The Politics of Disease Control. Mari K. Webel

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СКАЧАТЬ is a focal disease, its transmission limited to particular places: environments where its fly vector thrives and where human and animal hosts of the parasite live or transit. People, parasites, and flies have to be in specific places, together, within a particular span of time, in order for the trypanosome parasite to undergo development in both its host and vector and to survive successfully. Break the chain of contact at any point—secure people from fly bites or prevent flies from ingesting parasites as part of their blood meal—and transmission ceases. And so, biomedical approaches to trypanosomal infections, beginning in the period of my study, developed an environmental and ecological orientation that spatialized the disease and the potential for epidemic outbreaks around “fly zones.”⁴⁴ Work on sleeping sickness and other such ecologically specific, vector-borne diseases has since persistently prioritized the environmental dimensions of health and illness in identifying at-risk populations or ideal targets for vector control campaigns, generally limiting work by the climatic range or ecological niches of their disease vectors.⁴⁵ This has meant that, across the twentieth century, vulnerable and affected African populations have seen successive interventions by different regimes, states, and nongovernmental organizations, each oriented around that spatialized, environmental logic of sleeping sickness control and each building on precedents in particular ways. The book’s three case studies in the Ssese Islands, Kiziba, and the southern Imbo highlight the kinds of complex relationships that often accompanied and shaped public health interventions historically and continued to inform subsequent interventions after World War I. I prioritize people’s experiences to understand meaningful points of reference and resonance that impacted their engagement with, and therefore also the efficacy of, health interventions.

      After decades of centrality in imperial research agendas, eastern and interlacustrine Africa emerged as hubs of global health activity after the 1990s. Global health programs have frequently come to supplant the core health-related functions of the state and often altered citizens’ engagement with national governments.⁴⁶ Programs in Africa (as elsewhere) frequently focus on the strategic deployment of specific pharmaceutical or medical goods and emphasize community participation, sustainability, and capacity-building. Yet, while these programs are sometimes flummoxed by local complexity or unpredictability with historical roots, consideration of their contexts by global health practitioners tends to be strongly presentoriented. Programs and interventions often proceed without a sense of history, failing to reckon with historical precedents in specific contexts or lacking full perspective on comparable programs that have sought to solve the same or similar problems.

      Nuanced appraisals of the successes and failures of historic public health campaigns should provide an expanded framework within which we can evaluate modern programs’ practical tactics as well as their ethical implications. A rich, new vein of scholarship, relying on diverse scientific, medical, and political archives alongside ethnographic and oral history research, has built a narrative of health and politics stitching together the impacts of a long twentieth century.⁴⁷ This work has begun to carve out space for new, interdisciplinary dialogues, advancing productive conversations between health policymakers and scholars of health programs and informing the conceptualization of future programs. While my case studies examine the period a century ago, they highlight the historical contexts in which particular environmental approaches to vector-borne disease control proceeded or faltered—still pressing matters for modern campaigns around sleeping sickness, as well as onchocerciasis and schistosomiasis, among others.

      Current sleeping sickness programs fit with other global health programs aiming at the elimination or eradication of diseases that predominate in rural African communities, consonant with current trends toward the “scaling up” of health programs and the pursuit of ambitious global agendas.⁴⁸ This study of colonial sleeping sickness camps around Lake Victoria and Lake Tanganyika shows that scaling up has a longer history, one rooted in colonial desires for widely applicable public health schemes and economic efficiency. Likewise, it broadens the history of the paradigm of treatment-as-prevention so relevant for HIV/AIDS that was, as Guillaume Lachenal argues, truly pioneered in French colonial campaigns against sleeping sickness.⁴⁹ This book’s case studies demonstrate that targeted populations readily confounded public health policymakers’ and practitioners’ designs to operate at the level of entire territories or kinds of environments. This book also periodically considers mobility, in particular, to reveal the disconnects between plans and circumstances on the ground, exploring it as an epidemiological factor, a lens through which public health interventions came into focus, and an element of popular treatment-seeking strategies. This book thus speaks directly to the persistent challenges of surveilling, reaching, and monitoring access to interventions in the target populations of public health.⁵⁰ Considering how and why people have historically availed themselves of treatments and what factors shape those activities has implications for understanding the dynamics and difficulties of public health practice in the present day.⁵¹ I hope, then, that this book will raise questions about the nature of participation in public health interventions, about the importance of historical precedents and experience, and about the factors affecting the sustainability of interventions—questions that project organizers and planners might ask initially in order to achieve their wider goals.

      AN ORIENTATION TO THE GREAT LAKES REGION

      This book centers on the kingdoms and scattered peoples of Africa’s Great Lakes (interlacustrine) region. This region is distinctive on the African continent for its geography, containing Africa’s highest mountains and largest bodies of water. The book’s three case studies—the Ssese Islands, Kiziba, and the southern Imbo—focus our attention on the northern interlacustrine region, an area bounded by Tanzania’s Malagarasi River in the south and the hinterland of Lake Mwitanzige (Lake Albert) in the north. The distinctive climate and environment of the interlacustrine region differentiate it from nearby plains, semi-arid savannahs, or river basins in eastern-central Africa; the cultural innovations of its populations have given the region an enduring analytical coherence for scholars. Continuities in general cultural forms such as sacred kingship, patrilineal clans, or spirit mediumship stretched across this large territory and helped define the intellectual worlds of its inhabitants. Such continuities, borne of a connected past, meant that people across the region understood political power, causes of illness, and possible steps for its remediation from a similar perspective.

MAP I.1. The Great Lakes Region. Map by Brian Edward Balsley, GISP.

      This section introduces several of the root consistencies and broad continuities found across the region’s societies historically. It offers readers—particularly those less specialized in African history or less familiar with the Great Lakes region—an orientation to the central aspects of interlacustrine societies that shaped life and livelihood for people living in the late nineteenth century. It illuminates the important political and social institutions, as well as economic and environmental trends, that shaped daily life. These central elements and key trends in the region’s history provide a foundation for understanding the local variations and specific political and therapeutic frameworks that influenced how people in the Ssese Islands, Kiziba, and the Imbo lowlands managed illness and sought health and prosperity in the early twentieth century. This, in turn, allows us to see with greater precision how and why people affected by sleeping sickness interacted with colonial disease prevention campaigns as they did and to understand the broader consequences of these interactions for colonial public health.

       Environmental, Social, and Political Dynamics of Interlacustrine Societies

      Over the centuries after 1000 CE, populations in the Great Lakes region innovated political and social frameworks that would continue to influence the intellectual worlds and everyday lives of people living in the nineteenth century. Some of these innovations created structures that defined political power and governed land tenure and use, while others generated identities that bound together wide networks of kin and fictive kin groups. Still others provided ways of understanding connections between people, their environment, and wider cosmological СКАЧАТЬ