquent, it is a scandalous state of affairs, and if no law exists, one should be devised, to compel those who neglect, what in any other country, ordinary instincts of humanity prompt" (Phimister 1988, 54).
Outbreaks of scurvy in 1908 among laborers in the mines and on farms, for example, were viewed as industrial relations problems by the colonial government. Employers, in turn, blamed the employees for their ill health (Loewenson 1992). The cruel economic calculus of colonial capitalism for the mines depended on a flow of migrant labor created within a regional economic system, and not on the capacity of a fully developed proletariat to reproduce itself. As long as there was little stimulus to pay compensation, and as long as there was no compensation, there was little incentive for any coordinated attempt to reduce disease in the compounds. Even where huts and buildings were set aside as hospitals, in the great majority of cases they were singularly uncomfortable and totally unsuited for their purpose. There is little doubt that the growing profitability of mining in Southern Rhodesia was a road littered with the broken and diseased bodies of black workers (Phimister 1988, 55).
For example, as Phimister's important 1988 work illustrates, during the reconstruction of the mining industry from 1903 to 1910, poor diet and squalid living conditions led directly to a high mortality and morbidity rate (see also Ranger 1992, 261). Little provision was made for African housing, diet, and medical attention. Black workers often built their own housing. "As a rule," noted one compound inspector, "four or five natives agree to live together and start to build themselves a hut which may consist of anything from a substantial pole and grass hut to a few bundles of grass tied roughly on to a flimsy structure of twigs, usually the latter, according to the length of time the natives intend to remain on the mine" (Phimister 1988, 51). During the reconstruction period, such structures were often no more than corrugated iron sheds, hastily erected, generally without windows and floors, on sites that soon proved unsuitable. Built to accommodate either a day or a night shift but not both, they were usually overcrowded.
Food, too, succumbed to the cost-cutting demands of the ruthless extraction of absolute surplus value. Phimister (1988, 52) points out that fresh vegetables and meat,
because of the uneven development of commercial farming, were considerably more expensive, and efforts to include them as a regular part of miners' diets were loudly opposed and widely evaded. Compromised by considerations which had much more to do with the industry's profitability than with workers' needs, and by the fact that the state and its compound inspectors ignored all but the most blatant contraventions of the regulations, the diet scale was never nutritious enough on its own to maintain workers' health. Instead, black miners supplemented their rations where they could with purchases from the local store [where prices were usually inflated], from neighboring villages, and by hunting and fishing expeditions.
Outside the mine areas, similar economic pressures were squeezing urban blacks' diets. Nutritious fresh fruits and vegetables, peddled by women in either marketplaces or on various corners, were construed by many blacks on limited food budgets to be too expensive (Packard 1992). And while some blacks had garden plots around their living quarters for growing fresh vegetables, even these began to disappear as more and more people were squeezed into the same area (ibid.; Bonner 1982). Other dietary changes included the substitution of relatively innutritious white bread in place of maize and other grains. Relatively cheap coffee sometimes replaced milk as a staple beverage. The resulting loss of essential vitamins and animal protein may have made people more susceptible to infections such as tuberculosis (Packard 1992).
The 1944 Committee to Investigate the Economic, Social and Health Conditions of Africans Employed in Urban Areas, chaired by E. G. Howman, reported that about 70 percent of all black workers suffered from bilharzia. Other afflictions—malnutrition, tuberculosis, and pneumonia—all became increasingly common during the 1940s and, by the middle of the decade, medical examinations conducted in Salisbury (now Harare) discovered that about three "natives" in every four admitted to hospital with pneumonia, tuberculosis, and other complaints were also suffering from either malnutrition or a disease such as bilharzia or hookworm (Phimister 1988, 261). These diseases of poverty, so rampant in the wretched conditions created in the wake of a burgeoning monopoly capitalism and the creation of production zones and trading territories, foreshadow and help bring into clearer focus the devastating trajectory of HIV/AIDS and how socioeconomic forces come to be embodied as biological events.
The focus of European health initiatives shifted after World War I to be more inclusive of African populations. In most cases, this focus was by no means altruistic but shaped by narrowly economic concerns: colonial economic production depended on healthy (African) workers and not just healthy (usually European) managers. Some monies were directed toward combating illness among workers, at least while they were in the employ of Europeans. During much of the early 1900s, this material concern dominated most European health efforts in the tropics. Viewed through such an economic lens, the success or failure of health interventions was assessed by their ability to maintain or increase levels of production rather than levels of health. Losses in production, defined in terms of days or shifts lost, served as a surrogate measure for the health of the "native" work force (ibid., 68).
This emphasis on production shaped the distributive patterns of health services. For example, health services were usually concentrated near sites of production (mines, large-scale commercial farms, etc.) with little attention given to populations outside these productive areas. Missionary doctors and nurses usually provided services to the rural areas (Gelfand 1953, 1988). In fact, much of the rural medical infrastructure was intimately tied to missionaries, with hospitals being linked to the main mission of a particular area and clinics being tied to minor mission stations. Missions provided one or two completely equipped medical centers at the main mission stations, with qualified (European) doctors and African personnel. Male medical assistants (usually African) and nuns (also referred to as "sisters") staffed rural outposts. Such medical facilities proved to be a powerful socializing tool, in preparation for both Christian doctrine and incorporation into the cash and moral economy of the growing colony. In many hospitals, for example, regular morning prayers and special services were held for disseminating the gospel. Mission hospitals (and perhaps more specifically, mission doctors), like local n'anga, were the embodiment of the sacred and the secular worlds. The missionary efforts of Dr. M. H. Steyn, circa 1924, at the Dutch Reformed Church mission hospital at Morgenster eventually resulted in the local appellation "nganga huru yenyika" (the great diviner of the country) (Daneel 1971, 230–31). This is one example of local people's indigenization—their reframing through a local lens—of the therapeutic practices of Western doctors through the process of vernacular modernity.
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Excerpted from Modernizing Medicine in Zimbabwe by David S. Simmons. Copyright © 2012 Vanderbilt University Press. Excerpted by permission of Vanderbilt University Press.
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