John Manton

Introduction: Sustaining the Life of the Polis

How are publics of protection and care defined in African cities today? The effects of globalization and neo-liberal policies on urban space are well documented. From London to São Paulo, denationalization, privatization, offshoring and cuts in state expenditure are creating enclaves and exclusions, resulting in fragmented, stratified social geographies (see Caldeira 2000; Ong 2006; Harvey 2006; Murray 2011). ‘Networked archipelagoes’, islands connected by transnational circulations of capital, displace other spatial relations and imaginaries. Spaces of encompassment, especially, such as ‘the nation’ or simply ‘society’ as defined by inclusion within a whole, lose practical value and intellectual purchase as referents of citizenship (Gupta and Ferguson 2002; Ferguson 2005). In African cities, where humanitarian, experimental or market logics dominate the distribution of sanitation and healthcare, this fragmentation is particularly stark (see, for example, Redfield 2006, 2012; Fassin 2007; Bredeloup et al. 2008; Nguyen 2012). Privilege and crisis interrupt older contiguities, delineating spaces and times of exception. The ‘public’ of health is defined by survival or consumption, obscuring the human as bearer of civic rights and responsibilities, as inhabitants of ‘objective’ material worlds ‘common to all of us’ (Arendt 1958: 52). Is it possible, under these conditions, to enact and imagine public health as a project of citizens, animated in civic space?

Neglected Actors in Neglected Tropical Diseases Research: Historical Perspectives on Health Workers and Contemporary Buruli Ulcer Research in Ayos, Cameroon.

“We are neglected, just as Buruli ulcer is neglected” (WS1.KE). With these words, Kombang Ekodogo and Daniel Ze Bekolo, two nurses with long experience with Buruli ulcer disease (henceforth, BU) at the hospital of Ayos, Cameroon, expressed dissatisfaction about their involvement in international research projects. They felt that their contribution to crucial progress in the surgery, rehabilitative care, and epidemiology of BU was insufficiently recognized and rewarded. Although medical research projects meant considerable benefits for themselves and their communities, they insisted on their frustration with being, in the best cases, merely “acknowledged” in a footnote to the final publications. “When I tell my children that I participated in this and that project, they will ask: yes, dad, but where is your name [on the paper]?” (WS1.ZB). Collaborative research in Africa faces difficult ethical challenges. Inequalities between local and expatriate scientists constrain the functioning of research projects and contradict their official presentation as “partnerships” [1]. In spite of efforts to acknowledge and redress such inequalities among researchers, the “collaboration equation” remains hard to balance [2]. Debates over the ethics of transnational research rarely take into account the case of auxiliary staff such as nurses, laboratory technicians, research assistants, and fieldworkers. Although largely invisible in academic outputs of medical research, they play an essential role at the interface of community work, medical care, and scientific research [3]. Their pivotal contribution to disease control, including HIV, tuberculosis (TB), onchocerciasis, dracunculiasis, and BU [4– 9] is beginning to be acknowledged, as well as their crucial role as mediator of research ethics [10–14]. Their epistemological role as knowledge-producers has been less studied. In this research, we document the expertise of auxiliary health workers involved in BU research. We retrace historically how their knowledge about tropical diseases like leprosy, sleeping sickness, and BU has been transmitted across century-old genealogies of local nurses. This article aims to recognize and value this memory and expertise. The original idea for this paper emerged from repeated conversations between our team of historians and anthropologists and nurses working at Ayos Hospital. Our discussions focused

Global and local contexts: the Northern Ogoja Leprosy Scheme, Nigeria, 1945-1960

Deriving funding from missionary sources in Ireland, Britain and the USA, and from international leprosy relief organizations such as the British Empire Leprosy Relief Association (BELRA) and drawing on developing capacities in international public health under the auspices of WHO and UNICEF through the 1950s, the Roman Catholic Mission Ogoja Leprosy Scheme applied international expertise at a local level with ever-increasing success and coverage. This paper supplements the presentation of a successful leprosy control program in missionary narratives with an appreciation of how international medical politics shaped the parameters of success and the development of therapeutic understanding in the late colonial period in Nigeria.

Health Planning in 1960s Africa: International Health Organisations and the Post-Colonial State.

This article explores the programme of national health planning carried out in the 1960s in West and Central Africa by the World Health Organization (WHO), in collaboration with the United States Agency for International Development (USAID). Health plans were intended as integral aspects of economic development planning in five newly independent countries: Gabon, Liberia, Mali, Niger and Sierra Leone. We begin by showing that this episode is treated only superficially in the existing WHO historiography, then introduce some relevant critical literature on the history of development planning. Next we outline the context for health planning, noting: the opportunities which independence from colonial control offered to international development agencies; the WHO’s limited capacity in Africa; and its preliminary efforts to avoid imposing Western values or partisan views of health system organisation. Our analysis of the plans themselves suggests they lacked the necessary administrative and statistical capacity properly to gauge local needs, while the absence of significant financial resources meant that they proposed little more than augmentation of existing structures. By the late 1960s optimism gave way to disappointment as it became apparent that implementation had been minimal. We describe the ensuing conflict within WHO over programme evaluation and ongoing expenditure, which exposed differences of opinion between African and American officials over approaches to international health aid. We conclude with a discussion of how the plans set in train longer processes of development planning, and, perhaps less desirably, gave bureaucratic shape to the post-colonial state.

Book Reviews: Colonizing leprosy: imperialism and the politics of public health in the United States.

Direct comparisons of medical institutions in metropolitan and colonial settings are all too uncommon, given the intensive traffic in personnel, practices, and ideas across the imperial twentieth century and recent increased scholarly concern with this traffic. With this book, Michelle Moran has successfully anatomized the roots, controversies and innovations at the centre of a pair of institutions of global significance in the rhetoric and practice of Hansens Disease (leprosy) control; the US National Leprosarium at Carville, Louisiana, and the Hawaii territorial leprosy settlement at Kalaupapa. The books major strengths lie in its depiction of leprosy as a rhetorical resource deployed to varying and often contradictory effect by legislators, patients, and doctors, and in its presentation of the unfolding ironies of segregation policy from the early 1940s, an era when the mildly contagious nature of leprosy was more fully recognized, and the disease became curable with sulphone drugs. The unease with which the end to segregation was viewed by Louisiana communities keen to maintain an income stream based on the presence of a large federal institution, by doctors hoping to carry out groundbreaking research, and by territorial patients desperate to maintain a discernibly “Hawaiian” community and identity in the isolated confines of Kalaupapa, contrasted with Carville-based patient activism of global significance for therapeutic action and home therapy movements, as exemplified in the sixty-year plus publication history of The Star, with its express purpose of “radiating the light of truth on Hansens Disease”. In these areas, the comparative aspect of the books presentation works very well indeed. In the more expressly “imperial” arena, a more extended consideration of the American-run colonial leprosarium at Culion in the Philippines, such as that provided in Warwick Andersons Colonial pathologies (2006), would have advanced the argument on varieties of American imperialism in relation to public health. The Philippines is present in the text, but only as a source of contamination linked to United States’ military intervention in East Asia, whereas Culion, and American public health in the Philippines more broadly, was crucial in the elaboration of mainstream American medical and political thinking on race, health, the tropics, and the politics of empire. Culion was also highly significant in the development of chemotherapy in leprosy, particularly with regard to the refinement of chaulmoogra oil in the pre-sulphone era. While it is difficult to determine the prevalence of leprosy from the accounts provided, the sense of the expense of leprosy control is very well communicated in the authors consideration of legislation and medical politics surrounding segregation, monitoring and treatment of leprosy patients. The troublesome relation between Christian (and especially Catholic, in the case of Carvilles early history) medical workers and stigma is well described, if eventually unresolved. In this respect, the consideration of stigma as a remnant irony of out-patient treatment in the 1950s and 1960s is more completely convincing, painting a picture of leprosy as a medico-social syndrome comprising a discourse on national and imperial citizenship and exclusion alongside medical and institutional concerns. This is an excellent and well-written contribution to the literature on public health and leprosy. It continually, clearly, and usefully reinforces its central thematic concerns with federal, territorial, medical, religious, and patient experiences with leprosy. From an editorial perspective, the extensive range of archival sources referenced would have been more approachable with an easily consulted list of abbreviations, and the index might have included some of the more prominently cited authors. These minor points aside, the high production values do justice to Michelle Morans careful restitution of reports from the margins of American empire, medical research, and public health to the centre of historical concern.

Charles M Good, The steamer parish: the rise and fall of missionary medicine on an African frontier , University of Chicago Press, 2004, pp. xx, 487, illus.,

The portrait offered by Charles Good of the fates of the S.S. Chauncy Maples and the S.S. Charles Janson, wood-burning steamers upon which were built the fortunes of the Universities Mission to Central Africa (UMCA) in the Diocese of Nyasaland, exemplifies many of the contradictions of European colonialism in nineteenth- and twentieth-century Africa. Focusing on the socio-spatial ramifications of a novel transport technology, Goods elegant presentation unearths the tatters and the self-proclaimed glories of empire from the service history of a now-dilapidated hulk. Generously embracing both the poignancy of an ill-starred enterprise, and the blinkered obstinacy contributing to its eventual obsolescence, Good elaborates a thematic agenda no historian of medical mission can well ignore. At first glance, it may seem strange that a work devoting so much space and energy to the vicissitudes of mission transportation on Lake Malawi could purport to be a history of missionary medicine. However, in rapidly asserting that the history of medical mission is not primarily “about” medicine, and in contextualizing his presentation by means of a carefully reasoned depiction of missionary penetration with regard to local political economies, lacustrine ecology, and African philosophies of health and illness, Good obviates the need to ground his enquiries with respect to an epidemiological “baseline”. Though he covers such material extensively as his argument develops, it is the attuned sensitivity to place which gives this work its distinctive character. In considering the effects of social, economic, political and technical processes on populations and communities across Africa, historians have tended to assume that such processes act more or less equally across a given territory or selected area of analysis. The salience of these disciplinary habits emerge more clearly when contrasted with the concerns of geographers. Good makes explicit the links between the cost of maintaining a steamer and its drain on a poorly-resourced mission, the resulting need to use such a technological resource efficiently and effectively, the impact of local provisioning, site security (in the context of ongoing slave-raiding), and mooring on the development of the mission field, and the ramifications of technology for the politics of race, employment, education and medicine. Consequently, the exigencies driving medical mission, and the practicalities relegating it among the overall concerns of evangelists and traders, are detailed in all their manifold interactions. For the historian of medical mission, this represents a fundamental shift in sensibility, the subtleties of which are perhaps best exemplified in Goods commentary on Terence Rangers 1981 essay on UMCA medical mission in Tanzania. Demonstrating how an aetiology recognizing human agency as a prime cause of illness could supplement, and persist alongside, biomedical models of disease causation in the social contexts of colonial and post-colonial Africa, even given the constraints placed on UMCA medical mission by financial and personnel difficulties, its insistence on celibacy among European staff, and an intentional policy of overextension of its mission surrounding Lake Malawi, Good challenges and complements Rangers arguments, suggesting that issues internal to mission culture, contributing to its spatial extension and character, might well shape medical pluralism in Africa as much as a purported “passive resistance to ‘biomedicalisation’ ” (p. 309). Some issues with the presentation of the volume detract from its otherwise exemplary nature. Curiously, for instance, no distinction is made among illustrations between maps, photographs, and plans, all listed under the heading “figures”: a more comprehensive and clearer map of place names might also have facilitated the reading of a text which so carefully alternates thematic and chronological narrative. Arguments regarding climate, lakeshore levels, and topographical isolation of stations would have benefited from relevant maps; among these, the lack of a relief map is perhaps the most significant oversight. From the perspective of a non-geographer, if only to underline the distinctiveness of a geographic approach to the history of mission, it might help to indicate the intellectual heritage of terms such as “landscape” and “topology” with the care expended on explicating the use of the term “frontier”. These minor quibbles do not detract from an otherwise precise, sympathetic, detailed, and original depiction of the internal contradictions implied in the workings of an evangelical mission involved in medical provision in societies suffering the rapacities of political instability and unfettered imperial capitalism.