As the editors of this volume point out, in the last twenty years Africa has seen considerable growth in the number and financial resources of international organizations concerned with health. Surely this development has contributed to the marked change in the interest that my students bring to the study of Africa. Increasingly, they want to learn about health and disease, often because they hope one day to contribute to health care in Africa. Addressing their interests means placing Africa in the broader context of ‘global health’, a term defined by the editors as ‘the health initiatives launched within Africa by actors based outside of the continent’. Global Health in Africa serves this purpose well, for its essays address major problems encountered in teaching from a historical perspective about global health in Africa. One such problem is the view that Africa's disease burden is an ancient, unyielding condition to whose alleviation indigenous healing systems contribute little. Behind this view lurks the problem of Western constructions of race and cultural difference that diminish empathy for individual experience and curiosity about social context. Out of such assumptions emerge what Guillaume Lachenal calls ‘hubris’ – unqualified confidence in the efficacy of modern biomedicine.
‘Hubris’ is challenged by several contributions which, while acknowledging the undoubted successes of global health initiatives, show too their sometimes inadvertent and harmful outcomes. In Liberia, the use of DDT interrupted the maintenance of human immunological resistance. In Uganda, the distribution of protein-rich skim-milk powder initially seemed to reduce kwashiorkor, but later led to undernutrition and infectious disease in children because it inadvertently popularized bottle-feeding. More disturbing is iatrogenic disease, particularly the epidemic of hepatitis C that has raged in Egypt since the 1990s. It resulted from the mass treatment of schistosomiasis that was implemented, argues Anne Marie Moulin, by an exceptionally coercive system of public health. These and other cases in this volume warn against unconditional confidence in biomedical public health interventions.
Contributions to this volume demonstrate the importance of placing global and public health within specific historical and social circumstances. Efforts to eradicate smallpox in the colonial period, shows William Schneider, were impeded by arbitrary boundaries between colonies and empires. By contrast, conditions characteristic of postcolonial Africa made cholera an ‘African disease’. Ecological changes in major lakes, explains Myron Echenberg, together with war, refugee crises, and unfortunate ‘public health policy choices’ made by African governments, were responsible. Among the most fateful choices was the decision to buckle under to neo-liberal pressure by privatizing water provision or placing it on a user-fee basis. Such appreciation for the fine detail of social context, show Michel Garenne, Alain Giami, and Christophe Perrey, is equally important in assessing the efficacy of male circumcision as an HIV-control measure. Their essay carefully teases apart assumptions and apparent correlations. Assumptions about the timeless nature of African societies and their disease burden are most directly addressed by Tamara Giles-Vernick and Stephanie Rupp in their essay on human interaction with the great ape hosts of retroviruses and hemorrhagic fevers in the northern forests of central Africa. As they point out, the view that twentieth-century humans encroached on great ape habitats in wholly unprecedented fashion, thereby exposing themselves to new diseases, assumes the longstanding existence of a ‘precolonial equilibrium’ that was broken only by colonialism. However, rather than remaining separated, they argue, precolonial humans and apes competed for territory; as oral traditions show, dynamic interaction made humans familiar with apes and fearful of contracting illness from them.
A fundamental ethical problem raised by an historical approach to global health in Africa is whether public health practitioners should focus their efforts on communities and populations, or instead on the treatment of individuals. In his discussion of the categories of thought which encouraged mass treatment of sleeping sickness, Lachenal declares that ‘race… in the African colonial context’, led public health authorities to ignore the iatrogenic effects of vaccination on individuals. Making individual welfare the primary concern of public health remains an uphill fight across Africa, as Sheryl McCurdy and Haruka Maruyama demonstrate in their study of efforts to address heroin use. They advocate ‘harm reduction’, suggesting that measures such as providing individual addicts with clean syringes and methadone will better protect community health than criminalization of narcotic use. They point to remarkable successes in Mauritius and Tanzania, but also say that resistance to alternatives to criminalization is widespread. Thus a vital lesson from historical study of global health in Africa is that the end of colonialism did not eradicate the tendency to subordinate individual welfare and to overlook the complexity of social and cultural context.
