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Tamara Giles-Vernick and James L.A. Webb, Jr (eds), Global Health in Africa: Historical Perspectives on Disease Control ( Athens, OH: Ohio University Press, 2013), pp. v + 246, £21.99, paperback, ISBN: 978-0-8214-2068-3.
Melissa Graboyes, The Experiment Must Continue: Medical Research and Ethics in East Africa, 1940–2014 ( Athens, OH: Ohio University Press, 2015), pp. vii + 307, £23.99, paperback, ISBN: 9780821421734.
One of the great hopes of historical writing is that it may improve or enrich the lives of the living. The mundane experience of research can often seem detached from the actual business of healing and helping, yet we archive-dwellers do dream that our work will challenge even age-old inequalities and injustices. We stretch our arms out of the academy and expect, perhaps vainly, that we will make some kind of difference, to someone, somewhere. We tend not, however, to explicitly state our intentions, often assuming instead that our endeavour to study the past will itself create fresh worlds for today. By contrast, Graboyes in The Experiment Must Continue, and Giles-Vernick, Webb and the thirteen other scholars involved in producing Global Health in Africa, make exemplary, fascinating and even moving forays into a type of history writing which aims to address the present directly. The danger with this kind of work is that our analytical categories will follow present conceptions too closely and the very foreignness of past cultures will be lost. Instead of writing about contingencies, rejected visions, the losers of past contests and forgotten voices, we will emphasise only that which appears to bear directly on the present. We will fall headlong into what E. P. Thompson bitterly referred to as ‘the enormous condescension of posterity’, in which past actors are not allowed to speak for themselves.1 Periodisation – the very rudiment of historicity – will be replaced with grand continuous narratives that start with what matters today not with what mattered then. It is to their credit that in navigating such murky territory, Giles-Vernick, Webb and Graboyes tend not to lose their footing. Their reward is to produce histories which, on the whole, speak to contemporary concerns without, as Quentin Skinner put it, playing a ‘pack of tricks’ on the dead.2
Both books structure their histories creatively around how they link to the present, yet they lead to very different results. Giles-Vernick and Webb form their volume of essays around three parts: ‘Looking Back’, ‘The Past in the Present’ and ‘The Past in the Future’. Graboyes, by comparison, preludes her four main sections with a ‘Historical Narrative’ and a ‘Modern Narrative’. This is within an overall framework which follows a track through the medical research encounter, starting with the ‘The Experiment Begins’ and closing by exploring the ‘Exits and Longer-Term Obligations’ of medical experiments in East Africa. In doing so both texts straddle the late colonial and post-colonial divide, challenging this construction’s purchase on historical accounts by showing the continuities of colonial initiatives well beyond nationalist victory. On the other hand, the resulting analysis in each work is rather different. Graboyes’ themes work well in drawing out the ethical dilemmas at the heart of medical research encounters. This is partly because, by telling this history along a narrative which is very specific to medicine, the key features in the problems of unfolding encounters can be teased out. The chronology of structure and the diversity of subjects in Global Health in Africa, by contrast, lend themselves far better to the book’s more open approach, which encompasses a diverse range of histories of many forms of disease control.
By working thematically, Graboyes is able to draw out the strands of similar questions within medical research encounters from past into present. She links medical research occurring in colonial East Africa in the 1940s and 1950s, through residual hostilities, broken trust and changing individuals, to later medical programmes under the Wellcome Trust, East African medical ministries and East African–U.S. university collaborations. Her incisive ethnographic detail is twinned with historical narrative in ways that are often beautifully articulated. Furthermore, under her successive themes, Graboyes places historical accounts in conjunction with modern ones ensuring direct and fruitful comparisons. These are then unpacked and formed along with explorations of the overriding questions of responsibility, understanding and fairness in medical encounters. She shows how exchanges could be brokered or could fail completely under an array of complex factors in the relations between a variety of groups. Finally, her account challenges standard tropes about weak African communities, strong colonialism and the effectiveness of chiefly control, then steps into normative analysis, damning the ethics of some particularly bad forms of medical research.
The only issue with Graboyes’ themes is that they tend to lead to a slight underemphasis of causation and larger context. Why exactly encounters did or did not stay the same, is not fully related to world historical change. Graboyes does not overemphasise agency at the expense of structure; in fact, the dialectic between these two categories is another excellent element of her analysis. For example, her explorations of the jostling for power between colonial medical bureaucracy and its most maverick doctors is expertly connected to changing research relations with local communities. Moreover, the past speaks loudly in her work: Graboyes’s sophisticated understanding of Swahili translation allows her to unpick webs of linguistic confusion that are still relevant to ethical issues surrounding comprehension and consent in East Africa today. The only problem is that these are not always matched up to global trends or the changes in imperialism, national politics, religious beliefs or international conflict. In general, that which did not continue within medical research encounters tended to be sidelined in the analysis. Perhaps to explore how her local and regional studies relate to global and national shifts would have been a productive direction to follow.
Giles-Vernick and Webb structure their book chronologically, linking past and present in ways that are more sensitive to large-scale historical change. Unlike Graboyes’s text, the chief strength of Global Health in Africa is that it is able to range across very different countries and issues, whilst maintaining a focus on a particular aspect of global politics. The result is that the book provides newcomers to the subject with an expansive demonstration of the tremendous feats of scholarly activity going on in the discipline. There are too many topics to cover in this space, but it should suffice to say that there was no essay in this volume which did not draw something original and interesting out of its subject. Given that part of this book’s aim was to appeal to those outside the social sciences, it is an important success to cover such a wide sweep of histories so effectively.
The limitation with Global Health in Africa is that questions which surround the analytical categories through which we understand historical change are not much debated. It is left to the individual article author to ensure that past and present are linked well, and explicit dialogue between the sections is sometimes lacking. In William Schneider’s essay, which argues that colonial smallpox efforts made possible the more famous WHO and CDC campaigns after the Second World War, past and present connections are worked out brilliantly. However, the book itself provides few links between Schneider’s piece and later chapters. In fact, there is only a single instance in which (besides the opening piece) one of the individual articles explicitly refers to any of the others. With an increasingly narrow analytical perspective lenses, the reader is led from colonial history to more present-focused accounts over the course of the book, but the dots remain unjoined. The introduction gives an absolutely wonderful account of how global health in Africa has emerged over the century and its continuities, but there is little in the way of cohesion provided for the articles which follow. This does not detract from the extremely high quality of the articles themselves, but it means that the bigger themes which emerge from the book, such as the use of the generalising term ‘Africa’ in global health policies, are not fully explored.
Nevertheless, in both books the value of historical methods and practices for present concerns is very clearly demonstrated. In Webb’s chapter on malaria control in mid-century Liberia, he combines analysis of WHO reports and Liberia national archive material to show how difficult such campaigns could be (especially in migration contexts) and how local acquired immunities could be seriously harmed when health workers have to retreat. The result is a history which is vitally important for understanding recent ‘malaria “elimination” campaigns’ because both ‘rely on two of the same approaches…synthetic insecticides…[and] chemical therapy’. Webb shows convincingly that if the money and the desire to donate backing twenty-first century initiatives dry up, as they did in the 1960s, rebound malaria of epidemic proportions could result. In Anne Marie Moulin’s chapter on iatrogenesis and hepatitis C in Egypt she combines the sort of textual analysis in Webb’s article with oral historical tools (such as memory analysis and interviews) to brilliant effect. For example, by examining the ‘living archives’ of those who recall the mass schistosomiasis treatment and by showing how the campaign led to an epidemic of hepatitis C, Moulin explains clearly why government–patient trust has been severely compromised in Egypt today. Similarly, in The Experiment Must Continue, Graboyes shows how layer upon layer of confusion, deceit, mismanagement and disappointed expectations over long periods of time have led to current configurations where monetary payment is necessary to ensure fixed benefit for the participants in medical experiments. She argues that financial incentives are actually entirely fair and that researchers’ concern itself shows that when historical contexts and social memories continue to be ignored, experiments will continue to cause hostility and mistrust on both sides.
In an academic climate where proof of ‘public engagement’ is becoming central to funding decisions, where our budgets are squeezed to conform to changes outside the academy, and where eighty-two per cent of humanities researchers have performed at least one form of public engagement in the last twelve months, Global Health in Africa and The Experiment Must Continue show how to do present-focused history well. In the final article of Global Health in Africa a classic example of history as a critique of present policy is demonstrated. The article complains that top-down legal attempts to control drug use in Africa by U.S. governments have repeatedly failed, whereas more context-sensitive approaches which empower communities to tackle the problem themselves could improve the situation. It is often assumed that this – preaching the danger of repeating past mistakes – is the only way that historians can speak to the present. Yet what the two books as a whole show is that there is a wide variety of analytical perspectives which can be incredibly important to re-thinking present norms and expectations, and that the biomedical cultures and research encounters which inform health practices in Africa are the product of past relations. As Graboyes shows throughout her work, such lessons should also remind us to continue questioning our own ethical assumptions as historians. That thirty-six per cent of humanities researchers believe that they have a ‘moral duty’ to engage with the public is not as new as it sometimes appears. It too is the bound up with past failures and triumphs of forgotten theologies and seemingly discarded beliefs about scholarly virtue. To pursue this moral ‘responsibility’ we will have to interrogate again our own institutional and cultural pasts, find what we have lost and be more aware of who we are now.3 The result will not only be better history but, I hope, better public engagement and better health care.
1.Thompson E. P., The Making of the English Working Class (New York: Pantheon Books, 1964), 12.
2.Skinner Q., ‘Meaning and Understanding in the History of Ideas’, History and Theory, 8, 1 (1969), 14.
3.TNS-BMRB & PSI Factors Affecting Public Engagement By Researchers: A study on behalf of a Consortium of UK public research funders. Wellcome Trust; 2015 www.wellcome.ac.uk/PERSurvey.