Review: James McCann’s “The Historical Ecology of Malaria in Ethiopia”

James McCann’s newest book on malaria, agriculture, and ecology in Ethiopia is a superb and rich study. McCann helps fill many gaps in scholarship, including the grossly overlooked history of medicine in Ethiopia. The book narrates malaria in Ethiopia in both the past and present, demonstrating how this ever-evolving, clever disease has shifted with the ecological and political landscape of the nation. To understand malaria today, McCann rightly demonstrates how an exploration of the past is essential. Unfortunately, there is very little written about Ethiopia’s medical history – Kloos and Zein’s Ecology of Health and Disease in Ethiopia (1993) is the most useful volume in an otherwise bleak academic landscape. McCann’s new study is a welcome start to what should be an expansion of research on past efforts to combat disease and install an effective public health network in the country. Because of Ethiopia’s unique ecological and political character – a highland nation, free of a colonial past – the challenges faced are unique in comparison to other African states. McCann’s rigorous exploration of Ethiopia’s ecological and agricultural histories, both in this and previous books, provides refreshing insights into this singular landscape.

While this study is especially insightful for scholars of Ethiopia, it also provides a rigorous exploration of the failures to account for local ecology in the planning of disease management and control. This is a lesson worth exporting far outside both Ethiopia and even the specific case of malaria. McCann repeats often in the book how malaria is a deeply ‘local’ disease: the ways in which mosquitos breed and prey on human populations varies considerably based on ecological and political landscapes. While malaria ‘eradication’ efforts in the past century have been forged on a global scale, most notably with DDT spraying and bed-nets, such efforts have all fallen severely short of their goals, largely because of the highly adaptive nature of the disease. There is no ‘one-size-fits-all’ approach to malaria eradication, and in some cases, the insertion of development programming itself can increase the risk of disease.

Indeed, one of the most striking findings in the book is the relationship between increased maize production and the spread of malaria. McCann describes how mosquitoes thrive off the seed fall of maize plants, leading to a dramatic increase of malaria risk in highland zones of Ethiopia that were previously largely immune to malaria due to altitude. Large-scale maize production has been touted by international organizations as an answer to hunger and poverty in Africa, but this clearly has dangerous unintended consequences to the ecology of disease.

McCann’s work is truly a must-read for experts in many fields, from public health, agriculture, and history, to politics and development. This book is a brilliant demonstration of the deeply local and highly adaptable nature of disease and mortality, and the ways in which the historical ecology of disease effects household decision-making and trends in food production and economic development on a national scale.

Book details: James C. McCann. The Historical Ecology of Malaria in Ethiopia. Ohio University Press (2015). http://www.amazon.com/Historical-Ecology-Malaria-Ethiopia-Deposing/dp/0821421476/ref=sr_1_1?s=books&ie=UTF8&qid=1449160837&sr=1-1&keywords=ecology+of+malaria+in+ethiopia

A review copy of The Historical Ecology of Malaria in Ethiopia was kindly furnished by the Ohio University Press. 

Opening up historical wounds in Northern Kenya: were toxic wastes dumped in the Chalbi desert in the name of ‘oil exploration’?

By Hassan H. Kochore

Last weekend’s feature story by KTN, ‘Desert of death’, told the story of cancer patients in Marsabit County, northern Kenya. Young and old, they lay on their deathbeds, having exhausted their meager resources on hospital bills. With few resources and no government support, nurse Asunta Galgitelle cared for patients with the utmost dedication and humility.

The number of cancer victims in Marsabit County has been rising for some years ; KTN and other news reports have highlighted the increasing prevalence of throat cancer in particular. Suspicion has fallen on the oil exploration wells drilled in the 1980s by oil company Amoco Kenya. The KTN report argued some of the wells do not appear to have been properly sealed and people living in the areas around the wells fear the water table has been contaminated.

The people of the Chalbi Desert have for centuries occupied one of the most unforgiving terrains of the globe through resilience and perseverance – it is deeply unjust that they could now be subjected to such a man-made disaster.

Oil Explorers

In a book chapter in 2011 , American anthropologist John Wood described how the Gabra of Marsabit district were hospitable to ‘oil explorers’.  He says, “Contrary to my expectations, the Gabra did not see oil explorers as intruders or invaders.” It seems that at worst the Gabra were indifferent to the explorers: “sure they remembered the equipment, they had watched the activity but it was none of their business.”

For their hospitality, the people of Marsabit were paid with the defilement of their sacred land. Land in Chalbi does not only support human life but is central to spirituality in the region. The whole of the Chalbi Desert and Marsabit County more widely are dotted with ritual sites; movement across the landscape is not only a survival strategy but a spiritual necessity.

Today, the people of the Chalbi desert may no longer be able to trust the land and its resources. The polluted habitat renders the population in a perpetual state of fear, not knowing when the next patient will be diagnosed with the ‘silent  killer’ or when the next herd will fall one by one having drunk the waters from the ‘cursed well’. Herds have died in their hundreds before – at Kargi in January 2008, for example. A monster has invaded the land of the nomads. Things are indeed falling apart.

#weareone

Worse still, their own government may have been complicit. Northern Kenya has long had a fraught history with the governments of Kenya, both colonial and post-colonial. In these lands, the government has long been referred to as ‘nyaap’- ‘the enemy’ in the preponderant Borana dialect of the larger Oromo language. Seeing chiefs and government health officials in the documentary pointing fingers at the government is testimony enough that government here is not trusted even by ‘insiders’.

Massacres have punctuated the history of the North — from violence carried out during the Shifta War to killings at Wagalla, Bagalla, and Turbi. Some of these were orchestrated by the government, were carried out with its complicity, or came about because of its laxity, as revealed by the Truth Justice and Reconciliation Commission report released earlier this year. While many campaigned to air their painful memories to the TJRC and ensured that the suffering of the past was exposed, there are no signs at present that the recommendations of the report will be considered or even discussed.

Meanwhile, Northerners continue to be neglected more widely when it comes to the provision of basic infrastructure and services like roads and healthcare – most of the cancer patients in the feature had to go to hospitals in more developed ‘down’ country areas like Meru where they deposited all their hard earned cash.

It will be interesting to see how the Kenyan government will respond to this crisis in these times of #weareone and ‘national cohesion and integration’. What measures will it take to curb this epidemic, ‘detox’ the land and try and win back the hearts and minds of the population?

Community support will be central to the success of some of the government’s regional infrastructural projects such as the multi-billion shillings Lamu-Southern-Sudan-Ethiopia Transport (LAPSSET.) Great tracts of the railway, road and pipeline will pass through Northern Kenya. Community ownership of the project is key, and in these lands where the government is not very popular, a lot of ‘winning of hearts and minds’ will be necessary.  The oil exploitation in Northern County of Turkana will involve similar challenges. As a local lawyer said, summing up the feeling on the ground, “You cannot ignore us for 50 years then Turkana becomes the lingua franca after the discovery of oil.”

In summary, in order to redeem its legitimacy in the north, the government needs, as a matter of urgency, to begin fresh investigations into the rise in cancer cases and present a report to the County government of Marsabit, taking responsibility for any complicity it might have had in the disposal of toxic waste in the area. Without genuine efforts towards acknowledging and apologizing for its history in the region, the government will continue to alienate its Northern populations, the ‘integration’ rhetoric notwithstanding.

Hassan H. Kochore is a graduate student in African Studies at the University of Oxford.

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).

Modernism and development politics in Ethiopia

By Jacob McKnight

There are two paths between Addis Ababa’s top hotels. If you ask the guards at the Hilton how to get to the nearby Sheraton, they will politely point right, up the smooth concrete road. If you ask one of the kids who variously shine shoes, sell gum, shout ‘Farenji!’ and offer to be your guide however, they will beckon you across the street, off the tarmac, and onto a scrub road leading along the Sheraton’s high walls. While the guard’s looping route takes you past manicured gardens, and the newly painted periphery of the Prime Minister’s residence, the kid’s route is quicker and dirtier. Tin-roofed, but long established huts are stacked tight, breaking only for steep, winding pathways and haphazard open drains. Thousands live in these simple homes and go about their business while tourists, businesspeople and aid workers swell the swimming pools beyond the fences and guards.

This stark divide was shocking to me five years ago as I walked the route as a first time visitor to the country, but the locals didn’t see what I did. Over time, I became aware of a diverse middle class of shop owners, taxi drivers, and civil servants who lived in the centre of Addis Ababa on mediocre earnings and gave the city a feel of openness and egalitarianism. They saw wealth but didn’t feel threatened by it and were able to live happy and full lives amidst the bustle of Addis Abba.

All across the country however, a new economic urgency seems to be taking hold. As quick as the capital’s concrete shopping centres continue to rise, so Ethiopians are asked to modernise, develop and participate in building the country anew. The government has led the way. Alongside Korean laid roads, Chinese foremen oversee the installation of fibre-optic cable, promising broadband internet access to newly connected populations. In the fields beyond, recently constructed tunnel tents house flower growing businesses born out of fresh international partnerships. More ambitiously, the government is building the largest hydro-electric dam in Africa and aims to be a net exporter of energy when it is complete. Even within the country’s notoriously bureaucratic ministries, the spirit of modernism is taking hold. The Ethiopian civil service has completed the largest implementation of Business Process Reengineering ever attempted, and now schools, council offices and hospitals all talk of processes rather than departments and customers rather than citizens.

There are many positives to this new spirit of progress and Ethiopia remains a country sorely in need of development. But despite the positive rhetoric of the Ministry of Information, something is not quite right.

What are we neglecting with the clinic-based model of health delivery?

By Julianne Weis

If you follow the world of global health policy, particularly the debates surrounding maternal health and the ever-looming race to meet Millennium Development Goal number 5, it is easy to assume that the reason there are such poor indicators for maternal health across lower-income countries is that women are simply refusing care out of ignorance, cultural bias, and economic restrictions. This story is sounded repeatedly in regards Ethiopia, where less than 10% of women deliver with a medical assistant at hand. But the onus to change such indicators is often placed fully on the women, and we need to give them vouchers, get rid of their domineering husbands, and even pay them to attend ante-natal clinics and labour wards.

In some instances each of these solutions can work. However, they are by no means as universal fixes, as some in the development community often assumed. Not only does this narrative take away the agency of women, it also neglects the other side of the equation – the nature of care provided. It ignores what should be a fundamental question: why don’t we ensure that maternal health services are actually appealing to pregnant women?

In many cases, even in Ethiopia, with over 80% of the population living in rural areas, it is not mere financial stress or lengthy distance from a health clinic that prohibits women from attending. The care provided in clinics and hospitals is often so far divorced from the type of aid that women want that there is no incentive to attend unless a dire health emergency occurs, and all other options have been exhausted.