Seeking inclusivity in Ethiopian healthcare

By Julianne Weis

In a guest lecture last week at Oxford, Harvard historian Emmanuel Akyeampong began with a methodological caveat, stating that he was not interested in the tradition and modernity dichotomy, but rather saw the two terms as existing in a constant interchange of causation and process. His argument made me think of Jake McKnight’s post regarding those excluded from modernity politics in Ethiopia. Blankedly disregarding “tradition” in pursuit of “modernity,” rather than investigating the constant interchanges between the two terms, leads to an elitist form of development.

It was this dichotomous thinking that formed the basis of failed development politics in Ethiopia under previous regimes – Haile Selassie most notably – and only served to alienate the majority populace. Ethiopia today continues to contend with this exclusionist legacy – particularly when providing services like education and health. In developing a modern health network for Ethiopia, Haile Selassie truly saw himself as starting from zero – any indigenous system or network was conveniently wiped aside as the Imperial regime attempted to inject a fully modern mode of healthcare. In 1944, a British nurse working in Ethiopia called the country a “doctor’s paradise… if to provide a pretty clean slate on which to work is a paradise then it may be agreed that Ethiopia is one.” What is implied in this type of rhetoric is that because Western medical systems were so underdeveloped, Ethiopians had no existent networks of health and healing – the population was merely succumbing to illness and death without making any effort to develop curative or palliative services for themselves. Under this line of thinking, the Selassie regime strove to develop what they termed the first public health network for the empire, training hundreds of community nurses and health officers to man village health centres throughout the countryside – over 400 built before 1965.

Unfortunately these health officers and nurses were notoriously ineffective, owing largely to the elitist core of their operations. The centres’ staff were trained to believe it was they alone who were bringing healing services to this community, completely negating the existing network of indigenous medical personnel already serving the same patients the new health centres were targetting. Anthropologist Simon Messing published several studies in the 1960s showing how the health centres failed to change even the most basic behaviours of the communities they served (e.g. more rigorous hand-washing), pinning that failure directly on the lack of involvement of indigenous health leaders (debetras and wogeshas). Messing’s fieldwork showed how the debteras and wogeshas were in many cases eager to learn the new medical technologies utilised by health centre workers (if only to keep a competitive stake in the market), but were largely ignored by the newly-trained staff. Many indigenous health workers eventually became “black-market” dealers of modern medicine – peddling prescription drugs, needles, and syringes to existing clients. Thus despite their formal exclusion from the emerging Ethiopian health system, local healers sought out any medicine they could to appease persistent clients.

Overall, residents of those communities served by the new clinics preferred the services with the debteras and wogeshas over health officers and nurses not only because their prices were more affordable, but because it was believed they were simply more effective in their treatments. The key difference between the two types of care was in the conception of cure and treatment – with health officers prioritising imported concepts of medicalised modernity and sanitation, while debteras and wogeshas worked with a more inclusive and localised worldview. This worldview welcomed and continues to welcome modern medical technologies, but not at the expense of cultural idiosyncrasies or internal community dynamics and definitions of health. It’s not about throwing away “tradition” for “modernity,” but accepting a greater variety of forces, seen and un-seen, which define local conceptions of illness and cure.

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Filed under Development, Ethiopia, Haile Selassie, Health

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