Karen E. Flint
In December 2013, in Guinea near the borders of Sierra Leone and Liberia, a toddler became infected with and died from the Ebola virus. Within a matter of weeks the virus infected his family members and spread to his neighbors. As people died, distant relatives and friends who came to pay their respects became infected in turn. They sought treatment from healers and at medical facilities both near and far, and a disease that had historically been confined to rural tropical areas further south on the continent spread to the massive urban area of Monrovia, Liberia. From there it gained greater mobility and claimed more victims. A zoonotic disease – transmitted from animals (in this case fruit bats) to humans – Ebola’s main transmission was and is human‐to‐human contact. The disease is transmitted only from contact with a symptomatic person or infected corpse, though more recent evidence shows that male survivors may be able to pass on the disease through sexual transmission. By May 2015, when the disease had largely subsided, there had been some 27,000 confirmed and suspected cases and over 11,000 deaths, 507 of whom were health workers (WHO 2015). Ebola’s impact was far greater than the virus itself. Fear of the disease meant that people avoided clinics, while other clinics closed down out of fear or from the lack of health workers, and limited health resources were diverted to treating Ebola. As the UN Secretary General noted, “more people are dying in Liberia from treatable ailments and common medical conditions than from Ebola” (United Nations 2014). Only when white missionaries and doctors began seeking treatment in Europe and the United States did the rest of the world seemed to awake to the possibilities of a global pandemic and to mount a more vigorous global response.
The Ebola outbreak of 2014–2015 exposed what many Africans, medical anthropologists, and social medical historians already knew about the stark state of West Africa’s “public” health. Indeed, these scholars could have anticipated many of the challenges that would emerge in this latest Ebola crisis. The history of health, healing, and medicine in Africa is important for providing a context for current health‐care dilemmas. But it also complicates narratives that accept or expect Africa to be a place of disease, and contributes more broadly to African and medical history. Such histories show how indigenous medical cultures helped Africans to mediate and challenge ecological, political, and social change from the precolonial to the postcolonial period; how disease not only impacted morbidity and mortality rates but also shaped economies, societies, and cultures; and that medicine was an important site of encounter, contestation, and cultural exchange between Africans and between Africans and others. African and social historians of health and medicine helped challenged conventional notions that science and medicine are objective and universal. Instead, they situate medicine (generally biomedicine) in its context, showing how it not only reflects but also helps to shape its local environment. Africanists have demonstrated not only how biomedicine is practiced in Africa but also how Africans themselves have changed biomedicine globally. This chapter explores scholarship in this field from the 1970s to the present, and indicates how scholars may contribute to the relatively new fields of global health and historical epidemiology.
In 1974 David Patterson made a plea for a new type of medical history of Africa. Until this time, biomedical history in Africa had largely been described in heroic terms – with the likes of Albert Schweitzer and the defeat of pathogens in European laboratories. Visiting or settler medical practitioners, rather than historians, wrote about the impact of tropical diseases on European populations while largely ignoring or disparaging Africans and African medicine. Patterson (1974) urged historians to examine biomedicine’s impact on and reception by Africans. While African historians challenged the altruistic discourse of biomedicine in Africa, their attention remained largely biomedical in orientation. Some African scholars (primarily political economists of health) examined how social, political, and economic factors from slavery, colonialism, Cold War politics, the implementation of structural adjustment programs, globalization, and issues of corruption and graft changed and impacted African health. Others, largely anthropologists and social‐cultural historians, focused on understanding African medicine and African ways of knowing the body and illness. This divide between those who study biomedicine and diseases in Africa and those writing on African therapeutics has decreased as more recent literature focuses on medical pluralism (the encounter of two or more medical cultures). In some ways, histories of health and healing in Africa have mirrored global attitudes and interventions in Africa itself. During the 1970s and 1980s, when health campaigns aimed at boosting broad primary care intervention, historians and anthropologists sought broad explanations that explored how over time social, economic, and political institutions shaped the disease environment and contributed to the availability of health services and therapeutic choices. With the acceleration of the HIV/AIDs epidemic and neoliberal influences, international financial institutions demanded that African governments cut back on their public funding of primary health‐care initiatives. Philanthropic organizations like the Bill and Melinda Gates Foundation and the Carter Center stepped in to a certain extent, but in an effort to be more economical they focused on singular or vertical campaigns to eradicate diseases – targeting malaria, HIV/AIDs, tuberculosis, guinea worm, trachoma, and river blindness. Likewise, many scholars came to focus on the histories of specific diseases and practices, and the impact of these on African patients. It seems, however, that many scholars (like biomedical practitioners) deemed medical pluralism more of a nuisance than as something that could be harnessed and utilized for the benefit of local populations. While this chapter seems to organize authors into “camps” or “schools,” most historians utilize a variety of tools of analysis that defy easy classification. I have suggested a few loosely categorized “schools” while acknowledging overlaps and aberrations.
In the 1970s and 1980s, political economists of health greatly expanded how historians approached and understood malnutrition, disease, and mortality within the African context and how disease impacted economies and history. By contextualizing the etiology of disease within broader social, political, and economic spheres, scholars demonstrated how African health and demographics were often negatively impacted by trade, the imposition of colonial law, urban planning, and industrialization. John Ford (1971) demonstrated how European rule, far from being benevolent or benign, furthered the spread of sleeping sickness by destroying local ecological controls and by forcing Africans to move into tsetse‐fly‐infested regions. Hartwig and Patterson (1978) argue that Europeans (albeit inadvertently) made colonialism’s initial years (1890s–1930s) some of the deadliest. Disease vectors spread with the creation of roads, railroads, irrigation canals, migrant labor, and military recruitment. Similarly, Megan Vaughan (1987) demonstrated how colonialism’s social, political, and economic disruptions had real but unequal health consequences during the 1949 Malawi famine. In this case, migrant labor enabled many men to escape the ravishes of hunger while women and children left behind, with little access to the cash economy, bore the brunt of suffering. In South Africa, Randall Packard (1989) found that the mining industry’s economic priorities contributed to the rapid spread of tuberculosis in unventilated mines and, as they sent infected men home, in the countryside. Only when the industry had a hard time recruiting healthy workers did they investigate the possibility of changing practices and pursuing better health care and nutrition in the rural areas. Overall, political economists of health focused on larger capitalist forces, their ability to influence people’s access to clean water, and their overall health. This focus replaced earlier medical writings which either ignored African health or assumed that African illness and malnutrition stemmed from poor habits or failed adaptations to colonialism, or resulted from the malpractices of African “witch” doctors.
Despite this important corrective, political economists of health were critiqued for viewing Africans as inactive subjects at the mercy of larger structural forces. How did Africans respond and possibly resist biomedicine and the discourses that it created about Africa and Africans? How did Africans explain the increase in epidemics and epizootics that accompanied colonialism? How did these experiences change their own medical practices and beliefs? Biomedically oriented political economists of health tended to downplay or ignore African therapeutics let alone medical pluralism. But scholars also began to question how biomedicine itself was a product of culture and how the culture of imperialism and racism impacted and shaped knowledge of Africans and tropical diseases. The social history of medicine complicated the story and addressed many of these questions, but historians like Shula Marks (1997) and Lynn Schumaker (2011), reflecting on the trajectory of medical history in Africa, assert that the political economy of health was and is an important part of our understanding of health outcomes, and should not be left behind in the wake of social constructivism.
Much of the social history of health and medicine acknowledges the importance of larger structural causes of ill health, while also highlighting the role played by social determinants (such as status and relationships). They ask how culture and society shaped understandings of the body, illness, and health. The social‐cultural history of medicine did not only offer a critique of the dominant classes but also sought to explain how medicine was used to shape wider social and cultural ideas that supported the ruling classes’ interests. The idea that medicine is a social‐cultural institution emerged from anthropologists’ study of non‐biomedical medical cultures like African therapeutics, also referred to as folk, indigenous, vernacular, ethno, popular, or local medicines. Early British structural functionalists of the 1930s – like Evans‐Pritchard (1937) and Krige (1947) – initially cast African therapeutics under the rubrics of magic, witchcraft, and religion. In what seemed radical for the time, they sought to prove the rationality and function of Africans’ medical beliefs and practices. Yet, in their search for authenticity and “tradition,” they tended to render them as ahistorical. Later social historians and medical anthropologists firmly connected these practices to African ideas of health and healing, highlighting their fluidity and dynamism in the face of white rule, medical pluralism, and globalization. Medical anthropology and social history sought to understand how healers healed social relations, and how “tradition” changed but was sometimes manufactured and shaped by unexpected forces and participants. Social constructivists investigated how, when, and where traditions and medical cultures (be they African therapeutics or biomedicine) changed over time and were constructed by African and non‐African populations.
African therapeutics long remained the domain of anthropologists who very much influenced later historians writing about African healing cultures. Initially, scholars sought to reconstruct past African beliefs and medical practices with the aim of demonstrating the logic and viability of African public health, particularly as it mirrored biomedicine (Maier 1979; Pankhurst 1990; Waite 1992a). Scholars like Steve Feierman (1979) and Gloria Waite helped to reframe and expand notions of what constituted African medicine or therapeutics. Africans rooted ideas of health and wellness within the body and the physical and social environment which included territorial spirits and ancestors. Waite argued that African “public health” should include “rainmaking, identification of sorcerers, and control of infectious diseases, as well as public sanitation works and health education” (Waite 1992b: 213). Feierman (1995) urged the integration of healers and therapeutics into a broader history that connected African experiences of disease and epizootics with political conquest and anticolonial movements. Healer‐led revolts – from Nyabingi of Rwanda, Maji Maji of Tanganika, Nehanda and Kaguvi of Rhodesia, to Makanna and Mlenjeni of the Cape Colony – should be interpreted as the intertwining of healing, politics, and public health.
More recent scholarship has investigated the political and social role of healers in the precolonial period. Such studies certainly show why early colonists approached healers warily, but also why African rulers both lauded and feared them. As powerful individuals, healers could lend legitimacy to rulers but also critique and challenge them. Healers performed functions of public health, and grounded people in a sense of purpose or “tradition” that enabled them to adapt to new economies and environments. My own work shows the role healers and medicine played in the foundational stories of the Zulu Kingdom and how kings and chiefs used them to provide public health, adjudicate crimes such as witchcraft and theft, mediate succession disputes, and buttress their political power (Flint 2008). James Sweet (2013) tells a story of Alvarez, a Benin healer sold into captivity and taken to Brazil, where he helped other African captives adapt to their new environment at the same time as he also challenged Portuguese rule. Sweet speculates that this healer initially threatened the political stature of the Dahomey king, prompting his sale. Kodesh (2010) shows how Bugandan healers helped local populations transition to permanent settlement necessitated by intensive banana farming. By unmooring territorial spirits and making them portable, healers enabled settlement that legitimated clan membership and connected them to the larger Bugandan empire. Given the links between witchcraft, medicine, and power from the precolonial to the present era, it is not surprising that many Africans used the language of sorcery to describe those who had political and economic power. (Shaw 1997; West 2005). Such connections influenced how European settlers and governments approached the issue of witchcraft and healers, whom they called witch doctors. Not only did healers lead anticolonial movements but their very existence confirmed an alternative and viable way of understanding the world. They administered justice and empowered the very structures and governments that Europeans hoped to weaken.
African historians have examined the various ways in which biomedicine contributed both intentionally and inadvertently to colonialism. Biomedicine aided colonial expansion in Africa by enabling European bodies to better survive the tropics, by giving colonists social controls to punish the colonized and to control labor, by creating a healthier and more “efficient” workforce, and by creating new medical knowledge that legitimized and promoted racialized ideas about health, disease, and bodies. Some of these ideas were then used to legally and morally enforce public health measures that sanctioned segregation. This enabled colonists to blame Africans for (and thus ignore) poor sanitary conditions, undernourishment, and the overwork that led to sickness and death.
Daniel Headrick’s (1981) Tools of Empire placed medicine firmly in the imperial arsenal alongside other technological advancements such as steamboats, armaments, and the telegraph. The disease environment of Africa had proven deadly to traders, missionaries, explorers, and colonists, and quinine seemed pivotal in allowing European penetration of the continent. This Andean bark thus enabled colonialism by healing the bodies of invading colonists, while European colonialism in India and Indonesia enabled its mass production and wide distribution. Later historians contested the direct connection between quinine and colonialism, though not the wider argument regarding the role of medicine. Frantz Fanon (1967), a St. Martinique psychologist, understood medicine as a “tool of empire” early on when he wrote about the explicit ways in which the French employed medicine during the Algerian War of Independence. He witnessed how biomedical doctors used “truth serums” on Algerian captives, and were expected to repair bodies broken by torture and the minds of the torturers so that they could continue. The French banned the treatment and selling of biomedical substances to the enemy, thus inflicting painful and preventable death by sepsis and tetanus. Other scholars examined how biomedicine advanced and secured colonial power in less explicit ways.
Historians identified “tropical” medicine as a tool of empire in its initial enclavist approach, meaning that its primary concern was for the health of European administrators, troops, and traders (Farley 1991). The field of tropical medicine, developed during the late 1890s, identified the parasite‐vector mechanism and sought to limit disease transmission through environmental controls. Advantages gained from tropical medicine remained underutilized in the African population until after 1920, when Europeans, alarmed by African ill health, implemented more widespread public health measures. This belated public health effort was then evidenced as colonialism’s supposed civilizing mission, which Patrick Manson, founder of the London School of Tropical Medicine speculated, “will conciliate and foster the native” (1900: 192). Medicine and healing, as early missionaries discovered, could open a dialogue with Africans who otherwise remained uninterested (Landau 1996; Cooper 2006; Shankar 2014). Tropical medicine emphasized and reinforced notions of the tropics as dangerous places of disease where radical measures might be necessary for health intervention.
Historians argued that public health became a powerful tool used by colonists to assert social control and enforce segregation in the urban areas. European ideas of health and disease, and what constituted effective public health measures, let alone proper medicine, evolved during the colonial period. Initially, colonists and biomedical practitioners blamed illness on the climate and the local environment. These ideas, coupled with miasmatic theory, an earlier idea that disease was carried and caused by “bad air,” led Europeans to seek local cures and to prefer architectural styles that emphasized ventilation (i.e., elevated houses and large unscreened windows). As ideas about germ theory and connections between parasites and disease emerged with tropical medicine, Europeans regarded Africans as a source of contagion and as carriers of disease. Public health measures enabled colonists to move Africans into urban segregated locations or settlement camps. Maynard Swanson (1977, 1983) coined the term “sanitation syndrome” to refer to the white fear that associated Africans with squalor, disease, and crime and the medical rationalization used to legally segregate whites from Africans and Asians and to restrict them from the more desired and commercial areas of southern African cities. Sanitary segregation later led to racial segregation based on other, nonmedical, grounds and helped the dominant classes to erect a social order that promoted their own interests. Maynard Swanson pointed out that the heightened anxiety of epidemics allowed more radical and coercive measures to take place in the name of public health. Fellow historians proved this connection between epidemics and social change during other episodes involving yellow fever, cholera, sleeping sickness, and bubonic plague in both French and British African colonies (Curtin 1985; Lyons 1992; Ngalamulume 2004; Echenberg 2002, 2011). Swanson’s analysis of the discourse that accompanied epidemics also foreshadowed the social constructivists who came along in the 1990s and later.
Megan Vaughan’s Curing Their Ills (1991) highlights the rise of multiple and sometimes competing colonial discourses that used the language of science to socially construct Africans as the other. The production of such discourses parlayed social ideas about Africans that were already prevalent in European culture into “scientific knowledge,” hence lending legitimacy to colonialism on a number of levels. Vaughan shows how such discourses changed over time and differed depending on the context and between missionaries and different types of biomedical practitioners. The discipline of psychology, for instance, was used as a rational for locking up individuals deemed insane or (occasionally) Africans leading anticolonial movements, but it was also used to pathologize African culture at large. Thus anticolonial movements such as those in Madagascar in 1947 and the Mau Mau revolt in the 1950s were blamed on “deculturation” and a collective psychological instability (Vaughan 1991; Mahone 2006). The discipline also fluctuated between physical and cultural explanations of how the “African mind” was different from the “European mind” (Carothers 1953). For the most part, however, European discourse on race came to favor cultural explanations. Diana Wylie (2001), for instance, shows how white South African officials and scientists blamed African hunger and malnutrition on an African culture that was more obsessed with cattle as property rather than as food. Such discourses, combined with concerns about creating dependency and discouraging employment, seemed to justify state inaction during periods of acute hunger. Other social constructivists (Butchart 1998; Jochelson 2001), influenced by Michel Foucault and Antonio Gramsci, examined the construction of disease and medical discourse and how Europeans described African bodies and knowledge, often using them as a foil to build notions of European middle‐class respectability.
Many of these social historians painted biomedicine and its practitioners and interventions as largely negative and complicit in colonialism. Scholars then begun to ask if this was always true, whether social control were not the goal but perhaps an unintended consequence? Was biomedicine always damaging to the African population, or did it have a positive impact on African health? What of Africans who trained and served as biomedical practitioners? Were they always working at the behest of colonialism? And what about European or colonial scientists: were they a monolithic group? Did some challenge colonial rule? How might Africans have contributed to discourses on scientific racism or to scientific knowledge itself? Could one really generalize so broadly about biomedicine and the colonial experience?
Scholars have shown that, while some colonists may have manipulated medicine for social control, others seemed to genuinely care (Bell 1999; Thomas 2003). Though most benefits to African health did not occur until after the 1920s, Ngalamulume (2004) points out that some public health interventions meant to protect European settlers in the late nineteenth century, which were based on inaccurate scientific information, in fact led to improved sanitation for all residents of St. Louis, Senegal. Other research shows that, while early vaccination campaigns were notoriously unreliable given early serum’s susceptibility to the heat, technological improvements and better outcomes convinced many Africans to try them. The same is true of smallpox vaccines; colonists did not eradicate smallpox, but they did control and limit its spread. They also created surveillance and ring vaccination methods that were later used by the World Health Organization (WHO) to eradicate the disease (Schneider 2013). African biomedical practitioners also played an important role in delivering biomedicine and gaining greater compliance (Marks 1994; Iliffe 1998; Hunt 1999; Digby and Sweet 2002).
Early on a number of scholars challenged the binaries that set colonial medicine in opposition to traditional medicine, particularly those examining medical pluralism. More recently, Helen Tilley (2011) has shown the various ways in which colonial scientists working on issues of health, the environment, and nutrition both dissented from and challenged the foundation of colonial rule and racial science. Like Vaughan, she shows that scientists did not homogenize Africa, but saw it as a complex organism that needed to be studied on a case‐by‐case basis. Indeed, some of these scientists came to appreciate, adopt, and advocate indigenous practices and knowledges. Medical pluralism, particularly as viewed from an African perspective, provides a better approach for understanding African therapeutic and biomedical interaction.
Medical pluralism recognizes the coexistence of two or more medical cultures and that different communities have varying ways of understanding the body and disease and thus different approaches to health and healing. Its study is not necessarily new, though it initially focused only on interactions of biomedical and vernacular medicine in colonial times despite Africans historically utilizing various therapeutic options within and between African cultures. Scholars of medical pluralism focused on four main areas. (1) Anthropologists sought to understand how patients and their families made therapeutic decisions in a medically plural society. (2) Scholars sought to understand Africans’ various responses to biomedicine from widespread acceptance of certain types of medical practices such as anti‐yaws shots to resistance to amputation, quarantines, and hospitalization. (3) Scholars questioned the premise of bounded medical “systems,” and asked what makes something a part of one medical culture and not another. (4) Recognizing that such boundaries were porous, scholars asked how and what type of cultural exchange and influence may have occurred between communities.
Realizing that two‐thirds of the world’s population received their health care from “traditional” healers and medicine, a World Health Organization report called for the promotion and development of “traditional” medicine and its integration with “modern” medicine for primary care delivery (WHO 1978). This reflected changes in India and China where primary care had already incorporated local medicines, and the experiences of WHO leaders like the Nigerian psychologist Dr. T. A. Lambo, who also sought to integrate traditional practitioners into his own treatments. The main challenge to integration, both today and then, was convincing biomedical practitioners of the value of traditional therapies. Anthropologists took up this effort in a number of different ways. John Janzen (1978), seeking to understand how medical decisions were made in a plural therapeutic society, found that such decisions rested less on the patient and doctor than on the “therapeutic management group,” that is, on one’s kinship network. A person’s tendency for illness and recovery often reflected the status of his or her therapeutic management group, with widows and divorced women faring the worst. He also showed that an individual’s inclusion in a certain medical culture did not preclude cross‐referrals and consultations between medical “traditions,” even within a single case of illness. This showed that Africans deemed varying therapies to be compatible, and consulted another medical practitioner on the basis of new symptoms or the failure of past therapies (Janzen 1987; Jacobson‐Widding and Westerlund 1989). Increasingly, scholars have focused on the importance of case studies for understanding illness and treatment at the patient level (Prins 1989; Silla 1998; Fassin 2007; Livingston 2005, 2012). This highlights not only obstacles to treatment, but also the complicated decision making that takes place, and the fact that many Africans utilize more than one medical culture simultaneously. This problematizes universal health solutions or technological fixes floated by nongovernmental organizations (NGOs) and governments which assume a medical table rasa. During the recent Ebola outbreak people made therapeutic decisions as usual, utilizing a variety of different therapeutic options and changing their behavior as the disease and epidemic progressed. Likewise, the spread of Ebola slowed down with the greater involvement of local community leaders, reconsideration of local cultures and histories, and citizen involvement.
Historically, African reaction to the introduction of biomedicine depended on how it was offered and by whom, on its perceived effectiveness and similarity to local therapies, and on the perceived origin of the disease. For example, many Africans assumed that white doctors should treat a “white” disease like syphilis. At other times biomedical use was related to the charisma of the biomedical doctor or to his or her conformity to local ideas about strong medicine. In Natal, South Africa, one doctor gained greater compliance by preparing a liquid form of “blue” quinine. The liquid form and the terrible taste, combined with it turning the urine blue, convinced Africans to purchase this medicine rather than take the free government tablets (Flint 2008). Dawson (1987) shows that in the 1920s anti‐yaws injections became popular because they worked rapidly – clearing up painful skin lesions within days, so much so that when a more effective liquid remedy became available Africans refused to drink it. Nancy Rose Hunt (1999) investigates the medicalization of childbirth in the Belgian Congo which saw biomedically supervised births rise from 1 percent in 1935 to 43 percent in 1958. African biomedical practitioners (doctors, medical aids, nurses, and “dressers”) acted as cultural brokers to champion, negotiate, interpret, and challenge biomedicine, eventually increasing African acceptance and compliance with biomedical treatment. The voluntary adoption or use of some biomedical practices reflects both the openness of African therapeutics and specific circumstances rather than what colonial officials hoped was an African recognition of biomedicine’s superiority.
At the same time, many Africans remained skeptical of biomedicine, in part because of biomedical failures and forced compliance. Thus when early vaccines initially failed and led people to contract the very ailment they were meant to prevent, Africans wondered if in fact they had not been injected with the disease. Africans saw biomedicine used as a tool of empire (as described by Fanon or Swanson), and wondered why Europeans criminalized vernacular healers and medical practices as illnesses proliferated. Luise White (2000) suggests that colonial era African rumors about blood‐sucking whites who violently attacked and/or killed Africans and drained their blood emerged as a response to an alien medical system that employed blood transfusions and used chloroform in childbirth. In essence, rumors and fantastic stories may not be real but they reflect back real social, political, and economic concerns. This can be seen in the West African rumors that Ebola was really a conspiracy to conceal the nefarious activities of northern and West African governments (Epstein 2014). Skepticism about Ebola’s existence in this area was the result of a history of colonial biomedicine that had coercively enforced attendance at sleeping sickness treatment centers and, more recently, by hostility to and the failures of national governments and their inability to meet community needs (Bannister‐Tyrrell et al. 2015).
Scholars of medical pluralism show not only that patients chose different types of medical therapies and healers, but that practitioners themselves borrowed terms, practices, and the materia medica of other cultures. Despite acknowledging a plurality of medical cultures, Ernst (2002) argues that scholars tended to contrast “traditional” medicine to “modern” biomedicine, and that discussions of “hybridity” tend to assume stable entities. She and others emphasize that medical cultures or boundaries are never stable but instead are constantly in flux. This raises a number of questions about the porousness of medical cultures, where one medical culture ends and another begins, whether and why borders exist, and who polices them. In some cases, biomedicine and colonial law determine borders; in others it is patients and healers (Buchhausen and Roelcke 2002; Flint 2008). Luedke and West (2006) show how healers evoked borders and border crossings to reference power and to cultivate confidence in their clients.
Mirroring a wider historiography that examined how non‐Europeans participated in cross‐cultural appropriations and borrowings, scholars looked for African agency within medical exchange. Roberts (2011) shows that West Africans, for instance, embraced a number of tropical medicinal plants from Asia and the Americas, but never showed an interest in cinchona, the tree used to make quinine. Osseo‐Asare (2014) examines the adoption of a number of African plants by various global communities that date back to the medieval period. In some ways, medicine has been like food, a commodity that has been tested, rejected or traded, and innovated upon by outsiders. Sometimes populations copy the original use; at other times they are worked seamlessly into local flavors and cuisines. Yet, as Osseo‐Asare shows, determining the “origins” of herbal medicines has taken on new and important weight in an age of international patents and demands for benefit sharing. Attributing herbal medicinal use to a particular community, however, is complicated if not somewhat specious. Besides the obvious “evidentiary” disadvantage of many African communities, Osseo‐Asare’s work shows that African medicinal plants moved, often simultaneously, among different peoples and in multiple places, challenging the idea that “indigenous” knowledge is in fact local. For instance, she shows that periwinkle, a common weed in Madagascar, has pan‐tropical distribution from Jamaica to the Philippines, while pennywort, also from Madagascar, can be found in Ayurvedic medicines. Sometimes these herbal medicines find similar use globally, as in the case of periwinkle as a folk remedy for diabetes, or completely different uses, as with grains of paradise, which is used differently in places as close as Ghana and Nigeria and between men and women. She also counters the idea that scientific bioprospecting was and is the domain of the Global North, and shows how independent African governments and postcolonial African scientists tested and innovated upon herbal remedies to be marketed globally. Finally Heaton (2013) shows how African psychiatrists influenced the practices of global psychology by introducing the notion of transcultural counseling. T. A. Lambo and other Nigerian psychiatrists sought to categorize mental illnesses as universal and physical, not racial or cultural, and also to recognize the importance of culture in the manifestation of symptoms and for delivering effective care.
Governments or NGOs may not recognize the variety of African medical cultures and beliefs that are practiced alongside biomedicine, but Ebola has shown again that medical pluralism was and is a reality for most Africans. This plurality of medical experiences includes varying degrees of access to formal and informal biomedical centers, practitioners, and merchants, as well as to religious and indigenous healers. There are mission centers like the ELWA Hospital in Monrovia, Liberia, which buy their medicines in the Netherlands and use foreign doctors and staff in their hospital alongside local persons and nurses (who may then run informal clinics out of their homes). Yet, Liberians who seek biomedical drugs on the informal market or even from pharmacies must contend with often unreliable and ineffective pharmaceuticals that are past their due date, counterfeited, or contaminated. Likewise, government clinics are often ill equipped and understaffed. And then there are African healers – religious, herbal, and/or spiritual intermediators who have long tended to the health and well‐being of the African population. These last groups are not always benign or helpful, or for that matter less expensive, though they may offer services on credit. Still, they tend to be more accessible, culturally appropriate, and trusted and may have access to herbal remedies. Biomedical approaches are also not infallible; some seem to work better than others for certain ailments. In the case of Ebola a biomedical protocol was essential to stop the spread of the disease and, given the state of “public” health in the region, global interventions were clearly necessary. Yet there is also a clear need to link the global with the local, to find ways to elicit local input, cooperation, and participation and to both recognize and better empower cultural intermediaries and those with cultural capital who can help mediate various medical practices and ways of knowing. The Ebola epidemic demonstrated how such intermediaries were initially missing from government and NGO plans, and how their inclusion helped contribute to the end of the outbreak (Onishi 2015). Future historians will surely examine the successes and failures of the 2014–2015 Ebola crisis in the hope that the world can prevent or at least better control future zoonotic epidemics.
Students and historians wishing to reconstruct histories of biomedicine, medical pluralism, or vernacular therapeutics in Africa will find a variety of types of available sources – from material culture and historical linguistics to oral and written sources of biomedical personnel, missionaries, travelers, anthropologists, colonial officials, and Africans themselves. Finding historical information about biomedicine often proves easier than unearthing the specifics of African therapeutics, which usually appear (with some exceptions) as anecdotal and accompanied by a disparaging tone and terms like “witchcraft,” “witch doctors,” or “superstition.” More recently, historians have made use of oral histories to learn about biomedicine and vernacular medicines, and have interviewed medical practitioners – biomedical and “traditional” – as well as patients themselves about their encounters (Flint 2008; Livingston 2012; Osseo‐Asare 2014; Patterson 2015).
Reconstructing precolonial medical history in Africa has its own challenges. Utilizing historical linguistics and archaeology requires special skills, but consulting historical dictionaries and making use of archaeological findings can prove fruitful. Oral traditions, often fantastical, are critiqued for telling us more about the period of record than the period under study and must be used with care. Ethiopians, Nubians, Egyptians, and some Islamic communities in North, West, and East Africa left written documents that describe health and medicine prior to European contact. Much written information regarding African health and healing, however, comes from outsiders, predominantly Muslim traders and, in the later period, European traders who interacted with Africans along the coasts from the 1450s onward. Oral traditions from the ancient kingdom of Mali tell of the important role that kings and blacksmiths played in public health (Maier 1979), while historical linguistics reveals common medical traditions like the poison ordeal in southern and central Africa (Waite 1992a). Archaeology dates medical paraphernalia such as medicine containers, cupping horns, surgical tools, enemas, and snuff spoons, and African artworks sometimes depict the use of such paraphernalia and medicinal plants as well as various medical conditions and diseases. Skeletal remains can give us insights into Africans’ nutritional levels and to their various surgeries or bone settings. James Sweet also has shown how information on health and healing in precolonial Africa can be gleaned from diasporic sources.
For the colonial and postcolonial period, one can access a number of different types of sources, which are often easier to cross‐reference. Colonial governments collected a variety of information on biomedical practices and African responses to those practices, as well as the local disease environment. Prior to World War I, colonial medical services sought primarily to control epidemics, and thus African medical records tend to concentrate on cities, plantations, and mining communities. The extension of a health infrastructure and medical research centers increased the availability of morbidity and mortality statics. These came from government health departments, institutions, organizations, bureaus, and sometimes government commissions and surveys. Thus the African Research Survey, commissioned in 1929 to discover how “modern” scientific knowledge had been applied to problems in British Africa, also details African therapeutics and agricultural and nutritional practices. Furthermore because colonial states viewed witchcraft as disruptive to the social and political order, they also documented criminal cases regarding healers and witchcraft; these sources can be found within magisterial and court documents and commissions.
Biomedical practitioners and researchers also left a slew of records in scientific and medical journals, reports of the day, and institutes such as London and Liverpool’s School of Tropical Medicine, the Pasteur Institutes of Paris and Lille, and Robert Koch’s Institute for Infectious Diseases in Berlin. Such sources do not require special skills to read. They often include “scientific” and medical ideas as well as qualitative information regarding the various ways in which Africans responded to biomedical interventions and the scientific and medical cultural and racial biases of biomedicine. In South Africa, some heads of traditional healing associations also read the South African medical journals and wrote letters to the editor. Fortunately many of these published sources have now been digitized and others are available via microfilm. Private archives relating to tropical medicine, such as those of the Wellcome Institute or the School of Tropical Medicine in London have collections of books, journals, and manuscripts concerning issues of health in Britain and its empire. Other records can be found in private collections.
Missionary records enable historians a glimpse of the types of biomedical services missionaries offered, how Africans reacted to missionaries and their medicines, and African belief systems and therapeutic practices. Missionaries observed both African medical practitioners and practices keenly as they sought to understand the inner workings of African culture. Such records can be found as published memoirs or in private institutions and libraries. For instance, the American Board of Missionaries papers held at Harvard University are on microfilm, while a missionary society like SIM in Fort Mill, South Carolina, houses the papers of a number of previous missionary societies, consolidated by SIM, dating back to the nineteenth century, including the Soudan Interior Mission which began work in West Africa in 1893 (Shankar 2014; Cooper 2006).
Anthropologists, initially hired by colonists in the 1930s, sought to understand the problem of witchcraft, and then became interested in understanding African notions of health, disease, and therapeutics. While such studies are mere snapshots of history and often reflect the biases of anthropologists of the time, an accumulation of such sources tends to offer insights into how African therapeutics have changed historically and have continued. Most of these studies are published, though sometimes it is worth consulting the original notes of such anthropologists. In my own work examining African–Indian relations in South Africa I found the notes of Helen Kuper’s assistant (housed at UCLA’s Special Collections) much more detailed and actually different from what Kuper published (Kuper 1960).
Finally, I recommend interviewing healers and patients or observing healing practices firsthand. While such observations and testimonies reflect the present, they also show continuities with the past. With my own research, I interviewed Indian healers who had been involved in “African” traditional medicine for several generations. I collected family and individual histories. I also talked with African healers formally and informally about “Indian” substances that they used, and asked several to prepare special “protective” medicines that I knew were culturally specific. I also spent time observing clients who came to Indian “chemist” shops to find out who they consulted and for what purpose. Given past anthropologists’ and colonial officials’ general lack of interest in Indian–African relations, this was one of the only means of collecting information about this kind of medical exchange and to discover that Indians had actively participated in and shaped South Africa’s traditional medical culture.
In addition to generating one’s own archives through interviews and observation, there are other private “archives” to discover. This requires footwork if not also a personal place to store newly discovered records. In one case I asked the Natal Pharmaceutical Society if I could come and look at some of their records. They had recently moved to a new building but managed to find some yellowed minutes of the society from 1908 to 1923 on the floor of a closet. Julie Parle (2007) relayed a similar story in which a query for sources addressed to a former psychiatric hospital turned up a single European Patient Case Book and Staff Punishments Record. The rest of the records had been burned or thrown out following a renovation. Why these particular records had been chosen to survive may just have been happenstance. But it also points to the problems of preservation. A case needs to be made for keeping such private and government records, for if historic materials are not deposited in archives they can easily be misplaced or destroyed. Finally, now that Google and Hathi Trust have begun to digitize historical books, the digitization of government blue books and commissions would open up research to students worldwide and at the same time preserve otherwise crumbling inventories.
The study of health and medicine is clearly a vibrant field with room for growth. Africanists are needed to contribute in particular to the budding field of global health. Emerging in the 2000s along with other globalization studies and initiatives, global health includes a mixture of public health, international health, and tropical medicine. Like the WHO, founded in 1946, the field of global health recognizes that health issues and diseases like Ebola can easily cross national boundaries, require global surveillance and intervention, and quickly outstrip the capacity of a state. Global health centers, programs, and initiatives, however, are based primarily in high‐income countries and respond to health challenges in mostly middle‐ to low‐income countries. Participants of the Global North seem motivated primarily by concerns for global security, medical humanitarianism, and the expansion of biomedical services and markets. Given global disparities, one might say that this makes sense and at times there is a need to invoke the resources of the world. Yet, as the Ebola outbreak makes clear, this movement could not fix the underlying structural issues of the epidemic – two of the three affected countries were still recovering from civil war – and a broken health‐care system lacked the laboratory, surveillance, and health‐care services necessary to diagnose, track, and treat the disease. Likewise, global health governance systems like the WHO did not coordinate transnational efforts until early July, three and a half months after the first confirmed case of Ebola. Furthermore local governments, international NGOs, and the WHO alienated populations by banning bush meat; blaming victims for contracting the disease through cultural ignorance; ignoring the cultural importance of burial practices; failing to provide food and the necessary supplies to treat victims; using coercion to enforce quarantines and reporting of cases; and insisting on a top‐down public health message that often ignored traditional authorities and healers. Such alienation provoked local resistance, made containment difficult, and delayed treatment – with deadly consequences (Wilkinson and Leach 2015).
While some contributing factors to Ebola’s spread were unique to the virus itself, many more reflect longstanding political and economic challenges, structural inequalities, and issues associated with medical pluralism. Medical anthropologists and historians can be particularly useful in reminding global health practitioners that universal or biomedical solutions cannot be applied without consideration for the sociocultural, political, economic, and historical context. During the Ebola epidemic, medical anthropologists practiced outbreak anthropology. Fairhead (2014) published an open source article on local burial practices that unwittingly spread the disease. He explained that the dead had to have a “good death” so they could continue as ancestors. Funerary rites required contact with highly contaminated bodies, including touching, washing, and oiling the bodies of the dead and also the travel and burial of “unmarried” women’s bodies at their maternal homes. Other anthropologists worked with Doctors Without Borders and WHO, while others intervened in an ad hoc manner. Historians wrote about the history of cordon sanitaires, which were tried in West Africa during the Ebola epidemic, to show where these worked or did not work and why. Certainly historians can learn from medical anthropologists in pursuing advocacy and public scholarship, and in making their work more accessible to practitioners of global health by writing blogs and articles for reputable media outlets and medical journals.
Likewise medical historians or historical epidemiologists could be useful to global health by examining the histories of past global health initiatives in Africa (Webb and Giles‐Vernick 2013). Historical epidemiologists can help current global health efforts by studying the conditions under which diseases tend to flourish and rebound. For instance, Packard (2007) shows how Swaziland, which was almost malaria free by the late 1950s, became reinfected as the sugar cane industry set up plantations in the Lowveld and attracted Mozambican labor, but then did not properly maintain irrigation canals or provide adequate housing, thus effectively reintroducing malaria to the area. Iliffe (2006) has similarly written a comprehensive and accessible history of the AIDS epidemic in Africa. Such studies, as James Webb (2013) points out, are useful but often depend on the study of epidemiology. Webb suggests that there needs to be greater training for historians and that they need to publish their work in medical journals. Either way, medical historians need to find a wider audience, one that reaches beyond historians, in order to influence biomedical practitioners who work within Africa and in global health and those who make health policy.