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Struggles for Control

Struggles for Control

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Published by Sureshi Jayawardene
On intellectual labors of everyday individuals in East Africa.
On intellectual labors of everyday individuals in East Africa.

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Struggles for Control: The Social Roots of Health and Healing in Modern Africa Author(s): Steven Feierman Source

: African Studies Review, Vol. 28, No. 2/3 (Jun. - Sep., 1985), pp. 73-147 Published by: African Studies Association Stable URL: http://www.jstor.org/stable/524604 . Accessed: 05/12/2013 23:28
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STRUGGLES FOR CONTROL: THE SOCIALROOTS OF HEALTH AND HEALING IN MODERN AFRICA Steven Feierman
This paper is a general interpretationof the social determinantsof health and health care in Africa over the past century. The evolution of health cannot be separated from the broader story of social change. The political and economic forces which shaped the continent's history also established the framework within which patterns of diagnosis and treatment,health and disease, emerged. The implication of this is that healers of all kinds-whether doctors or "traditional healers"-have been less influential than we commonly think in shaping states of health or in healing the sick. This position opens up a range of difficult problems which are addressed in the following pages. What is the exact nature of the link between the broad political-economic forces and the distribution of health or disease? Which of these forces have driven therapeutics along its historical path, and by what means? What role do healers actually play? The body of the paper is divided into three main sections. The first explores the micro-sociology of changing treatment of illness. In most African communities several kinds of healers work side by side: physicians or medical assistants, specialists in sorcery or spirit possession, Christian or Muslim religious healers, and others. Multiple authorities co-exist, and therefore no one healer decides the cause or cure of illnesses in a way which others accept as beyond challenge. But treatment cannot exist without coordination. Someone must decide on a course of action when lives are threatened. It is most often a loose network of the patient's relatives and neighbors who make this decision. The history of therapeutics must therefore take account of all the forces which shape local networks, in other words everything which affects community and domestic organization. The history of health care is inseparable from the total history of communal organizationand of the economy. The second major section tries to understandthe social context of health and disease, life and death, population growth and decline, in Africa over the past century. It is sub-divided into two halves. The first half reviews the literatureon early colonial population decline, and more recent population growth. The second half, which is crucial for the entire argumentof the paper, identifies types of political and economic decisions which have an impact on the distribution of
AfricanStudies Review, vol. 28, nos. 2/3, June/September1985.

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AFRICAN STUDIES REVIEW

sickness and death. Death is not distributedin a random way. It comes sooner to poor people than to the rich, sooner to people in the country than in the city, and sooner to the children of absent migrant workersthan to children of women who live with their husbands. These inequalities are a consequence of decisions by power holders on the distribution of social costs-who is to sufferthe disease costs of large-scale irrigation, which children are to be malnourished, which workersare to lose their health at work, and which farmersto be hungriestin the months before they harvest their new crops. Readers who skim through this paper need to read the section titled "Social Costs of Production"if they are to understandthe general argument. The first two sections ask about what healers cannot do-the important things over which they have little influence. The third looks at the impact they have within the largerpolitical and economic framework.It asks first whetherthe therapies of either biomedicine or popularhealing are effective.' In what way? Is one body of knowledge and techniques more useful than the other? The essay then explores the history of healers over the past century, and their social role today. To what extent can healers change the distribution of social factors which shape health and disease? Healers, when they are at their most effective, play a mediating role in society. They have the freedom, on occasion, to ally themselves with groups of lay people who want to improve the social conditions of health. By choosing allies and issues, they can improve states of health in the wider society. A study on national health policies, another on control over sexuality, and yet another on the psychiatric or psychologicalliteraturewould have fitted into the perspective of this paper. They are not covered because the essay is too long as it is; I hope to write future essays on those subjects. The paper concentrates on literature published after 1970 to give a sense of current debates, but refers to earlier publications when necessary. It concentrates on Africa South of the Sahara. Its coverage of the social costs of production is limited to a few cases which are, nevertheless,important ones for the total picture of African health.
I. PATTERNS OF CONTROL: THE INTEGRATION OF HEALTH, HEALING, AND IDEOLOGY

No colonial power and no independent African state has ever intervened decisively to destroy popular healing. Governments have been either unable or unwilling to provide biomedical care to their entire populations, and have therefore been forced to tolerate the survival of African healing. This fortunate outcome is also a consequence of the determination and cunning exercised by popular healers over generations. Healers have long cultivated secretivenessas a survival strategy. Harriet Ngubane (1981), for example, tells the story of Zulu healers who created tight guilds invisible to the South African authorities. The survival of popular healing, the spread of competing popular therapies over wide areas, and the introduction of biomedicine, Christian healing, and Muslim healing, have combined to create a profusion of therapeutic forms in contemporary Africa. In a single place, many kinds of practitioners co-exist: African physicians, dispensary aides, Christian prophets, Muslim teachers, spirit possession mediums, specialists in sorcery, diviners of all kinds, herbalists,faith healers, and specialists in kinship therapyand in the removal of pollution.

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an object separate from social relations-one which resembles a commodity. The Cultural Interpretation The literatureof African therapeuticsystems provides three very differentsets of answers-overlapping in important ways-on how therapeutic choices are This content downloaded from 129. Therapy shapes ideology by interpretingthe patient's experience of illness. According to Taussig the relationship between doctor and patient is a "social interaction which can reinforce the culture's basic premises in a most powerful manner. Accordingto Taussig. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions .215. 1982b: 276. by contrast. 1972). 1981b). But values are not narrowlyrestrictedto the sphere of medicine-they pervade society as a whole. It was one of the central themes of a generation of anthropological studies which interpreted witchcraft as a system of beliefs sustaining and stabilizing the social order (reviewed in Douglas. even if his central contrast is oversimplifiedin three important ways: he romanticizesZande healing. The doctor's interpretationmakes illness an individual experience rather than a social one.105.This is not a new point. in which divination served to support the domination of aristocrats over the common people (Young. The person who controls therapyserves as a conduit transmitting general social values. "This gives the doctor a powerful point of entry into the patient's psyche" for the doctor offers the patient an interpretation of what is happening in his or her own body. The person who makes an authoritative diagnosis decides when a person is too sick to work or to meet obligations to relatives and neighbors. The power to name an illness. McLeod.HEALTH AND HEALING IN MODERN AFRICA 75 The patient has access to the broadest possible range of therapeutic alternatives. 1979). to identify its causes." Serious illness interrupts the everyday routine. 1980. Control over healing is important also in shaping ideology. Abdallah. and Jean Comaroff (1982) argue a similar case transposed into a different historical and sociological framework. accounts fully for the social context of health problems. and the uncritical acceptance of the meaning of life. The decision on sickness leads to others-that relatives ought to pay for treatments. and denies the importance of the social conditions out of which disability emerges. admittedly. to treat health problems as individual disorders divorced from their social context (Guttmacher. is also the power to say which elements in the experience of life lead to suffering. 1970). Zande healing. and he ignores the contribution of those who struggle to create therapeutic alternatives in industrial countries-alternatives which tend. he does not discuss commoditized popular healing in contemporary Africa. Recent writings by Allan Young (1982b). where some healers work impersonally and entrepreneurs mass-produce herbal remedies (Frankenberg.for example. The struggleto create alternativesillustratesthe ideological role of those who control healing. leaving the scholar to grapple with one of the most difficult and important puzzles in the study of African healing: who controls the therapeutic process? Control over healing carries with it power over other practical matters. Michael Taussig (1980). but is also capable of reshaping and reinterpretingthose values in the healing process. Taussig's general point holds. Taussig argues that American doctors working under capitalist conditions interpret disease as a thing. or to provide nursingcare.146 on Thu.

Scientificmedicine has achieved monopoly power in Europe and the U.146 on Thu. Certainly.is in control. Horton returns to EvansPritchard'squestion: how can a system of causal explanation persist if it is not verifiable when tested against experience. where non-scientific therapeutic alternatives are systematicallyexcluded." By contrast to this closed system. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . Charles Good (1980: 14). with an emphasis on shared values rather than on who. For example. move pragmatically from one type of healing to another. Watt and Breyer-Brandwijk. and a Zande cannot get out of its meshes because it is the only world he knows. by contrast.D.76 AFRICAN STUDIES REVIEW made. The patient's condition is interpreted in light of this knowledgein order to name the condition and arrive at a course of therapy. Scholarly observers differ on the extent to which the body of cultural knowledge forms a coherent medical system. because of its need for economy. who finds a closed set of causal categories. following Fabrega (1977) defines an ethnomedical care system (EMCS). who at the time of her study had almost no access to doctors or dispensaries. Horton's argument goes.Those who actually manage the process of therapyin Africa. ethnic groups tend not to be clearly bounded entities.S. 1982. In one isolated and therefore inconclusive case described by Buxton (1973) the Mandari. work on African medicinal plants shows that an empirical basis exists (Soforowa. has its own body of cultural knowledge for the interpretation of illness.215. The first is cultural. and therefore on the nature of control.105. In her view. Tola Olu Pearce (1983) and others maintain that African medicine can be tested against experience and found effective. in particular. On Horton's central point." It is not clear whether pluralism characterizedthe African healing of earlier generations. Horton argues that African traditional thought forms a tight system from which escape is impossible. 1979) that Europeanmedicine is not a fully open system. ranging from Robin Horton. the argument goes. I argue elsewhere (Feierman. Horton's "African Traditional Thought and Western Science" (1967) makes the clearest case for folk thought as a closed system..or whether it is a consequenceof this century'smedical competition. to MurrayLast (1981) who writes that the Hausa Maguzawaengage in therapywhile neither knowing nor wanting to know about a coherent medical tradition. contrasting closed and open systems. the oral transmission of medical knowledge. "conceived as the whole approach of an ethnic community to disease and illness" including the work of diviners. But Good (1980: 42) then finds "frequent consultation across ethnic lines and social classes. western scientific thought constantly tests its assumptions against experience. He quotes EvansPritchard on witchcraft and oracles: "In this web of belief every strand depends upon every other strand. M. 1962). nor is African medicine closed. Pluralism in this case was not a consequence This content downloaded from 129. Each society.to John Janzen (1983) who rejectswhat he calls "systems monism" and arguesthat multiple healing traditions co-exist side by side in a pluralistic system.'s. Horton stresses the coherence of closed patternsof causal explanationand does not acknowledge the coexistence of multiple explanations in each African society and in each individual's thought. In other words. and practitioners frequently cross local lines of language and culture. Medical authoritiestend not to test alternativetherapies for their efficacy. may be more successful at passing on medical prescriptions than at recording their empirical basis. Even where scholars identify a core medical tradition. still identified therapeutic conceptions which were not coherently integrated into the core tradition. and herbalists.

or they are contradictory. Because healing is a process of general culturalinterpretation. The cultural interpretation of illness changes as the illness itself changes through time. can predict the folk diagnosis. illness episodes which are interpretedas "natural" at an early stage are later explained in terms of sorcery or spirit causes (for a contrary case see Ngubane. assess the patient's stomach cramps. only to find that his analysis is confounded by differencesin diagnosis of a single illness at an early or late stage. In addition to the patient's physical signs and social relationships. 1974: 238).S.AND HEALING HEALTH IN MODERN AFRICA 77 of the intrusion of biomedical practice. for example. In biomedical practice. people must move to the pace set up by the progress of the disease . 1977: chapter 2). physical signs do not usually lead ineluctably to a particular diagnosis or treatment. the relationship of experience to time is at the core of the cultural construction of illness. . the body This content downloaded from 129. This is the passage of time. of critical incapacitatingdysfunctions as opposed to chronic non-incapacitating dysfunctions. Kramer and Thomas (1982) demonstratethat Kamba diagnosticiansgive radicallydifferentinterpretationsof cases which continue for less than one month." It is this unfolding which is the central organizing process-the unfolding rather than the symptoms at any one moment which the healers must explain. A fascinating ethnographyof medical experimentationin the U. among the Shona. "Illness brings to bear upon the family of the patient the pressure of time speeded up. In many cases. blossom-like from within it. concludes that "in a sense every clinical act is an investigation" (Fox. sadness (see Young's interpretation of this. In many actual cases the signs are not clear. between one month and two years. According to Christopher Davis-Roberts (1981: 315). Sargent(1982: 93) brings Kleinman's interpretationto bear on the question of therapeuticchoice. Instead of basing their choices upon their own necessities and convenience. 1961. pregnancy. One common goal of cultural studies of African medicine is to understandthe indigenous logic of classification so thoroughly that the analyst. identify herbs which might cure them. For Good and for Kleinman the broaderprocess of cultural interpretationis at the heart of healing-more crucial to it than finding the right narrow label for a particular kind of skin rash. age. A healer might. Two of the most influential medical anthropologists(neither of whom writes about Africa) discuss illness and therapy as a broad interpretiveprocess. 1982b). The likelihood of ambiguity is at least as high in the practice of popular healers who must assess both the physical signs (Frake. given a set of symptoms. 1968). for example. . for in any therapeutic culture the healer who assesses the patient's condition must organize ambiguous information. In the particular illness he studies the condition is linked to childbirth. Chavunduka(1978: 38-40) explores the comparative diagnosis. For Byron Good (1977) and for Arthur Kleinman (1980) healing is a process in which the individual's experience is interpretedin relationshipto an entire network of symbols. In practice this is nearly impossible. miscarriage.146 on Thu. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions .. Warren.215. 1974) and the totality of the patient's social situation (Turner. .as the illness unfolds through time therapists locate it in a network of core symbols. and not simply the selection of the most appropriatetaxonomic category for each set of physical signs. but then also consider the fact that the patient is a married woman whose husband never paid bridewealth. According to Good's interpretation. is but the artifact of the processes unfolding. and more than two years.105.. a third factor is crucial to the unfolding of therapeutic action.

African healing churches. 1982. patients choose healers with whom they share fundamental assumptions regarding clinical reality. it is not the patient as an individual whose view of clinical reality is in question. or that only doctors can excuse the work absences of government employees.The sick person's family plays a role in care. 1978. Hospital medicine is. Omoyajowo. Islamic healing. Much of the literature assumes that health specialists.146 on Thu. with maximum tolerance of diversity. patients move back and forth from the hospital. but has no competence to assess the patient's condition or suggest treatment. as when national law requires that cases of cholera or of tuberculosis be treated biomedically. he does not often act on his own. there needs to be a mechanism to separate legitimate from illegitimate exemptions. Parsonian sociology plays an important part in this assumption. of course. Janzen and Feierman. 1968. share a sense of clinical reality with such diverse therapists? Part of the answer is that the patient does not come to the therapeutic process as an isolated atom. whether physicians or popular healers. The Interpretation Based on Controlby Healers The second body of literature on therapeutic choice in Africa analyzes the nature of competition among alternative sets of healers. In Sargent'sown study they appear to agree. How could a single patient. The patient's close relatives make important judgments on the therapeutic process. but even here the sharing of clinical assumptions between parturients and birth attendants is likely to be a secondary consequence of the fact that 77 percent of birth attendants live in the same household as the parturient(Sargent. But in most illnesses the range of therapeuticchoice is very wide. 1981). Only in a few limited contexts do governmentalauthorities impose a requirement that patients must use a particular therapy. Sargent appears to assume that if the patient's view of clinical reality diverges significantlyfrom that of the healer. and I suspect in most parts of Africa. 1982: 99).105. not the only innovation. Janzen. control therapy. it becomes impossible to locate the illness in the core semantic network.78 AFRICAN STUDIES REVIEW she argues. whether or not patient and relatives agree on a single view of clinical reality. to local healers of one type and then another (Janzen. Over the course of time.who is the ultimate arbiter.215.who found that neither income nor education was a factor in determining whether Shona patients were treated in a hospital or by a popular healer (1978: 45). Since sickness exempts a person from some responsibilities. in a single illness. people who ought to be recognizedas sick from those who ought not (1951: 436-37. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . 446-47).and the diffusion of cults of affliction are all part of the changing picture (Redmayne. new healing alternatives become available to ordinary people living in any particular locality. 1970. The role of relatives in choosing a therapy is clear in the work of Chavunduka. 1982). But in most chronic illnesses. For Parsons it is the physician. His kinsmen both educated and uneducated jointly take the decisions throughout the illness and are responsible for paying the medical fees. The reason is that "When a person is taken ill. MacGaffey. 1968. even in the This content downloaded from 129. 1979. the entire group of relatives works out a shared view of clinical reality. new forms of witch-finding. Janzen and Prins. 1981b. 1983. Abdallah. The Parsonian interpretationhas of course been modified. with his autonomous technical knowledge. Parkin. Parsons treated the therapeuticrelationshipas one of authority and legitimation. for most parts of Africa. Peel." In the Shona case.

neighbors. Those who organize therapy consult a diviner so as to understandthe social. Most important of all is the suggestion of Sindzingre and Zempleni (1981: 287) about the Senoufo. Even where divination is extremely important. a process poorly understood in "scientific" This content downloaded from 129. and consult a second diviner (Whyte. and whether the practitioner is able to control dangerous side effects. They choose treatments by trying first one cure and then another. But the parallel is not precise. 1972: 74). "Why is this person ill. The diviner answers the question.146 on Thu. or because those who manage therapy are not satisfiedwith the diviner's assessment of cause.and healers take to help the patient (Maclean. 1982: 2059).215. in a pragmaticway. 1971: 17-20).HEALTH AND HEALING IN MODERN AFRICA 79 study of American medicine. One possible way for scholars to sort out the pragmatictherapeuticchoices is to ask which treatment works better in each particularcase-which is the most efficacious?But this is difficult because efficacy is not limited to the effects of therapy on symptomatic behavior. describes a Zulu case in which a lay person makes a sorcery accusation but then angrily rejects the diviner's choice of sorcerer. on the course of therapy management. but not for the purpose of organizingthe healing process. in an autonomous way. it is only one step in an extended series which family. and often does not prescribea single course of therapy." and not "Is this person ill?" (Adler and Zempleni. The diviner usually does not make the initial differential diagnosis. The literature about Africa often assigns the role of the Parsonian physician to the diviner.either because of the structureof divinatory statements (Adler and Zempleni. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . does not define the sick role. as among the Yoruba.His or her conclusions are often ambiguous. The diviner often does not decide. This gets at the heart of the process of healing. on the assumption that diviners make authoritativejudgments about illness causes. 1972: 144-45). Patients can also judge efficacy on the basis of technical features of the therapy-whether the healer's purgatives and emetics have short term effects." in other words an illness with a moral cause. The efficacy of a therapy might be judged by its effect on social relations-as when an American who does not wish to be called mentally ill chooses to be treated by an internist for mild hypertension rather than by a psychiatrist for associated emotional distress. Renee Fox and Judith Swazey explore the fascinating ambiguities which emerge when physicians balance ethical considerations against technical ones in acting as gatekeepers for organ transplantation(1974). natural. with applicability over a much wider area-that divination is separate from therapy. for example.Turner(1975: 215) heard of instances where diviners were speared by the angry relatives of people declaredto be sorcerers. By the time the patient's relatives visit the diviner they have already decided that the illness is one which has a serious cause-one which in many Bantu languages would be characterized as "an illness of man. Ngubane (1977: 39). The relatives narrowtheir diagnosis before divination. They can also judge the accuracy of prognosis in the absence of cure-as when a physician accurately sums up what is about to happen in the life of an incurablecancer patient. Even more fundamental than this is the emphasis in many African therapies on restructuringsocial relations and on the emotional context of illness. 1982). or mystical context of an illness. or to effects which are reproducible under controlled conditions (Young. In most places it is not the diviner's job to legitimize the sick role.105.

because it is such a strong work. Then her brothers offered to make a payment which they hoped would win Lwezi her father's blessing.co-exist with little capacity to exclude one another from the range of practical options. In the case of the young woman Lwezi Louise. a patient whose illness lasts over a period of time moves through the broadest possible range of therapeutic alternatives. pain in her joints. Pearce. unethical. In that year Gordon Chavundukapublished TraditionalHealers and the Shona Patient (a revision of a 1970 Ph. leads to the third approach to control over therapeuticdecisions.215. one in which it is the sick person's relatives and neighbors who choose among the many therapeutic options. each with legitimate claims to efficacy. to subject Janzen's work to the most searchingcriticism possible. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . both published in 1978. In the absence of centralized public authority it is the patients and their relatives who make the crucial decisions on therapy. where she was treated for a couple of months. thesis) emphasizingthe role of the patient's relatives in a large city. The problem is not that therapeuticefficacyis lacking in African medicine. Lwezi fell ill with periodic fever and chills.80 AFRICAN STUDIES REVIEW terms (Kleinman. John Janzen published The Questfor Therapyin Lower Zaire painting a similar picture for a rural area. so that other scholars who want to analyze the implications of his approach have materials on which to work. If any of us are to build on Janzen's approach. which alone is capable of prohibiting forms of medical practice (as discussed in Section III). or incompetent. then. Based on Lay Control The Interpretation This. Janzen provides a series of extended case histories. Two books. Her relatives took her first to a dispensary. radiatingback pain. Popular healers themselves lack authority to exclude practitioners who are ill-trained. In the accounts given by both Janzen and Chavunduka. for the people most qualified to make therapeutic decisions have the least technical knowledge of medicine and the greatestpersonalknowledgeof the patient. The nganga's This content downloaded from 129. and generalmalaise. here. He also tries to describe the approach in terms which lead to comparative research. but cannot define a legitimate popular healer. then to an nganga for daily treatments of razor-bladeincisions rubbed in with medicines and combined with both counseling sessions and worship. Lwezi went to an nganga after discharge from the dispensary even though its staff had not suggestedthat she do this. The case history continues throughanother prophet. Ministries of health and national medical associations can define who is or is not a legitimate physician. furthervisits to the dispensary." I intend. for he emphasizes the importance of what he calls the "therapy managing group. for example (Janzen. 1983). we will need to begin with a critical understanding. 1978: chapter 7). made a major breakthrough in understanding lay authority over African healing. it is that diverse healing traditions. 1980.146 on Thu.and a period of hospitalization. and then a group of Lwezi's maternal and paternal kin accompanied her to the Christian prophet Mama Marie Kukunda.D. This is because popular healers do not have access (and possibly cannot have access) to government power. loss of appetite. Accordingto this approachthe pattern of therapy management is an inversion of the one a Parsonianwould expect. It is obvious in this case that the healers did not make the basic decisions on therapy management.105.

they wanted to pay the upbringing gift and bridewealth on behalf of Lwezi's urban suitor. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . "The pastors on both sides rejected this. but who contribute to the process of therapy management. "must achieve internal cognitive agreement and social consensus in order to be an effective decision-making body. The paragraph discusses a single therapy manager with jural rights. or slavemaster. Lwezi fell ill at a time when she ought to have received her father's blessing. They. This can be illustrated with further details from the case of Lwezi Louise. but had not. brother. Lwezi's relatives paid no attention to his request. Thus the lay therapy manager retains the right to choose the therapist even after a consulting doctor-diviner-has made his diagnosis and recommended action.HEALTHAND HEALINGIN MODERN AFRICA 81 recommendation at the end of his treatment was that Lweze return to him again after a three-week interval. "Cognitive agreement" and "social consensus" are not relevant here except as consensus and agreement on the rules governing general procedures of therapy management. It is important to make a distinction here between Janzen's analysis of the extended case studies. 1978: 107). Lwezi's father had a direct responsibility for the blessing. but then there are other individuals who do not have those rights. to become a public woman" (Janzen. the person who is jurally responsible for the sufferer (muntu vwidi mbevo) quickly consults a doctor. This content downloaded from 129. Janzen (1978: 134) explains that "unlike the lay referral system in Europe and North America. child's father. which are subtle. the Kongo therapy managing group continues to exercise its authority and frequently even increases it while the sufferer is in the hands of a specialist. and not the nganga. Her father was upset at not having received the proper gift from the man Lwezi had married in the city. parents.215." It plays this role only through a subtle process of social negotiation. "The therapy managing group. Janzen (1978: 130) himself provides the key to understanding the process when he talks about "conveying rights.105." he writes (1978: 139). and fully contextualized." It is worth quoting at length: The process of conveying rights of therapeutic decision making has been identified by a MuKongo writer in the following terms: "When an illness occurs. it is again this jurally responsible person who sends for the appropriatetreatingdoctor. In Janzen's analysis the "therapy managing group" is the critical decisionmaking body. other members act effectively without consultation. for according to Janzen it must act collectively. and the general abstract discussion which reifies therapy managing groups. No professionalor bureaucraticreferralenforcementis possible in this setting. held ultimate authority over her therapy. If and when the consultingdoctor has made his diagnosis. "to have or possess") denotes the guardianship of a mother's brother. It implies proprietaryrights over the sufferer in keeping with the legal definition of a conveyance. Janzen talks about "quasi-groups" as a way of harmonizing analysis and description. which is described as discharging its duties after a professional takes over. nuanced. Lwezi's brothers tried to save their sister's health." The problem with this analysis is that the groups Janzen describes as managing therapy do not have clear boundaries-they are fluid." The term vwidi(from vwa. their members ever changing. No one else could give it in his place. noting that it would set Lwezi free. with a blessing.146 on Thu. but it is difficult to see how a group which might have different members on each of three successive days can act as an authoritative deliberative body. Some members express opinions which are never translated into action.

The second implication of the abortive bridewealth transaction is that the therapy managersrejected. in The Questfor Therapy. Janzen does not discuss this distinction. An understandingof lay therapy managementalters the basic terms in which we explain patterns of change in modern African healing. whether in the biomedical or popular medical sphere. Healers of all kinds merely present therapeuticoptions from among which those in control choose.82 AFRICAN STUDIES REVIEW The implications of this series of events are important.They wanted to make a voluntarygesture.146 on Thu. although the gap is one which is clear to us only because of the excellence of his own research. turns out to be of secondary importance. of their ideas and their practices.215. The interpretation of the illness in terms of bridewealth and her father's blessing must have reinforced Lwezi's sense that her well-being was linked indissolubly with respect for her father's authority.out of a moral or sentimental obligation to help their sister become well again. Lay therapy management does not have a distinctive institutional hierarchy. and thereforealso healing. but ultimate authority rests in the hands of the person with the clearest claim to jural responsibility. The history of healers. Spring (1978) finds that Luvale women's therapeutic cults are based on an ideology which assigns power to women and to matrilinealancestors. separate from general kinship authority. If Lwezi's brothers had been allowed to pay the bridewealth it would have undermined her father's authority and established a social precedent for reducingthe authority of husbandsand fathers more generally. It is for this important reason that feminist scholarsfocus on cults of affliction(see Berger. When deciding on therapy they tend not to separate considerations of the social effects of therapy from questions of the patient's physical condition and the likely therapeuticeffects of particulartreatments. They show that the loose unity of the therapy managing group conceals a fundamental division between one set of people who have jural responsibilityfor the patient's welfare in a given context. or education profoundly affect the shape of local society.105. At a later point in the same case a nurse at a dispensary asked Lwezi her story and then made her much better by telling her "you can die and leave as a corpse.ignores this central social process. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . it is fully embedded within general patterns of control over domestic and community affairs. Because the authority of lay therapy managers is not separate from generalized authority in the domestic and community sphere. The people who make the most crucial therapeuticdecisions tend not to have expert medical knowledge. When healing and the stability of authority patterns came into conflict. authoritywon. which challenge dominant ideology. The values and assumptions communicated through therapy are usually the dominant local values-in this case patriarchalones. marketing. In Lwezi's case her brothershad no jural responsibilityfor paying the gift or the bridewealth. they have the capacity to sustain alternative patterns of values. and others who offer voluntary assistance but have no rights or obligations in the particular transaction.He establishes the historical context of his account by writing about the This content downloaded from 129. all the factors which shape local communities affect healing. 1978: 112).a course of therapeuticaction which promised success but which challenged fundamental authority patterns. Anyone can offer help. production techniques. 1981). Janzen. When therapeutic cults establish their own hierarchies of control. or you can get better and leave" (Janzen. as unacceptable. Changes in transport.

Now virtually all children went to school. along with other measuresby which men expanded the number of their dependent children. in the other. and of government control over medicine. A man's most important way of attracting dependents was by demonstrating his generosity at moments of need. It is not the history of a transformation from "traditional" to "scientific" medicine (Twumasi. Widow inheritance. As the cash crop economy grew in the twentieth century. and other elements in local social change. Each fraternal group held a fund of common wealth to pay for food in famine. In the two decades after colonial conquest these groups fell rapidly into decline. leaving each male-headedhousehold on its own.two alternativelabor patterns appeared. no one would discuss therapy management. The proportion of households headed by women increased. became unpopular. In the most extreme of these cases (some investigated in the village setting and some in the hospital pediatrics ward) the child would not be fed adequatelywhen ill. the history of the fundamental social institutions which control therapeuticchoice. and cooperated fully in responding to major reproductivecrises. Most of them divided the funds of common wealth. with very strong moral obligations to help each other (for example to participatein therapymanagement). In one.People did not make a conscious and callous decision to neglect these children. 1975). Wealthy coffee farmers welcomed widow inheritance (practiced within a broad group of agnates) as a way of increasing the size of their dependent labor force. It is.105. in this particularregion. ritual. nor is it a history of therapeutic pluralism. was more likely to inherit widows and to attract dependents in general. needed school clothes.146 on Thu. health. All this changed with the introduction of Universal Primary Education in the mid-1970s. In the 1880s. The implications can best be understood through an illustration of relations among therapy. These children proved much more vulnerable than other children to severe malnutrition. or peasant politics at the most local level. the proprietor (for example of a coffee farm) used hired labor. and were more likely to die. each group of adult brothers together with their father (if he was alive) coordinatedfarmingactivities in a limited way.215.HEALTH ANDHEALING IN MODERN AFRICA 83 history of types of healing. much more common. A man who took an active part in therapy management for relatives. In our village study of 1979-1980 we paid special attention to children of those widows or divorcees who did not live with their parents or brothers. The most satisfying historical context for the evolution of Kongo therapeutics would be the total history of local social organization and ideology. to nutritionally induced complications of infectious disease. and who had not been remarried or inherited. This view of the history of therapybreaksdown all barriersbetween the study of healing and the generalstudy of social life. and to pay for communal therapeuticrituals. and were absent from farm work.The other part must be found in the institutions of domestic and community life-not separable in any way from those which manage the peasant economy. or who paid school fees for the children of impoverished relatives. he used family labor. to ransom members taken captive. with significantconsequencesfor the health of their children. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . It was replaced by hired labor.but without jural obligations. This is merely one part of the frameworkwithin which people shape therapy. Elizabeth Karlin) in northeasternTanzania. and family labor declined rapidly. instead. The children and their mothers were close to This content downloaded from 129. The illustrative case is based on my own field research (in collaboration with Dr.

even if too briefly. 1953.84 AFRICAN STUDIES REVIEW invisible. the conditions of health for particular individuals. 1963. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . 1983: chapter 5. patternsof health care and of health are inseparable. but to understand the specific domestic mechanisms through which the general social conditions have their greatest impact. What reseachers have not explored. the power structure of the local community. Therapy management. Local studies in Africa have challenged the definition of the household. which are the victims of extreme exploitation. But when the network of mutually supportive domestic groups is small.215. In these cases as with invisible children. Thomas (1981). is the relationship between patterns of therapy managementas conditioned by change in domestic organizationand levels of health. however. The burden of the argument is not to lay the blame on the households themselves. In much of Africa therapy assistance networks are shrinking. It may. This extended example has been worth setting out because it demonstrates. The interrelated evolution of therapy management and peasant economy is one on which the literature of African studies is close to silent. child care. found in the Ciskei that 70 percent of children in the malnourished portion of his sample came from households from which the father had deserted. When they were broughtto the attention of their neighborsand distant relatives they were given care.leaving sick people stranded without care.105. We found that the network of support at times of illness must be larger than the unit which organizes production and consumption. cooking. between cash crop productionand nutrition.it is possible for the system of care and of production to be overwhelmed. But even these excellent works limit their main attention to production and consumption. Otherwisethe small domestic units are overwhelmed. is ambivalent. and the illnesses numerous. South African researchershave found that the kinship support network is important for levels of child nutrition. Jakobsen(1978) found children of migrantlaborersto be at risk of malnutrition. as in the case of Lwezi Louise. leading to health crises. like all therapeutic power in the African tradition. This content downloaded from 129.146 on Thu. and so on.for example. and the pattern of control over therapy. In addition to the intense problems of women cut off from extended support. In Tanzania. 1976). but not the importance of the labor-consumption balance. Some important works have described the way large units for agricultural production and consumption have shrunk with the increasing penetration of capitalist relations of production (Haswell. Scholarsof peasant society ever since Chayanov (1966) have understood the need for each household to balance the amount of productive labor of which its members are capable against the household's consumption needs. Raynault. and even for survival. for example. my own research pointed to a second set of problems where mutual support networks were overwhelmed by health problems because of an imbalance between the number of sick and healthy people. The analysis could obviously be extended further in a number of directions-into the relationship. reinforce patriarchal assumptions. Watts. the way a single set of transformationsshapes the division of labor. 1975. We need to expand Chayanov'scalculus to take account of all the local community's reproductive functions-therapy management in all its aspects (including nursing and the payment of health care costs). But it also clearly reassuresthe patients who can expect the support and care necessaryfor health.

the cult requires much less family participation in Kinshasa than in rural areas. The first has a long history going back to the time of conquest. The order of presentation reflects a judgment that the central point of the argument on control over therapy needs special emphasis because it is invisible to most health planners and to scholars in fields related to health. and the second on the effects of particular forms of production. P. The point is that local laypeople are able to reorderthe social frameworkof their daily lives so as to shape their own experience of health and healing. even though our knowledge is not built on careful censuses. and population over the past century in two parts-the first on the consequencesof colonialism (and especially of conquest). and moved on to ways of coping with them. During the inter-waryears that pattern reverseditself. Instead. the discussion of control over therapy came first. The essay will show that the course of this reordering affects the outcome of struggles to control society's overall direction. THE SOCIAL CONTEXT OF DISEASE IN AFRICA I am not presenting the sections of this essay in their logical order. Accordingto Corin's descriptionof Zebola possession in Zaire (1979).although she emphasizes that the process is not a clearly linear one. On the eastern side of the continent. in Bunyole.146 on Thu. Historians give three basic interpretationsof early colonial population loss. the literatureshows this to us only in the most limited glimpses.HEALTH AND HEALING IN MODERN AFRICA 85 "What changes.105. Thompson as quoted in Comaroff. 1982: 63). Alongside Raynault's and Watts's description of the narrowing of Hausa economic cooperation. II. disease. and the rise of a new illness treated by the woman alone in her husband'shousehold by self help. Whyte (1982) describes the weakening of kin group organizationattendant upon cotton cultivation. and the appearanceof individualistic treatments in Nyole therapeutics. of which the second and third are not mutually exclusive. I will consider the constraints shaping health. we have MurrayLast's study (1979) of the decline of an illness which reinforces women's links with their natal homes. is the experience of living men and women" (E. Collective therapies survive alongside individualistic ones. Henderson(1965: 123).Once again. Population began to grow with increasingrapidity. Colonialismand Population The very broad trends in African population over the past century are clear. in the Oxford History of East Africa. during which the continent's population declined quite substantially.215. its content must change along with the changes in its organization. Janzen (1983) suggests that cults of affliction may work in an urban setting to provide a therapy managementgroup for those who do not live near a full network of relatives. as the mode of productionand productiverelations change. Colonial conquest brought a period. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . But it is important to begin by showing that the weight of the constraintsdoes not reduce human actors to helplessness. The discussion ought to have begun with disease and disability. states the position dramatically: This content downloaded from 129. This happens within a frameworkof powerfulpolitical and economic forces. Because healing plays a basic role in framing and giving meaning to that experience. lasting for several decades.

trypanosomiasis. Henderson argues that Africa had always been a continent of horrendous diseases. and Tanganyikadeclined sharply during the years between colonial conquest and 1920. Uganda. 1978: 188). newly introduced from overseas. was indescribably native inhabitants They lived in terrorof the frommalaria. and land use despite their own ignorance of African ecology. for example. they suffered typhus.sleeping andotherdiseases. East Africa The literature on East Africa offers a rich selection of interpretations of disease history along with a dearth of population figures. swept across the continent in the African version of the Columbian Exchange. The lot of manyof the depredations wretched. in their introductionto Disease in AfricanHistory (1978).146 on Thu. Hartwig and Patterson. and thereby destroyed the basis of survival. smallpox. The third and final approach to population trends under early colonial rule says that conquest was a political event which deprived Africans of the capacity to control their own environment. and that diseases. The second position focuses on changes in population distribution and movement in the colonial period. attributes the greatest burden of mortality to labor migration (1981: 134. in a book on East African ecology which owes much to Ford. Good's chapter (1978) provides an especially clear example of this sort of localized tolerance. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . and perhaps other indigenous diseases" (1978: 12). Dawson. The record of East African population history does not support his case. It is unwise to evaluate the overall worth of the three interpretationswithout first looking at regional differences.105. Urbanization. was necessaryeven though costly in human life (Azevedo. His approachis a useful variant of a much less defensible position taken by others:that Africa as a whole had been isolated in the pre-colonial period. their fieldswere stripped increased by locusts.The population trends which define the early colonial experience in East Africa did not exist in the west.86 AFRICAN STUDIES REVIEW East Africa [before conquest]was ravagedby tribal wars and by the of the Ngoniandthe Arabslavetraders. that the epidemics of the early colonial period were in no way unusual. Helge Kjekshus (1977). The crucial comparative questions-why regions differed from one another-have not been studied carefully. in this view. theircattlewerevictimsof the tsetseflyandof rinderpest. slave-raiders.But all recent scholars agree that the population of Kenya. see also 1983: 7). labor.Slaveraidingand epidemics recourse to witchcraft. the building of roads and railways. and the health problems of the equatorialforest were differentfrom those in either East or West Africa. labor migration. Breaching Africa's isolation. in his disease-by-diseaseaccount of Kenya in the early colonial period.215. sickness. and that colonial rule was needed to change this situation. and the movement of armies all increased the possibilities of transmittingcommunicablediseases. dysentery. The Europeanconquerorsforcibly instituted new patterns of settlement. combine the argumenton mobility with a second that improved communications "disturbed the relative tolerance which many rural Africans had developed for local strains of the parasites causing malaria. This is the essence of the position John Ford takes in his book on trypanosomiases(1971). makes the same case. This content downloaded from 129.

He argues that the region's population had been growing in the nineteenth century only to suffer disastrous decline after conquest. Sleeping sickness brought some of the most substantial population losses in early colonial eastern Africa. which. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . which wiped out cattle and wildlife.The density of population would then have been a result of population movement. reduced the human population.2 Ford emphasizes the role of two disasters in the breakdownof control-the rinderpest panzootic. or consequencesof colonial conquest. It is more likely that warfare and insecurity drove people into dense defensive settlements where they were forced to intensify their agriculture. and smallpox. 1978).They had succeeded in isolating the most what Ford called dangerous trypanosomiases in Grenzwildnisse-wilderness areas at the borders of populated territory.105.famine led to population movement and concentration because the search for food drove people out of their homes. showing that in the pre-colonial decades famine. Hartwig(1979. who had a long career as a colonial scientist. 1979. John Ford's The Role of the Trypanosomiases in African Ecology. 1971: 143). Ford. LiketheirBritish in Ankole across the Kagera the Germans looked neighbours as saviours of peoplesunkin centuries of barbaric upon themselves misery. The new population patterns then aided the disease's spread. attributes an especially significant role to smallpox epidemics which raged in the aftermathof the major famines of 1892 and 18991900. that they almostentirelyoverlooked the very considerable achievements of the indigenouspeoples in overcoming the obstacleof trypanosomiasis to tame and exploitthe naturalecosystemof and physiological both in themselves tropicalAfricaby cultural adjustment andtheirdomestic animals. The European conquerors destroyed a whole range of controls. together with famine. not of population growth.146 on Thu. Later in the book he wrote (Ford. argued that African societies had developed effective ecological controls for trypanosomiasis. Ford wrote (1971: 9): It is a curiouscommentto makeupon the effectsof colonialscientiststo controlthe trypanosomiases. upset the ecological controls which had long contained the threat of trypanosomiasis. This interpretation underemphasizesthe destructive impact of internationaltrade in the years before conquest.215. These are rare expressions of opinion in a massive work of detailed ecological analysis.arranged so that people and cattle did not come into frequentcontact with tsetse flies. cholera. Its central point is that the conquest destroyed African control of the ecosystem and thereby let loose diseases which had long been held in check. A Study of the Tsetse-FlyProblem (1971). in his valuable recent work on the history of disease in Kenya (1983. This is the subject of one of the great (although difficult)books of African history. asks whether the famines of the 1890s were natural events. 1981. He takes the intensification of agriculture in nineteenth century East Africa as a sign of population growth. and unleashed a plague on Africa. Few realized thattheywerethe primecauseof the suffering they weretrying to alleviate. writing about German East Africa (1977). 1976) gave a reasoned rebuttal to Kjekshus's claims of population growth. This content downloaded from 129. Helge Kjekshus. together with the colonial wars which broughtthem. and smallpox took a great toll.HEALTH ANDHEALING IN MODERN AFRICA 87 Marc Dawson. These two sets of events. Accordingto Dawson's interpretation. Once this happened.

work patterns. Colonial boundaries rigidified the Grenzwildnisse. 1981: 181-83).In some of the region's societies. Central African Republic. Congo. led to the expansion of fly belts. Concessionaires achieved these by terrorizing or This content downloaded from 129. Belsey (1976: 326) cites infant mortality figures ranging from 30 percent to 80 percent for nine villages in Zaire. Dennis Cordell (1983) points to the works of Thomas (1963) and Dupre (1982) as examples of studies working along these lines (see also Lux. 1967) and Retel-Laurentin (1974b. It is no wonder that some Africans of the region saw colonial actions as a form of biological warfare(Nayenga. under French and Belgian control. for example. Sexually transmitted diseases appear not to have spread widely before the nineteenth century. for reasons which are not clear.215.3Retel-Laurentin emphasizes the role of syphilis. The problem of infertility could not have been one of long standing. CoqueryVidrovitch. as reported in 1911. 1979). 1972). spreading from the coast in the 1880s. for extremely high infant and child mortality also played a role. and sexual division of labor for the period both before and after colonial conquest. whose residents were forced to move from the upper hillsides to certain death of sleeping sickness in the valley bottom. In addition. Scholars could illuminate the problem by mapping military forces in the early colonial period in relation to the distribution of venereal disease and of infertility. The concessionary system of early colonial EquatorialAfrica was one which would not make a substantiallong term capital investment in colonies. Equatorial Africa Large regions of Equatorial Africa. The regime of enforced rubber collection. 1976: 320-22). Infertility also threatened long term survival in Gabon. 1985). Perhaps military forces played a role in spreading sexually transmitted diseases. won notoriety even at the time (Harms. but which aimed at short term profits. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . 1976). 1976). 346). Romaniuk (1980.and a host of ecologicallyignorantauthoritarianmeasures. Trypanosomiasis played a role here.88 AFRICAN STUDIES REVIEW tsetse belts never stopped advancing. but gonorrheais a more likely cause of infertility (Belsey.146 on Thu. 20 percent to 40 percent of fifty-yearold women have never had children (Belsey.many of them intended to control tsetse. 1979b) agreethat sexually transmitted diseases were the major cause of infertility. and parts of Zaire and Cameroun. even in recent times. was so deeply feared that local judges could impose the death sentence on women who slept with Europeans (Harms. the colonial disruptions of local economy and society were among the most sweeping and intense on the continent. because the population could not have sustained itself over the long term while threatened by late nineteenth century levels of loss (Caldwell. too. experienced population decline more extreme than East Africa's (CoqueryVidrovitch. The areas of EquatorialAfrica occupied by concessionary regimes tended to suffer high levels of infertility. 1975. 1977: 341. This would have been one additional consequence of the upheavalsbroughtby early colonialism. Harms describes how syphilis. No one has written a serious analysis of patterns of sexuality in the transmission of disease.105. Such an analysis would need to take account of the economy. One of the core images of Ford's book is of the Semliki Valley. In any event. 1979a. population decline in that period was not solely a result of infertility.

West Africa West Africa saw few signs of the population decline which was so significanta part of the early colonial period in Equatorialand East Africa. Perhaps disease adaptation in nineteenth century West Africa was less localized than on the eastern side of the continent.215. As a result West Africa suffered the equivalent of its shock of conquest-its period of demographicdecline-long before the colonial period. In this region as in other parts of the continent the statistics of the period are unsatisfactory. West African populations were in movement over centuries. Patterson. 1977 and Miller.146 on Thu. 1981: 87.HEALTH AND HEALING IN MODERN AFRICA 89 killing people unless they broughtgoods for export. This interpretationdoes not pass the test of comparativeanalysis across regional lines. 1976). yet this did not protect it from population loss in the nineteenth century when colonial pressuresbecame intense (Dias. motivation. This content downloaded from 129. 1975: 90-93. People living in the driest zones have always moved southward into the wetter savanna during the dry season and in dry years. This was more significant for biological adaptation than the movement of traders because it meant that whole populations interacted with one another and with alien environments. 1977. especially in the savanna and at the desert edge. This is clear not only for the concessionary regimes.but scholars seem generally to agree at an impressionistic level that West Africa's population was relatively stable." according to Patterson and Hartwig. The foreign enterpriseswhich have been most disastrous for the survival of Africans on their own continent have been those which are capitalist in ethos. Inikori. 1979: 128. 1972: 12. with many returning northward again with the rains. Other pilgrimageswere also substantial (Al-Naqar.000 West Africans accompanied King Mansa Musa to Mecca. why did it not have the same effect in the west? Inikori (1981) is one of the few scholars who tries to answer this question. were exposed to alien disease environments over long periods. 1977: 227. "West Africans had had many generations to build up defenses to cope with their more complex disease environment"(1978: 8. enjoying gains in others. 1981.4He relies on Cissoko's description of sixteenth and seventeenth century epidemics at Timbuktu (1968) to argue that the slave trade led to political upheavals which in turn caused demographic disasters. 1977). 1982). Frishman. Ismail Abdalla). 1981.for it was a form of movement in which West Africans left their homes. Pilgrimage to Mecca may also have been significant. "By 1800.but which do not (or cannot) invest sufficient capital and which therefore intensify exploitation in order to survive. for sources see Ajaegbu. Perrot. see also Patterson. Even if the figure is not precise. He assigns an important role to the West African slave trade. personal communication. 1977: 8. 96. see also Thornton. and organization. possibly suffering small losses in some places. Wilks. Angola suffered intense slave trading from an early date. 1981: 2-3). 1977. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions .105. Al-Naqar estimates that 15. but also for the undercapitalizedmines of Southern Rhodesia at the same time (Van Onselen. Hill. Wrigley. If African surrenderof control over the local environment led to disastrous populaton loss in East Africa. Patterson. The peoples of West Africa had probably never been as narrowly restricted as East Africans to particular zones. 1981: 299. and then returnedhome. it is clear that large numbers of people were involved. but in no way similar to the drastic declines of Uganda or French EquatorialAfrica (Caldwell.

except for the effects of interaction with aliens at the coast. Gregory and Piche. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . 1967). These were among the highest in the world. mergingU. The final disastrous event which marked the end of early colonial population decline struck all the regions of the African continent. The great growth in African population must be understood against a backgroundof poor health. tetanus. and cannot be taken (without more specific evidence) as a sign of generally improved conditions. but it was through disruption of food supplies and the impact on disease transmission. pre-colonial populations probably did not share This content downloaded from 129. as was the infant mortality rate of about 200 per thousand (Vallin. which is then unlikely to rise further as conditions change. We do not yet have the detailed regional populaton histories which must precedeworks of broadersynthesis. Cantrelle.146 on Thu.215. in his view. estimate the continent's population as 164 million in 1930. Caldwell writes that a decline in mortality caused the population explosion. and respiratory diseases. The high rates of population growth do not. 1975. typical through the long span of African history. This was the influenza pandemic of 1918-1919 which. however. It is possible that maternal mortality is also a significant cause of death (Ware. Second. Gregoryand Piche. Political upheavals may have had an impact on population. There are two problems. The precise determinants of population growth are largely unknown. 1982). Since then. Another sign of poor health is the prominenceof infectious disease among causes of death. indicate that people are healthy.90 AFRICAN STUDIES REVIEW The picture is less clear in the forest zone of West Africa. 1979). 1977. see also Pool.S. showing that populations were probably not tied as narrowlyto particularmicro-environmentsas on the eastern side of the continent.105. and U. 1976. which moved rapidly among newly constructedrail lines. statistics. Wrigley. Cantrelle. diarrhealdiseases. 1985. Caldwell's assumptions about pre-colonialpopulation are weak. First. The equilibriumof gene and disease is much less precise in West Africa (Livingstone. at which point degenerative diseases like cancer and cardiovascular disease became more important. War-time movement of soldiers and laborers helped to spread the disease. For Caldwell it was high fertility which sustained pre-colonial population despite the very high mortality. the rate of growth has increased rapidly. In parts of East Africa where falciparum malaria is a significant problem a much larger percentageof the population has the gene than in malaria-freeareas.N. 1975. The crude death rates of the 1970s varied between fifteen and forty per thousand. The fertility levels recorded in the 1950s were. caused by an unhealthy environment made worse by the dangersof warfare. measles. 1977) that precapitalist modes of production in Africa require high fertility. This was characteristic of West European mortality patterns before life expectancy began to increase. 1978. and the consequences of tradeinduced warfare. according to Patterson and Pyle (1983). Gregoryand Piche (1982). At some point in the 1920s population began to grow. took between one-and-a-half and two million lives in sub-SaharanAfrica. His argument grows inexorably out of his assumption (1975b. 219 million in 1950. and 458 million in 1979. The gene confers some resistance to falciparum malaria.The distribution of the sickle cell gene is one piece of evidence showing that West African populations were less localized in their adaptationsto their environment than the peoples of East Africa. 1977. 352 million in 1970. 1982).In Africa today the great killers include malaria. warfare was not a major direct cause of mortality (Kjekshus.

where Cantrelleplaced infant mortality in Dakar at fifty-seven per 1. that mortality has in fact been declining over the past sixty years. even though the causes of the decline are largelyunknown. and anti-malarials. sulpha drugs and then antibiotics for pneumonia.105. In the Khombol survey zone in Senegal. Most people on the continent in this century have lived where there is no doctor. compared to 47. antibiotics. Patterson (1979) shows that Accra's piped water supply expanded rapidly in the years after World War I. The most common base-line for answeringthis is the early colonial period.HEALTH AND HEALING IN MODERN AFRICA 91 mid-twentieth century fertility patterns (Swindell. but in others the national governments made the first censuses only in the 1970s. Yet people do continue to die during major famines (Watts.146 on Thu.000 in ruralThienaba.asking about all deaths within the preceding twelve months. At that late date a large proportion of censuses collected no information on fertility and mortality (Tabutin. A second possibility is that medical interventions have saved lives. while it reached 247 per 1. Some of the most precise estimates are for Senegal. 1975). Ganon. vaccination for smallpox. whereas continuous observation over the following three years showed the same zone averaging 233 deaths each year in that age group (Cantrelle. Access to clean water makes diseases of the gut less likely. 1984). Sanders(1982) estimates similarly drastic urban-rural differentialsfor Zimbabwe.Immunizations also made a contribution. 1983). and follow-up. which was long during the pre-colonial period but became progressivelyshorter as the twentieth century unfolded.5 in Rift Valley Province. 1977) showed the importance of the duration of post-partum sexual abstinence. The question is whether the number of deaths has declined. It is likely. a few innovations seem important. the informationis often inaccurate. including sulpha drugs. Where biomedical care exists it is usually a brief encounterbetween patient and doctor-rarely a matter of thorough diagnosis. a retrospectivesurvey in 1963-64 counted 126 deaths among one to four year-olds. In Kenya. nevertheless. These differentials show that mobility and urban crowding. leaving governments more dependent on censuses. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions .215. One possibility is that improvements in transportationreduced famine mortality by making it easier for people to move away from famine zones (Caldwell. a time of unusuallyhigh mortality. 1981.8. In one of the rare local case studies. life expectancy for women in Nairobi in 1969 was 63.are less important than other factors. Nevertheless.In most cases the interviewercollects mortalitydata retrospectively. Manning. at a time when the city made few advances in the disposal of human waste. and treatmentof traumaticinjuries. 1975c). vector control and therapy for trypanosomiasis. 1978: 69). 1981. Geographical variations in mortality give some clues on the long-term mortality decline. Public registration of births and deaths is still rare on the continent. treatment. But which ones? Clean water supply is a possibility. This procedure almost invariably underestimates the number of deaths. The Caldwells themselves (Caldwell and Caldwell. 1975: 697). Patterson (1981) estimates that colonial Gold Coasts's mortality declined because of chemotherapyfor malaria. We do not have comprehensive data on fertility and mortality in the twentieth century. and 50. which are sometimes taken as the major causes of disease and mortality. Even when it is collected. for example. Rural mortality is consistently higher than urban.000. Some colonies collected census information throughout the century.0 in Western Province (Monsted and Walji. These This content downloaded from 129.

for example. Most important of all. wherever post-partum abstinence was important. The only indicator on which the urban sample was worse off. Orubuloye and Caldwell (1975). As we have already seen." The general picture. Post-partum abstinence raises a question which is at the core of local level social change in the twentieth century. fertility was not higher than it is now. in an attempt to demonstrate the effects of medical care. shapes the distribution of water supplies. studied two towns in Ekiti Division of Nigeria's Western State.105. men from the hospital town were more likely to live at home with their families. they say. although urban food supplies have gotten worse recently with the intensificationof economic crisis in many countries. anti-malarials.. is of declining duration and gradualdisappearancein this century (Schoenmaeckerset al. They found that children were much more likely to survive in the town with a hospital. People in the hospital town drew water from shallow wells.and city dwellers had higher hematocrits (indicating less anemia). as are their effects on fertility. In those days of higher mortality.215.. 1972: 13-14). and some surgical interventions. The timing of declines in mortalityand in abstinence are largely unknown. spent two dollars per capita on urban water supplies. The Caldwells claim that even in the days when customary abstinence lasted for long periods. as opposed to water in the other town from streams in which people defecated. mothers often made an early end to abstinence after a child's death. The assumption that declining mortality is the only source of African population growth in this century needs to be questioned. it is unwise to presume that nineteenth century fertility patterns were identical to currentones. But they ignored several possible explanatory factors. In studies around the continent absent fathers and child malnutrition often go together.146 on Thu. include a softening of the effects of seasonal hunger for citydwellers who purchasefood in all seasons. because higher. They found that city women were heavier than their rural counterparts. one with biomedical facilities and one reliant only on popular healers for care.. which sometimes continued for long periods.why did women's reproductive lives This content downloaded from 129. In a large part of the continent post-partumabstinence. aside from water supplies. which is concentratedin Africa's cities. 1974) compared rural and urban samples in Senegalwith respectto a number of health indicators. antibiotics. It is possible that nutrition. Kenya in the late 1960s. 1981). 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . Possible reasons for the differential in nutrition. whereas many of the other town's men migratedto find work.One report (Benyoussef et al. which might make some difference because of immunizations. City people also have easier access to medical care. It continues to play a significant role in some places. and a shorteningof women's work day making it possible for them to cook more frequently. and two-and-a-half cents per capita on rural water in a country where the vast majorityof the population was rural (White et al. The authors lump together all medical interventions as "care" without distinguishingthe effects of immunization and of therapy. Caldwell and Caldwell (1977: 212) found that even in the 1970s the average woman in their study population "experienced sexual relations for less than half of her fecund married years. Political and economic power. is better in the city.92 AFRICANSTUDIES REVIEW are major killers and major causes of malnutrition.was cholesterol. too. was the major form of pre-colonial fertility control. We cannot rule out a rise in fertility which contributed to the growth of twentieth century population.

health care. and family support. but also for peasant producers who may benefit from extension services. The only way to cope was to increase fertility (Turshen. Questions about the distribution of social costs of production are relevant not only for understandingthe fate of those employed for wages. made great labor demands on each domestic group (Meillassoux.. Another possibility is that when large caregiving groups declined. who then chose to have more children? If this is so. 1984) by shorteningabstinence periods. Social costs of production include the cost of making working conditions healthy. public education and health services. as discussed above. the cost of feeding workersand their families. or workers' families. and the paradox that hungry farmers feed city people all need to be understood in this light. the need for maximum fertility. a pre-capitalistsurvival. The most common justification of the custom is that it is essential for the health of the infant. whether in places which supplied male migrant workers or where export crops were important. education.146 on Thu. for example. and for people who happen by chance to live near fields sprayedby harmfulpesticides. For example. This content downloaded from 129. small domestic groups became more insecure. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . The problem with the explanation based on labor needs is that it would et al. The social costs of production are not only the ones normally counted as factors of production.215. why did they choose more children? The answer is not clear. The Social Costs of Production Studying the social costs of production makes it possible to identify political and economic decisions which have an impact on the distribution of sickness and death-decisions. 1981). 1981. Abstinence has something to do with control over women's bodies (Schoenmaeckers et al. nevertheless. The concentration of health investments in the cities. or that it is a sign of the mother's morality. The concept of "social costs of production" will illuminate the central relationships.and of either controllingor sufferingthe environmentaleffects of the production process. The larger pattern of rapid population growth alongside poor health is. and at other times are borne by the state. Caldwell sound alien to those who actually abstain (Schoenmaeckers and Caldwell. then they did not. in complete harmony with an enclave economy. 1975).105.AND HEALING IN MODERN AFRICA HEALTH 93 change in this consistent way over large areas? The literature offers few considered hypotheses. In this case maximum fertility is not. The colonial economy. or who may be compelled to produce cash crops at price levels which lead to immiserization. on whetherto invest in sanitation. communal care for the aged might well have been better in the nineteenth century than it is today. The over-all process met colonial needs for labor.but take in a wide range of costs which in some societies and at some times are counted as productioncosts. but was mediated by new forms of ideology and organizationat the local level.. These days old people need many children for support. or the entire population. but instead the creation of capitalism in its colonial form. 1981)-but what? Could its decline mean that patriarchalsocial groups lost some degree of control over women. The decline in abstinence can only be understoodwithin a generalunderstanding of the way people have re-shaped domestic and community organizationin the twentieth century. as Caldwell would have it. Alongside care-givingneeds are needs for labor. Perhaps in that case people a hundred years ago did not want maximum fertility. of maintaining retired workers.

and their larger circle of kin. These liberal definitions of social cost and social good do not take account of any levels of experience or solidarity other than the whole of society on the one hand. gender. in South Africa the cost is assigned to the sphere of reproduction. a cook who fries eggs in a restaurantis seen as producing. For example. or by the afflicted individual.S. while the rural population pays costs in ill health. Some elements in the distribution seem to those in a society to be almost a part of the natural order. the state. it is thereforeprovided by public policy. or the state). They therefore direct attention away from issues of class control. 1969: 219). Yet from the point of view of health policy it is very relevant to know that urban dwellers derive benefit from irrigation without sanitation. but the term itself does not have strong connotations tying it to a particular level (whether domestic. sent back to a ruralhome for relatives to support. polluters do not usually pay the health costs of industrial pollution. or by the state. must be paid at some level of society. in colonial Africa women produced the food which sustained the families of migrant laborers. The first is that reproduction is something we intuitively think of as being private. and treated by any one individual or firm as an externally caused shift in the utility curve (Samuelson. corporate capital.215. a local community. on the other hand.In the U.while one who fries eggs in a domestic kitchen is reproducing. and the individual or the firm on the other. whether based on class.In the U.A "social good" is one which cannot be divided and sold separately to individuals (Samuelson. or the differentiation of rich and poor geographicalregions.S.146 on Thu. but varies according to historical context. At each historical moment political conflicts bring into question some previous decisions on the distribution of social costs of production. which is concerned with external economies (benefits) and diseconomies (costs) only for the individual or firm. Many recent works define costs of family support or workerhealth as costs of the reproduction of labor. second by specifying costs and benefits in terms of relevant social sub-groupings. as evaluated by society" (Lipsey and Steiner. for the worker is exposed and then. as in the Reagan administration's This content downloaded from 129. 1970: 454). and not to be questioned.S.94 AFRICANSTUDIES REVIEW "Social cost of production" is closely related to the terms "social good" and "social cost" as used by liberal economists. 1970: 149-51). we easily forget that the assignmentof costs to either the productive or the reproductivecategory is not objective or universal. I intend to retain both terms for use in different contexts. "Social cost of production"differs from the liberal definitions of social cost in two ways: first by specifying that the relevant linkages are between production and social costs. but to give greater emphasis to "social costs of production" for two reasons. These are paid either by health insurance subsidized by all employers. today. "Social cost measures the value of the best alternative uses of resourcesthat are available to the whole society. Questions about which groups within society pay the social costs and which enjoy the benefits are irrelevantfrom the point of view of liberal economic theory. the concern of a wife. Second. In any given historical setting the particular distribution of social costs of production among workers. Social costs of production. In the U. The definitions furthermore assume that decisions taken by the whole of society benefit the whole of society. but with crucial differences. and consumers has a certain stability. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . the level of a business enterprise. the cost of protectinga workerfrom very high levels of exposure to lead is a productive cost. at a certain point.105. a husband.

expelling those who are needed to populate the labor market. This is so. the costs of old age support. Malaria is also worth studying as one of the most important and rapidly growing disease problems in Africa today. the relief system contracts. then women ought to be (1950). as turbulence subsides. They are meant as a corrective to the ideology which finds its clearest expression in the migrant economy. and as we can see from the radical differencebetween the distributionof social costs within the metropolitan countries and within their colonies in Africa. economy entitled The Social Costs of PrivateEnterprise show that social costs will never be redistributedby the invisible hand of the market or because of the rationality of this argument. on malaria. reveals some of the same relationships among production. as though it is neither labor nor production. the landscape. The costs of caring for ailments. women's work and malnutrition. which is not discussed. Piven and Cloward (1971: 3) have shown that in the U. Kapp had made the essential core of the argumentmore than thirty years earlier in a book about the U." As this example makes clear. informed me that K. W.146 on Thu. child rearing. even women's farmingin Africa. The case study on women's work shows that malnutrition. or among non-workers living near the factory. The issues can only be addressedin practicalways by political action.HEALTHAND HEALINGIN MODERN AFRICA 95 attempt to reduce social security and health care for the elderly and poor in the U. and food for workers' families. because the effects of technology are mediated by decisions on which social costs of production should be paid. but rarely accept responsibility for cancers which appear fifteen years later.215. Scholars often describe the disease as an inevitable consequence of development. A colleague. hosts and parasitescould as easily been illustrated with an account of trypanosomiasis. each concrete form of the organization of production and of political power has its own characteristicpatterns of payment for the social costs of production. into question. in which conditions only count as work-relatedif they occur duringthe brief period the worker is receiving wages.. The case studies define the sphere of productionbroadly. Schistosomiasis radically changes its frequency when economic activities alter the landscape. malaria. Employers describe industrial accidents as work-related. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . The four case studies which follow-on schistosomiasis. then. and the distribution of disease.105. The second case study. the "naturalness"of the disease. emerges from the way policies and economic pressures create the structureswithin which women shape their daily work.S. The patterns of morbidity and mortality which grow out of particular forms of production should therefore not be seen as inevitable consequences of the technology of production. the ruraleconomy.S. "when mass unemployment leads to periods of turmoil. The obscurity into which the book and the concept have fallen This content downloaded from 129. on reading an early draft of this essay. The complex set of relations in schistosomiasis among governmentplanning. the division between the work place and the rest of society has the effect of defining most women's work. The final case study shows that South Africa's decision to use a migrant labor force has had significant consequences for health within the country and the southern African region. If we accept this.and occupationalhealth in southernAfrica-are selective illustrations of social costs and their distribution. In addition. and by whom.which often interacts disastrously with infection. relief programs are ordinarily initiated or expanded to absorb and control enough of the unemployedto restore order. are borne to the greatest extent possible by the workersand their families. The present discussion is meant to bring that inevitability.S.

Large irrigation projects and large-scalecommercial agricultureusually contributeto a process of simplification. The present definition of social costs and the case studies try to show. and the fewer the individuals per unit area. articles on large-scaleirrigation continue Dunn's line of thought (Kloos. instead. There is frequent contact between people and water in which the parasiteslive in their free-swimming stage. are very diverse ecosystems. In Dunn's interpretation. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . Schistosomiasis The Social Costs of Production: Hunter describe schistosomiasis as one of the "diseases of and (1970) Hughes is a disease for which snails are the intermediate It parasitic development. The chain of events by which irrigation creates disease is best understood in terms of "simplification of the ecosystem.146 on Thu. Irrigation does not. Sexually reproducing organisms which happen to find the particular environment favorable achieve very high densities-because of the uniformity of the environment-leading to intense infections." The more species of plants and animals per unit area. Thorn woodlands are simple ecosystems. with many of the species represented by single individuals. lead inevitably to schistosomiasis (Bruijning. burdens of worms are heavier. 1977). Chandler. This sense of the inevitability of schistosomiasisas a cost of irrigation is misleading.simple ecosystems (as comparedwith complex ones) have fewer species of parasitic and infectious organisms. Infection rates of Schistosoma mansoni among schoolchildren in some irrigated areas reach 80 percent. and the increases in infection are enormous. which have many species of trees per hectare (60 species in one particular study cited by Dunn). however. and they need piped domestic water. Tropical forests. however. "Parasitic and infectious disease rates of prevalence and incidence are related to ecosystem diversity and complexity. DeSole and Lemma." hosts. With simplification.96 AFRICANSTUDIES REVIEW studied almost entirely in the reproductive sphere. 1981. Hill. after they emerge from the snails. People living near the irrigation ditches need adequate latrines so as not to evacuate schistosome eggs into the water. But the process of indirect disease transmission (whether of sexual or asexual infectious agents) tends to be highly efficient. In the case of schistosomiasis. that a broad interpretation of production comes closer to revealingthe health consequencesof production. In environments where worms reproduce easily. Schistosomiasis is inevitable only if policy-makersdecide not to pay for sanitation and water supplies. there are also fewer species of potential intermediate hosts for parasitic and infectious organisms. This disease provides us with a case study of how a clear decision not to pay one of the social costs of production created a substantialhealth problem. the greater the diversity. the snails are intermediatehosts. for example. and is therefore spread easily at large scale irrigationworks where people live near snail-infested water. 1980)." Dunn (1968) explored the Recent implications of this process in his work on the health of hunter-gatherers.and Highton. mansoni. Those who plan the irrigation works can introduce measures to control the snails which are hosts to S. The problem is This content downloaded from 129.105.215. the irrigation projects are simplified ecosystems which provide an excellent uniform environment for snails. According to Dunn (1968: 225). Proper measures can break the cycle of transmission and lower the incidence of infection.

In my own view this method has the effect of systematically removing many of the social costs of production from the calculation of cost and benefit. but in leisure" (emphasis as in the original. They found that none of the farmers who benefited from irrigated plots in settlement schemes were infected with S.. DeSole. Weisbrod. who form 90 percent of the population of the scheme. mansoni. the cost of reduced smallholderfood production. but that infected workers "respondto a decrease in their daily productive capacity by working more days per week . (1973). 1973: 75). in food preparation. et al. and shift the greatest proportionof social costs of productionto those who are poorest.. the authors consider only the work done on multinational-owned banana plantations as economic.146 on Thu. not in market production and earnings.AND HEALING HEALTH IN MODERN AFRICA 97 that African governmentsand aid donors (who want the largest and most visible projects for the least money) usually underestimate costs of resettling people.1978). as leisure. whether on subsistence farms. Andreano. and Lemma (1981: 463) studied 363 people living near irrigation schemes in the Awash Valley in Ethiopia. as were an identical percentage of migrant laborers and their families." The most important effect of this distorted measurementof economic cost is to justify the policy of providing irrigationwithout significantsanitation or disease control. et al. In short. even without latrines and piped water. and which has been quoted widely (see for example Stockard. 1973). Accordingto the authors of the study. It is often the poorest of the people in the irrigated areas who pay the cost in debilitation. but 57 percent of crowded subsistence farmers were infected.. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . the cost of schistosomiasis infection for males is a reduction. Final costs are often two to three times the amount budgeted (Scudder. and all other work. which directly approaches the question of the costs and benefits of schistosomiasis control. and remains a major strand of currentdevelopment policies. The authors studied the effects of schistosomiasis on the economic production of banana plantation workers in the Caribbean. largelydue to high population density and the use of all available land for irrigation agriculture. One important study is a book by Weisbrod. Policy planners who make decisions on irrigation works rely on a limited range of social researchin deciding whetherto pay the social costs of production. This pattern was at the heart of colonial policies. they calculate the costs for one disease at a time. Andreano. Kloos.105.6 Simplification of the ecosystem combined with narrow limitations on paying social costs of production is characteristicnot only of irrigationschemes but also of plantation agriculture. in crafts.215. In other words. the cost of reduced craft production-all of these the researchers account for as losses of leisure. even though the conditions which lead to schistosomiasis also increase the prevalence and incidence of other infectious diseases. or in child care. In addition. This content downloaded from 129. "Availabilityof land for defecation is most limited in labor camps in irrigationfarms.. in health care. The authors show that schistosomiasis reduced the amount the male banana plantation workersearned each day by about 30 percent. The cost of caringfor those who are debilitated in old age after a lifetime of schistosomiasis."In this particularcase it looks as if those who pay the social costs of production are not the people who gain the benefits.In the enclave pattern government and business invest only in what is directly productive (with production defined in the narrowest way).

gambiae went from 1 percent to 65 percent of the mosquito population (Desowitz. A. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . 1977). In undisturbedforest. like the spread of schistosomiasis.105. the major African malaria vector. will serve the same purpose in twentieth century Africa that cholera served in nineteenth century Europe-as a scourge which crosses class lines and therefore gives those with power an additional incentive to work vigorously for its control.especially plantations. such as the provision of drains.1974. however. took to deal with pest problems emergingfrom simplification of the ecosystem. and especially to an enormous expansion of Anopheles gambiae. but the crucial fact is that when authorities decide to pay the costs. Wide agriculturaluse led to pest resistance.8The use of a single plant species as a crop over an extensive area leads to an increase in the density of the pests able to feed on that crop (Gillham. much less is used for disease control (Busvine. and therefore to the expansion of A. Chandler. But in Africa none of the authorities-colonial. brickworks. Brown et al. and Highton. Even in holoendemic regions. All over the continent the twentieth century has seen a process of clearing forest and brush. The job seemed hopeless in a region without widely distributed health services.215.because of its rapid expansion. gains can be made.Hedman et al. 1972). 1976. achievements are possible.farming. is related to the enclave pattern of development and to the simplification of ecosystems. and urban building all lead to the creation of small accumulations of water. Most of the insecticide produced in the world is applied directly to the land for these sorts of agriculturalpurposes. In the years after World War II. have been minimal. DDT was the highly-capitalizedfarmer'spanacea. The failure of control efforts in India and Latin America and the consequent resurgence of malaria were direct results of measures which large scale commercial agriculture. and where rates of prevalence were high (Bruce-Chwatt. Many of the ecological changes resulting from the expansion of commercial agriculturehave led to a change in the distribution of mosquito species. 1978). road construction. gambiae among mosquito species. however. 1978). National governments (and later world health authorities) took vigorous measures before World War II to control malaria in Europe.and irrigation should be abandond. national. (1979) estimate the cost of the control programat $4 per person (probablyan underestimate). A. 1980. Quarrying. 1976).7 In the Kano plains rice scheme in Kenya. and after the War used DDT to control the disease in India and Latin America. Rural poverty plays a role because quality of housing for both people and domestic animals affects prevalencerates. gambiae (Dutta and Dutt. Measuresfor basic environmental control. The characteristic response of capitalist agriculture on an industrial model is to find the silver bullet-the chemical capable of wiping out the pest wherever it is found. and then DDT entered agriculturalrun-off flowing into lakes or streams. leading to an increase in the percentageof A.146 on Thu.. the economics of colonialism and the enclave pattern of development contributed to the seriousness of the problem. It would be impossible to arguethat all forest clearing. as shown by the success of a mining company in Liberia in drasticallyreducingthe prevalenceof malaria. Bruce-Chwattand De Zulueta. Farmers sprayed entire fields. The one hopeful possibility is that malaria. Hill.98 AFRICAN STUDIES REVIEW The Social Costs of Production: Malaria The spread of malaria in the twentieth century. or international-made full-scale efforts at malaria control. Under these This content downloaded from 129. gambiae is one of the less common mosquito species. mining. As in the case of schistosomiasis.

" 1978). If the hypothesis is correct.The picture is not altogether clear.with significant consequencesfor the distribution of infant and child malnutrition. In most African settings where malnutrition is a serious problem. and have directed credit and extension or marketingservices towards men. "BiologicalControl of Insect Vectors.S. of little interest for economic development. Even now researchtends to be restricted to farming work-only one part of a total picture which ought to include cooking. crafts. child care. The tie between malnutrition and rural women's work is clear.have all tended to count commercial crops as masculine. based on a broad but not overwhelmingrange of data. when women's production is not counted as economic. but pesticide manufacturers and large farmers have been unwilling to do this (Agarwal. 1973. while treating women's farming as uneconomic subsistence. internationalaid agencies. If DDT had been used only for malaria control-for spraying in houses or limited outdoor areas-the likelihood of insecticide resistance would have been much smaller. and national governments. however. It would be wise to reserve some insecticides for mosquito control.HEALTH ANDHEALING AFRICA IN MODERN 99 conditions the weakened solution kills some but not all of the larvae present. A second element in a rational approach would be integratedpest control. 1978. My hypothesis. 1978. the sphere of uneconomic domestic activity is defined even more broadly to include women's farming for household consumption. in which insecticides are "carefullychosen and applied to maximize their action on the target organisms and to minimize their impact on non-target species and on human and animal health" (Brader. According to Wolpe (1972). Those which survive are more likely to become resistant mosquitoes. The general point about women's hidden subsidy of African labor systems is well known and widely discussed. for scholars have only recently begun to study historical changes in women's work. and many others. PAHO Advisory Committee on Medical Research. and also to intensify seasonal variations in the demands on women's work time. 1979).105. however. have systematically explored how the organization of women's work under these conditions shapes basic patterns of malnutrition. This led in turn to higher seasonal peaks of both malnutritionand death among infants and children. 1979: 226). Meillassoux (1975). care of the sick. Barbara Rogers (1980: 142-45) and others show that colonial regimes. Biological controls would then be part of an integratedprogram(Ruesink. 1976. it means that today's characteristicpattern of malnutrition is a recent phenomenon related to changingdemands on women's work time. In Africa. employers can reduce wage levels. 1975.215. and a range of other activities.146 on Thu. is that in much of Sub-Saharan Africa crop regimes have changed over the past century so as to intensify seasonal food shortages. 1972. carrying firewood and water. WHO Expert Committee on Insecticides. since workingmen do not need to supporttheir families. This is similar to the way most economists in the U. fats and oils are in This content downloaded from 129. Few scholars. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . Davidson and Zahar.9 The distribution of women's work time in peasant agriculturehas changed drasticallyover the past century. Murray(1981). treat housework. The Social Costs of Production: Malnutritionand Rural Women'sWork The majority of policy makers in twentieth century Africa (whether colonial or national) count women's non-wagework as domestic activity. WHO Expert Committee on Insecticides.

Linares.they leave the cooking pot to simmer. and do other chores. According to McGregor. It is clear for the places on which we have detailed information that people grew many more varieties of food crops a hundred years ago than This content downloaded from 129.The old system of hungry season sharing therefore declined.105. and Richards.. however. Onchere and Slooff. that women-centered households without men become especially vulnerable. as do debtor households. 1979. destroying vitamins. at this time of year. Nutritional levels and climatic conditions affect the disease picture at the same time. often go hungry. and had even greater difficulty facing the next hungry season. care for children. The way to improve child nutrition seems obvious: children need more meals a day. and Oldfield. The heaviest work seasons come at times when the previous year's food is nearly exhausted and the new year's food has not yet ripened. women do not have time to gathergreen leafy vegetables. Haswell found in the Gambia that in the 1950s and 1960s men who grew cash crops withdrew from large mutual insurancekin-groups. they come home to cook after the children have fallen asleep. Households use men's cash income to supplement food stocks in the hungry season. The multiple demands on their work time can make it impossible for them to provide adequate food. Ndagala. appears to affect more children in the hungry rainy season (Rowland et al. and to make up the deficits after harvest (Bayliss-Smith.1981). cook. 1978. Williams. and mothers devote less time to their children's care. 1983). At the best of times. 1981. the level of child nutrition depends on the number of times a day children eat cooked foods.100 REVIEW AFRICAN STUDIES short supply and foods are relatively low in energy. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . but for the vast majority of peasant mothers the constraintsof work time limit child nutrition. Williams.146 on Thu. the amount of labor women devote to agriculture varies widely from one season to another. 1981. If convenience foods are unavailable. and if possible meals with higher energy content. Johnny. 1983). Hull. During the months which demand the heaviest labor. 1981). the nutrition of women and children suffers. especially those with a single main rainy season. Diarrhea. The women themselves. Birthweightsare also seasonally depressed.215. They thereforepay much less attention than they did a century ago to food crops for home consumption (Bukh.they do less housecleaning and limit fuel and water collection. 78 percent of childhood deaths in the Gambia occurred during the rainy season (1964.. The first is change in the agricultural division of labor by gender. and Oldfield.o The second major change is a reduction in the number of food crops each household grows. Rural mothers who are a bit better off might buy firewoodor use piped water. Women tend to get fewer calories than they need at the heavy workingtime. Men increasingly devote their working time to either wage employment or cash crop production. carry firewood and water. 1981). In rural areas. of course. 1981. Two sets of changes have had a profound effect on the seasonal distribution of women's work time. peasant mothers must farm. This means. became indebted to those better off. even if food is available in adequatequantities. Schofield (1974) surveyed the effects of seasonal labor peaks on child nutrition: women prepare meals less frequently. which is one of the commonest causes of childhood morbidity and mortality in Africa. to be replaced by a new one in which the poor borrowedmoney for hungryseason food. as reported in Hull. Karimu. The evidence is strong for a correlation between an infant's birthweightand the probabilitythat infant will survive (Mata. Rowland et al. 1981.

5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . and continue to exist both in Africa and in the guest-workersegment of industrial economies. The Social Costs of Production: Migrant Laborand OccupationalHealth in SouthernAfrica The differential valuation of women's and men's labor. colonial (and later national) governments either forced or encouraged peasants to grow a few chosen crops-often the ones most easily transportedand sold (Chauveau. A second is a basic alteration in peasant farming strategies. reports the same pattern for much of Zaire. 1981). Jan Vansina. The alternative crops often had slightly different moisture requirements from the main staple. Migrant labor is less skilled but cheaper than stable labor-cheaper because costs of health. It is remarkablethat after decades of mature scholarshipon African history we are ignoranton so fundamentalan issue. The implication of this somewhat speculative history is that patterns of malnutrition are probably quite different today from what they had been a hundred years ago. Governments which help to organize the use of male migrant labor on a large scale necessarily place a low value on the health of the migrants' wives and children.HEALTH AND HEALING IN MODERN AFRICA 101 they grow today. alongside the differential provision of health services (and in general the differentialpayment of the social costs of production). In addition. they are necessary consequences of the migrant labor system. The governmentsthereforedo not collect adequate This content downloaded from 129. and Richard.105.146 on Thu. I found this to be true in northeastern Tanzania. In those days the rare killing famine was a serious affair. and because men spent more of their time growing food crops. although the precise labor schedule must be examined in each locality. in a personal communication. but were dominant in most parts of Africa during the height of colonial influence." Most recently the authors of a WHO report on Apartheidand Health (1983) pieced together an assessment despite the biases in the data. These have assumed an extreme form in contemporarySouth Africa.215. African agriculture in the nineteenth century placed heavy emphasis on hedging risks-on growingalternativefoods in case drought or irregular rains caused a shortage of the main staple. Patterns of mutual assistance tended to spread the effects of famine relatively evenly over all those who had full rights in a particularlocality. Quite probablythe seasonal malnutritionwhich is so important a part of the health picture in today's Africa did not exist then.but women would have been able to distributetheir work more evenly in non-famine years because each of the many crops had its own work calendar. Indeed it is clear on a world-wide scale that a few food crops are becoming ubiquitous while very many localized crops are no longer produced. Dozon. and retirement are not paid. Scholars have known for decades that systems of male migrant labor affect the health of women and children. The loss of men's labor is only one reason for the change. The diversity of food crops made it possible to spread labor inputs relatively widely over the labor calendar. although the precise impact has usually been difficult to document. is particularlyclear in migrant labor systems. The gaps in our knowledge are not accidental. education. where Germans at the turn of the century reported dozens of varieties of food crops which no longer appear in today's diet.

In this context. The bias in the data explains. He therefore focuses on the Gold Coast's capital city. 1977: 10. particularly theirhealth endemic suchas malaria andbilharzia. This content downloaded from 129. in part.This fact must be borne in mind in the siting of Bantu homelands or borderareas. Guest workers in Western Europe (in many cases coming from Africa) hold the dirtiest and most dangerousjobs. Dr. where the migrant system is carriedto a level of cynical perfection. H. and so there is a built-in tendency in all our writings to underestimate the damage done by a system of migrant labor. for by eradicating diseases. Senior Epidemiologist for the South African Medical Research Council. 1983: 188). for they need precise data in order to be able to sketch the effects of the labor system. Wyndham.Turshen.102 AFRICANSTUDIES REVIEW health statistics about rural areas in which migrants originate (which are sometimes beyond the national borders). 15). Scholars then are caught in a peculiar trap of data and method.Patterson defines his interests according to the availability of archives. witness the law suit alleging that a significant part of New York City's population was not counted in the most recent census.." excluding African women and children who are not of direct use to South African employers(1983: 188-89). but the authorities rarely document their occupational diseases (ILO. it is unlikely thatthe healthandwelfare of rural willbe improved populations in WHO. Those effects are very much better documented for parts of the population which do receive government services.146 on Thu.1983:188). and does not track working men of the capital back to their families in Northern Ghana or Upper Volta. The crucial statistics are missing not only in South Africa. This example supports the more general sense that the authorities do not collect data of the kind needed for health planning for the families of migrant laborers because they rarely do the planning. In the South African mines. a Human Sciences Laboratoryworks on the assumption that not all Africans raised in the mines' periphery will be strong enough to do strenuous work in the mines. Statistics are especially weak on the women and children from among the migrant population. C. for which governmentrecordsare richest. and should aim at policies which draw the fittest workers out of the Bantustans. by theirownefforts (quoted The authors of the WHO report on Apartheidand Health stress the importance of the assumptions in this statement that senior members of the South African medical establishment ought to promote medical interventions which maximize profits. commented on the importanceof work capability data for health planning: It is also apparent fromtheseresults thata muchsmaller of rural percentage BantumalesthanurbanBantumalesis capable of continuous highlevelsof physicaleffort. but also on the health (and even at times the existence) of migrants in the U. and by improving nutrition.S.105.or new industries which requirehardphysical work.This couldbe doneby better physical morecaloriesand animalproteins.who defines the focus of her reseachto match the contours of the labor system.consideration shouldbe givento the improving of the workcapacities of ruralBantumales.215. They also note the emphasis on the health and nutrition of "rural Bantu males. why Patterson'sbook on Gold Coast (1981) draws a more benign picture of the nutritional consequences of colonial rule than does Turshen's (1984) on Tanganyika. It therefore developed a test chamber for sorting out potential workers (WHO. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . concentrateson a labor-exporting area.

during the period of employment. The South African labor system therefore creates systematic biases in the reporting of health problems as they relate to work. regulation of the work force defines the way statistics are collected. His evidence was (in his own view) unsatisfying. The information base is (in South Africa as elsewhere) an integral part of the system for regulatinglabor. According to Leary and Lewis. is even more dramaticallyskewed when it comes to occupational health. by the time symptoms appear migrants have often left the work place. South Africa collects health data on migrant workers only so long as they are at the work place. 1979).146 on Thu. Westcott and Stott (1977: 967) report that 30 percent of Transkei children die of malnutrition before the age of two. In some occupations migrantworkersare simply sent home when they become too sick to work. Occupational health problems are defined in the narrowestpossible way. Most African workersare not covered by the system. and therefore their health problems go unreported. Official statistics drastically under-report infant and child mortality levels among Africans (Unterhalter. and had a higher percentageof malnourishedchildren. but suggestive. that kwashiorkorwould no longer be a condition of which the authorities must be notified (Unterhalter. or in Mozambique. where mortality is the highest. received a much smaller proportionof men's wages than did illegal squattersliving near the urban work place. to deal only with workers while they are employed. Botswana.or Lesotho. and they therefore die in places where their deaths are not counted-or where the people are counted as non-citizens of South Africa. Despite all this. leading to underreportingof the health problems of migrants who return home. which then shapes scholarlythought. The occupational health system covers less than 30 percent of all workers (Green and Miller. 1973: 39). and are being cared for by their wives and sisters in rural South Africa. 1979) because the government does not collect mortality statistics for Africans in the whole of the country. and Zulu appear to have become shorter over the three or four decades preceding the 1960s. 1982: 1112. The South African evidence on rural health is rarely satisfying. have no choice but to rely on the official statistics. 1979).105. Mechanic. Southern Sotho. 50 percent of all children born in Sekhukunilandfail to reach their fifth birthday (both these studies are reported by Savage. but only for thirty-threemagisterialdistricts of which thirty-one are urban (Simkins.but it is impossible to construct a systematic account because there are no national statistics. 1979: 95). The government dealt with the problem of malnutrition by deciding. White (1980) discussed one of the reasons for raised levels of rural malnutrition. most writers on South African health. Even when this is not the case. 1982: 1113. in three ways.HEALTH AND HEALING IN MODERN AFRICA 103 In South Africa. Entering employment is difficult for sick men in South Africa-migrants are screened carefully before beginning work-but leaving it is easy. First. Tobias (1975) reported that adult Venda. Rural areas. Rural families. which investigated occupational health. This content downloaded from 129.215. Wyndham and Irwig. and where women and children are concentrated. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . in the 1960s. These workers return to rural areas when they are no longer vigorous enough for employment. and not after they have left employment.go unreported. in his study of two localities. and therefore of the scholarshipwhich relies on it. It was the brief of the ErasmusCommission. Local studies report very high levels of rural mortality and malnutrition. even critical writers of conscience. The pattern of data collection.

see also WHO. 1981). But precisely because South African employers have greater arbitrarycontrol over their racially disenfranchised workers. because the mines (where accidents are a major problem) keep relatively good records. substantiallyreduce the costs of industrial production.000 workers are potentially exposed (Green and Miller. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions .215. and health services for the families of workers. The most damaging effects of exposure to asbestos begin to appear between thirteen and thirty years after exposure. 1983) argues that hazardous industries are exported to Third World countries because weak standards of occupational health (for example. How many migrant workers are still at the workplace to be examined after that period of time? This is closely tied to the third set of biases in reporting. that the dichotomy between health standardsand labor costs is a false one. South Africa can serve as a recipient country for some of the most dangerous industries. 1981.105. standards.This happens in part because of very low standards. I think.8 percent of all reported mesotheliomas (relatedto asbestos exposure). are not limited to South Africa.The crucial study by Irwig and Botha on asbestos related disease studied only whites and so-called "coloureds. Africans. who fear an attack on occupational health on the grounds of cost. The effects of time lag on migrant workersis dramaticin asbestos mining.104 AFRICAN STUDIES REVIEW accidents tend to be reported more accurately than degenerative diseases. It is clear that the South African occupational health picture can only be understood as part of the overall international division of labor. reported only 28 percent of the cases (Myers. and weak reportingon it. Labor is cheap when neither the government nor the employer pays the costs of reproducinglabor. the more adequate are statistics on degenerative diseases.and in part because migrants leave the work place before symptoms appear. 1983: 190-94). Over 150.S. 1980: 148-49). In 1979 white workers accounted for 51. then 44 percent of the South African workers exposed to lead would have to be withdrawn from exposure.146 on Thu. and because accidents actually happen at the work place-it is difficult to defer their effects until workers return home. In this respect Castleman's debate with Levenstein and Eller is particularlyrelevant here. The toll of accidents is in fact heavy. and in the asbestos-based industries."because it was impossible to find adequate epidemiologicaldata on the African workers (Flynn. but to follow cheaper labor costs. The argument here shows. 1981). Second.The more stable the work force. between 700 and 800 workersdied in mine accidents. White workers in the asbestos industry are employed continuously over long periods. If lead in the blood were measured by U.000 were injured each year (Kooy. including the costs of occupational health at the work place. who were 92 percent of the work force. In every year from 1970 to 1977. 1982). argue that dangerous industries are exported to the third world not to follow lower occupational health standards (which are relatively inexpensive to enforce). Levenstein and Eller (1981). The weak position of migrant labor. This is part of a general system for reducingresponsibilityfor the social costs of production. Castleman (1979. Does this mean that there is no hope of improving health in South Africa without a total transformationof the labor system? Perhaps in one sense this is This content downloaded from 129. 1980. the extremely weak South African standards for exposure to asbestos fibers-see Myers.even though they were only 5 percent of the work force in the mines. the effects of carcinogens and of toxic substances are very strongly underreported. and are therefore still in employment when cancers appear. and nearly 28.

is incompatible with an economy heavily dependent on migrant labor. Evans-Pritchardand later scholars find system at a second level-in the way witchcraft is embedded in the social fabric. and that biomedicine works whereas popular medicine does not.HEALTH AND HEALING IN MODERN AFRICA 105 so. Certainlya broad definition of occupationalhealth (Laurell. concerned with the families of workers. democratically-based III. Centralized health planning. THE HEALING OCCUPATIONS AND THEIR USES It is time to talk about healers. and to movements for change. Is the position of popular healers in these respects fundamentallydifferentfrom that of biomedical healers? The second part explores attempts by biomedical practitionersto affect the course of events at social levels where important decisions on health are made-either in the local intimate networks within which people organize therapy. differenceswhich make one preferableto the other? Much of the literature about healing in Africa assumes that biomedicine is based on objective knowledge of real phenomena whereas popular medicine is not. Witchcraft. The anthropologist(and not the popularpractitioners)creates a coherent and consistent natural philosophy by discovering and elucidating hidden interconnections. and how political and economic power shape states of health and disease. Does it work? Are there basic differences of knowledge and effectiveness between biomedicine and popular medicine. Any policy position on the future of medicine in Africa and any careful interpretationof its past must decide whetherpopular medicine is effective. it is an idiom in which everyday events happen. is not likely to create significant change. and with the long term effects of carcinogens.215. or in the wider political arena where forces struggle to change the distribution of social costs.105. and to what extent do they act in concert with established political and economic powerholders? Do they take socially effective action to promote health. with those living next to factories. The possibilities for change become clear only by examining the relation of the healing occupations to power. and their relationship to political power. These anthropologistsuse witchcraft to learn the locus of social tensions by exploringthe social roles most likely to be This content downloaded from 129. and if so what are the circumstancesof this effectiveness? The discussion is divided into two parts. and especially the nature of their knowledge. The essay so far has put them aside to concentrate on other subjects-how networks of ordinary people take charge of therapy. is not autonomous knowledge-coherent and useful irrespective of social context.These assumptionsneed to be examined carefully. except perhapsas psychotherapy. 1981).the degree of their autonomy. but the people who hold it never expound it systematically. by itself. at this point in the essay-having explored what healers cannot do-to ask about their impact. in his view. But it would be wrong to correct a myth of professional dominance in Africa by creating a new countervailing myth of professional impotence. The judgment on African healing has deep roots. Evans-Pritchard (1937: 63).146 on Thu. Does their therapywork?To what extent do they act as an independent source of technical knowledge in society." It is a system of thought. in his classic study on the Azande wrote that witchcraft "is not an objective reality. It is possible now. The first asks about the healing occupations in Africa. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions .

a certain percentageof patients given placebos improve. and not giving an inch. 1980: 33). under siege. healing is a mysterious process (Kleinman. 1967). then investigators would be unable to say. but difficult to know how. 1970. They have significant effects in making people better (Frank. or the one which asks more appropriatelywhether scientific language or thought within any given society is more rational than ordinary popular language and thought. much of it published in the journal Culture. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . M. 1977: 35). but an irreducible core of ignorance remains about why one patient gets better and another does not. "All other things being equal. Lewis (1971) treats spirit possession in a similar way as a form of negotiation between the afflicted and their relatives.106 REVIEW AFRICAN STUDIES occupied by accuser and accused (Douglas. If it did not. social relations. Clinical knowledge in biomedicine specifies that a particularintervention-for example. He is interested in raising This content downloaded from 129." It is the question of "all other things being equal" which makes healing mysterious. By contrast. perhaps 600 out of a thousand.215.In most experiments it must do so. administeringa drug-leads to improvementin a certain proportionof patients. and emotional context of healing. to science would be able to the claim that an integrated social/medical/agricultural if field of the solutions to expertise were defined complex problems only provide broadly enough to take in all the variables (Hughes and Hunter. It is clear that the patient's total emotional state. I. social.'" Nevertheless. within any type of therapeutic practice. the vast majority of works on biomedicine in Africa treat its knowledge as both autonomous and efficacious. The biggest body of researchon this concerns placebos-inactive substances given to the patient with the false claim that they are active drugs. there are clear and useful things one can say about the comparative effectiveness of popular-and bio-medicine.105. The various sides are entrenched. But its founder does not claim that his own methods hold the key to understanding healing. 1970). A body of recent writing. First. quite characteristically.Medical knowledgeaccordingto this body of literature is impartial and expert. but the result is a stalemate. and culturallyconditioned understandingof illness all have something to do with healing. or as imperfect theory (Horton. Using witchcraft or possession for sociological diagnosis is useful so long as one does not reduce African medicine to the expression and palliation of social tensions. the clear implication of this strand of thought is that African medicine is deeply embedded in social life but not in biology. No matter whether the interpretationtreats African medical practice as social negotiation or symbolism (in the works of Turner). Researcherstry to learn which 600.146 on Thu. Medicine and Psychiatry. Biomedical researchon placebos normallyputs to one side. 1974). with some distillation of the issues along the way. I do not propose to address the literaturewhich asks whetherwesternthought is more rational than African. and that it has no medical efficacy.12 This debate has continued in various forms for a century. Coumbaras.questions about a rich or satisfying web of personal relationships. The strategies for dealing with social forces vary widely among authors-from the sense that scientific researchcan be formulated"solely on the merit of the problem regardlessof practical considerations"(Beck. not as a phenomenon which exists in the real world or as a system of knowledge. It can offer technical solutions to practicalproblems without choosing one side or another when social forces are in conflict. gives careful attention to the symbolic.1977b).

105. what actually happens. .HEALTHAND HEALINGIN MODERN AFRICA 107 questions which will make clinicians more broad-minded." We have no way of knowing whether stories do move the birth organs. also find a strong tradition of pragmatictherapy and naturalcausation. We must therefore be tolerant of alien cultural strategies for healing unless we have good reason for not doing so. decided that vitamins (of no demonstratedmedical value) were the drug he requiredand that laughter was central to healing. But at the same time. but the mythical itinerary through that world becomes fused with the uterus and vagina of the pregnant woman so that narration is in fact manipulation. Dennis M. writing about the Luvale of Zambia and Maier (1979) on bone-setting and lancing infections in nineteenth century Asante. to be "quick and dirty. Warren began ethnoscientific research in Ghana accepting Field's generalization that for Africans. in his research on Techiman-Bono healing. sickness and health are ultimately of supernatural origin (Field. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . Levi-Strauss writes about the nature of healing in his essay on a Central American treatment for women in difficultchild-birth(1963). He ate vitamins and laughed and in the end he went home. This is one issue on which the ethnoscientificmethod. and as such have neither structuralnor functional relations with Bono religion. in his own description of it. Healing is mysterious. easing the birth. has shifted the terms of the debate in a useful way. Anthropologistsinterested in the differentnessof African thought patterns have underemphasizedthe pragmatic strand of African therapeutics.215. He therefore consumed great quantities of vitamins. 1960: 112. One of the central points of Witchcraft." not to solve the problem of how it is that healing works (Kleinman. 1981). His method is meant. It also alleviates suffering in chronic illness. Warren.more willing to accept that important elements of their patients' experience and knowledgeescape their observation. Norman Cousins (1981). or whether mine take place through the medium of theirs." Spring (1980). Warren therefore intended. "it is in the last resort immaterial whether in this book the thought processes of the South American Indians take shape through the medium of my thought. and asked his nurse to set up a motion picture projectorso that he could watch funny films.. because it is systematic even if clumsy. We do not know whether Levi-Strauss'saccount is true because he thinks of fact. creaing a false contrast between pragmaticbiomedicine and supernatural popularmedicine. popular African medicine has strong pragmatic elements and gives weight to natural explanation. cured. Again the lesson is not a simple one. having learned that he was dying of an incurable disease. confined in a North American university hospital. to resume a normal life. symbolic representationsof the human body do in fact become entangled with the body itself in ways difficultto understandbut important for healing. The classic texts on African therapeutics reported pragmatic treatments but gave them little emphasis. The healer tells the story of a quest through the supernatural world. reality. which biomedicine is weak at doing. 1979: 36).Oraclesand This content downloaded from 129.146 on Thu. to look at how disease concepts were "related structurally and functionally to the indigenous system of religion" (1974: 3). The symbolic and social content of popular African therapies contributes to the process of healing.He writes (1969: 13) in another work. as irrelevant. But Levi-Strauss's own narration has a core of validity. Warren's (1974: 431) ethnoscientific collection of thousands of disease terms convinced him that most diseases "are classified as naturallycaused .

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Magic (Evans-Pritchard, 1937: 479) was that "Azande attribute sickness, whatever its nature, to witchcraft and sorcery." Gillies, however, shows that Evans-Pritchardsays in the same book (488) that "When a Zande suffersfrom a mild ailment he doctors himself. There are always older men of his kin or vicinity who will tell him a suitable drug to take." Gillies explores similar contradictory tensions in the deservedly influential works of Turner and Horton.14 In each case, careful review of the ethnography shows that natural causation is a major part of the explanatoryframework.The illness classification can give weight to natural causes and at the same time be embedded in the particularculture'swider set of assumptions about humanity and society. This is, in fact, the case in biomedicine. Several of the most satisfying recent works in medical anthropology treat biomedicine as merely one more ethnomedical system, its assumptions to be respected and explored, but not to be treated as privileged or as objective in some special sense. This is the message of Foucault's historical writings (1973). Some historians accept the idea that past science was culturally bound while unfortunatelypreservingthe illusion that today's science is true, objective, not to be questioned, and not contaminatedby the prejudicesof its historical era. Several recent ethnographiesof biomedical thought and practice in the U.S. have come to similar conclusions:biomedicine is permeatedwith the assumption that doctors can know the individual body, separate from the mind and from social relations, and can treat the individual through technical interventions. These are some of its central assumptions as an ethnomedical system. Hahn (1982) consults Stedman's Medical Dictionary for core definitions, and finds the following:
Medicine

or curing the sciencethattreats (1) A drug.(2) The art of preventing disease; of diseasein all its relations. of general diseases (3) The studyand treatment or thoseaffecting the internal fromsurgery. partsof thebody,distinguished Disease an interruption, or disorder of body illness;sickness; (1) Morbus; cessation, or organs. functions, systems, (2) A diseaseentity,characterized usually by at least two of these criteria:a recognized etiologic agent (or agents);an identifiable of signsandsymptoms; consistent anatomical alterations. group Hahn points out that "there is no mention here of non-bodily aspects of persons, or even of persons at all. ... Diseases are thought of as discrete 'entities,' with measurable'lesions'," treated with medicines which are material artifacts. Hahn explores the significance of these definitions in an extended ethnographyof one American internist's medical practice. The internist talks about treating the patient and not treating the isolated laboratory tests. But the patient, in this definition, is the set of relations among all lab tests, the overall syndrome, and not the "patient's world and his or her sufferingin it." I would go both less far and further than Hahn. Physicians do get drawn in to a concern for the humanity of their patients, and for the larger context of illnesses, but at that point they usually leave systematic medical knowledge behind. It is difficult (often impossible) within the canons of medical knowledge for the physician to integrate an understandingof the patient's human relations with the numbers in the lab tests. The inherent difficulties are compounded by the division of knowledgeamong the various medical specialties and sub-specialties.

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Corporealindividualism pervades biomedical knowledge.This is cultural,not natural or objective. Young (1980) shows that this is the case for research on stress. Researchers accept stressors as "given" ("all other things being equal," again), with little attention to the social organization of stress. They study stressful events (being fired from a job, marital separation)with no attention to hierarchiesin the determinationof stress. Why not start at some earlier point in the hierarchy,Young (1980: 142) asks, such as "the socioeconomic determinants of being fired," or at some later point such as "the employment consequencesof becoming pregnant?"The discourse on stress depends on a tacit assumption that the individual can be abstractedfrom his or her social context. This assumption obscures the fact, demonstrated in the section on social costs of production in this essay, that decisions made by the powerful distribute stress in a systematicallyunequal way. Michael Taussig (1980) studied the case of a forty-nine year old woman with a fatal degenerativedisease of the muscles. She was being treated at a prestigious teaching hospital in the U.S. The woman describedher personalcircumstancesto Taussig (1980:6)-her early marriageagainst her mother's wishes, and her long years of grinding poverty and hard work. She placed the illness in the context of her own life experience. "You can take a perfect piece of cloth," she said, "and if you rub it on the scrub board long enough, you're going to wear holes in it. It's going to be in shreds. You can take a healthy person and take away the things that they need that are essential, and they become thin and sickly. So I mean ... it all just comes together." She did not tell this to the doctors because "The would laugh at my ignorance." As seen by the doctors her disease was purely organic, not the product of social conditions. When the woman became distressed while in the hospital, the examining psychiatrist suggested that "evidence is strongly suggestive of an organic brain syndrome."Taussig writes, "Having stated that the evidence was strongly suggestive of an organic brain syndrome (i.e. a physical disease of the brain) the psychiatrist in his Recommendations wrote: 'Regardingthe patient's organic brain syndrome.... In other words, what was initially put forward as a suggestion (and what a suggestion!) now becomes a real thing. The denial of authorship could not be more patent" (1980: 9). Once again the patient and her disease were being treated as objects, torn out of their social context. The woman described how patients helped one another at the hospital. The neighboringpatient, who was able to get out of bed and move about, helped with the light switch, the food tray, and anything else which needed moving. But patients could not help one another with physical therapywhich, as treatmentof illness, was the work of professionals. Patients gave one another friendship. The hospital, which objectifiedthem, "monitored"their emotions. Kleinman, who is working to create a more humane form of clinical practice, insists that there is no necessaryreason biomedicine must treat the individual as removed from the context of social relations.'" New orientations in biopsychosocial primary care in the U.S. and some forms of biomedical practice in Asia avoid decontextualization,and treat the patient within a social network. However, the obstacles to humane practice are to be found not only in the culture of biomedicine, but also in the legal and institutional framework of medical practice. Constraints on the social treatment of illness in the United States include rules of confidentiality which have positive value but which prevent doctors from sharingknowledgeabout a patient's condition with another

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patient, a system of record-keepingwhich treats individuals as cases, a threat of malpractice suits which enforces rigid standards of case management, a set of rules by which insurance companies pay doctors for treating certain objectively defined clinical conditions, and so on. Changing the practitioners' culture, important as it is, can have only limited effectswithin this institutional structure. Biomedicine in Africa is practiced within a very different legal and in institutional framework-one which depersonalization and decontextualization are equally extreme. In most cases a great cultural gap separates practitioners and patients. In earlier generations most practitioners were Europeans.Today, most practitionersare Africans drawn from a stratumof society whose members are in a small minority in terms of income and education. The majority of African patients receive treatment under conditions of extreme medical scarcity. This means that doctors must examine, assess, and prescribe in a very short time, to get on to other pressing cases. We can assume that the doctors do their best, but under these conditions patients are often treated like faceless cases. "Tradition" and the "Traditional" in AfricanHealing Both popular medicine and biomedicine are forms of ethnomedicine:they are embedded within a system of social relations, and give concrete form to assumptions about reality drawn from the wider culture, which in turn influences the wider culture. They are products of history. It makes sense thereforeto use the term "traditional" for both biomedicine and popular medicine, or alternativelyto use it for neither. As they have actually been used, "traditional" and "tradition" are words onto which many writers have projectedassumptions about African healing in its historical context. Examiningthese words and their uses is therefore a tool for uncoveringthe range of common assumptionsbefore looking more carefullyat the actual evolution of the healing occupations. The large and representativesample of articles in African Therpeutic Systems is a convenient text for reviewing assumptions about "tradition" and the "traditional."The collection, edited by Z. A. Ademuwagun,John. A. A. Ayoade, Ira E. Harrison, and Dennis M. Warren(1979) is large (41 articles), eclectic, and not shaped to reflect a single carefully defined viewpoint. Many of the articles were published earlier in journals and have been cited frequently. The assumptions are quite diverse, with five major strands. The first is that "traditionalhealing" is what "traditionalAfricans"do, and that these are special and peculiar people. Imperato and Traore (1979: 16), for example, say that the Dogon "are the most traditional of all Mali's peoples." Imperato (1979: 202) writes that some African cities like Djenne and Timbuktu have not experienced dynamic growth in the twentieth century and therefore traditional medical beliefs and practices in those cities "have tended to remain static." The authors make the unjustifiedassumption that where dramaticgrowthdoes not take place, change does not occur. The second set of assumptions characterizes tradition by the presumed quality of its reasoning about cause and effect. For Imperato and Traore (1979: 16) traditional reasoning is "prescientific,"and for Conco it is characterizedby supernaturalcausation (1979: 61). Other authors in the same collection disagree with these characterizations.Janzen (1979: 216) and Young (1979: 132) define

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But the distinction has entered scholarly languageand thought in a way which sometimes makes the connection between the traditional and the non-rational a matter of definition. Ademuwagun (1979: 160) describes traditional healers as living among health consumers and as sharing a common culture with the consumers. The third definition of "tradition"in African healing is of a residuum-those parts of contemporarytherapeutic practice which are left over once other kinds of medicine are accounted for. The legal position of traditional healing is similar in most parts of the continent. For Zeller (1979) traditional Ganda healing is whatever kind of therapy existed in precolonial Buganda.105.'s and share their culture. offers a more sophisticated version of the same position by outlining a set of core conceptions This content downloaded from 129. traditional medicine is everything outside biomedical practice. Janzen (1979: 211).AND HEALING IN MODERN AFRICA HEALTH 111 traditional medicine as "rational. He (Edgerton. been a member of the elite "among whom traditional belief in supernaturalcausation coexisted with an intense pragmatic belief in natural cause and effect. The way these assumptions work can be seen from a fascinatingsentence in the otherwise excellent article by Edgerton. not as a description of any particular concrete reality. The effect of defining the "traditional"as a residuum is to leave the healing traditions of Islam and Christianityin an ambiguousposition." What Edgerton seems to be saying here is that in the pre-colonial period belief in supernatural causation coexisted with belief in natural cause and effect. The fifth definition of "traditional healing" is a historical one. Universityeducated African consumers.215. Asuni (1979: 179) shows how important it is that the traditional healer lacks legal standing. This is. but exists as an altogether separate alternative. For Warrenon the Bono of Ghana. Diop (1979: 85) et al. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . to take one example. The mergingof all non-biomedical practice as traditional leads to a loss of clarity. or to avoid being chargedwith manslaughterin the care of someone who dies. Abdalla (1981b) and Last (1981) have shown that Islamic healing cannot simply be merged with traditional medicine." "clinic and hospital. of course. This point emerges from articles on Yoruba healing by two Nigerian scholars. usually live near M. This is a position which emphasizes one stream in traditional thought while suppressing our consciousness of a second. define some kinds of Muslim healing as "traditional. but only supernatural causation is to be characterizedas traditional!When authors are less thoughtful than Edgerton. writing on Kongo healing. whether to vouch for a patient at work. the ideal-typical association leads easily to an assumption that traditional medicine is based solely on supernaturalcausation. Fourth." and Christian "Zionist" into three separate categories. true most (but not all) of the time. 1979: 93) writes that a particularhealer's father had.146 on Thu."Maclean (1979: 225) includes Apostolic faith healing as part of traditional medicine.D." The assumption that what is traditional is not rational is built right into the core concepts of modern sociology. a straightforward and comprehensibledistinction. Max Weber intended his distinction between rational-legalauthority and traditional authority as an ideal-typicalone. By contrast Ulin (1979: 243) puts "traditional. and occasionally further assumes that this is not merely a definition but a description of life. The consequencesare damaging. traditional healing can be defined in terms of its twentieth century social context. in the pre-colonialperiod. with its own substantial impact on traditional practice. Different authors disagree over what is to be accounted for before defining the residuum.

5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . mental or social imbalance. some with an identifiable material basis and some without. or it has dealt with social problems at a domestic or village level-one which could be construed as private."the fruit of "practical experience. It interprets departures from health (and by implication health itself) in broad and inclusive terms as "physical. and elimination of physical. whether materialor not. It places great emphasis on traditional medicine as knowledge inherited from past generations.presumablybiomedicine is to be the source of innovation (WHO. andto curehimself. Traditional African medicine to be the sumtotal mightalsobe considered of practices.It is unlikely that authorities with control over government medical policy in most African countries would agree to give popular healers real power to correct social imbalance or to plan irrigation works. verbally Traditional medicine as a solidamalgamation of mightalsobe considered medical know-how andancestral dynamic experience. The problem is this: if we accept the proposition that popular medicine is practical. whether or not. WHO. Above all the concern for efficacy comes through: traditional medicine is "dynamic medical know-how. traditional African medicine is: the sum total of all the knowledge and practices. 1976. whichfrom time immemorial had enabledthe Africanto to alleviate his sufferings.ingredients and procedures of all kinds.and that it legitimatelydeals with practicalpublic matters. "the first imported and the second an extension of autochthonousmedical traditions. (1979: 217) make a distinction between two medical systems in Zaire. This content downloaded from 129. According to the WHO Committee. To the extent that popular healing has been organized on a public scale in recent years. and which have also continued on into the twentieth century. whether or in writing." which enables the African "to cure himself." This is the languageof those who wish to use the services and knowledge of traditional practitioners. But popular healers lost power at the time of colonial conquest and have never regained it." African traditional medicine has also been defined by a Regional Expert Committee of the WHO. explicable used in diagnosis. except in rare and unusual circumstances. for it takes vigorous debatable positions on a number of difficult issues.215. guard against This is far from a colorless committee document. The healers are therefore left to treat illness in its private aspects. some explicable and some not.away from the view of the authorities. disease. mentalor social prevention imbalance and relyingexclusively on practical and observation experience downfromgeneration handed to generation.146 on Thu. 1978). The emphasis on practical efficacy raises difficult questions about the role of popular healing today if one accepts the broad definition of health (as it is accepted in the document quoted). it has (in most cases) either operated underground.105.measures. The discussion below will show that pre-colonialhealers dealt with a whole range of practical matters-including the planning of economic production. Kikhela et al. as opposed to the public realm of politics." It recognizes that a range of traditional medical procedures exists. then popularhealers need political influenceor power to be effective. which appear to have been relatively stable through periods of great pre-colonial change. 1978: 9).112 AFRICANSTUDIES REVIEW which existed in the pre-colonial period. with much more emphasis on the efficacyof traditional healing than in most contributionsto African Therapeutic Systems (WHO.

Traditional intellectuals' knowledge and practice show strong continuities with the earlier era-for example. popular healers are just such a set of traditional intellectuals. Even the most degradedphysical work includes a minimum of creative intellectual activity. or educative.146 on Thu.one or more strata of intellectuals which give it homogeneity and an awareness of its own function not only in the economic but also in the social and political fields" (Gramsci. coming into existence on the original terrain of an essential function in the world of economic production. and as an expression of a development of this structure. He understood that under some circumstances intellectuals could-if they achieved relative autonomy and range of choice-affect the outcome of the core strugglesto control the instrumentsof power. among academics a concern for humanistic knowledge. once elaborated in an earlier stage of development. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . He did not accept the notion that intellectuals are a special set of people who think.traditionalbecause the content of their knowledge and practice were shaped by a different set of associations from an earlier age. "creates alongside himself the industrial technician. 1971: 5). Even though class and the social organization of production were at the heart of his analysis.for example. The system of class and production. having once elaborated a set of intellectuals. do not necessarily fade from existence with successive transformationsof fundamental structures. Seen from the point of view of colonial rulers or plantation owners. Or still worse. It evolves. creates together with itself. the specialist in political economy. or among western EuropeanM.HEALTHAND HEALINGIN MODERN AFRICA 113 A GramscianInterpretation of the "Traditional" We need something more than a new definition of tradition. Gramsci defined intellectuals in an idiosyncratic way. These are the traditional intellectuals.has found (at least in all of history up to the present) categories of intellectuals already in existence and which seemed indeed to represent an historical continuity uninterruptedeven by the most complicated and radical changes in political and social forms" (Gramsci.215. he did not reduce all knowledgeto class knowledge. and elaborates new intellectuals. "Every essential social group which emerges into history out of the preceding economic structure. inherited from the terrain of production and control in an earlierage. organizational. We need a different style of analysis-one which explores whether healers can use their knowledge to shape the public distribution of health and disease.In some cases a set of intellectuals is indissolubly linked to a class. or alternatively whether they are merely society's sweepers. organically. All people are intellectuals. do healers preserve their own privileges at the expense of general health? The question can be stated in more general terms: what has been the relationshipbetween knowledgeand power in modern African healing? Antonio Gramsci (who did not focus his attention on doctors.'s continuities in training practices This content downloaded from 129. The capitalist entrepreneur. Organic intellectuals. because it is clear that all people think.cleaning up the mess others make. The reasons for the variation are historical. health. Intellectuals play a variable role in the class structure.nor did he assume that all intellectualswere bound to take predeterminedclass positions. "Every social group.D. but only some have the social function of intellectuals.105. a function which is directive." and so on. is transformed. does not remain static. or Africa) was a profound student of the relationship between knowledge and power. in others the intellectualsachieve a greaterdegree of autonomy. 1971: 7).

215. social knowledge exists which has no direct and unmediated utility in either organizing production or defending class interests.146 on Thu. It can succeed if we retain a Weberian concern with autonomy and authority. physicians and "traditional healers. and over the authority to certify medical conditions (as. and class.16 Paul Unschuld (1975. Professionalization is a process in which an occupational group establishes control over medical resources. While scholars are preoccupiedwith the competitive game. The problem is that the contest between competing groups-allopaths and homeopaths. they would probably forbid popular healers to administer drugs or herbs of any kind.105. In particular. The second strategy. Part of the contest. One is to take up the formal distinction between organic and traditional intellectuals. over the right to administer drugs or receive payment for therapy. who writes about the professionalization of medicine in Imperial China. defines the range of potential resources broadly. The history of professionalization is one of competition. Do healers find their interests linked tightly to those of ruling political elites or dominant classes? To what extent does healing serve the interests of privileged sub-groupswithin society? How does the place of healers influence the definition of public issues affecting health and illness? Can healers use their authority to help the oppressed win control over their own health? This analysis merges issues defined by Gramsci in his writings on intellectuals with others drawn from Weberian sociology of the professions-a thoroughly unorthodox strategy." or obstetricians and midwives-absorbs attention (as contests tend to do). These are issues of the distribution of social costs. If physicians in Africa today were to win great professional power.this leads to fruitless debate over whether a given occupation at a given moment ought to be categorized one way or another. it is important to understand the degree to which healers of any kind-biomedical or popular-enjoy autonomy within the structure of power and class. but reject Talcott Parsons's argument (within this sociological tradition) that autonomous professionalsrise above class to serve the whole society. or when physicians give students illness excuses). is to study African healing in ways loosely informed by Gramsci's problematic. and achieves cultural authority-broad public acceptance of its knowledge and practice. the fundamentalissues slide past unobserved. of the relationship between production and health. and more generally of the way changes in society generatepatterns of health and disease. for example.political power. Two alternative strategies present themselves if we are to use Gramsci's analysis in understandingstrugglesto control African health. when diviners sort out witchcraft accusations. is aimed at winning general cultural authority. 1979).power.114 AFRICANSTUDIES REVIEW or canons of medical ethics. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . The most important unexamined question is about the place of professionalswithin the structureof production. Because categories of intellectuals survive from one era to another. which promises richer returns. as both Unschuld and Starr show. Professional ethics and an ideology of service are important tools in doing this because they demonstratethat the group struggling for monopoly aims at improving the health of the general population and not This content downloaded from 129. These include exclusive control over medical education.but they achieve a degree of autonomy-the capacity to negotiate their own place within the organizationof production. The traditional intellectuals never win for themselves a place outside the class structure. Victory for one group is defeat for another. and class.

Furthermore. He cannot ignore the distribution of social costs of production if it is so powerful a cause of ill health. The only possibility for making a significant improvement in Tongaat workers' health is through improved conditions of work. In some cases it is because of the class origins of those who become professionals. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . The great strengthof professionalautonomy. reported on an acute form of cardiac failure among African field workers.105. after which "not one case has needed to be repatriated. They rise at 4:30 in the morning. for lengthyperiods of follow-up." Dr.HEALTHAND HEALINGIN MODERN AFRICA 115 just at winning victories of narrowself-interest. at various times. it has been found that they can be kept out of failure. Lamont (1973).215. of course. in others because alliances with the powerless would damage the profession's own position. The contradiction is rarely visible or widely understood. Our own study of professionalization needs to show who in society the profession serves. Then it is possible to address the most fascinating problem: when do healers succeed in influencing the social distribution of ill health?Under what conditions do healersmake alliances which empower the unhealthy to improve their own health? This content downloaded from 129. with only sour. McE. Dr. N. This happens only rarely. In this case doctors retain the ideology of public service but redefine the public being served. Lamont introduced a potassium-sparingdiuretic. and who is not served. Dr. difficult to explain why a particular action does not happen. The ethic requires that all people be served. is that it leaves open the possibility that professionals will struggle to make allies among categories of people who are deprived of health. In this particularcase it is unacceptable for the physician to define his job in narrowlymedical terms.provided the patients continue on maintenance therapy. It is obscured in a range of ways. According to Lamont's report the workers all live in compounds. making the unseen visible. drink a cup of coffee. doing heavy manual labour. Under these conditions.146 on Thu. of the sort enjoyed by successful categories of traditional intellectuals. watery maize porridgeto eat until the evening meal. and were therefore sent back to the homeland from which they came.how do you serve the whole of society ethically? A single case of medical treatment illuminates the contradiction inherent in narrowly professional practice. The plantation supplies large quantities of so-called "kaffir beer" on the weekend. But it is one of the few courses of action with any real promise of improving health. and work in the sun until late in the afternoon. owners of a large South African sugar plantation in Natal. There is invariably a contradictionbetween the unequal distributionof social costs and the professional ethic of public service. the unequal distribution of social costs requiressome people to do without health or health care. eat a slice of bread. Lamont appears to measure his own success as a physician in terms of the capacity of workers to keep working under inhuman conditions. employed by the Tongaat Group. It is. as outside the sphere of concern:not members of the public being served. many workers experienced intractable heart failure. We have alreadyseen that migrant workers and rural women and children have been defined. If you are a doctor in South Africa and do not choose to make alliances among the disenfranchised.

in others. Old men recount the story of a famous healer who travelled through the land successfully treating people. or held power themselves. because rain charms confer access to sovereignty. the king pitted his political authority against the healing authority of a cult leader.There was no one characteristicAfrican pattern. the king ordered his execution. In Southeastern Nigeria the Aro oracle was crucial for the maintenance of public order and administration of laws.146 on Thu. of political authority. only outsiders could treat illness successfully. The literatureon healing. Healing skills were at the core of political. The advisors called in the mghanga. as a healing cult. for regulatingtrade. for example. in any event. Healing was. into local communities. and promised him an enormous reward if only he would teach the king the secret of his rain medicines. In the Shambaa kingdom. anyone who controlled medicine for the fertility of the land was seen as exercising sovereignty. the evolution of local authority structuresrevolved in part around the question of whether mbandwa spirits were to be the most important for healing in place of descent group spirits (Berger. It is impossible to make a serious review of pre-colonial healing in a few pages. If. 1981). or patriarchs. economic. perhaps. In fact. But it also means that to understand healing we would need to explore the totality of social and intellectualhistory over many centuries. be defined as one of autonomy without authority.116 AFRICAN STUDIES REVIEW Pre-ColonialHealing A rough sketch of the history of healing over the past century and a half will show that some categories of popular healers played a basic role in organizing production in the pre-colonial period. then anyone with the moral authority to assess the causes of evil was a health worker. The network of Nyoro spirit mediums reached. 85). 1973: 82. and conversely every healer of substance was concernedwith social order and disorder. Healing authority and other kinds of authority were institutionalized with a limitless range of gradations. In some localities. of course. This meant. Once the mghanga finished teaching what he knew. rarely describes the interconnectionsclearly.215. This is one reason for the subject's fascination. Colonial conquest deprived healers of control over production. and broke most of the links between healing and public authority. The king's advisors brought back reports of the visitor's skill. The king's own fertility and the success of his armies depended in part on his relations with the mediums (Nyakatura. based largely on twentieth century practices. 1972). In the kingdom of Bunyoro. important spirit mediums were separate from the king. but also left them relatively powerless. organically bound up with basic political and economic processes. for the explanation of misfortune. in others. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . This freed some healers from the control exercised by chiefs. and of ritual specialist all overlapped and in many cases fused with one another. In some places the king was a healer. and as part of the system of ritual. East and Central African This content downloaded from 129. This contradictorystate of affairs in the colonial period could.17 Merely attempting to define the sphere of healing in pre-colonialsociety raises difficult questions about medicine as an ethnographiccategory. and religious practices in much of pre-colonial Africa. people in the Tio kingdom during the 1880s interpreted most deaths as being caused by evil (Vansina. and also rumors about the power of his rain charms. that the roles of healer. and others were linked organicallyto the holders of political power.105. kings. the elders of a descent group controlled collective healing rituals.

No cult was ever the entirety of a system of health.105. 1976). Schoffeleers (1978) and van Binsbergen (1978. 1968. 1981b) describes how the Fulani conquerors of Sokoto. He argues (1971: 333-35. tried to establish the primacy of prophetic Islamic healing. Ford." which regulated practical activities.215. are described in the classic ethnographicliteratureas they have functioned in the twentieth century within the constraints of colonial or national sovereignty(V. and chiefs (1982a: 317). W.. But it was also was a form of therapy for resolving contradictionsbetween the region's egalitarianethic and the acquisition of wealth and influence through trade. diviners. either maintain or damage health. and vegetation cover.Janzen situates Lemba (a cult in the area between the Atlantic and what is now Kinshasa)as merely one part of a therapeutic system alongside other drums of affliction. writing about an area near the one described by Schoffeleers. Werbner.scholars have not studied cults of affliction as organizationsfor the maintenance of health (even though this is their avowed purpose). Lemba provided the metaphors and the institutional mechanisms which allowed leaders to grow in influence and wealth without tearing either themselves or local society asunder (1982a: 318). and also secular treatments (1982a. trypanosomiasis. Schoffeleers describes a pre-colonial Malawian cult as "a ritually directed eco-system. that the Nguni chief Mzila (on what is now the western border of Mozambique) understood the relationships among tsetse. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . Lemba.HEALTH AND HEALING IN MODERN AFRICA 117 cults of affliction. for example. which have historical roots in the distant past (De Craemeret al. Ismail Abdalla (1981a. A few authors have broken through the restrictions of this narrow interpretation. One weakness of Schoffeleers'sidea of a ritually directed ecosystem is that not all health practices in any society were ritually based. who were wealthy and influential merchants. On the other side of the continent. Lemba was a form of government and trade organization for its priests. Fry. Schoffeleersdescribes one instance in the 1930s in which the Mbona cult put pressure on part of the population of the Lower Shire Valley to emigrate in order to relieve conditions of overcrowding (1978: 4).146 on Thu. Scholarsfind it difficultto either accept or reinterpretnineteenth century cultic conceptions of what it is that maintains health. judges. lesser charms. With normal practices of bush clearing a tsetse free zone would be established. Mzila also ordered the creation of a game reserve outside of which all wild animals were hunted. remarkably. Schoffeleers's examples are limited because. 1650-1930: A Drum of Afflictionin Africa and the New World. I take Schoffeleers'sposition to be one which considers the adaptive consequences of an entire pattern of organization rather than of any one isolated feature which may. from an academic point of view. 1979). 1981) understand cults as essential parts of the ecological system. 1979: 269).1977. following Swynnerton. healers. and at the same time to lay out towns with wide This content downloaded from 129. Mzila compelled his followers to "draw near to the king" in concentrated settlements. in Northern Nigeria. Alongside the ritual regulation of well-being were health practices which were either simply customary or instituted on a purely pragmatic basis. Cult mediums at times compelled people to plant particular crops. Turner. The drum regulated markets and settled disputes. most notably John Janzen in his book. The cult protected large areas of wilderness from burning. see also Janzen. and restricted fishing and grazing so as to protect fragile resources. 1976).describes pragmaic institutions for maintaining health.

irrespectiveof the interests of particularsocial groups. 1982. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions .The British later. Once colonial conquest was secure. reinforcingthe authority of those in power. and not extended analyses of African control over conditions of health. This paper has already discussed the strongly patriarchal assumptions found in some varieties of African therapeutics.105. Retel-Laurentin (1969: 26-28. Nineteenth century control over the conditions of health was part of a largersystem of domination. and those of their allies.) We must be careful not to imagine an idealized picture of merry Africa. The Asante practiced variolation for the control of smallpox (a practice discussed for Africa as a whole by Herbert. where chiefs and healers were in harmony. (See also McCaskie. 1974: 15) argues that slaves were most likely to die of the effects of the poison oracle. colonial conquest fundamentallychanged the basis of healing. (For a comparable case in East Africa see African Water and Sewage.despite the wealth of detail in historical sources. the Nsumankwehene. She describes the carefully maintained latrines of Kumase. 1981 on anti-witchcraftmovements in the period. down which people poured boiling water each day. healers in most places were denied any hint of public authority.146 on Thu. for example. This was certainly true in the nineteenth century. Conquestand the Formationof TraditionalHealing Because African healing was bound indissolubly with control over production and with political power. which were another form of health control. subject to the inequities and contradictionsof that system. All healers around Kumase were organized under the stool of the Asantehene's doctor. using well-known sources to make an original case for the importance of rational prevention and treatment in the nineteenth century. commoners next most likely.215. assigned this officer the job of licensing African healers. Institutions for the maintenance of health in pre-colonial Africa were not impartial or class-neutral. A great many historical works describe preventive health measures briefly in passing. British attacks on the Aro oracle in Nigeria and German persecution of healers in Tanganyika are part of the same picture. 38. The examples of Mzila and of the Fulani jihad are isolated ones culled from larger works. but in every case the authorities punished healers severely if they showed signs of wanting to exercise sovereign power by deciding on life or death issues. Donna Maier (1979) is another scholar who demonstratesthat a strong and coherent argument can be made for pragmatic public control of health in precolonial Africa. and where medicine served society as a whole. even when (as This content downloaded from 129. in the 1930s. or on questions of public order.) Residents burned rubbish behind each house daily.Healers exercised their authority to defend their own interests. 1975). At the time of the white conquest of Zimbabwe. healers who worked in close association with the holders of power were unlikely to challenge the bases of that power. She writes on Asante. but few explore the subject systematically. the conquerors held consistently to the goal of suppressing Shona spirit mediums. by destroying independent African control of politics and of the economy. The 'Public Works Department'under the stool of the Akwammofo Akonnwa organized street cleaning and sanitation. McLeod (1972) shows that Zande poison oracles were used in ways which divided nonaristocrats against one another.118 AFRICAN STUDIES REVIEW streets to improve conditions of health. Colonial policy towards popular healing varied. In addition. and membersof chiefly household the least.

by hospitals. The government controlled the siting of villages. The king.These controlled the conditions of health in several different ways. either by bringing them under control at chiefly capitals. Some healers were arrested and beaten. European planters interfered with irrigation ditches and dug up graves. is to outline the effects of conquest on the organizationof health for the area in which I have done research. its system of thought and action was transformed. The same triad of healing specialists. A worker'ssick excuse would never be accepted if it came from a popular healer. The authorities also regulatedland use to increase chances of survival.215. Once popular healing was removed from power.to late-nineteenthcentury.when the area was governed by local chiefs who were at times dominated by a central king (Feierman. But traditionality on plantations never extended to authority over health. 1974). burial of the dead.105. and chiefs eliminated them. There are no systematic studies of the actual conquest as it affected health institutions. or by killing them and selling their children into slavery. chiefs. and (in more places than in the pre-colonialperiod) by Muslim healers. and patriarchsregulatedthe use of irrigationchannels.146 on Thu. and damagingwars. whose body was a symbol of fertility and public health. Patriarchs. The base line for change is the mid. European managers often appointed quasi-traditional"tribal headmen" to prevent the emergenceof worker unity. and also people with smallpox who were sent out of the village into isolation. whether through the killing of witches. and gave shelter to lepers. The communal funds for This content downloaded from 129. Chiefs maintained treasuriesfor public crises. and local patriarchs. Those with authority also organized rites for communal well-being. drove out or killed polluted individuals whose presence threatened the survival of local kinship groups. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . German conquest can be interpreted(and quite probablywas at the time) as an assault on health. The simplest way to sketch the problem. At the same time acceptance of the central forms of popular healing weakened. or through the ecologically sound management of land. Biomedical health authorities would no doubt agree with them on some points and not others.Popular healers were forced to abandon the expectation that they would control public conditions of health. given the weakness of the literature. to prevent famine. At least one chief was killed for his role in administering communal medicines. The area is in northeasternTanzania. In the mines of Northern Rhodesia or the plantations of Tanganyika. Some of the unquestiondassumptionswhich underlay the varieties of pre-colonial healing were now challenged by missions. through large scale communal rites for rain.on the advice of diviners. extending from the Usambara Mountains eastwardto a line about fifteen miles inland from the Indian Ocean. patriarchshad control over collective kin funds to be used for the preservation of health and security. First.AND HEALING IN MODERN AFRICA HEALTH 119 under indirect rule) the colonial rulers made alliances with chiefs. Diviners identified witches. was executed. Authority for control of health was in the hands of a set of leaders which included chiefs. through the isolation of individuals in polluted conditions. they were responsible for controlling the kinds of deviance which were thought to threaten communal health. Missionaries cut down bits of ritually dangerousforest. epidemics. Forced labor interfered with the farming activities-the source of satiety and well-being. to make the case that loss of African sovereigntytransformedhealing. These included twins. placement of villages and the location of sites for human waste. healers.

or denying them the chiefship and with it any vestige of authority (MacGaffey. Individual aspects of the assault are describedwell by historians. althoughshe is concernedwith the period after the first sharp blows of conquest had been delivered and had receded into the past. 1967. we are all dying" (Nigeria. and French military doctors in West Africa. in the words of a leader of the women's war at Aba in Nigeria. Schoffeleers (1978: 40-41) discusses the role of colonial bureaucracyin undermining cult leadership. 361. A number of works examine relations between colonial powers and healers in the period after conquest. They were expected to oppose measures which threatened to undermine government authority. 1972. and throughthem of divination). The earliest doctors in most of colonial Africa were military doctors: the West African Medical Service of the British. Isaacman.120 AFRICAN STUDIES REVIEW survival and reproduction dissolved. Zeller (1971: 349. Armah. Colonial Health Services Early colonial doctors played a role closer to that of pre-colonialhealers than to American doctors in private practice. 1976). Colonialism as a threat to survival has not been strongly emphasized in this literature. This literature is rich in its analysis of the African struggle to retain autonomy and control. 366. 369) gives several examples of the way the British exercised sovereignty over healing in Buganda. the Schutztruppein German East Africa. 1974).nor has the role of mediums in fighting for life and health. 1930). This was true not only of the funds administered by chefs.The popular medicine which emerged from this experience was less oriented towards public health than it had been. and more a collection of treatments for individual conditions or. Military doctors served the state. The issue often was. Indian Army doctors in British East Africa.105. Ranger. And they played a direct part in supporting production. and then completed the process of undermining their authority by either making them chiefs with responsibility for unpopulartaxation. Janzen (1982a: chapter 3) gives a fascinating account of how colonial rule undercut the economic base of the Lemba cult's priests. They rarely made common cause with Africans who were deprived of their health by being moved from their villages. Iliffe. at most.1970). 1958. along with the racist ideologies of the period. 1979). but also of those in the hands of patriarchs. Egyptian Army doctors in the Sudan. The literature about conquest has included extensive discussion of spirit mediums and medicine in resistance (Gwassa. The cultural distance between the doctors and the African population. made it less likely that colonial doctors would ally themselveswith the subject population. Cobbing. 1968 on the missionary destruction of Fipa shrines. Their autonomy as European professionals was in conflict with the discipline normally expected of government employees.215. The most important stream of early colonial biomedicine is one to which scholars have paid relatively little attention: military medicine (Cantlie. Beck (1979) argues that the British preferrednot to intervene in the affairsof healers. as in Isichei's account of the attacks on the Aro oracle (1973). 1979. for afflictionswhich affectedlocalized groups. that "the land is changed. or by being made to serve as forced This content downloaded from 129.146 on Thu. 1977. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . They came to Africa as government employees. The assault on the institutions of health is a subject best described in novels (Achebe. and by anthropologists (see Willis.

. most especially. After leaving the colonial service." This content downloaded from 129. They wanted to foster population growth in order to preserve the labor supply. The pattern of environmentalcontrol in military encampments is one of the roots of urban segregation. Turshen. 1979. Lasker(1977: 283) quotes the Minister of Colonies as writing. most of them provided private care for the tiny elite of urban Africans.105. The objections to African doctors were that Africans might achieve positions where they could give orders to white officers. . The French placed much more emphasis than the British on mobile health teams. then other whites. argues that curative services were in harmony with capitalism and were therefore favored in colonial health policy. The most substantial recent histories of health services in British colonies (Bayoumi.D.'s. But there might also have been fears that it would be difficult to challenge African doctors who were able to argue with full technical authority on matters of social and economic policy. Their main responsibility was for the health of soldiers. and maternal and child health. prevention. Because military doctors were expected to serve the interests of the colonial authorities rather than the interests of the African population. Adeloye. 1981) shows that after the colonies expanded beyond their limited coastal spheres. All of these appear to me to have had an impact on medical practice in Africa. in 1923.HEALTH AND HEALING IN MODERN AFRICA 121 laborers. African doctors with degrees from British universities had served the military in the West African coastal colonies of the nineteenth century (Fyfe. and then returned to base (see McKelvey. They then served a widening circle extending to other government employees. Schram.215. Adell Patton (1980. 1981) discuss the equity and rationality of distribution in terms of a division between curative and preventative services.146 on Thu. and then to African prisoners. The argument is not a convincng one. hygiene. to ignore the problems of women and children (unless they were military dependents). 1971. . 1973 on Jamot). then Africans employed by the government. 1972. African M. the British decided to exclude African doctors from the normal ranks of the Medical Service. of a sort which scholars have not discussed. men of the medical services marched throughthe countrysideroundingpeople up and innoculating them."Where prevention became important. a question of labor.The writings collected by Adeloye (1977) show that this generation of early African physicians had a remarkableawarenessof public health issues and of environmentaldeterminants of health. and to establish encampments inside which there was tight environmental control and outside which there was little responsibility. Patterson. They all agree that prevention was underemphasized. 1977). The military period came to an end sooner or later-in most places by the mid1920s-but left its legacies for the future. which Swanson (1977) has discussed as "the sanitation syndrome. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . "The growthof colonial population is. for example the health consequences of labor recruitmentor of urban segregation. Military medicine tended to treat epidemic but not endemic diseases. Lasker describes the French decision that they could achieve more significant results with less money if they emphasized prevention. and education. to be accomplished by a major program of hygiene. ostensibly on health grounds. in her dissertation (1975). medical assistance.and that the races would mix at the mess table. of preserving the population and the birth rate.'s were unsuitable in the years after conquest.D. as in the French colonies. and apparentlydiscouragedthe practice of sending Africans for training as M.

Gelfand. and prevention as oppressive. The differencesemerged. and curative services were provided for the rich and the city-dwellers (Sankale. "The sudden deaths of Algerians in hospitals. The British." Turshen (1975. but when the local missionary fell ill. in one of the classic statements on colonial medicine." Questions of prevention as opposed to cure need to be consideredwithin the context of the distribution of social costs in colonial Africa. Janzen (1979: 209) describes public health measures in the Belgian Congo which were used as punishmentsfor local resistance. 1969). medical services were concentratedat the workplace (Aidoo. because EquatorialAfrica was the scene of some of the worst population disasters of the early colonial period. according to Lasker (1977: 288). The first two of these inequalities were complements of an economic policy which used rural production (either to feed male workers or to provide export crops) without significant investment in rural areas. this meant that in 1952 all of the territory's eleven major hospitals and twenty-six of its thirty-seven medical posts were located in the rich south of the country. so that the process of production would go on. to bear significantsocial costs. behaved as though the labor force would reproduceitself in the rural regions while paying a wide range of its own social costs. and to the rich but not the poor. 1976: 100.122 AFRICAN STUDIES REVIEW Most of the pressuresfavoring prevention would have applied equally to the British. they saw that he was sent to Abidjan to be healed. where it existed. including healing. and which therefore depended on rural social forms. and because the French were more sensitive to questions of population in the metropole. "are interpretedas the effects of a murderousand deliberatedecision. This provided a basis for meeting the next urgent need-for health care at places where large numbersof Africanswere employed." Mburu(1977) explores some of the same issues in a discussion of what he calls the "ProsperoCaliban Situation. Turshen also shows that health services were better in plantation districts than in ones devoted to labor reserves. Because colonial medical services had as their earliest mission the protection of the health of whites. mostly in cities." he wrote. In the French colonies hygiene and vaccination campaignswere the medicine of the poor. Fetter.215.to men but not to women and children. Hygienic meaures in the French colonies often amounted to chastising African mothers for abhorrent practices. It is important not to assume that colonial prevention. The continent's rulers provided medical services to the cities but not the countryside.105. The medical police could be oppressive. as in the British West African colonies. services tended to concentrate in places where whites lived in large numbers. Fanon (1967: 123). Lasker (1977: 291) quotes an Ivorian doctor as saying that "the villagers saw physicians only when they came (accompanied by soldiers) for vaccinations. throughoutthe period before World War II. In the Ivory Coast. 1981 discusses spatial distribution of services). 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . was a panacea. Africans sometimes saw curative care as a positive contribution (hence its importance to those who wanted to win hearts and minds). Reports from most parts of the continent attest to continuation after independence of the rural-urbaninequalities and class inequalities which began in the colonial period.In SouthernRhodesia. Frankenbergand Leeson (1974) show that the cost of four This content downloaded from 129. But this point is much too simply put.146 on Thu. I think. 1982. 1984) and Nsekela and Nhonoli (1976) describe the urban emphasis in colonial Tanganyika. explored the ambiguities of being treated medically by one's conquerors.

complains that all his patients are men.). while the rural ratio is 1:70. The perception must have been common. reports that women patients outnumbered men in the hospitals only after 1950. mines. and railroads. although the Sudan had a successful midwife school from 1921. This is not all the legacy of colonialism. In all the British colonies maternaland child health services were more the exception than the rule. This was in part a consequence of the total pattern of paying social costs at the work place while the population reproduceditself in the rural areas. total facilities (of both government and missions) rarely reached more than 20 percent of the population.215. 1980.000. were places where labor had been stabilized. Men who went to work in mines or on plantations were fed once they got there. and could join only on inferior terms (Patterson.Bradley. (For a similar case in South Africa see Gaitskell. in the Belgian Congo for example. The exceptions.HEALTH ANDHEALING IN MODERN AFRICA 123 beds at the university hospital in Lusakacould finance a health center for 20. 1977). Some doctors in the British colonies expected mission medicine to fill in the services for women and children. were those in health services provided to men as opposed to women and children. 1978). In SouthernRhodesia the first small numberof African maternity assistants were trained only after World War II (Gelfand. Accordingto Okafor (1982).105. the average Nigerian government hospital had no children's ward before 1950. thanks to the individual efforts of one determined woman (Squires. even though the women and children of the area were in desperate medical need. 1981: 14-15). according to Mburu (1981: 22) the urban doctor patient ratio is 1:987. 1980: 226-27). However.What influence they had emerged from the politics of resistance and of nationalism-revolving around an ideology and a form of political activity Europeandoctors in colonial service were unlikely to find sympathethic. But in the colonial situation the ultimate arbiterwas in the metropole. and rural ones where the doctor/population ratio is sometimes as high as 1:70. In Kenya. plantations. 1983. and Kirkwood. but the potential African beneficiariesof improved health care had little influence in the colonial mother-country. Where government concentrated on cities. Along with the neglect of women and children went an underemphasison nutrition before about 1945 (Turshen. written in the 1950s by a plantation doctor. Sabben-Clare. Services for women in the British colonies were most often the work of women doctors or midwives who worked for mission societies. alongside urban-rural ones and those of class. Acording to Schram (1971: 307). according to estimates of the Christian Medical Commission. In the Gold Coast women physicians (who tended to provide services for women and children)were denied entry in the regular medical service. Bendel State in Nigeria has urban areas with plentiful medical care. 1984. where whole families came to the workplace. but what was a doctor to do about the situation? In most countries professionals who wish to improve social services develop constituencies among those who would benefit. the missions established hospitals in isolated rural areas. Eddy (1980: 37). 1958: 61ff. the figure cannot be precise.000 people. but the point is This content downloaded from 129. who recalls long service in Sierra Leone. A third set of inequalities.A reportin the Tanzania National Archives. for it is reinforcedby today's class structure. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions .and where their welfare thereforebecame the concern of colonial or corporate physicians (Janssens. employers of labor were well-representedthere.146 on Thu. Were physicians unaware of inequalities in the distribution of ill-health and of health care? Researchershave not explored this question seriously.000.but the inequalities were built in from the start.

in this case. and not by popular healers (unless they are related to the patient). Medical Activities by the Churchin Africa). 58): "This will of course entail heavier charges on industry for the social services at present lacking or superfluous. In the great majority of African countries health services grew in the post-independence period much more rapidly than before. and when new African governments needed to show that self-rule would improve the lives of citizens.This is not easy." The increased social services. In East Africa. however. and education. The great expansion of health services in most African countries came after independence when a permanentlyurbanizedlabor force grew rapidly. therefore. 1975/76. Health care. 1976: 39).1984: 110-16). and to expand the payment of social costs. Even these inadequate services were a result of great improvements in the years after World War II. a period of very rapid expansion came in the late 1970s. 1967. This essay has shown that decisions on the management of illness are usually made by relatives and neighborsof the sick person-not by doctors. when rural services and services for women and children expanded.105.124 AFRICAN STUDIES REVIEW clearly valid (Akerele. had 875 health centers and dispensariesin the year of its independence and 1443 ten years later (van Etten.215. and eliminate any increase in the cost of production which might handicap competition with trade rivals in other countries. to have stemmed less from pressureexerted by doctors than from basic changes in labor policy. 1946: para.was to stabilize labor. Their decision. The labor advisor to the Secretary of State for the Colonies wrote about stabilization at the time (Orde Browne. was one in which demand continued to outrun supply. for example. National governmentswhich cannot meet the exploding demand This content downloaded from 129. included health. for example. like health. BiomedicineReachingOut It should be clear by this point that building a bigger health service does not necessarily lead to better health care or to improved states of health. 1976. and McGilvray. however. The typical pattern. is resistant to directed change from above. We saw in an earlier section that major efforts to improve health would requireplannersto take control of the social costs of production. In Nigeria. Within each country regions which benefited from expansion expected still more. housing. McGilvray. The experiments at integrating so-called "traditional practitioners" into government health services are attempts to solve several recalcitrantproblems at the same time. and the resultant increase in efficiency should counterbalance this expense. This is enormously difficult because the distribution of social costs emerges from the most basic strugglesof groups competing for dominance over society's direction. see also Pro Mundi Vita. and impoverished regions demanded to catch up. Tabibzadeh. in an attempt to overcome rural-urbanimbalances (Onokerhoraye.146 on Thu. No narrow bureaucraticdecree can impose a solution concerningthese issues. Tanzania. British changes in economic policy led to changes in the distribution of social costs.but the great economy effected. Bulletin 21. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . The improvements appear. The British wanted to expand exports of primary products and to substitute African manufacturesfor imports from outside the sterling zone. For health planners to take control of treatment they would need to intervene effectively in the workings of therapy managing networks.

" but so-called "anti-witchcraftlaws" in most British colonies were so broad as to prohibit almost any kind of popular medical practice (Stepan.ANDHEALING HEALTH IN MODERN AFRICA 125 for health services can. declare thousands of popular healers to be part of the health service. For example.215. This is not to say that popular healing is totally without standards. which was a part of Zimbabwe'slaw when the country achieved majority rule. also. In Central Africa. French law. Ifa diviners among the Yoruba go through long and careful training careers. Healers' organizations have only limited utility as an alternative source of regulation.105. Planners hope that the popular healers can serve. after added training and careful integrationinto the health services. like the Yoruba associations Oyebola (1981) describes. In all colonies. In most places the healers themselves have been eager for government recognition.of a kind which would likely destroy popular healing as it is known today. popular healing was able to continue because the laws were rarelyenforced. which is still on the books in most of the nations which had been French colonies. The law made many normal medical practices illegal. Actual attempts to integrate popular healers have faced difficult problems almost everywhere. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . National medical establishmentshave been eager. have histories going back into the pre-colonialperiod. although it is doubtful that they would welcome losing their freedom to practice as they wish and becoming instead carefullycontrolled junior health workerswithin the governmentsystem. of a kind they are unlikely to win. But in general there are few practical ways of preventing people from declaringthemselves to be healers. according to Chavunduka (1980: 134). Recognizingpopular healers is also a way of affirmingthe value of African technology and culture. but have no practicalway of judging whether someone is qualified to practice in any of the sub-specialties of popular healing. 1983: 297. They have proven valuable in defending the interests of popular healers. one normally becomes a healer in an established drum of affliction through a long process of treatment in which suffererlearns cultic knowledge.146 on Thu. 1968). Some. Ministries of health review the credentials of physicians. 1976). The fundamental problem.with periodic checks on competence after the end of training(Abimbola. Institutes in a number of countries are testing herbal therapies for this purpose. 1976). Their number has grown rapidly in recent years. 311). The central problem can be seen in Chavunduka's discussion of the Witchcraft SuppressionAct of 1899. Other associations are relatively new. with the stroke of a pen. But they cannot function as regulatorybodies without full governmentbacking. as a large corps of useful workers(WHO." British law makes alternative medical practice legal so long as the practitioner does not take measures "implying that he is registered. popular healers are free of any control. denied by white rulers during their years of control. but it did not prohibit witchcraft itself. Witchfinding movements are methods of mobilizing popular sentiment to prevent some practitioners from healing in the future (Parkin. makes it illegal for anyone but a licensed physician to perform "medical acts. There is therefore no way of regulating their practice or of distinguishing between useful and damaging therapies without creating a whole new system of regulation. and forbade the levelling of witchcraft accusations. 1968. Popular healing is illegal in most African countries. In the system as it has evolved since the time of colonial conquest. is that "when an individual in this society accuses This content downloaded from 129. to build their own pharmaceuticalindustries using herbs drawn from popular healing.

1983.1983). as opposed to small scale pilot projects. 1982). 1977.105. Pillsbury lists two African countries (Nigeria and Zimbabwe) in which popular healers are used in their healing roles within the national health system. the aim of the law should be to prohibit malignant practices while permitting legitimate practitioners to carry on." but argues nevertheless that African governments should license popular healers after collecting systematic information about the record of each healer'spractice.storage." In Chavunduka'sview. for training periods of fourteen weeks. The large training team worked with eight to ten healers at a time. it has not in fact been done systematically anywhere. Thorough-goingacceptance of popular healing would mean thorough-goingregulation. But it is virtually impossible for secular African nation-states to go far enough in accepting the theoretical bases of popular healing to make this distinction in any meaningful way. Dennis Warrenand his associates developed a successfulhospital-based training scheme for practitionersin Techiman. Training programsfor midwives have been significant.as have reviews of herbal therapies. The general picture at this time is that experiments at integrating popular healers into biomedical services have not made great contributions to African health. except in midwifery and the study of herbal knowledge (Ampofo. however.146 on Thu. it is not likely to serve as a model for national programs. A few rare imaginative efforts show that some form of modest cooperation is possible. and a range of other subjects. The distinguishing features of the program show. destroy popular therapeuticsas it is known today. Chavunduka. I believe. 1981). although they were also instructed on diarrhea and rehydration. Barbara Pillsbury (1982) reviews the actual use of popular healers in biomedical health services all around the world. in discussions of actual integration. argued that recognizingtraditional healers was like licensing killers (Oyebola. in Ghana (Warrenet al. And the learning goals were modest-the healers felt that they benefited most from sessions on preparation. Midwives have received formal training in sixteen African countries. But popularhealers at this time seem far more effective working under their own rules than as adjuncts in national health services.126 AFRICAN STUDIES REVIEW another of witchcraft he may well be right. of which only two have created national programs. Whether or not this is theoretically possible.Warren had worked with Techiman-Bonohealers and had developed rapport with them over a ten-year period before starting the training program. which underlytraditionaltherapy. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . This content downloaded from 129.. Even modest experiments at a local level involve many of the same issues: how are biomedical practitionersto use the services of popularhealers if they do not accept the basic premises of popular practice? The history of integrating biomedical and popular healing in Africa has been much stronger on international and national pronouncements than on actual practice.215. Preparatorydiscussions lasted for some months. that even though it might deserve imitation. Bannerman. The probability is small that national programswould go about their business with the same patience and respect. and preservation of herbs. . Neither of these cases bears closer examination: in Zimbabwe the official council which was to regulate integration under the Traditional Medical Practitioners'Act of 1981 has never met.1977.so that full integrationwould. Bibeau (1982: 1846) acknowledges "the impossibility for modern legal codes as they now stand to incorporatethe fundamentalconceptions . nutrition. the majority of members of the Nigerian Medical Association..

on which a very special set of physicians proposed the creation of a health service for South Africans of all races.105. There is a peculiar trap here. the African workers. for example. The Health Commission's plan. The problem here is that the health workers need to find a political constituency-to form a coalition of those who would work for change and have the power to win it. and Cornell. and on how to use the laws to maximum advantage. a well-planned health service offered to keep the work force healthy for less cost than an expansion of existing hospital-basedcare. The group provides advice on health and safety issues to worker organizations.As it happened. Medical ethics and the norms of public employment require that state health workers serve the entire population. White. Myers. Even progressivepolitical regimes do not welcome challenges to their own authority. 1983. It is therefore difficult to make alliances with those who have been deprived. The Group's research helps to uncover systematic but well-hidden ties between the stresses at the work place and ill-health among the workers. University-basedhealth workers. The proposalcame at a time when the capacity of the reserves to support their African population was declining. had the possibility of helping to create a political coalition for fundamental change in the South African economy. in alliance with This content downloaded from 129. To mobilize the deprived is to challengethe established order of political priorities. 1981). have greater autonomy-a greater capacity to establish links with those deprived of health-than do employees of national health services. I doubt. made demands which showed a similar desire for stabilization. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . Today the IndustrialHealth ResearchGroup at the University of Cape Town is working on a much more modest scale to make common cause with some of those who have been deprived of health. was turned back by the coalition of forces which won the election of 1948 and codified apartheid. and that they do so within the pre-existing political framework. The Commission's proposal had the possibility of winning support within the political-economiccontext of South Africa at that time. which would have provided benefits for poor whites as well as for Africans. and when manufacturing was growing very rapidly. In the mining sector.It provides expert testimony under the unenforced occupational health laws.who struck in 1946.like those of the IndustrialHealth Research Group. the possibility of stabilization. or the way African workers are deprived of compensation for poor lung function by a system of valuation which sets different standards for each ethnic group (Myers. Manufacturers needed stable semi-skilled labor. From the government's point of view.215. that the Tanzanian government would welcome a workers' movement. advice to unions on how to preserve the health of members. 1984. Shula Marks and Neil Andersson (1983) explore the fascinatinghistory of the South African National Health Commission of 1944. Apartheid brought the disastrous health policies which have been described in the section on the social costs of production. 1982.HEALTHAND HEALINGIN MODERN AFRICA 127 A second possible strategyfor biomedicine reachingout to influencethe social conditions of health is throughwork to change the distributionof the social costs of production. Cornell and Kooy. Labor stabilization and improvements to health services tend to go together. uniting all the groups in favor of labor stabilization. Manufacturerswho invested in training labor wanted to get the best return for their investment-not to sustain losses because of ill health.of course. which was real in the years after the war.146 on Thu.as for example in the case of the high prevalenceof hypertensionamong stevedores. Myers and Steinberg.

The Mozambique health services were. the Government . and that party leaders must be treated in separate wards (Walt and Melamed. in an article about "Health Dilemmas Ronald Frankenberg in the Post-colonial World" (1974). the expansion of the primary care segment by extending the distribution of health centres and health posts to as many settlements as possible and by developing the promotive and preventive services... is professionally ethical and politically populist. 1983).F. a sympathetic Vice-Chancellor and Deputy ViceChancellor.128 AFRICANSTUDIES REVIEW doctors. The approach leads to valuable work which must be respected. but which is necessarily limited by the contradictions of the society in which it is implemented.." The descriptionof good intentions frustratedis repeated over and over in the literatureon currenthealth services. the President gave a speech stressing that councils ought not to challenge doctors' authority. or textile factories. The IDS team which evaluated health services in Ghana describesrural-urban inequities.This is usually the best we can hope for. and then writes: "The Government has committed itself in the Plan to correctingthe situation. by requesting that they form councils-for example. 1966). 1981: 411). The professional and political tendencies both are expressed as a need to serve the entire public.. as Professor of Social Medicine. will emphasise . When the councils had functioned for a period.) as a leading administrator.yet three quarters of our medical resources are spent in the towns where three quartersof our doctors live. to change the basic organization of work in breweries. nevertheless. and more successful also at controlling priorities by limiting the freedom of action of internationaldrug companies. and Joyce Leeson. within hospital wards for collective managment (Walt and Melamed. It is the approach which has come to be known as Primary Health Care (InternationalConference on Primary Health Care. discuss the contradictionsin their own work in Zambia. Despite King. it was not possible to establish medical education on an appropriatebasis. 1978). The most common form of political action. far more determined to extend health care to the underservedmajority in the countryside than most other African governments. but to do so without challengingthe establishd frameworkof power and class relations. Three quartersof the people die from diseases which could be prevented at low cost and yet three quarters of medical budgets are spent on curative services" (for this general position see King. one of us (R.215. They quote Morley: "Three quartersof our population are rural. 1983: 37).146 on Thu. to redistribute resources so as to serve those who need help most.a friendly Ministry of Health. The Mozambique government tried to create a framework within which health workers would make alliances across narrow professional lines. A bit later the evaluation team comments (1981: 411): "The future looks particularlybleak when even the Plan's commitment to reallocateresources was contradictedby the actual allocations within the Plan. Government will seek the involvement of the local communities in efforts to satisfy their own simple needs" (IDS Health Group. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . Cases of health workers reachingout effectively to the deprived are rare. to improve the health conditions of work. within national health services. and WHO backing. Frankenbergand Leeson (1974: 265) then begin their lament: "The Republic of Zambia was committed to many of these [improvementsto health services] by the First National Development Plan. But these councils appear not to have been expected to reach out into factories or farms." The reasons for this This content downloaded from 129. yet they proved difficult to put into practice.105.

Many Shambaa women die in childbirth. this would have profound positive effects. They share one This content downloaded from 129.105. but often with no drugs.146 on Thu. for health education. Furthermore. but cannot push beyond the limits on social costs. improvements in health and care are likely to result. has made great achievements. Populism wins its victories. with independence. Then. Despite these gloomy truths. Maternal and child health teams are there. In Lushoto District the nationalists in 1947 listed the failings of their Paramount Chief: "Usambara has no midwifery. The very great accomplishmentswould be changes in the distribution of social costs.HEALTHAND HEALINGIN MODERN AFRICA 129 state of affairsare clear:those with the power to make decisions live in the cities. What we are left with is pessimism of the intellect and optimism of the will. but without vaccines.18But the health services have stumbled once again. and so on. The peasant nationalism of Tanzania had this effect.215. more recently. The achievements are real. or if they have vaccines then without refrigeration. planners must of course continue to work for the redistribution of health resources. Shambaa women give birth in miserable circumstances. and those with the capacity to offer effective resistance to the government also live in the cities. against the realities of social costs-this time in their international distribution. It is possible to hope for very great accomplishmentsand for very modest ones. And then there are the initiatives which make no great claim to changing entire health systems. Elsewhere in Africa.Waterpipes are there.or without transport for mobile units. were able to win victories which would undermine the migrant system and the rigidity of the homelands. but hopeful. inspired by nationalist politics. local nationalist politicians of the 1940s and 1950s made passionate demands for improved health services. peasants demanded rural dispensaries and paid through their local government units to create them. for improved water supplies. The demands of the 1940s and 1950s helped to push along improvements being made by a government ready to begin stabilizing labor. this would lead inevitably to enormous improvements in health. Dispensaries are there. None of these are easy to accomplish. If political movements were capable of winning power for rural women. for example. where political movements have won (or might win) greater power for the rural population. for maternaland child health. But it is only broadly based political or economic change which can alter the entire system of constraints on the way people live and die. In the absence of broad power change. Later. so that ruralinvestments must transportationand infrastructure be much largerto achieve an identical effect. but with no spare parts for the valves. Either kind is difficult. If the labor movement and the political movements in South Africa. for lack of foreign exchange. the entire pattern of past investment in favors the cities. for better rural health. and none can be written in any simple way into a national health plan. health services were among the contributions the new government could make to the well-being of its citizens. just as the inequalities are. The enormous expansion in health services and piped water led to rapid declines in infant mortality and to increasesin life expectancy. It would be disastrous if recognition of the major constraints destroyed the will to act constructively. Why are there no maternity clinics?" The popularly-builtclinics of the 1920s were the first core of the rural health system. at a time when the British had decided to provide health services only at work places and administrativecenters. populist and ethical primary health care. In Tanganyikain the 1920s. which are modest in scale. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions .

older midwives continued to supervise most births. the government workers. and through them of health. The same approach is carried further in the Sierra Leone village projct. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . A few brief examples will illustratethe case. in these matters. The hospital workers serve as technical consultants.105. The villagers then intervene to make improvements.146 on Thu. both use related approaches. At the national level. they accepted some advice and rejected some. The second example from the same project. In the Tanzanian project. and at the level of national health plans. and what they expect health workersto do (von Troil. At this modest level. Health professionals do not make the most important health-giving decisions. 1983). and those who deliver primary care are the most likely to reform it. They resisted. The nurses found that dispensaries drew patients from very small areas. the lesson is similar. The villagers themselves make the crucial decisions. 1982).But village women trust the judgment. Each nurse recordedthe home villages of patients who attended dispensary. and quarreled with their trainers. The older women did not easily accept the advice they were given-they resisted. only of older women who have experienced motherhood. Two examples from a project in Niger show how a concern for primarycare can either increase or undermine the power of those most likely to help with primary health (Belloncle and Fournier. and the "experts" make This content downloaded from 129. Health decrees from on high have not had a good record in modern Africa. to recruit young girls out of school rather than older midwives. One project for training health care workers in Tanzania. In either case the professionals. trusted those who do the work to assess the situation. Nurses at local dispensaries were instructed to cooperate with and to supervise an emerging stratum of local-level health workers. The first trainees were older women who were serving already as midwives in their own villages. and another for improving health in villages near a hospital in Sierra Leone. In the event. At the local level. networks of people caring for their own health within their home communities decide on the crucial changes. Evading their control was merely a way of escaping the realities of lay health practices.130 AFRICAN STUDIES REVIEW characteristic:they are built on the assumption that those who suffer ill health are the ones most likely to create effective techniques for changing health conditions. 1975). a small team of health care workers must report in detail on what the people of a single village see as their most important health problems. what they now do about those problems. based on the idea of participantresearch (Swantz. These would much more easily accept the judgments of their trainers. The nurses then sought out the help of local-level workers because their own analysis had shown that this was necessary. and continue to study child health to learn whetherthese are working. where villagers are expected to do collective researchto construct a picture of morbidity and mortality among children (Edwards and Lyon. in the same period. why it is that some difficultiesremain. They were then given the job of assessing the spatial distribution of health care in their own district. A project in the 1960s aimed at improving the health of new-born infants by changing birthing practices. The project organizersthen tried to change the basis of recruitment. and that large parts of the district never sent patients to any dispensary. 1982).215. political movements and political factions of all kinds struggleto influence the shape of the polity and of the economy. The village health committee can then ask for the help of hospital workers at dealing with the most urgent problems. given the appropriateopportunity.

held at Gaborone in September. Bayoumi (1979: 203) on the importanceof an integratedapproachto waterprojectssee Coumbaras1977b. 8. 13." Traditional intellectuals.for a similar processin Ghana see Bukh (1979). Shweder(1981) cites literatureon this subject. Nor is biomedicine solely "western. exist in Europe as well as in Africa. on easternZambia see Vail (1977). and Ellen Brickweddefor comments on drafts.d. 1976. and Inikori." Paper deliveredto AfricanStudies Association Meeting. Manning. Thanks should also go to Arthur Kleinman. and Scott. For the inequalitiessee Klouda (1983). 1975. Michael MacDonald. See Patterson (1981: 37) on forest clearing for cocoa.Indiana. in the terms defined below. The demographicconsequencesof the slave trade have been the subject of a large and impressive literature:Curtin. Murray Last and Gordon Chavunduka are editing a volume of the conference proceedings. Inikori. Hunter.HEALTHAND HEALINGIN MODERN AFRICA 131 important but marginal contributions.146 on Thu. 1976. and Gerda Lerner for encouragementand helpful criticism. 1982. and that they must try to identify and to serve that special sub-group of laypeople who are already at work to improve health." African physicianshave practicedmedicine since the nineteenthcentury. Jean Comaroff.215. 3. For an early exception see Richards(1939) and Wisner(1983). 1963. "Medicine. 1969. For one of the rareattemptsat reconstructing pre-colonialhealingsee Waite (1981). Austen. 17. On the issue of rationalitysee BryanWilson (1970) and Young (1981). Roberts (1974: 306) on the enormousexpansionof malariain westernKenya. This essay uses the terms popular medicine and biomedicine instead of the more common terms "traditional" and "western. see Janzen (1981). On the nature of this process.University of Wisconsin-Madison. 18. 5. 15. 1981.Authorityand Kinship:The Case of the Sokoto Jihad. For the fascinatingbut grim story of the way tuberculosisspreadfrom the mines to the ruralpopulation. .D. 5 Dec 2013 23:28:21 PM All use subject to JSTOR Terms and Conditions . 1979. John Janzen. Haswell (1953. This content downloaded from 129. 1. Private communication22 October 1984.Rey.Ismail Hussein.Bloomington. 12. On infertility in contemporary Africa.105. REFERENCES Abbreviations: IJHS InternationalJournalof Health Services JAH Journalof AfricanHistory SSM Social Science and Medicine Abdalla. Antony Klouda. Curtin."Ph. 1968. 4. NOTES Special thanks are due to Allen Isaacman. "Islamic Medicine and its Influenceon TraditionalHausa Practitionersin NorthernNigeria. See the contributionson the cost of schistosomiasisin Abdallah(1978). 1981a. Curtin. 14. 10. The International African Institute sponsored an important conference on the professionalization of medicine in Africa. 2. Fage. 6. the fullest and most interesting interpretationis by Chapin and Wasserstrom(n. 7. Dissertation. For a later review of these issues see Iliffe (1979). For furtherdiscussion of naturalcausationin Evans-Pritchard. see Packard(1983).Anstey. 1975. see also Adadevoh(1974).). Jan Vansina. 9. 1983. "Tradition"cannot therefore be used on only the African side of the equation. 16. 1981b. They are most constructive if they recognize that their own role is secondary. 11. 1981).

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