Volume II, Issue II, Fall 2009

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Undergraduate Research Applied to International DevelopmentArticulAte

Volume II Issue II Fall 2009

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ar•ti•cu•late / -v., (of an idea or feeling) to express or state clearly.

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ar•ti•cu•late / -v., (of an idea or feeling) to express or state clearly.

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editor-in-chiefJonars Spielberg

Michigan State [email protected]

designer

Brandon BourdganisMichigan State University

[email protected]

editoriAl BoArd

Peer reviewers

fAculty Advisors

Articulate: Undergraduate Research Applied to International Development is an undergraduate scholarly journal that publishes academic papers and writings online and in-print on issues concerning international

development and health care in Africa.

Articulate is a sub-division and publication of the non-profit SCOUT BANANA, which seeks to educate, motivate, and activate the

public about the health care crisis in Africa. This journal will act as a forum for students to contribute to, as well as make, the debates in international development. We believe undergraduate students are a vital, untapped force to bring fresh ideas, perspectives, and concepts

into the development dialogue. Our goal is to spark, share, and spread knowledge for the sake of innovative change now.

SCOUT BANANA Mission: To combine efforts to save lives. We seek to build a domestic and international movement dedicated

to fundamental social change in which global health is everyone’s responsibility and every individual’s human right.

Articulate operates under a Creative Commons (CC) “Attribution – Noncommercial – No derivative” license. Anyone is free to make use

of all materials found in this issue, as long as such use complies with the terms of the license. More detailed information can be found at

http://creativecommons.org/licenses/by-nc-nd/3.0/.

educAte motivAte ActivAte

iiissn 1943-6742

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editor-in-chiefJonars Spielberg

Michigan State [email protected]

designer

Brandon BourdganisMichigan State University

[email protected]

Cory ConnollyMichigan State University

John Metzler, Outreach DirectorMichigan State University

[email protected]

Stacie DodgsonMichigan State University

Mary Anne Walker, DirectorMichigan State University

[email protected]

Alejandro Lara-BrisenoUC-Berkeley

Alexandra GhalyMichigan State University

Bethany YoungUC-Berkeley

Sophia MosherMichigan State University

Emily LawlerMichigan State University

Nada ZhodyMichigan State University

editoriAl BoArd

Peer reviewers

fAculty Advisors

Undergraduate Research Applied to International DevelopmentArticulAte

The opinions expressed within this journal are exlusively those of the individual authors and do not represent the views of the editorial board, SCOUT BANANA, or any of the organization’s chapters, advisors, or affiliates.

Current and past issues of Articulate can be accessed at http://scoutbanana.org/articulate.

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Letter From the EditorDear Readers,

With generous support from the Michigan State University African Studies Center, James Madison College, editors, and peer reviewers, it gives me great pleasure to offer you this second issue of the second volume of Articulate: Undergraduate Research Applied to International Development.

The world is in the midst of monumental change. America inaugurated its first African-American president, the European Union ratified the Lisbon Treaty and selected its first permanent president, and Iranian citizens challenged the outcome of their presidential election, demonstrating in the streets and calling for full-fledged democracy. All of these events were deemed dubious at best, and impossible by many. That they did happen challenges our conception of what is possible. Similarly, the articles in this issue challenge us to see old problems in new and different ways, giving us license us to expand the borders of what is “realistic” or “feasible.”

Dara Carroll examines the challenging task of treating mental illness in Uganda, and urges health care providers and informal caretakers to provide more supportive social environments. Brian Beachler evaluates the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and the United States President’s Emergency Plan for AIDS Relief (PEPFAR), using the key concern of equity as his reference point for comparison. Geoffrey Levin lays bare the consequences of cumbersome intellectual property rights, as enshrined in the Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement, to critical health needs in Africa. Pedro Marcelino describes the current renegotiation and evolution of identity in Cape Verde, a dynamic process informed by post-colonialism, geography, immigration, and globalization.

This issue also includes two personal essays. Sarah Lynn-Andrews Losinski relates an intensely personal, enlightening, and perhaps sobering account of her five-month stay in Durban, South Africa that captures the bewildering experience of working abroad. The issue ends with an essay by Gracie Vivian, who takes an incisive, inquisitive look into her work as a medical volunteer and the work of the entire development industry.

During his inaugural visit to Africa as president, Barack Obama delivered a speech to the Ghanaian Parliament on July 11, 2009. In his speech – which covered issues of democracy, opportunity, health, and conflict resolution – he appealed to a sense of mutual responsibility and respect, and directed his comments specifically to young people. “I see Africa as a fundamental part of our interconnected world, as partners with America on behalf of the future we want for all of our children…It will be the young people brimming with talent and energy and hope who can claim the future that so many in previous generations never realized.” The authors in this issue are exemplary examples of such young people who are claiming that future with a sense of purpose. They realize that the twenty-first century will be shaped by what happens not only in the U.S. or Europe, but also by what will happen in Africa.

I urge you to read the following pages with care and attention. Not only have the authors combined intelligence and insight with dedication and passion, they have also produced well-crafted and timely pieces. Their work is impressive, and I am confident that their analyses and conclusions will have lasting resonance.

Sincerely,Jonars SpielbergMichigan State UniversityDecember 2009

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Table of Contents

young PeoPle in the field

scholArly Articles

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Africa Map of Contents

rwAndAVivian

ugAndACarroll

south AfricALevinLosinski

suB-sAhArAn AfricABeachler

cAPe verdeMarcelino

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forewordJonathan Choti, Ph.D. Candidate

the core resource

The Role of Informal Caretakers of the Mentally Ill in UgandaDara Carroll

equity in hiv/Aids fundingA Comparison of the Global Fund and PEPFAR

Brian Beachler

mAking triPs workA South African Case Study

Geoffrey Levin

PostcoloniAl identity, trAnsition, And chAllenges to nAtionAl identity in cAPe verde

Pedro Marcelino

nkosi sikelel’ iAfrikASarah Lynn-Andrews Losinski

A different dimension of develoPmentHolding the Mirror up to Oneself

Gracie Vivian

cAll for PAPers

style sheet

Table of Contents


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Africa Map of Contents

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Foreword

In the international arena, the past few months have been extremely eventful. The culmination of all of this activity has been the United Nations Climate Change Conference, commonly known as the Copenhagen Summit, held from December 7-18, 2009. To some, the Summit was a failure; to others, its outcome was half a loaf, judged better than having nothing at all. The outcome of the Conference, the Copenhagen Accord, drafted by the USA, South Africa, Brazil and China, was recognized but not agreed upon, and is not legally binding. A key debate emerging within and around the summit was the relationship between developed and developing nations, and the responsibilities of each group. On the one hand, many claimed that those of the Global South were using the summit as a forum in which to make demands that the world help improve their standards of living. On the other hand, representatives of developing nations, especially those from Africa, felt that developed nations were not making the necessary concessions or demonstrating enough leadership.

These two positions illustrate the fact that Africa’s role in world affairs cannot be ignored. For instance, in the climate change realm, Africa will be the continent hardest hit by adverse impacts, with implications for health care and larger development aims; and although Africa is still vexed with many problems, the potential for growth and improvement is vast. The future of the continent will ultimately rest with the actions of its citizens, but that future will also be shaped by people and events outside of Africa.

Now than ever before, the citizens of the world have come to realize that we live in a global village in which we share our misfortunes and opportunities alike. The Copenhagen Summit bears testimony to this fact. It is this realization that is also the driving force behind the articles in this issue. By highlighting the development and health care situation in Africa, and incorporating a keen understanding of historical antecedents, the authors are in essence training their spotlight on an eyesore in our own village.

One may argue that these young writers are out to accomplish an academic task. So be it – that too is a feat! An academic enterprise it may be, but these articles also make a variety of notable contributions. They will remain a monument of the individual authors’ efforts in making a difference in the world. Indeed, the point of writing about an issue is to help draw others’ attention to the issue at hand. Historians have done their part in tracing the events of slave trade, World War I and II, colonization and liberation efforts, et cetera. In Volume II Issue II, determined young scholars have elucidated the nature, trend, extent and effects of the numerous situations in Africa, a continent broken by civil wars, dictatorial regimes, poverty, disease (notably HIV/AIDS and Malaria), high levels of illiteracy, and environmental degradation. The authors in this issue see all of this, what is, but also see before and beyond it, to what was and should be, and how they are crucial for action in the present.

The Swahili believe that mwenye shibe hamjui mwenye njaa, a proverb that means “he whose stomach is full never thinks about the hungry.” This issue of Articulate embodies a different philosophy. Its authors may be from the “developed,” “first world,” but still their hearts have space for those ailing elsewhere. I applaud their effort.

Jonathan ChotiPh.D. candidate, LinguisticsMichigan State University

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scholArly Articles

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The Core ResourceThe Role of Informal Caretakers for the Mentally Ill in Uganda

Dara CarrollNorthwestern University

ABstrActRecent studies have highlighted the significant role of culture in mental health, mental illness, and mental illness treatment. The aim of this paper is to identify the cultural determinants of mental illness treatment in Uganda. Specifically, I examine the role of family members in the recovery process for individuals with serious mental illness. In Uganda, family members and close friends often assume the role of caretaker for a mentally ill person. Family members are typically the first to recognize that the individual is ill, take him or her for treatment, and monitor or administer treatment during and after hospitalization. Recently, there have also been attempts to use family members to fight the stigma of mental illness. Although social support is often heralded as a positive force in the African context, I argue that this assumption be examined critically. Unfortunately, family members and informal caregivers sometimes neglect or even aggravate mentally ill patients. This often occurs because of social stigma, a misunderstanding of mental health, or increased economic stress. Mental health professionals and mental health service providers must find ways to assist caretakers to create a more supportive home environment for people suffering from serious mental illness.

introduction

In 2001, the Ministers of the World Health Organization (WHO) published Mental Health: A Call for Action, in which they expressed their commitment “to put mental health right at the core of the global health and development.” They found that “four of the ten leading causes of disability worldwide [were] neuropsychiatric disorders, accounting for 30.8% of total disability and 12.3% of the total burden of disease,” with these figures expected to rise.1 Mental health, however, is inextricably linked with culture and society. Culture plays a significant role in how people conceptualize mental health, normality, and healing.2 For this reason, mental health treatment is most effective when it is informed by knowledge and understanding of the socio-cultural factors influencing the patient. For this reason, WHO’s 2001 world health report called for further research into the cultural context of mental health, especially in developing countries. In particular, there was an “urgent need” for research on “factors likely to enhance uptake and utilization of effective interventions.”3

One important socio-cultural factor in the treatment of the mentally ill is the family structure. It has been shown that social ties, such as the family, can both help and hinder recovery from mental illness. Time-consuming and demanding social relationships are correlated with mental illness. This is one explanation for higher rates of mental illness in women. Social support networks, on the other hand, can decrease the likelihood of

1 WHO, Mental Health: a Call for Action by World Health Ministers, World Health Organization:54th World Health Assembly, World Health Organization (2001), 4.2 Laurence J. Kirmayer, “Cultural Variations in the Response to Psychiatric Disorders and Emotional Dis-tress,” Social Science Medicine 29 (1989): 327-331.3 WHO, “Chapter 4: Mental Health Policy and Service Provision,” WHO, 1-2.

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mental illness and help with a speedy recovery.4 Although a support network may exist naturally within a family, it has also been found that family resources in the treatment of the mentally ill are often underused. Professional mental health practitioners can overlook the useful information that family members could provide, and take for granted the effectiveness of a well-informed family member acting as a caretaker.5

These studies, however, were all conducted in Western societies, where the nuclear family is the most common family structure. Ugandan families are much more likely to consist of large, extended networks. There may be grandparents, uncles, aunts, nieces, and nephews all in one home. Even when not living together, the concept of the family extends beyond the physical household, unlike in the US or Europe.6

Previous mental health research has produced three major findings. First, mental illness is a serious health consideration. Second, culture plays an important role with respect to mental health and finding effective mental health treatments. Finally, it has been shown that family structure and behavior affects treatment outcomes of patients in Western countries. What has not been rigorously researched is whether family has a strong influence on treatment outcomes in Uganda. It seems likely that families do play an important role in the healing process, based on the fact that culture is known to be a strong mediator of mental health in Uganda, and that it is common for families to play such a role in other countries.

For this reason, further research is needed to determine how families in Uganda are affecting the treatment of mentally ill relatives. Such a study has yet to be conducted. This study was designed to begin to fill this gap in the literature on culture and mental health in Uganda. In doing so, it also addresses the research areas that the WHO has highlighted as essential to improving and disseminating effective mental health services to all. This study draws from over 90 semi-structured, open-ended interviews conducted with mental health professionals, mental health NGO workers, and informal caretakers of individuals with mental illness. Additionally, over 30 home visits with families dealing with mental illness and several site visits to mental health units and hospitals throughout Uganda were also conducted. Participants were divided into three groups: Group 1 – mental health professionals; Group 2 – mental health NGO workers; and Group 3 – informal caretakers (family or friends) of persons with mental illness.

gloBAl trends in mentAl heAlth

Mental health has recently been recognized as a priority for global and public health intervention. The WHO has stated that “nearly 450 million people suffer from mental and behavioral disorders” and that “mental health problems represent five of the ten

4 Ichiro Kawachi and Lisa F. Berkman, “Social Ties and Mental Health,” Journal of Urban Health 78 (2001): 458-460.5 B. Friesen, and N. Korolof, “Family-Centered Services: Implications for Mental Health Administration and Research,” Journal of Mental Health Administration 17 (1990): 13-16.6 Jerome Del Pino and Gordon L. Anderson, eds., “Uganda,” Worldwide State of the Family (New York: Paragon House, 1995), 206-207.

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leading causes of disability.”7 Depression is projected to be the second leading cause of disability by 2020. It is also clear that, in many areas of the world, this challenge is not being met. A recent WHO study has revealed that:

Over 40% of countries do not have an explicit mental health policy. •Over 30% of countries do not have a mental health program. •More than 25% of countries do not have access to basic psychiatric •medication at the primary care level. 70% of the world’s population have access to less than one psychiatrist per •100,000 people.8

In addition to few resources, many countries are also failing to effectively use the resources they have for mental health service provision. For this reason, WHO has made an urgent call for research on the effectiveness of mental health interventions and policies in low-resource settings, as well as research on “factors likely to enhance uptake and utilization of effective interventions.”9 One such factor may be family members and informal caretakers.

Community mental health programs are one way that the world has confronted mental health in resource-poor settings. These programs seek to utilize existing infrastructure and human resources to deliver mental health care efficiently and at a grass-roots level. One new strategy for such programs is to train non-medical workers to diagnose and treat common mental disorders. The largest current project implementing this strategy runs out of Goa, India. Designed by Dr. Vikram Patel, over 2,000 patients (as of March 2008) have been treated in this program. As Dr. Patel explains, in caring for the mentally ill, “the core resource is humans.”10 So far the project has received positive feedback from users, but there is an ongoing randomized clinical trial to determine the effectiveness of the project.11 This project is an example of one way that local resources can be used effectively. One local resource that has not been seriously studied is the people living with and caring for mentally ill patients.

The methods used in the Goa project are promising in that they use culturally relevant models and treatments of mental illness. It has been shown that cultural models play a significant role in the definition and interpretation of illness. This may occur in a number of ways, including socially learned symptomatology and culturally mediated somatization.12 The convergence of anthropology and psychiatry to study how culture

7 WHO, Mental Health Policy Project; Policy and Service Guidance Package (World Health Organization, 2001), 8. 8 Elialilia Okello, “Cultural explanatory models of depression in Uganda,” Thesis for doctoral degree (Kam-pala: Makerere University and Karolinska Intitutet, 2006), 3. 9 WHO, “Chapter 4: Mental Health Policy and Service Provision,” 1-2.10 David Kohn, “Psychotherapy for All: an Experiment,” New York Times, March 11, 2008, US edition, p. 2. 11 Ibid., 1-3. 12 Kirmayer 1989, 327-331

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influences mental health and illness is being termed “the new cross-cultural psychiatry.”13 This type of research would be useful in understanding one of cross-cultural

psychiatry’s biggest surprises. In 1976, the WHO conducted a study on schizophrenia treatment outcomes in developed and developing countries. Despite significant advantages in terms of resources and training for the developed countries, treatment outcomes in developing countries were much better. There was so much skepticism about these results that another study followed, which confirmed the original results. It has been posited that because the extended family network is a stronger social force in developing countries, mentally ill individuals are getting more social support.14 This theory, however, has never been subjected to empirical analysis, and must be studied country-by-country or cultural setting-by-cultural setting.

There is yet another reason to consider culture. As science delves further into the mechanics of the human brain, psychiatry and psychology are increasingly equated to neurological processes and therefore illnesses are treated with biomedical interventions. To date, however, “social, psychotherapeutic, and educational interventions are still the only known forms of prevention.”15 There is no immunization for mental illness, so it is to society that we must turn in order to prevent and treat individuals from mental illness.

the AfricAn context

In 2001, the WHO conducted a self-reporting study on countries’ resources to address mental health. Of the African countries that responded, less than half had a mental health policy.16,17 In most African countries, the psychiatrist to patient ratio is 1:2 million, with most of the psychiatrists and even lower-level mental health workers concentrated around the wealth and infrastructure of urban centers. Common mental disorders (CMD)18 are, however, among the most frequent disorders of persons seeking primary health care in Africa.

It has also been demonstrated that there are certain commonalities in explanatory models of mental illness within Sub-Saharan Africa. Namely, many believe the mind to be distinct from the body and to be housed in the head as well as the heart or elsewhere in the torso. Often, mental illness is explained as a spiritual disruption or dysfunction. “Madness,” or psychotic disorders, are often defined by presenting behavioral and or somatic symptoms.19 This information indicates that Western medical measurements of mental illness are not especially useful in Africa because they do not focus on the

13 Arthur M. Kleinman, “Depression, Somatization and the ‘New Cross-Cultural Psychiatry,” Social Science and Medicine 11 (1977): 3; Vikram Patel, “Explanatory Models of Mental Illness in Sub-Saharan Africa,” Social Science Medicine 40 (1995): 1292. 14 Byron J. Good, “Studying Mental Illness in Context: Local, Global, or Universal?” Ethos 25 (1997): 234. 15 Ibid., 230-23116 It is predicted that the actual number of countries with a mental health policy in Africa is lower. 17 WHO, “Chapter 4: Mental Health Policy and Service Provision,” 1-2. 18 Defined as “disorders which are commonly encountered in the community and whose occurrence signals a break down in the normal functioning.” 19 Patel 1995, 1291-1298.

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symptoms that are be reported. Instead, studies should include cultural contextualization to determine what different populations consider to be mental illness so that the correct symptomatology can be incorporated into applicable measurements and diagnostic tools.

mentAl heAlth in ugAndA While Uganda’s mental health care system is somewhat developed relative to other

African countries, it still suffers from serious resource shortages. In 2006, the WHO categorized Uganda as “research constrained” when it came to mental health, because the country lacked sufficient infrastructure and personnel.20 As of 2006, Uganda had only approximately 25 trained psychiatrists, 18 of which were working in Kampala.21 Due to the lack of knowledge about mental illnesses, individuals with depression are three times more likely to seek formal health care because depression is not a recognized illness; therefore, individuals go untreated.22 If depression were recognized earlier and the correct treatment were given, it could lower health care costs.23

The WHO specifies four major challenges to the mental health of populations: poverty, urbanization, natural disasters, and war and conflict.24 Unfortunately, Uganda currently experiences three of these four challenges. Poverty and urbanization exist on a wide scale. Violence and war have long been a part of life in Uganda, creating traumatized populations. As a result of civil wars and the ongoing wars in the surrounding East African countries, refugees and internally displaced persons (IDPs) pose another significant challenge.

It has been estimated that 26% of the population of Uganda lives in chronic poverty. Chronic poverty is defined as a family or individual that is trapped in “severe” and “multidimensional poverty” for a long period of time, often being transmitted across generations.25 Mental illness and poverty create a cycle: Just as poverty can lead to mental illness, mental illness can impoverish an individual because it may cause disability or discrimination that prevents him or her from working. Similarly, poverty makes treatment less readily available. Rural poverty, in turn, forces people into urban centers to find work. Between 2000 and 2005, the urban population growth rate in Uganda was 4.2%; in 2007, 13% of the population was living in an urban area. “The population of Kampala has steadily grown in the last three decades, faster than the pace at which urban services and housing are provided.”26

It has been posited that urbanization has had deleterious effects on the close-

20 WHO, Working Together for Health: The 2006 World Health Report (World Health Organization: Geneva, 2006). 21 Okello 2006, 11-12. 22 Figure determined after controlling for medical co-morbidity. 23 Okello 2006, 3. 24 WHO, Mental Health: a Call for Action by World Health Ministers 2001, 4. 25 “Does Chronic Poverty Matter in Uganda?” 2006: 1-2. 26 Shuaib Lwasa, “Urban Expansion Processes of Kampala in Uganda: Perspectives on contrasts with cities of developed countries,” PERN Cyberseminar on Urban Spatial Expansion. http://www.populationenvi-ronmentresearch.org/papers/Lwasa_contribution.pdf.

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knit extended family that is common throughout Africa and in Uganda in particular. The theory suggests that urbanization has 1) removed the social pressure to maintain family bonds, and 2) put new and increased economic strain on families. This is in comparison to the formerly strong bonds between extended family members, which created a psychosocial support network. Recently this assumption has been called into question based on evidence that large families can also cause psychological stress.27 What remains clear, however, is that urbanization has disrupted family dynamics in Africa. Furthermore, functional families (of any size or shape) are known to help minimize the effects and/or risk factors of mental illness. Although a recent study found that family structure was not a risk factor for depression in Uganda, it discovered that family-related negative life events were. The depressed participants in this study were much less likely to have regular incomes and more likely to be separated from their spouses, a condition more common in an urban setting.28

One community is particularly at risk to the social and psychological dangers of urban centers. Street children, or children that do not have homes and are living in slum areas, are numerous in Kampala. In a recent study has examined the lives of street children in Kampala, the most common reason that children left home was because of abuse or neglect from parents or other caregivers in the home. Other common reasons included looking for work, the break-up of the family due to separation or divorce, and parental death.29 As mentioned above, these types of events are significant risk factors for the development of mental illness.

Street children are also subject to a wide range of traumatic events. Among the participants of the aforementioned study, 80% reported physical harassment from the police and general public, 50% reported not having shelter, and 28% reported going hungry regularly. Although the girls were the only ones to report sexual harassment, the figures are staggering. Eighty-four percent of the girls reported being sexually abused, and 43% reported being raped, while 11% of them turned to prostitution for survival. Other common survival tactics included stealing (100% reported stealing) and substance abuse (27%). The most common reasons given for abusing substances such as alcohol, marijuana, and fuel, were to numb feelings or go to sleep. Due to the many negative life events to which street children are exposed, they often experience some degree of psychological and emotional damage, especially relating to abandonment and insecurity.30 It has been shown that, in Uganda, successful rehabilitation and reintegration of street children involves an extremely supportive social environment,

27 Good 1997, 236. 28 Wilson Muhwezi et al., “Life events and depression in the context of the changing African family; the case of Uganda,” World Cultural Psychiatry Research Review 10 (2007): 12-18. 29 Seggane Musisi, “Chapter 10: The Life and Causes of Street Children in Kampala, Uganda,” 195-208, in Poverty, AIDS, and Street Children in East Africa, Joe Lugalla and Colleta Kibassa, eds (Lewiston, New York: The Edwin Mallen Press, 1992), 197. 30 Lorraine Young, “The place of street children in Kampala, Uganda: marginalization, resistance and accep-tance in the urban environment,” Environment and Planning D: Society and Space 21:5 (2002): 607-612.

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most importantly in the home and family unit.31

Trauma also exists in Uganda as a result of war and torture. It is widely accepted that torture can lead to a variety of mental health complications; in fact, this is often the goal of the perpetrators of torture. A study of patient records at the Kampala-based African Centre for Treatment and Rehabilitation of Torture Victims showed that the most common forms of torture were kicking and beating, witnessing the torture of family members or other victims, and rape. The prevalence of mental illness in these patients was significantly higher than in the general population: 75.4% were diagnosed with Post-Traumatic Stress Disorder (PTSD),32 32% with somatoform disorders, 28% with depression, and 17% with anxiety disorders.33

There are also a number of civil conflicts, both resolved and ongoing, that have been disrupting mental health prevention and treatment in Uganda. It is estimated that, in populations affected by armed conflict, at least 10% will develop mental health problems and an additional 10% will have trouble functioning as a result of trauma. Mental health problems due to trauma emerge most prevalently immediately following the incident. Studies of populations that had recently experienced trauma showed depression rates of 40-80%. The war experienced in Uganda can be characterized as “low intensity warfare” or conflicts that target civilian populations. The goal in such wars is often to destroy, terrorize and demoralize a population to stop or prevent resistance, which is exactly what happened.34 Among the war-affected Ugandans in the North, prevalence rates of disorders are high: PTSD at 39.9%, depression at 52%, anxiety disorders at 60%, somatization disorders at 72.2%, suicidal behavior at 22.7%, and alcohol abuse at 18.2%. The study that yielded these results also found that the number of traumatic events in a person’s lifetime is highly related to developing PTSD. Prevalence rates were 23% in those reporting three or more trauma experiences, and 100% in those reporting twenty-eight or more trauma experiences.35

Another result of past and current conflicts in Uganda and East Africa is a large number of refugees and internally displaced persons (IDPs). These populations are not only exposed to trauma because of conflict, but also experience additional trauma as a result of being displaced. In the process, many societal constructs and bonds are destroyed. This type of “cultural discontinuity” is often correlated with depression, alcoholism, suicide, and violence.36 These psychological stressors exist in Uganda refugee

31 Christopher Wakiraza, “Chapter Twelve: Reintegration of Street Children: A Critical Look at Sustain-able Success,” in Poverty, AIDS, and Street Children in East Africa, Joe Lugalla and Colleta Kibassa, eds. (Lewiston, New York: The Edwin Mallen Press, 1992): 223-233. 32 The most common forms of PTSD were chronic (67% of patients in the study) and complex (9% of patients in the study). 33 Seggane Musisi, Eugene Kinyanda, Helen Liebling, and R. Mayengo-Kiziri, “Post-traumatic torture disorders in Uganda: A three-year retrospective study of patient records at a specialized torture treatment centre in Kampala, Uganda,” Torture 10 (2000): 81-87.34 Seggane Musisi, “Mass trauma and mental health in Africa,” African Health Sciences 4 (2004): 80. 35 Frank Njenga, Anna Nguithi, Rachel Kang’ethe, “War and mental disorders in Africa,” World Psychiatry 5 (2006): 38-39. 36 Laurence Kirmayer, J., G.M. Brass, and C.L. Tait, “The mental health of Aboriginal people: transforma-

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and IDP camps. Among refugees at a camp in the West Nile region,37 31.6% of the males and 40.1% of the females were diagnosed with PTSD.38 Another study found that over 25% of refugee children were severely psychologically disturbed. Among these children, a supportive family was found to be the most effective factor form at preventing mental illness.39 At a camp in Gulu District, high rates of mental illness existed, with 6% of respondents reporting homicidal thoughts.40 This points to the cyclic nature of violence and psychological trauma. It has been found that in Uganda, mass trauma can create a tendency to solve all conflicts militarily, even interpersonal ones.41

Previously, Western researchers claimed that PTSD and other trauma-related mental disorders did not exist in Africa. It was soon uncovered by researchers native to African countries that the former studies had yielded inaccurate results because the studies were designed for Western societies and with Western biases. More comprehensive and culturally sensitive research has shown that in traumatized populations there is a core set of mental health symptoms that manifest themselves differently in varying cultural situations. These are now referred to as “post-traumatic culture bound syndromes.” In Africa, dissociation and possession syndromes are most common.42 In Northern Uganda, group interpersonal psychotherapy was an effective intervention for depressed adolescents, partially because the measurements and treatment took locally described syndromes into account.43

When interventions do not provide for cultural considerations, treatment and diagnosis are less effective. In fact, it may even cause additional stress to the patient. For example, Western models of treatment that are based on the modern concept of science and the individual – as opposed to tradition, religion, and community – can put unwanted pressure on the individual to accept Western conceptual models.44 Additionally, in Uganda, it is clear that mentally ill individuals respond better to treatment when the caregiver is somebody who understands the cultural meaning behind his or her illness.45 This has demonstrated through studies that investigate the work of traditional healers, but it is also possible that family members could be utilized in the

tions of identity and community,” Canadian Journal of Psychiatry 45 (2000): 607-608. 37 The majority of the refuges were from Sudan. 38 Frank Njenga et al. 2006, 38. 39 Mina Fazel and Alan Stein, “The mental health of refugee children,” Arch Dis Child 87 (2002): 367-368. 40 Eugene Kinyanda and Seggane Musisi, “War traumatization and its psychological consequences on women of Gulu District,” Review of Women’s Studies: 102-122.41 Musisi 2004, 81. 42 Ibid., 80-82; 94. 43 Paul Bolton et al., “Interventions for Depressive Symptoms Among Adolescent Survivors of War and Displacement in Northern Uganda; A Randomized Controlled Study,” Journal of the American Medical Association 298 (2007): 519-521. 44 Patrick Bracken, Patrick, Joan E. Giller, and Derek Summerfield, “Rethinking Mental Health Work with Survivors of Wartime Violence and Refugees,” Journal of Refugee Studies 10 (1997): 431-442. 45 Seggane Musisi and Sudarmono, “Traditional Healing in Conflict/Post-Conflict Societies,” 107; Elialilia Okello, Solvig Ekblad, and Stella Neema, “Beliefs and practices of traditional healers regarding non-psychot-ic depression: Implications for the health policy in Uganda,” (Submitted 2006): 15.

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capacity of providing socially and culturally meaningful treatment.

mentAl heAlth service users in ugAndA

For present study, the first step was to ascertain who in Uganda was coming to study sites, namely the Mulago National Referral Hospital’s S.B. Bosa Mental Health Unit and the Butabika National Referral Hospital. Both institutions see more male patients, with a 2-3:1 ratio of men to women, depending on the time. This is due to the fact that men are more likely than women to become violent, which is the most common reason for the hospitalization of the mentally ill in Uganda. As one participant put it, “quietly depressed women are ignored.” Most patients are roughly between the ages of twenty and forty. This is because most of the illnesses manifest during this age bracket. The most common diagnoses are bi-polar disorder, schizophrenia, depression, and epilepsy46. Because Mulago and Butabika are both national referral hospitals, and because mental health services are not usually sought out except in extreme cases, the patients there are often very severely ill.

Because only those individual with the most severe cases of illness are brought to Mulago and Butabika, treatment almost always involves psychopharmacological interventions. Few patients are able to see psychologists because they are a scarce commodity and are not readily available, and the severe psychotic disorders do not necessarily lend themselves to psychotherapy. A patient presenting depression or an affective disorder usually stays at Butabika for two to three weeks, while a patient with a substance abuse problem stays for about one month, and a patient with schizophrenia or other psychosis stays for one or two months. These figures are similar at Mulago, although the stays are generally a bit shorter.

There are several reasons for short admission periods. First, as mentioned, many patients brought to these clinics are severely ill, so they respond quickly to drug therapy. Second, hospitalization at Mulago can be a burden to family members because an attendant is required. Thus, a member of the family is removed from economic and social activity for the hospitalization period. Additionally, there is some evidence to show that hospitalizations for mental health should be as short as possible to avoid “social breakdown syndrome.” This occurs when a mentally ill individual is removed from his or her social environment and social role for an extended period of time, and can be just as detrimental as the original illness.47

Outpatients can be seen for a period of anywhere from a few months to several years, depending on the severity of the illness. The frequency of visits also depends on the disorder, but follow-ups generally take place weekly, bi-weekly, monthly, or bi-monthly.

informAl cAretAkers for the mentAlly ill in the ugAndAn setting

A number of factors make family members and friends of the mentally ill an important group to study. First, there is the problem of human capacity. There are simply

46 Although not considered a mental illness in the West, epilepsy is dealt with in mental health units be-cause of the frequency of behavioral symptoms and the neurological basis. 47 Good 1997, 236.

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not enough mental health professionals to deal with the average burden of mental health, let alone the additional challenges in Uganda resulting from poverty, urbanization, torture, war, and displacement. Therefore, it is necessary to look for support beyond and outside of the professional sphere. Furthermore, the beliefs and attitudes of a society toward mental illness have a considerable effect on the way the community interacts with and responds to mentally ill individuals. These interactions both directly and indirectly influence the illness and treatment outcome.48 It is possible that this influence is even stronger among family members, but such a hypothesis has yet to be tested and studied. Finally, it has been shown that caregivers who are familiar to the patient are more effective.49 There often exists a large gap between patients and doctors, who often come from a higher socioeconomic class and are viewed as “bosses.” For example, one attendant at Mulago reported that the patient would not accept food, medication, or assistance from basawo (Luganda for doctors) because they were frightening. Despite knowing that patients benefit more from care given by someone with whom he or she feels comfortable, it has not been determined to what degree family members and friends are filling this role in Uganda, or if there is any way to improve the utilization of informal caregivers.

Results of this study indicate that the people close to mentally ill individuals fill the role of caregiver in numerous ways. It is most often somebody living with or near a mentally ill person who recognizes the illness. With the exception of cases that require police involvement, relatives almost always bring the patient to the hospital or clinic. All except for two of the nineteen caretakers interviewed were family members. Female relatives visit more frequently than their male counterparts. Only one of the fourteen interviewed attendants at Mulago was male, and none of the five family members that were interviewed from the Schizophrenia Fellowship (SF) were male. Men only became involved if the patient was extremely violent or physically unmanageable. There are several explanations for why women are more involved in taking care of the mentally ill. First, there is a strong cultural expectation that women fill the care-giving role, while men financially support the family. Since men are also more likely to be supporting the family, there is also an economic component in charging women with the time-consuming caretaker role.

After the patient has gone to the hospital, informal caretakers are essential for providing three types of support. They often ensure that the patient’s basic needs are met. While at Mulago Hospital, attendants help with everything from feeding, to washing clothes, to bathing and hygiene. Many attendants also make sure that the patients are eating properly and that any special dietary needs are met. After discharge, it is usually a family member who takes over the responsibility for ensuring the physical well being of the patient. This includes protecting them from harm and harassment, whether it be self-inflicted or at the hands of others. In Uganda, it is also common for mentally ill persons to wander, so it is the caregiver’s job to ensure that they do not become lost.

48 Ibid., 233.49 Musisi and Sudarmono, 99-100.

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Doctors and nurses also use caregivers to assist in treatment. Even when patients are still at Mulago, the attendants monitor and give medication. Occasionally, it is necessary for family members to find and purchase medications that are not available at the hospital. After discharge, mental health workers depend completely on informal caregivers. They are the ones who remind and encourage the patient to continue taking medication properly, and are considered responsible for ensuring that the patient attends his or her follow-up appointments.

Finally, informal caregivers can provide crucial emotional and social support. In Uganda, this type of assistance takes two forms. The first, and possibly most effective, is listening. Many caretakers reported that they help the patient by listening to them. Several also said that they “counsel” patients, or offer them advice on how to face certain challenges, including stress. Secondly, sometimes the caretakers, without intention, help the patient psychologically. One psychiatrist reported that his patients’ treatment outcomes were better when the family was treating the patient like a “normal” human being, or similarly to the way they were treated before the illness. For example, patients whose families were able to keep them involved in the work at home were very successful. Families or caretakers who encourage individuals to become as independent as possible by pushing them to take care of themselves and find work increase the likelihood of a quicker and more complete recovery.

Children, in particular, are in need of informal caregivers, and it is best if the family is the source. Children respond strongly to negative life events associated with family members, particularly parents. In fact, it is the most significant risk factor for deliberate self-harm (DSH), which is not only possibly fatal, but also is itself a risk factor for suicide.50 Children are also more likely to be psychologically traumatized if the parents are also traumatized. 51 Although negative experiences related to family are the most damaging in children, family is also the saving grace. A strong, functional family is cited in a Ugandan training manual for health workers as the number one protective factor against psychological trauma. For this reason, family members and caregivers of mentally ill children are given special attention. The aforementioned manual mentions in several places the importance of counseling and psycho-educating parents. In particular, it is important for parents to recognize that the child is ill, despite the fact that this realization may be upsetting. For this reason, Butabika children’s ward conducts group sessions for family members. These group sessions involve some psychoeducation and then ample time for the family members to ask questions and talk among themselves. In this way it also functions as an informal support group or group therapy. The family members also undergo their own form of counseling, to help them deal with having a mentally ill child and prepare them to care for the child.

Unfortunately, the effect that family members and friends have on the mentally ill

50 Eugene Kinyanda, H. Hjelmeland, and Seggane Musisi, “Negative Life Events Associated With Deliber-ate Self-Harm in an African Population in Uganda,” Crisis 26 (2005): 4-11. 51 Eugene Kinyanda, Sheila Ndyanabangi, Ruth Ochieng, and Juliet Were Oguttu, eds., Management of Medical and Psychological Effects of War Trauma; Training Manual for Operational Level Health Workers (Kampala: Isis WICCE), 88.

16

is not always positive. First of all, they do not always exhibit ideal help seeking-behavior on the behalf of the patient. As previously discussed, it is only patients displaying severe behavioral symptoms that are recognized as ill. In the absence of recognizably “mad” or disturbing behavior, an individual is not considered ill, and therefore not brought to the hospital.

Even when patients are brought to the hospital or clinic, it is often as a last resort. Traditional healers and churches are preferred over hospitals and clinics for a variety of reasons. When a community or family recognizes a mental illness, or “madness” as it is commonly referred to, the consensus is usually that it is caused by something other than psychological or psychiatric factors. There are a variety of cultural explanations, from a curse from a neighbor to a neglected ancestor. In this case, a traditional or spiritual healer is sought. Some also believe that the problem stems from a spiritual deficiency or problem from within a Christian religion, in which case the family turns to the church for healing. One Group 3 participant was still convinced that the patient’s problem was a result of being bewitched by a female neighbor, and that God was the only answer to the problem. Furthermore, traditional healers and churches are more available. As mentioned before, mental health workers are few and far between. If the family or community is far from a well-known mental health center like Butabika, they may decide that it would be too expensive to travel the far distance to the health center. Traditional healers and churches, on the other hand, are plentiful. Families may also face social pressure from the community to seek out cultural or spiritual assistance first, even if they are questioning the effectiveness of these measures.

Another reason to avoid the mental health unit or hospital is stigma. Community members who do not understand mental illness have been observed harassing and abusing mentally ill persons, including taunting, beating, demoralizing, name calling, and ignoring in order to dehumanize. When faced with stigmatizing behavior, patients often internalize the stigma, which translates into self-hatred and low self-esteem, both of which have very detrimental effects on recovery and improvement. Also, in order to avoid such abuses, mentally ill persons may withdraw from social situations, perpetuating the poor social functioning that often accompanies mental illness. To protect himself or herself from community abuse, a mentally ill person may try to hide his or her illness for as long as possible, in anticipation of stigmatization.

Mental illness is not only stigmatizing for the individual, but also for the whole family. To avoid judgment, families might try to hide the patient instead of seeking treatment. Butabika, in particular, is well known as a mental health hospital, and therefore does not appeal to families who are uncomfortable with public knowledge that such an illness exists in their family. Unfortunately, fewer people know about the mental health services offered at alternate institutions, such as Mulago or other health centers. Most attendants and family members who were part of the study were referred from another ward of the hospital, usually the emergency ward. In Jinja, the Schizophrenia Fellowship is working to spread the word that there is treatment for mental illness. Most of the members are relatives to and caretakers of mentally ill persons. Of the ones interviewed, they had all heard about mental health services offered at Bugembe Health

17

Center IV from somebody who was already a member of the organization. This kind of grass roots information dissemination was found to be very effective in this setting. Finally, families or caretakers may simply be in denial about the illness. It can be upsetting to acknowledge that somebody is seriously ill, especially if the family or caretakers is blaming themselves or the ill individual. As a result of lack of knowledge, fear of stigma, and denial, most mentally ill persons do not receive formal care until he or she has been ill for some time and the illness has become severe.

The ways in which family members can negatively impact treatment outcomes go beyond missing out on formal services. They can actually reverse some of the progress made by treatment. Stigma does not only come from the community. Caretakers are often observed using the term mulalu, or “mad person,” when addressing or referring to the patient. Even more common and less obvious is the tendency for the family or other people living with the patient to marginalize him or her. They quietly remove the patient from daily activities, refuse to eat with them, discount what he or she says, expect little or no productive activity from the person, and so on. Some parents go so far as to remove children from school unnecessarily. If the patient becomes upset at any point, it is often attributed to the illness, despite the fact that anger and sadness are common emotions. While it is true that mental illness can cause disability, most people in treatment can function quite well in his or her previous role. When they are denied the chance to function in these roles, the result is withdrawal and self-stigmatization.

Sometimes families or caretakers give up on the patient and recovery. Instead of taking them for help, they will bring them to hospitals to get rid of them. Some even go so far as to beg psychiatrists to admit them, when the chosen course of intervention was outpatient treatment. One doctor had observed families that brought in a patient repeatedly, hoping that a different doctor would admit the patient. If they are unsuccessful at “dumping” the patient at the hospital, the family may force the person out of the home or pretend not to know the patient. In other cases, the patient is tied up, tied to a tree, or locked in a room to remove them from the family and society. Frustration on the part of the caretakers can also lead to what is called “high expressed emotions,” which is essentially a lack of patience or understanding leading to visible anger with the patient. Even physical abuse is fairly common, especially toward patients who are aggressive as a result of their illness.

All of this behavior has negative impacts on treatment and is known to aggravate mental illnesses in most patients. At the very least, these behaviors inhibit recovery. If a patient is being told or shown through marginalization that they are not able to function in society, it can become a self-fulfilling prophecy. Several mental health professionals had observed that the above actions consistently cause relapses or “episodes.” One member of the Schizophrenia Fellowship, herself a former patient, explained that when community members stigmatize or harass her, her natural response is to get upset or angry. Stress caused by hurtful and abusive behavior made it more difficult for her to overcome her illness.

At this point, the prescribed intervention for damaging family or caretakers is family therapy or counseling. It would also be useful to counsel communities in which

18

mentally ill persons are living. The community mental health program based at Butabika has attempted to do some of this, but faces resource restraints that prevent them from doing the necessary follow-up. Another protective factor is the patient’s ability to care for himself or herself. Those that are able to provide for their own basic needs are better at overcoming community stigma and familial abuse. Because women are more often involved in activities like cooking, cleaning, etc., a female patient is more likely to function well in the absence of a supportive network of friends and/or family. Additionally, psychoeducation and sensitization are extremely effective methods for preventing harmful practices in the care of the mentally ill.

chAllenges for And to informAl cAretAkers

The most common difficulty in caring for a mentally ill person mentioned by the caretakers interviewed was financial challenges. It is expensive to transport the individual and caretaker or caretakers – who often accompany patients to the hospital the first time and for follow-ups – to the hospital. The best solution is decentralization of mental health services, which the government is currently working on. There is also a community mental health program being run through Butabika. The program, which is “rather amorphous” according to one psychiatrist, runs four outreach clinics and handles some cases that require special attention to the discharge and reintegration process. Although it is only reaching communitieswithin a ten-kilometer radius of Butabika, it is having a positive. For example, women are more plentiful at the outreach clinics, which means that in some areas, it is not only the violent male patients that are getting treatment. The outreach workers are also more likely to examine the family and social environment of the patient. Even when the patient is going to an outreach clinic, however, it may require a considerable amount of time and money to reach. The program itself also lacks the funds and resources to do the home visits and follow-ups on reintegration that are necessary in many cases. For patients whose home is far away, “reintegration” may involve putting them on public transport to return home by themselves, because there are not enough funds to send a counselor or nurse with them.

Another financial hurdle is medication. The majority of the Group 3 respondents specifically requested or suggested that drug availability be improved, and prices lowered. Mental health treatment is now part of the Basic Health Care Package (BHCP), which means that it should be free at government health centers, including psychopharmacological treatments. While most necessary medication can be found at Mulago and Butabika, the supply is inconsistent. Patients may come in for follow-up and the medication that they were taking successfully is not in stock. The patient is then forced to take a chance on whatever drugs are available, or locate and pay for the effective one. At smaller hospitals and health centers, the problem is even more pronounced. Additionally, psychiatrists do not always consider the patient’s or family’s economic situation when prescribing medications. In an attempt to give the patient the best prognosis, a doctor may prescribe the medication that he or she knows is most effective, but is not on the list of drugs provided by the government. When the family cannot afford to buy the medications, however, they cannot help no matter how much

19

better they are. Families are reluctant to admit to doctors or authority figures that they cannot afford the medication, and so they may keep quiet and leave the patient without necessary drugs.

The patients themselves can also be an economic strain to families and caretakers. In all Mental Health Units (MHUs) excluding Butabika, attendants are required for admission. This means that the caretaker is removed from economic activity for the period of hospitalization. Once at home, it is often still necessary for someone to forego work in order to care for the patient. Wandering is an extremely common symptom of mental illness in Uganda, meaning careful observation of the patient is often necessary. In some cases, someone is needed to vigilantly watch the patient for signs of relapse, which can distract from work or chores. A relapse may also result in property destruction, such as the mother of a patient whose family is without bedding because the patient destroyed the family’s bedding. Finally, patients often become financially dependent on family members, at least for a period of time, which leaves the caretaker with an additional dependent, one who would otherwise be living independently or supporting himself or herself. In cases where the patient is a mother, the family (usually the patient’s mother) steps in to care for the children, translating to even more dependents and work for the caretaker.

Caring for a mentally ill person can cause emotional and psychological stress. Most caretakers are somebody very close to the patient. Seeing a close friend or relative in serious distress often leads to distress. In particular, it can be very upsetting for parents or older family members to see the patient’s chances at success in school and work diminish. As one psychiatrist explained, it is hard for family members to accept the fact that the patient “is not going to become the person that they thought they were.” Furthermore, the mental illness can put strain on and damage the relationship between the two people. In some cases, family members (particularly mothers) blame themselves for the illness. Similarly, the community may blame the caretakers. Communities also stigmatize the family or people living with mentally ill persons. Many Ugandans, for example, consider epilepsy contagious, and so people will stop visiting the home or family members of an epileptic.

Unfortunately, the mental health system is not equipped to address the psychological needs of family members and caretakers, although attempts to do so have begun. The previously mentioned group sessions for parents of children with a mental illness may be offering some solace to family members. Family therapy is also used fairly often when the patient is a child. In addition, the community mental health program seeks to ensure a healthy social environment for patients by counseling family members when necessary. The financial problems of the community mental health program still apply to these attempts, however, and therefore they are not extensive. In general, the formalized mental health system is not addressing the needs of informal caretakers.

It is organizations that provide mental health services that are currently most successful in the role of caring for the caregivers. Hope After Rape (HAR) provides both individual and group counseling to family members of victims of sexual abuse. It is considered a necessary step because the distress caused by having a family member

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who is a victim, and a family member who is mentally ill as a result, can make it difficult for family members to care properly for victims. The Transcultural Psychosocial Organization (TPO) also makes stabilizing the family and social environment a priority, through group counseling and community awareness.

Support groups are an extremely valuable method of assisting caretakers. BasicNeeds Uganda (BN) has helped organize several caretakers groups. Not only do these groups offer support to each other, some have formed drug banks. Drug banks are groups of caretakers in which each member contributes some money so that the group can buy expensive drugs in bulk, thereby saving each member money. The Schizophrenia Fellowship (SF) has formed similar groups. SF is a membership organization based in Masaka and Jinja. The Jinja group is based at Bugembe HCIV, and is run by the health center’s PCO. Most members are parents or relatives caring for someone with mental illness. All of the respondents who were members from SF reported that they were having a difficult time caring for their family member, and that they were unhappy for some time. They also all responded that – since joining the group – while they still face difficulties, they are much happier. They described the group as “a place to laugh and feel relieved,” a place they feel “embraced,” “at peace,” and “a lot of joy.”

Ignorance and misunderstanding is a dilemma for both caretakers and mental health care workers. The general public has a very different conception of mental illness than formally trained professionals. First, mental health professionals have sometimes found it difficult to explain to family members and patients that mental illness is, in most cases, a chronic disorder. There are certain cultural expectations of doctors in Uganda. Namely, people expect medication in the form of pills or an injection. They expect the medication to work quickly, and that once the symptoms are no longer visible the disorder is cured, making the drugs unnecessary. As a result, drug therapy is often terminated much too early: indeed, in some cases it is needed for the duration of the patient’s life. It is easier for the patient to accept that he or she must take medication permanently because they are able to observe what happens to them without medication. In the case of Butabika patients, they are also interacting with mental health professionals on a daily basis, and can see other patients that are there because they have relapsed. Once they are in the home, however, the patient is subject to pressure from the caretaker or family. It can be difficult for families to accept that the patient is not cured because of cultural preconceptions and because it is upsetting news that is often difficult to process. When the caretaker is encouraging a patient to discontinue medication, the patient often acquiesces. Thus, if caretakers were made to accept the long-term nature of mental illness, it would reduce the quantity of patients that relapse. There is, however, a Catch-22. It has been shown that societies that conceptualize mental illnesses as curable as opposed to permanent have better treatment outcomes.52 More research is needed to determine how best to inform patients and caretakers about medication options.

As mentioned earlier, violence is the symptom most likely to prompt hospitalization. This fits into a general tendency for people to recognize and identify behavioral

52 Good 1997, 233.

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symptoms over emotional ones.53 The Group 3 participants were asked about how they knew the patient was ill, and what happened when the patient became ill. Besides violent or uncontrollable behavior, the most common responses were “over-talking,” “over-walking,” and disrupted speech. When asked about the cause of the illness, the Group 3 participants also had a very consistent view: The fact that the patients were in the hospital was an indicator that most of the caretakers had accepted that it is not caused by cultural or spiritual factors. Only one attendant cited the cause as being “bewitched.” Instead, the explanation usually begins with environmental factors, like too much work or stress. The patient is unable to deal with the circumstances, and the result is “too many thoughts” or “over-thinking.” In summary, the vast majority of the Group 3 participants had the following conception of mental illness:

Environmental stress → Cognitive disruption → Behavioral symptoms (too much stress or work) (“too many thoughts”) (violence, “over-talking”)

While most of the Group 3 participants were sympathetic to the patients, this sample is biased toward this result because the caretakers have taken the time to seek treatment and participate in treatment. There are, however, some families that will actually blame the patient for the illness. As shown above, biological or organic causes do not factor into the common conception of mental illness, which is also confirmed by the observations of Group 1 and 2 participants, and Dr. Elialilia Okello’s work on the cultural construction of depression in Uganda.54 It becomes the responsibility of the mental health workers and community sensitization programs to explain that the patient is not at fault. In order to remove blame, Ugandan psychiatrists have found it useful to explain the organic causes of mental illness. Although medical terms are not always easily or effectively translated from English to local languages, there are certain semantic constructions that have proven useful. One experienced psychiatrist explains mental illness as a result of “imbalances” in the “fluids” in the brain. Other phrases that have proven useful are “the illness disturbed the brain,” the illness is “in the blood,” or “runs in families.” It is important that mental health workers take the time to translate and explain mental illness in terms that are not only easy to understand, but are also culturally significant to patients, families, and communities.

the imPortAnce of PsychoeducAtion

Psychoeducation has been found to be the most effective method of improving informal caretaking practices and fighting stigma, and has the added benefit of being inexpensive. Psychoeducation, as it exists in Uganda, essentially consists of revealing the nature and causes of mental illness and the forms of treatment for mental illness. The primary sphere of influence is the mental health worker to the patient and caretaker. As discussed earlier, many problems result from misunderstandings and misconceptions on the part of caregivers. Most, if not all, psychiatrists attempt to perform some degree of

53 Okello 2006, 1-43. 54 Ibid.

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psychoeducation during consultations, but for some reason it often does not get through to caretakers. The attendants that were Group 3 participants were quick to praise the staff at Mulago. However, none of the respondents who were asked the following three questions could answer all of them:55

a. What do the doctors tell you about your family member’s illness?b. What do the doctors tell you about why your family member is ill?c. What do the doctors tell you about your family member’s treatment?

Over half were able to answer the third question by saying that the patient was on medication, or that the patient was to take drugs regularly. Others, however, said “nothing” or “not yet.” These were also the most common responses for the first and second questions. None of the respondents had been informed of the biological nature of mental illness, and only two reported having been given any information about the cause of the illness. Before these questions were introduced, the interviewees were still being asked if he or she knew what caused the illness. Again, none mentioned biological causes.

These findings make it clear that more psychoeducation is needed for caretakers at MHUs. Psychiatrists, however, are facing serious challenges. They are forced to see many patients and often do not have the time to explain details and causes. Many are also forced to work at private clinics because of low pay. Some report that they only explain the details and causes of the illness if the patient or caretaker asks, or if it is necessary because the caretaker is blaming or stigmatizing the patient. It is possible that there is an additional justification for withholding the organic nature of mental illness. Many caretakers reported that because the illness was caused by stress, they made sure to help the patient avoid stress. Many of the illnesses seen in Uganda are brought on or exacerbated by environmental circumstances, so this practice is extremely helpful. More research is needed to determine exactly what should be included in psychoeducation, and if explaining biological origins of mental illness is always necessary. What is not in question is that caretakers should be advised on how to care for the patient, that the patient is not to blame, and that it is extremely detrimental to stigmatize or marginalize the patient.

Psychoeducation is also an effective solution for stigma in the community. The Ministry of Health has taken some steps in this direction by promoting public awareness on the radio and in posters. The community mental health program is also helping by working in communities and outreach centers. BasicNeeds Uganda, Hope After Rape, and the Trans-cultural Psychosocial Organization- Uganda are all involved in community education programs like health talks or awareness promotion session. These methods have been found effective. A new approach – more like an old approach with a new appreciation – is also yielding impressive results. Family members of the mentally ill are uniquely positioned within society to promote awareness and fight stigma. The community is less likely to discount what they are saying because they are not ill, as

55 Eight of the fourteen attendants were asked these three questions; the other six were interviewed before the questions were included.

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opposed to patients themselves. Caretakers have also been exposed to psych-education through the mental health system and different organizations. In addition, they can offer compelling testimonies to make the community understand important messages, for example, that the mentally ill should not be blamed for their illness. Perhaps most importantly, they have a strong motivation to end stigma. SF in Jinja has had considerable success in using family members to educate communities.

Their grassroots approach is ideal for communities which cannot be easily convinced by a poster or meeting. The members themselves are proof of the success. A few of the members are simply concerned citizens, who were recruited by caretakers. They report that they are involved even though they are not related to a mentally ill individual because they recognize mental illness as the community’s responsibility, and because they know mental illness could happen to anybody. There is an increasing awareness among mental health professionals and organizations that family members are ideal contact points for community psychoeducation. With encouragement and assistance from the mental health system and organizations caretakers could be at the forefront of fighting stigma and raising awareness from mental health issues.

conclusion

In order to maximize the potential of informal caregivers in the treatment of mental illness, they are in need of several types of support. First, the government must to ensure that medications are available, free, and in supply. Mental health care workers and organizations should be lobbying the government for the medications, as well as providing valuable psychoeducation. They should also encourage and promote networking among caretakers. Caretakers can then form groups to support each other psychologically and financially. Finally, if all of the aforementioned parties work together to increase community awareness and understanding of mental illness, then harmful stigma can be avoided, and caretakers will gain more outside support.

In order for caregivers to receive the necessary support, several things must occur. First, decentralization is essential to ensure that the mental health needs of the country are being met. The government’s current method of decentralization is incorporating mental health into primary health care, which is exactly what is needed. There are, however, several limitations to the practical execution of this plan. For one, there is little to no coordination between district hospitals and health centers, district level governments, and community-based organizations. Furthermore, little effort has been made to ensure that the district level MHUs are fully functional. There is little district funding (only federal), and staffing is inadequate. At the local government level, there is almost no planning or implementation because there is no guidance from the district or national level. Record keeping at all levels is insufficient, making it difficult to assess community needs and to lobby for services and resources. Finally, NGO coverage for mental health concerns is low. The NGOs that are in existence operate in small areas of Uganda, leaving most districts without services.56

56 BasicNeeds Uganda, Basic Needs Uganda Baseline Study 2004-2005; The Situation of Mental Health in Kamwokya, Masaka, Hoima, and Masindi (Kampala: BasicNeeds Uganda, 2006).

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While these issues are being addressed, continued research is required to assess the effectiveness of new measures. In particular, findings from this study indicate that there is a need for research that can determine which methods of psychoeducation are most effective in what settings, and what information should be included or excluded. In addition, there is effective work being done on incorporating traditional healers into mental health care. These studies could lead to important changes and improvements in the way mental health services are delivered in Uganda.57

Until infrastructure and resources for mental health service delivery are greatly improved, psychoeducation is an inexpensive and effective intervention. If caretakers and family members of the mentally ill are properly and thoroughly informed about mental illness, they can be much more successful in the caretaking role, even to the point of alleviating some of the burden of the mental health system. Additionally, armed with complete and accurate information, they can serve as a powerful tool in their communities for increased education and awareness.

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57 Okello 2006, 1-43.

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Fazel, Mina and Alan Stein. “The mental health of refugee children.” Arch Dis Child 87 (2002): 366-370.

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Kinyanda, Eugene, H. Hjelmeland, and Seggane Musisi. “Negative Life Events Associated With Deliberate Self-Harm in an African Population in Uganda.” Crisis 26 (2005): 4-11.

Kinyanda, Eugene, Sheila Ndyanabangi, Ruth Ochieng, and Juliet Were Oguttu, eds. Management of Medical and Psychological Effects of War Trauma; Training Manual for Operational Level Health Workers. Kampala: Isis WICCE, 2006.

Kirmayer, Laurence J. “Cultural Variations in the Response to Psychiatric Disorders and Emotional Distress.” Social Science Medicine 29 (1989): 327-339.

Kirmayer, Laurence J., G.M. Brass, and C.L. Tait. “The mental health of Aboriginal people: transformations of identity and community.” Canadian Journal of Psychiatry 45 (2000): 607-616.

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Kohn, David. “Psychotherapy for All: an Experiment.” New York Times, March 11, 2008, US edition.

Lwasa, Shuaib. “Urban Expansion Processes of Kampala in Uganda: Perspectives on contrasts with cities of developed countries.” PERN Cyberseminar on Urban Spatial Expansion. http://www.populationenvironmentresearch.org/papers/Lwasa_contribution.pdf (Accessed May 15, 2008).

Mbulaiteye, S.M., et al. “Alcohol and HIV: a study among sexually active adults in rural southwest Uganda.” International Epidemiological Association (2000): 911-915.

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Equity in HIV/AIDS FundingA Comparison of the Global Fund and PEPFAR

Brian BeachlerPennsylvania State University

ABstrActThe emergence of the Global Fund to Fight AIDS, Tuberculosis and Malaria and the United States President’s Emergency Plan for AIDS Relief (PEPFAR) greatly increased funding for HIV/AIDS. With this influx of aid, it became imperative that all available resources be used equitably. This paper compares the HIV/AIDS programs established through the Global Fund and PEPFAR based upon Margaret Whitehead’s theory of health care equity. After providing a brief history of the epidemic and detailing the current realities of the epidemic, this piece details both funding mechanisms. This paper argues that the Global Fund provides more equitable assistance. Whitehead’s model requires the following three principles for equity in health care: equitable health care must provide equal access to care for equal need; equal utilization for equal need; and equal quality of care for all. By providing fewer restrictions on funding, allotting a greater amount of assistance to a larger number of people, and including more local community members in the assistance process, the Global Fund offers more equitable aid than PEPFAR. Certainly both funding mechanisms have their respective advantages and disadvantages. However, considering Margaret Whitehead’s theory of health care equity, this paper argues that the Global Fund provides more equitable assistance.

introduction The emergence of HIV/AIDS is arguably the worst and most pressing modern

public health crisis. The global epidemic affected over 33 million in 2007 according to UNAIDS estimates.1 Since 1983, when researchers first isolated the retrovirus later to be named the human immunodeficiency virus (HIV), more than 25 million have died from complications, and over 65 million have been infected.2 In 2007, it was projected that 2.5 million people were infected with HIV, and over 2 million people died.3

Concerned donors throughout the world have responded to the widespread crisis. Within the past five years the international community, spearheaded by the United Nations , has responded to HIV/AIDS and the other modern plagues - tuberculosis and malaria with the Global Fund to Fight AIDS, Tuberculosis and Malaria. The United States government under President George W. Bush felt similar concerns and funded the United States President’s Emergency Plan for AIDS Relief (PEPFAR), another initiative to halt the spread of and treat HIV/AIDS throughout the world. Both the Global Fund and PEPFAR have spent billions of dollars attempting to combat HIV/AIDS.

Critics have analyzed the progress of both programs on many levels, but little to no work has assessed the programs within an equity framework. This paper will compare the equity of both funding initiatives. First, a basic background in HIV/AIDS and both

1 S. Barton-Knott, “Revised HIV Estimates,” UNAIDS: Joint United Nations Programme on HIV/AIDS, http://data.unaids.org/pub/EPISlides/2007/071118_epi_revisions_factsheet_en.pdf.2 M. Merson, “The HIV-AIDS Pandemic at 25 – The Global Response,” The New England Journal of Medi-cine 354 (June 8, 2006): 2414-2417. 3 UNAIDS, AIDS epidemic update: December 2007 (Geneva: World Health Organization, 2007).

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programs will summarize the necessary historical perspective. This will be followed by a discussion on the structure of equity in foreign aid as provided by Margaret Whitehead’s theory of health care equity. Once the framework for equity in foreign aid is established, an analysis on which program provides more equitable treatment will follow.

HIV/AIDS at one time was a relatively obscure infection, only thought to affect gay men, Haitian immigrants, and drug abusers. In 1981, researchers first identified a new disease causing immune deficiency in young homosexual men in the states of California and New York. Scientists slowly uncovered more about the disease during the 1980s. At the same time, an enormous stigma prevented wide-spread education or acceptance of the up-and-coming epidemic throughout the world. In the late 1980s and 1990s the undiscriminating nature of the virus became apparent as the disease spread outside of stigmatized groups to notable celebrities and millions of others across the world. Fortunately, scientists made major medical advances during the mid-to-late 1990s concerning prevention and treatment of HIV/AIDS, which included the effectiveness of Azido-Thymidine (AZT) and antiretroviral (ARV) treatments. AZT and ARV treatments respectively decreased the spread of the infection from mother to child and suppressed the progression of the disease. As a result of these scientific breakthroughs, the incidence in many developed nations is now declining or stagnant, and HIV-positive patients often live for many years if they receive proper treatment.

Despite the miraculous breakthroughs concerning new medication available to quell the epidemic, millions of people throughout the world do not receive treatment for the disease.4 Unfortunately, two-thirds of HIV/AIDS cases occur in Sub-Saharan Africa where many health systems cannot support adequate prevention or treatment.5 In 2001, the international community began to realize the necessity of creating an independent funding body for HIV/AIDS. In that same year, then United Nations Secretary-General Kofi Annan called for the need of a funding body that would help quell the modern plagues of tuberculosis (TB), malaria, and HIV/AIDS. He argued that it was imperative to increase funding in prevention and treatment of these diseases, as well as support local health systems.6 After widespread support from the United Nations and African leaders, and with funding from G8 countries, the Global Fund was founded in 2002 as a unique private-public funding mechanism for countries burdened by HIV/AIDS, malaria, and TB.

The Global Fund’s core objectives are to provide increased resources to prevent and treat malaria, TB, and HIV/AIDS. The independent organization prides itself on involving participation from wide-ranging entities including political activists, government officials, the affected community, and the private sector in the decision-

4 The Kaiser Family Foundation, “U.S. Global Health Policy,” Global Health Facts.org, http://www.global-healthfacts.org/topic.jsp.5 UNAIDS, UNAIDS 2008 report on the global AIDS epidemic (Geneva: World Health Organization, 2008).6 Kofi Annan, “Secretary-Gereral Proposes Global Fund for Fight Against HIV/AIDS and other Infec-tious Diseases at African Leaders Summit,” United Nations Press Release, http://www.un.org/News/Press/docs/2001/SGSM7779R1.doc.htm.

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making process.7 Weary of the intensely political bilateral agreements between nations, the Global Fund desires to present humanitarian aid that is effective rather than politically symbolic. The Global Fund is unique in that it does not implement its own programs; rather, the Global Fund provides grants to governments, community groups, and non-governmental organizations (NGOs).

The United States government and the international community had similar concerns regarding the HIV/AIDS epidemic. A diverse group, ranging from liberal HIV/AIDS and foreign development activists to conservative religious leaders, joined forces with the Bush administration to appropriate a serious commitment to combat HIV/AIDS in Africa. The support of the Bush administration and republican senators Bill Frist and Jesse Helms proved crucial in building a bipartisan alliance for the passage of major legislation.8 In his 2003 State of the Union Address, President Bush announced a $15 billion proposal for HIV/AIDS prevention and treatment. PEPFAR has proved to be the largest humanitarian program by one country.

PEPFAR and the Global Fund have been extremely effective at combating HIV/AIDS throughout the world. According to a 2009 study, PEPFAR prevented 1.1 million deaths through ARV treatment.9 The Global Fund has demonstrated similar success. By 2004 it had provided 2 million people with ARV treatment and supported over 1.7 million AIDS orphans.10 Because of the mutual success, it is important to note that one program is not inherently better than the other. Both funding mechanisms have made a difference in countless lives, and it is not the objective of this paper to belittle either intitiatve’s accomplishments. Rather, the equity of the aid allocation will be analyzed. Subsequent analysis will demonstrate that, when evaluating the funding mechanisms using Margaret Whitehead’s theory of health care equity, the Global Fund provides more equitable funding.

literAture review

The number of people living with HIV/AIDS has risen from approximately 3 million people in 1990 to the current estimate in 2007 of 33 million people. The epidemic’s rate of growth has decreased considerably, but there are still an increasing number of people living with HIV/AIDS. Despite the estimate that two million people died from HIV/AIDS in 2007, there are an increasing number of individuals living with HIV, as infections outpace deaths. Figure 1 summarizes the growth of the epidemic within the last fifteen years and it demonstrates that, although global prevalence is stagnate, the number of people with HIV/AIDS has continued to increase.

7 R. Brugha et al., “The Global Fund: managing great expectations,” The Lancet 364.9428 (3 July-9 July 2004): 95-100.8 J. Dietrich, “The politics of PEPFAR: The president’s emergency plan for AIDS relief,” Ethics & Interna-tional Affairs 21.3 (Fall 2007): 277-292.9 S. Dinan, “Bush AIDS fight saved 1.1M, study says,” The Washington Times, April 7, 2009, Section A01, U.S. Edition.10 J. Guiver, “The Global Fund to Fight AIDS, Tuberculosis and Malaria,”Avert, http://www.avert.org/global-fund.htm.

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Despite treatment and prevention efforts, the HIV/AIDS epidemic continues to infect and kill millions of people every year.11 After getting past the pure magnitude of the epidemic, it is imperative to recognize the geographic disparities that exist. Figure 2 lists prevalence, incidence, and mortality rates by geographical region. The severity of the epidemic within Sub–Saharan Africa is evident through the data within Figure 2.

Not surprisingly, future projections of the epidemic estimate that the disease will most severely affect Sub-Saharan Africa. More specifically, countries within Southern Africa face the largest burden by HIV/AIDS. Of all nations throughout the world and Africa, Southern African nations such as Botswana, Namibia, Swaziland, South Africa, Lesotho, and Zimbabwe all have the highest prevalence rates. Figure 3 displays the prevalence of HIV/AIDS among adults by country throughout Africa.

Figure 1. Estimated Number of People Living with HIV

Source: UNAIDS 2008 Report on the Global AIDS Epidemic

Figure 2. Regional HIV and AIDS statistics and Features, 2007

Source: UNAIDS 2008 Report on the Global AIDS Epidemic

11 UNAIDS 2008.

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Figure 3. 2007 HIV Prevalence in Africa by Country

Source: Joint UN Programme on HIV/AIDS

review of PePfAr And the gloBAl fund

PEPFAR has evolved over time. In 2008, Congress reauthorized and expanded PEPFAR by appropriating 48 billion dollars for HIV/AIDS, Malaria, and TB.12 Over a five-year span, PEPFAR will allot 39 billion dollars for HIV/AIDS prevention and treatment. Between 2003 and 2008, before the legislation was reauthorized, PEPFAR had several stipulations for receiving aid. Legislation required 55% of the money to fund treatment for individuals, 10% to orphans or vulnerable children, 15% to palliative care, and 20% to go toward prevention, of which one third must be spent on abstinence programs.13 In addition to these requirements, PEPFAR provides assistance to over 100 countries, but the main funding goes to 15 focus nations, which are: Botswana, Côte d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam and Zambia.14

12 N. Bristol, “US Senate passes new PEPFAR Bill,” The Lancet 372.9635 (26 July-1 August 2008): 277-278. 13 A. Kanabus, “The U.S. President’s Emergency Plan for AIDS Relief,” Avert, http://www.avert.org/pep-far.htm.14 N. Oomman, “Following the Funding for HIV/AIDS: A Comparative Analysis of the Funding Practices of PEPFAR, The Global Fund and World Bank MAP in Mozambique, Uganda and Zambia,” Center for Global Development, http://www.cgdev.org/content/publications/detail/14569.

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The Global Fund model has a unique structure in the manner that it allocates aid. Each nation that desires funding must establish a Country Coordination Mechanism (CCM), which is a group made up of individuals ranging from activists to government officials from the recipient nation.15 The CCM must submit country-specific grant proposals to the Technical Review Panel, an international non-partisan expert committee that determines which grants proposals to fund. Once approved, the Principal Recipient receives the grant, and an independent agency known as the Local Fund Agent (LAF) assesses the implementation of the funding. The LAF observes and report on the progress, usage, and effectiveness of the grant.16 After two years, the LAF will make a recommendation to renew, modify, or discontinue the program. This comprehensive model allows for the Global Fund to obtain an independent review of the effectiveness of the aid.

In addition to providing the necessary medicines and prevention material, the Global Fund also believes in improving infrastructure in order to combat the epidemic using a horizontal approach. Horizontal funding promotes the development of health systems whereas vertical funding focuses solely on disease specific initiatives.17 By funding horizontally, the Global Fund does not only provide aid for ARVs and condoms, but funding will improve medical facilities and develop an infrastructure that can effectively utilize the monetary support. Horizontal funding considers the training of nurses and the construction of facilities in rural areas as equally essential to providing funding for ARV therapy in combating HIV/AIDS.

equity frAmework In order to properly evaluate equity in foreign aid, Dr. Margaret Whitehead’s

theories on equity in health will be used to compare PEPFAR and the Global Fund. Whitehead argues that in order for differences to be considered inequities, the differences must not only be unnessecary and avoidable, but also unfair and unjust.18 The judgement of something to be considered unfair is not a concrete yes or no response, but involves providing context for the judgment. Discerning inequities requires context. In evaluating equity one must consider the broad societal forces and a comparable situation that is not inequitable. Therefore, in order to properly evaluate equity, there must be a standard of what equity is. Whitehead summarizes by adding, “Equity is therefore concerned with creating equal opportunities for health and with bringing health differentials down to the lowest level possible.”19 Once societal forces that contribute to inequities are nonexistent and citizens are presented with fair choices and chances of how to live their lives, equity is attained. Whitehead continues to elaborate on equity in

15 Brugha et al. 2004.16 Ibid.17 V. Roy, “Horizontal, vertical, or diagonal?” GlobeMed, http://www.globemed.org/blog/posts/horizon-tal-vertical-or-diagonal/.18 G. Allenye, “Principles and basic concepts of equity and health,” Re Pan American Health Organization, http://www.paho.org/english/hdp/hdd/pahowho.pdf.19 Whitehead 1999.

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health by providing three principles necessary for equity in health care: equitable health care must provide equal access to care for equal need, equal utilization for equal need, and equal quality of care for all.20

Allocating equal resources for equal need is defined as horizontal equity. Whitehead argues that frequent barriers should not prevent equitable care. Common barriers include discrimination of health care by sex, income, race, age, and religion. It is also essential to ensure citizens have equal access to care. In order to ensure equity, equal opportunity to care must exist even through larger systemic barriers such as geographical location and the inadequate infrastructure of certain regions.

Adapting Whitehead’s equity framework to foreign aid requires some modifications. The basic principles remain. Equitable aid distribution must be just and fair. Instead of focusing on providing equitable opportunities, the goal in equitable aid is to provide equitable resources based upon need. Following the ideology of horizontal equity outlined by Whitehead, equal resources should be allocated when there is equal need. For example, equitable aid would provide two communities with identical HIV infection rates equal resources regardless of geographic, social, or political barriers.

The second aspect of Whitehead’s theory on equity in health care, equal utilization for equal need, should also be considered as a principle for equity in foreign aid. Whitehead argues that even if unequal utilization of resources based upon demographic variables occurs, the scenario itself is not inherently inequitable.21 On the contrary, researchers should investigate the explanations of why utilization rates vary among different groups. If the differences result from free choice, then the situation is not inequitable. However, if the utilization differences result from economic, social, or political barriers, the circumstance may likely be inequitable.22 Considering foreign aid, allocation functions as representative comparison to utilization. Nations have historically allocated unequal amounts of foreign aid, and it remains a problem today. When nations are differentially allocated aid, the difference is not inherently inequitable. Rather, the differences must be understood. If nations do not have the capacity to effectively administer ARV treatment to hundreds of thousands of citizens, less funding should be allotted. However, if reduced or no aid is provided because of political explanations, the funding is inequitable. Foreign aid funding should not be politically motivated; it should be an equitable process that has humanitarian considerations.

Whitehead’s last consideration of equity in health care is equal quality of care for all. She argues that citizens should not receive inferior treatment based upon social, economic, or political reasons.23 The same concept applies directly to foreign assistance. All recipients of the assistance should attain similar quality from the results. No recipient should receive second-rate supplies while another benefits fully from the aid.

Expanding on the notion of horizontal equity in foreign aid, not only should equal

20 M. Whitehead, “The concepts and principles of equity and health,” Health Promotion International 6.3 (1991): 217-228.21 Whitehead 1991.22 Ibid.23 Ibid.

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resources be provided for equal need, but certain nations or groups of people should not be excluded. Foreign aid has almost always had additional political motivations rather than being solely humanitarian in nature. Citizens should not suffer the consequences of not receiving foreign aid because of conflicting political ideologies between the donor and recipient nation. For example, a communist nation refusing to give foreign aid to a capitalist nation, based purely on the conflicting economic systems, would be considered inequitable.

In addition to her theory on equity, Whitehead provides principles to pursue in order to create equitable policies. These include: improving living and working conditions, enabling people to live healthier lifestyles, involving the public in the policy-making process, making equity decisions based upon research, and intervening on the international level.24 Improving living and working conditions, involving the public and policy-making process, and intervening on the international level all have direct implications to foreign aid. The concepts are not intrinsic within the theory of equity, but the fulfillment of these policies can create equitable health care systems. Both PEPFAR and the Global Fund have policies that attempt to meet the concerns of Dr. Whitehead.

discussion

When considering Margaret Whitehead’s theory of equity, the Global Fund provides more equitable aid than PEPFAR. PEPFAR and the Global Fund have their distinct advantages and weaknesses, but employing Whitehead’s equity framework, I conclude that the Global Fund provides more equitable treatment. Both funding mechanisms require reform in order to incorporate community, governmental, corporate, and international involvement. Moreover, the Global Fund has fewer funding restrictions, which allows a greater number of nations and groups receive aid. Additionally, the Global Fund allocates funds in a more horizontal manner, which facilitates improvements for health systems. These critiques should not quiet the successes of PEPFAR, including the millions of people who have received life-saving ARV treatment.25 However, because of the manner in which both funding initiatives are structured, the Global Fund provides more equitable treatment.

Both initiatives need to involve local communities in the policy-making process. Although the structure of the Global Fund allows for more community involvement in the allocation of grants, early results have shown limited integration of the community.26 In a study by Brugha et al., CCMs were dominated by the government in most cases, which hindered public involvement. Margaret Whitehead stressed establishing community involvement in the policy-making process in order to create equity. In the grant-making process for the Global Fund, the CCM ideally engages individuals who represent various institutions such as the government, business, and the affected

24 Ibid.25 Dinan 2009.26 Brugha et al. 2004.

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community of the recipient nation. As noted earlier, the CCM is responsible for writing grants to be reviewed, so if community leaders take part in the CCM, they have an integral role of policy-making.

Within PEPFAR there is a smaller role for community members of the recipient nation in the policy-making process. Most funding decisions come from the Office of the U.S. Global AIDS Coordinator (OGAC) in Washington.27 Country specific management of PEPFAR is run by United States staff employed by USAID, CDC, Department of Defense, the Department of Labor, the Peace Corps, and the US Embassy within the recipient nation.28 The United States staff collaborates with the host country government to implement a country operational plan every year, but community members of the recipient country are not directly involved with the planning. Neither initiative has an excellent background at involving the locals of the recipient nation. The Global Fund has a framework that can incorporate community members, while PEPFAR should alter its structure to engage locals of the recipient nation in policy decisions.

From 2003 to 2008 PEPFAR legislation restricted care from certain groups of people, which was inherently inequitable. Whitehead’s theory of health care equity states that equal access, utilization, and quality of care should be attained by all individuals.29 The original PEPFAR legislation from 2003 to 2008 prevented funding to any foreign nongovernmental organizations that provide any abortion services. Known as the “Mexico City” policy, this broad family planning restriction limited the distribution of condoms and educational materials under a mandate that crippled multiple family planning NGOs.30 In early 2009, the Obama administration reversed the Mexico City policy and now these family planning agencies have access to PEPFAR funds.31 This is an indication that government policies can change over time when new leadership is in place. Another restriction before the Obama administration took office was a moratorium on funding toward needle exchange programs. Needle exchange programs have been proven effective to reduce the incidence of HIV/AIDS among drug users.32

A restriction that has been ingrained within PEPFAR since 2003 has been requiring recipients of aid to sign a pledge opposing prostitution and sex trafficking.33 Opponents of this policy argue that such a clause prevents confronting one of the most vulnerable and dangerous groups for acquiring and spreading the disease. This restriction alienates sex workers, as interventions cannot reach this high-risk group. In 2005 Brazil rejected 40 million dollars in aid from PEPFAR citing that accepting the pledge of opposition

27 Oomman 2007.28 Kanabus 2007.29 Whitehead 1991.30 Bristol 2008.31 M. Sessions, “Overview of the president’s emergency plan for AIDS relief (PEPFAR),” HIV/AIDS Monitor, Center for Global Development, http://www.cgdev.org/section/initiatives/_active/hivmonitor/funding/pepfar_overview#1.32 Bristol 2008.33 Kanabus 2009.

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would endanger sex workers and their clients from acquiring necessary protection.34 The mentioned restrictions limit the reach of PEPFAR. These politically motivated limitations reflect the opinions of the politicians who passed the legislation. The restrictions may have been necessary in order to pass legislation, but the restrictions create inequities for the recipients.

The Global Fund does not restrict aid in the manner that PEPFAR does. Within the structure of the Global Fund, the grant proposal process allows any CCM to apply for funding. The technical review panel decides to whom the Global Fund will allocate funding. This process may slow the disbursement of funding, but it does not inherently restrict funding to certain groups.35

In addition to the noted restrictions on aid from PEPFAR, focusing the vast majority of aid on 15 “focus nations” excludes millions of people who also require HIV/AIDS treatment. Ninety-two percent of the funding for PEPFAR goes to the 15 focus nations.36 This funding benefits millions in the selected countries, but the PEPFAR aid rarely reaches people outside the 15 focus countries. As of 2009, the Global Fund has provided over 10 million dollars to over 73 nations.37 Up until 2008 PEPFAR funded approximately 4 billion dollars to HIV/AIDS, giving over 10 million or more to only 23 nations.38 Table 1 summarizes the amount of funding distributed by PEPFAR and the Global Fund to 23 nations sorted by the amount of funds each country has received.

As displayed in Table 1, PEPFAR provides an extraordinary amount of funding to a few nations, while the Global Fund provides a smaller amount of funding to a greater number of nations. HIV/AIDS treatment and prevention does not reach every citizen in either program, but the Global Fund method of disbursing aid is more equitable because it promotes access to a more diverse group of people as more nations are served. Having CCMs write grants allows funding to be distributed to a larger number of nations. Table 1 demonstrates that both initiatives have donated large sums of money to countries with great need.

Surprisingly, not all Southern African nations with the highest HIV prevalence in the world receive the most aid. Four Southern African nations appear in the top ten of disbursements for both initiatives, but nations with high HIV/AIDS infection rates such as Zimbabwe, Lesotho, and Botswana do not appear in the top ten of either list. Unstable governments, relatively small populations, and many other factors help explain the disparity between HIV prevalence and funding. When evaluating equity by examining the amount of funding, it is important to understand the entire set of circumstances before classifying a situation as unfair or unjust.

34 Ibid.35 Guiver 2009.36 The Global Fund, “Funding Decisions - Grant Portfolio,” The Global Fund to Fight AIDS Tuberculosis and Malaria, http://www.theglobalfund.org/en/fundingdecisions/.37 The Kaiser Family Foundation 2008.38 Ibid.

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Table 1. Total Aid Donated Directed toward HIV/AIDS: PEPFAR vs Global Fund

PEPFAR Global Fund

Rank Country Amount Rank Country Amount

Global $3,999,535,858 Global $4,516,112,464

1 South Africa $590,897,685 1 Ethiopia $404,268,659

2 Kenya $534,794,604 2Tanzania (United

Rep. of)$243,312,051

3 Nigeria $447,635,679 3 India $220,117,696

4 Ethiopia $354,539,354 4 Malawi $189,174,001

5Tanzania

(United Rep. of)$313,415,559 5 Zambia $179,560,187

6 Uganda $283,635,476 6 Russian Federation $179,415,268

7 Zambia $269,246,552 7 China $172,270,427

8 Mozambique $228,624,654 8 South Africa $152,810,440

9 Rwanda $123,468,840 9 Thailand $134,565,001

10 Cote d’Ivoire $120,537,903 10 Ukraine $128,135,782

11 Namibia $108,864,477 11 Rwanda $124,930,156

12 Haiti $100,646,286 12 Haiti $104,263,455

13 Botswana $93,159,747 13Congo (Dem. Republic of)

$97,551,814

14 Viet Nam $88,855,000 14 Nigeria $91,278,915

15 India $29,829,900 15 Mozambique $88,274,817

16 Zimbabwe $26,366,350 16 Cambodia $79,233,084

17 Malawi $23,862,300 17 Namibia $78,484,360

18 Guyana $23,799,308 18 Kenya $75,614,063

19 Cambodia $17,898,750 19 Uganda $72,522,979

20Congo (Dem. Republic of)

$15,413,330 20 Swaziland $67,202,255

21 Lesotho $13,127,910 21 Cameroon $64,321,294

22 Swaziland $12,731,960 22 Ghana $63,389,207

23Russian

Federation$12,000,000 23 Sudan $51,656,484

Source: The Henry J. Kaiser Family Foundation

The Global Fund allocates aid in a more horizontal approach than PEPFAR. Whitehead argued that in order to establish health equity working and living conditions should be improved along with promoting healthy lifestyles. Horizontal funding is more likely to promote healthy lifestyles and improve working conditions than vertical funding. Therefore, by promoting horizontal funding, the Global Fund also promotes equity in aid allocation.

Although PEPFAR and the Global Fund are both vertical funding initiatives designed to combat HIV/AIDS, they also serve as mechanisms for health system development. Before 2008, the main focus of PEPFAR was to focus on disease

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specific interventions such as prevention and treatment of HIV/AIDS. However, with the reauthorization of PEPFAR in 2008, the legislation plans to train over 140,000 health care workers throughout the recipient nations.39 The addition of this goal by American politicians displays a new dedication to horizontal funding and health system development. In 2009, 42% of aid through the Global Fund went to horizontal commitments that included infrastructure, administration, human resources, and training.40 As is evident from the large sum, the Global Fund champions the development of health systems. Both initiatives demonstrate a commitment to horizontal funding, but the Global Fund has displayed it as a higher priority.

conclusion

When using Whitehead’s theory of equity, the Global Fund provides more equitable aid than PEPFAR. However, both initiatives need to improve community involvement in the policy-making process in order to establish equitable policies. The Global Fund already has the necessary framework to engage a local perspective, but in some cases it needs to be used more effectively. A CCM should not be dominated by the government, and it should include a community perspective in order to follow the principles provided by Whitehead. PEPFAR should broaden the in-country staff outside of US officials to embrace a local perspective within the policy-making process. Until community members of the recipient nation partake in policy discussions, PEPFAR will fall short of adhering to the principal of community involvement as outlined by Whitehead.

The Global Fund has fewer restrictions and necessary conditions for donor recipients. Whitehead encouraged access to all when detailing the ideals of health equity. The Global Fund grant review and proposal process does not limit applicants in any way, and more nations and a wider range of groups have received funding because of these policies. PEPFAR has several politically motivated guidelines and limitations on whom and under what conditions a group will receive funding. These restrictions limit access to treatment and prevention to many, which by Whitehead’s theory is inequitable. In addition, the Global Fund allocates funds in a more horizontal manner than PEPFAR, which facilitates improvements for health systems. Improving health systems has implications for developing primary care and living conditions.

From this information, it is evident that the Global Fund provides more equitable aid than PEPFAR when considering Whitehead’s theory of health care equity. This conclusion should not be misconstrued to argue that the Global Fund is better than PEPFAR. Moreover, the claims presented within this paper only represent the equity framework provided by Whitehead; other theories of equity could argue that PEPFAR is more equitable than the Global Fund.

Future investigations should evaluate the evolution of both initiatives over time. The United States Congress drastically changed many aspects of PEPFAR in a five year span from its first authorization in 2003 to its reauthorization in 2008. As time progresses, the Global Fund and PEPFAR will both adapt. By comparing these initiatives with equity

39 Bristol 2008.40 The Global Fund 2009.

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in mind, an individual can construct a fair and just system for aid allocation. The relative strengths and weaknesses of both funding mechanisms should be considered to improve both projects. It is important to remember that both funding mechanisms have the same goal in mind. As the Global Fund and PEPFAR continue to age, hopefully they will develop a more equitable approach to aid allocation, while promoting a more equitable world through the reduction of HIV/AIDS.

references

Allenye, G. “Principles and basic concepts of equity and health.” Re Pan American Health Organization. http://www.paho.org/english/hdp/hdd/pahowho.pdf (Accessed May 2, 2009).

Annan, K. “Secretary-Gereral Proposes Global Fund for Fight Against HIV/AIDS and other Infectious Diseases at African Leaders Summit.” United Nations Press Release. http://www.un.org/News/Press/docs/2001/SGSM7779R1.doc.htm (Accessed May 2, 2009).

Barton-Knott, S. “Revised HIV Estimates.” UNAIDS: Joint United Nations Programme on HIV/AIDS. http://data.unaids.org/pub/EPISlides/2007/071118_epi_revisions_factsheet_en.pdf (Accessed May 2, 2009).

Bristol, N. “US Senate passes new PEPFAR Bill.” The Lancet 372.9635 (26 July-1 August 2008): 277-278.

Brugha, R., M. Donoghue, M. Starling, P. Ndubani, and F. Ssengooba. “The Global Fund: managing great expectations.” The Lancet 364.9428 (3 July-9 July 2004): 95-100.

Dietrich, J. “The politics of PEPFAR: The president’s emergency plan for AIDS relief.” Ethics & International Affairs 21.3 (Fall 2007): 277-292.

Dinan, S. “Bush AIDS fight saved 1.1M, study says.” The Washington Times, April 7, 2009, Section A01, U.S. Edition.

Global Fund, The. “Funding Decisions - Grant Portfolio.” The Global Fund to Fight AIDS Tuberculosis and Malaria. http://www.theglobalfund.org/en/fundingdecisions/ (Accessed May 2, 2009).

Guiver, J. “The Global Fund to Fight AIDS, Tuberculosis and Malaria.” Avert. http://www.avert.org/global-fund.htm (Accessed May 3, 2009).

Kaiser Family Foundation, The. “U.S. Global Health Policy.” Global Health Facts. http://www.globalhealthfacts.org/topic.jsp (Accessed May 2, 2009).

Kanabus, A. “The U.S. President’s Emergency Plan for AIDS Relief.” Avert. http://www.avert.org/pepfar.htm (Accessed May 2, 2009).

Merson, M. “The HIV-AIDS Pandemic at 25 – The Global Response.” The New England Journal of Medicine 354 ( June 8, 2006): 2414-2417.

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Oomman, N. “Following the Funding for HIV/AIDS: A Comparative Analysis of the Funding Practices of PEPFAR, The Global Fund and World Bank MAP in Mozambique, Uganda and Zambia.” Center for Global Development. http://www.cgdev.org/content/publications/detail/14569 (Accessed May 2, 2009).

Roy, V. “Horizontal, vertical, or diagonal?” GlobeMed. http://www.globemed.org/blog/posts/horizontal-vertical-or-diagonal/ (Accessed May 3, 2009).

Sessions, M. “Overview of the president’s emergency plan for AIDS relief (PEPFAR).” HIV/AIDS Monitor. Center for Global Development. http://www.cgdev.org/section/initiatives/_active/hivmonitor/funding/pepfar_overview#1 (Accessed May 2, 2009).

UNAIDS. AIDS epidemic update: December 2007. Geneva: World Health Organization, 2007.

UNAIDS. UNAIDS 2008 report on the global AIDS epidemic (Annex 1). Geneva: World Health Organization, 2008.

Whitehead, M. “The concepts and principles of equity and health.” Health Promotion International, 6.3 (1991): 217-228.

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Making TRIPS WorkA South African Case Study

Geoffrey LevinMichigan State University

ABstrAct Advances in modern medical technology have saved millions of lives in the developed world, but have created a new moral quandary with which scholars, leaders, and businessmen must now grapple. While manufacturing pills and other remedies may be inexpensive, research and development requires millions of dollars of investment. Who should ultimately pay the research costs, especially considering the suffering of the sick and impoverished in places like Africa? In line with contemporary views on intellectual property, many believe that the company that owns the rights to a new treatment should be able to defend its patent rights all over the world, allowing pharmaceutical companies to charge incredibly high amounts to sick and desperate people. After the United Nations added the Trade-Related Aspect Intellectual Property Rights, or TRIPS, provision to the WTO, WTO member countries were forced to protect the intellectual property rights of foreign corporations. This created a humanitarian crisis in places like South Africa, where HIV victims could not afford legal HIV drugs and were denied access to cheap generic alternatives. This case study sheds light on the larger issue of intellectual property rights and Africa’s lack of access to medical treatments that are considered basic and inexpensive in the developed world.

introduction: is triPs triPPing uP the Progress of develoPing countries?Each day, AIDS kills nearly 5,500 people around the world. Another 2.7 million

people are infected with HIV, the precursor to AIDS, each year.1 The majority of these victims live on the African continent in some degree of poverty. The AIDS crisis is one of the most pressing problems facing the world today, yet few would imagine that the AIDS crisis is an important case study for world intellectual property law, stimulating a worldwide debate. TRIPS, the World Trade Organization’s (WTO) provision on intellectual property, led to protests across the globe, most notably in South Africa, a G20 nation with a 25% HIV infection rate.2 Despite their emerging-market status, millions of South African HIV victims were simply unable to afford the inflated prices charged by the American drug companies that held the patents to life-saving antiretroviral drugs. In light of the public health crisis, South Africa took action by breaking the TRIPS provision and importing a cheap Indian generic HIV drug, triggering a worldwide debate and a confrontation with the U.S. pharmaceutical industry. Clearly, exceptions for public health crises had to be made, and the Doha Declaration, which amended TRIPS, created such exceptions. Overall, however, more must be done to prevent unnecessary deaths resulting from inadequacies in international intellectual property law.

As long as patents have existed, the idea of intellectual property rights has been heavily contested. While the merits of patent laws are still debated within academic settings, it is generally accepted among developed countries that intellectual property laws are necessary to provide incentive for innovation. These developed countries

1 Avert, “Worldwide HIV and AIDS Statistics,” Avert: HIV and AIDS, http://www.avert.org/worldstats.htm.2 Ibid.

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inserted intellectual property laws into the General Agreement on Tariffs and Trade (GATT) and later the WTO. The agreement was on the Trade-Related Aspects of Intellectual Property Rights, or TRIPS, and includes rules requiring countries to enforce international trademarks, copyrights, and patents. Many advocates for developing countries criticize TRIPS on various grounds. Some claim that such restrictions keep nations from developing by forcing increased dependence on the developed world. Most controversially, TRIPS institutionalized the idea that “…imports of the patented product or products made by the patented process constitute working the patent.”3 This provision makes it more difficult for many people to buy the goods or medicines they need, as it effectively raises the price, therefore further hindering economic development in the Third World by sucking up its income.

give the PeoPle whAt they need!

Most of the time, developing countries give in to TRIPS’ demands, as they fear that the United States will impose painful unilateral retaliatory trade sanctions if they do not enforce patent laws. An example of an agreement conceptually similar to TRIPS was the 1998 “Africa Growth and Recovery Act”, which was promoted as a way to help African countries’ governments and economies by “tying economic benefits to economic reforms.”4 However, it was essentially a tariff reduction act that forced African governments to protect American intellectual property rights and implement market-friendly reforms; any country that did not comply would face economic repercussions, thus inspiring Congressman Jessie Jackson Jr. to label it the “African Recolonization Act.”5 But in the case of HIV antiretroviral drug cocktails, at least one country was willing to take its chances. In the 1990s, an American pharmaceutical company created an HIV antiviral cocktail that prevented HIV from turning into lethal AIDS. While a year’s worth of the patented product cost about $15,000, a generic brand made in India, which had no such patent restrictions, sold for $200 a year.6 As nearly 25% of its population was HIV-positive, South Africa declared it was in a state of emergency and imported the affordable Indian alternative.7 The American pharmaceutical companies sued, but those advocating for developing countries fought back, claiming that it was highly immoral to prohibit sick people from buying the only type of life-saving drug they could afford.

The resulting lawsuit caught the attention of the world, but not the type of attention that the pharmaceutical companies wanted. Their actions and their lawsuit was condemned and criticized by many in the international community; even many TRIPS advocates were too ashamed by the companies’ gross display of greed and

3 David N. Balaam and Veseth, Michael, Introduction to International Political Economy, 3rd ed., (Upper Saddle River, NJ: Pearson Prentice Hall, 2005), 231.4 William K. Tabb, The Immoral Elephant: Globalization and the Search for Social Justice, 1st ed., (New York City: Monthly Review Press, 2001), 1530. 5 Ibid., 154.6 Balaam and Veseth 2005, 233.7 Avert 2009.

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callousness to stand up for them. The incident caused a great deal of embarrassment for the pharmaceutical corporations, so much so that they not only dropped the suit, but also worked out a deal with South Africa and other developing nations to sell them the drugs at a greatly reduced price.8 Of course, even this deal worked out to the US drug companies’ advantage, as they still were able to hold onto the African market and sold their medicines for slightly more than the Indian companies did, while also decreasing the incentive for South Africa to work to develop its own pharmaceutical industry.9 However, many continue to fight against international patent laws under the same banner, arguing that preventing people around the world from getting the products they need at wholesale prices is patently unethical.

the dohA declArAtion: An internAtionAl solution or A gloBAl BAnd-Aid?

In response to the uproar over the South African incident, the developing world began a major push to amend TRIPS. The resulting amendment, called the Doha Declaration, was adopted in November 2001. It stated in unequivocal terms that:

The TRIPS Agreement does not and should not prevent Members from taking measures to protect public health…we reaffirm the right of WTO Member to use…the provisions in the TRIPS Agreement, which provide flexibility for this purpose…Each Member has the right to grant compulsory licenses…(and) to determine what constitutes a national emergency.10

Essentially, the Declaration permitted all WTO members to grant compulsory licenses whenever they deemed it was necessary to combat an epidemic or national emergency. A compulsory license is a license that a government may grant to one of its own companies to allow that company to manufacture a patented product and thus break the patent rights of the inventing corporation without its permission. In addition, the Declaration allows “WTO Members with insufficient or no manufacturing capabilities in the pharmaceutical sector” to work with the WTO to find an expeditious solution, such as importing cheap generic drugs from non-TRIPS signatories like India.11 whAt ABout the Big Picture?

Even if pharmaceutical companies were simply greedy, there is far more to their argument in general than in that specific incident. The merits of TRIPS are easiest to see by envisioning a world in which international pharmaceutical patents did not exist. There likely would be no HIV drug cocktails, as wealthy investors would refuse to invest the massive sums of money required to research for the cure because they would know that

8 The Economist, “The right to good ideas; How patents help the poor,” The Economist 359.8227 (June 23, 2001): 27-30. 9 Balaam and Veseth 2005, 235.10 WTO, “Obligations and Exceptions Under TRIPS,” World Trade Organization, http://www.wto.org/english/tratop_e/trips_e/factsheet_pharm02_e.htm.11 Ibid.

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the pharmaceutical company would not be able to recoup those expenses if people could legally purchase cheap generic alternatives. For example, US drug companies estimate that they lose almost $500 billion in sales because India, a non-TRIPS nation, allows its companies to make unlicensed generic drugs. Not only does this hurt the companies’ profit margins, it means that this is $500 million that these companies cannot use for further HIV drug research.12 Additionally, people often forget that patentees must “provide a detailed description of their invention.”13 Often times, other companies use this public information to innovate even further. Without patent laws, companies would keep their innovations secret to cut out competitors, yet in the process they would also prevent other companies from adding onto their current innovation.

stiglitz And intellectuAl ProPerty lAw: Better mAnAgement needed

According to economist Joseph Stiglitz, “Intellectual property does not really belong in a trade agreement.”14 Yet the United States has continually pushed for more and more intellectual property protections in their trade agreements, despite the protests of other countries. For example, Stiglitz cites the 2004 protests in Rabat and Paris where people “took to the streets to protest a proposed new trade agreement between the United States and Morocco that they feared would ban Moroccan companies from manufacturing AIDS drugs.”15 This said, it is surprising how hard the United States pushed for the controversial TRIPS provision in the WTO. The US has continued to go out of its way to protect the economic intellectual property interests of its corporations, insisting that all countries accept its conditions. Stiglitz says explicitly that the TRIPS provision should not exist, and questions how much it had done to increase innovation in comparison with the inefficiencies and high costs it engendered.

That being said, Stiglitz does offer solutions to make international intellectual property laws fairer and more efficient, again stressing that like globalization itself, IPRs are not inherently bad; they are just being mismanaged. He acknowledges that innovation is important, but questions how much TRIPS actually adds to innovation, explaining how “poorly designed intellectual property regimes not only reduce access to medicine, but also lead to a less efficient economy, and may even slow the pace of innovation.”16 He advocates not for the abolition of international intellectual property rights, but rather for a better and more balanced intellectual property system. He starts by pointing out the differences between normal property laws and intellectual property laws. Property rights “provide incentives to take care of your property and put it to best use, but these rights are not unfettered; uses which impede economic efficiency or infringe upon the well being of others” are restricted. There are no such restrictions

12 The Economist 2001.13 Paulo Bifani, “International Stakes of Biotechnology and Patent Wars,” Agriculture and Human Values Spring (1993): 47-59. 14 Joseph Stiglitz, Making Globalization Work, 2nd ed., (New York City: W.W. Norton & Company, Inc., 2007), 116.15 Ibid., 104.16 Ibid., 106.

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on intellectual property rights, which could potentially allow for monopolies and conspiracies that harm others and impede economic growth.17 Patent holders effectively receive temporary monopolies on their products, and often use the patents and the resulting profits to quash any potential competitors, thus stifling innovation, much like Microsoft once did when it marginalized Netscape and RealNetworks.18 fixing A Broken And unBAlAnced system

Due to such abuses, Stiglitz and others make the case for additional changes that would make intellectual property rights fairer on a global scale. First, patent rights should be made narrower to ensure maximum innovation. For example, at the turn of the century, when someone tried to patent all four-wheeled motorized vehicles, Henry Ford and other innovators challenged the patent, which they saw as being too broad. If Ford had not had won and the patent not been narrowed, Ford and other innovators would have been shut out of the industry and the nation would have suffered. After all, it was Ford who came up with the idea of creating a mass-produced “people’s car,” and it was this revolutionary concept that fundamentally altered American culture.19

Secondly, the patent license duration, which is currently twenty years for most products, should be shortened in light of the increasingly fast pace in which our society innovates. Innovating companies would still be able to reap the benefits of a patent, but shaving a few years off of the license could greatly benefit society by spreading innovation and cutting prices.

Thirdly, those applying for patents must be forced to prove that they themselves invented the product. There are numerous cases of people who have made millions by patenting things that they did not invent, ranging from free software to indigenous plants and treatments.

Fourthly, some industries should consider not patenting at all. Societies without patents, such as 19th century Switzerland and the Netherlands, had innovation without intellectual property protection; today, there is a growing movement within the software industry toward free-base innovation, in which people freely work off each others’ innovations, creating gradual improvements. Linux and Mozilla Firefox have been highly successful at this, and many say that their software is better than what Microsoft has to offer because it has been less subject to security breaches than Microsoft’s Internet Explorer; however, many fear that Linux may hit a hidden patent while free-basing, which could force it to pay millions of dollars in fines and threaten its very existence.20

Stiglitz also sees a greater role for the government in encouraging innovation. Not only does he encourage the government to fund more research and ask for more of a say in what happens to the results of that research, he wants to take things a step further. If the point of IPR is to ensure that corporations recoup their research costs and are rewarded with a decent profit, then perhaps there is a more efficient and humane way

17 Ibid., 107.18 Ibid., 109.19 Ibid.20 Ibid., 110.

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of doing that. The government could offer a certain amount of money, say $2 billion, to any company that creates a drug to combat some of the world’s most dangerous diseases, such as AIDS. Upon creating the AIDS drug, the company would receive the $2 billion without receiving any additional intellectual property rights, thus allowing that company and any other able company to manufacture the drug at generic prices, thus forcing the companies to compete to figure out the least expensive way of manufacturing that drug. Yes, that $2 billion would be taxpayer money, but if the disease is harming society that much, then the whole society should pay for it. After all, the alternative would be only having each sick person pay an equal part of that $2 billion when buying expensive patented drugs, no matter how rich or poor the person is. conclusion: tough questions, comPlicAted solutions

If every HIV victim had to pay high prices for their treatment, the pharmaceutical companies could spend more for research and development and find the actual cure for AIDS even faster. However, millions in developing countries may die waiting. On the other hand, if there were no international patents and HIV treatment only cost $200 a year, it would be difficult to raise funds for future AIDS advances because there would be neither income nor investors. Perhaps it is possible to have it both ways, and the WTO has already taken steps in the right direction after the South African crisis. The Doha Declaration made many important changes to TRIPS, allowing countries with public health crises to either issue compulsory licenses domestically or import cheap generics from abroad, but it did not go far enough. By implementing the intellectual property reforms listed earlier, ranging from narrowing patent definitions to offering government monetary rewards, the United States and the WTO could even the playing field and create an IPR system that is both more humane and more efficient.

references

Avert. “Worldwide HIV and AIDS Statistics.” Avert: HIV and AIDS. http://www.avert.org/worldstats.htm (Accessed March 17, 2009).

Balaam, David N., and Veseth, Michael. Introduction to International Political Economy, 3rd ed. Upper Saddle River, NJ: Pearson Prentice Hall, 2005.

Bifani, Paulo. “International Stakes of Biotechnology and Patent Wars.” Agriculture and Human Values Spring (1993): 47-59.

Economist, The. “The right to good ideas; How patents help the poor.” The Economist 359.8227 ( June 23, 2001): 27-30.

Stiglitz, Joseph. Making Globalization Work, 2nd ed. New York City: W.W. Norton & Company, Inc., 2007.

Tabb, William K. The Immoral Elephant: Globalization and the Search for Social Justice, 1st ed. New York City: Monthly Review Press, 2001.

WTO. “Obligations and Exceptions Under TRIPS.” World Trade Organization. http://www.wto.org/english/tratop_e/trips_e/factsheet_pharm02_e.htm (Accessed May 2, 2009).

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Postnational Identity, Transition, and Challeneges to Tradition in Cape Verde

Pedro MarcelinoUniversity of Wales Aberystwyth (undergraduate)

York University (current)

ABstrActCape Verde is an island-nation located 500 km west of Dakar, Senegal. Although it does not possess any economically relevant natural resources, it has achieved reasonable development through good governance, democracy, sound economic policies and efficient management of foreign aid. The country is still learning to manage its newly found affluence and the attendant growing pains. For the first time since the onset of colonization Cape Verde is a net receiver of immigrants: mainland Africans, Chinese entrepreneurs and European paradise-seekers. This has fueled social tensions partly motivated by economic concerns but diguised by a perceived challenge to the homogeneity of the islands. Although at base an economic issue, these tensions often inform public discourses of loss of identity and the dilution of “capeverdeanness,” the very essence of what Cape Verdeans believe makes them “different” or “unique.” Through a postcolonial lens, this article explores an exciting new period in the country’s history. Core values are being questioned and renegotiated while Cape Verde and its citizens attempt to adapt to its new demography and to the demands of a globalized world.

The author wishes to acknowledge the helpful comments and advice on sources provided by Dr. Rita Abrahamsen (University of Ottawa), Dr. Jørgen Carling (Peace Research Institute of Oslo), Luzia Oca

González (University of Trás-os-Montes, Portugal), and Martina Giuffrè (La Sapienza University, Rome), among others – particularly in Cape Verde.

the roots of cAPe verde

The story is all but original: a small, independent island-nation develops a successful economy based on political stability, mature democracy, sound financial management, universal education and health care, and a strong sense of national identity. In the African context, Cape Verde joins textbook cases such as the Seychelles and Mauritius. In spite of limited reliable and comprehensive statistical information, it is usually accepted that with a national population of 500,000 at least an equal number of first, second, and third generation Cape Verdeans live overseas. By some accounts, this number may be closer to one million, actually exceeding the population in the islands.1

It is generally agreed that the islands were uninhabited when first discovered by the Portuguese around 1456. Some historians do concede to the presence of ancient signs of human life, possibly from short, seasonal stays by groups from mainland Africa, but they agree that there were no permanent settlers before Portuguese settlement.2

Cape Verdeans ironically refer to the creation of their own territory as a “joke of

1 There are large Cape Verdean communities in Boston, Lisbon, Rotterdam and Paris; significant numbers in Rome, Madrid, São Tomé and Dakar; and smaller or residual communities in Luxembourg, Libreville, Luanda, Bissau, Banjul, Toronto, Rio and Buenos Aires, as well as in other former Portuguese colonies and territories. 2 J. Thornton, “Monumenta Missionaria Africana, edited by António Brásio” (book review), The Inter-national Journal of African Historical Studies 20.1 (1987): 31.

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God.”3 According to the legend, God created the world in six days, and while preparing for the Sabbath He shook His hands to cleanse them of dry clay. This dirt fell in ten clumps in the Atlantic Ocean, roughly 450 km west of the Cap Vert, in today’s Senegal. God, tired of much sculpting and distributing of riches throughout the week, thought nothing more of it. Surely, in such a vast world no one would bother inhabiting the dirt from His hands. But God was wrong. The Portuguese sent their lower nobility, their peasants, their merchants, their criminals, their priests and their amanuenses; they then brought in slaves from the western coasts of Africa. Isolated and protected from the enforcement of all but the starkest social norms most of the time, it was not long before the islands’ new inhabitants were – as in other insular colonies – allowing sexuality to dictate the future ethnic composition of the country.

By the early 1600s, the roots of what could be understood as the Cape Verdean nation were set. The falsehood of the country’s name, with its promise of lush forests and fertile soils when it in fact lacks natural resources, is a perennial reminder of its quasi-abandonment by the colonizer for most of the last five centuries. The climate and isolation help explain the “democratization of poverty,”4 and partially justify a perceived racial homogeneity in a society in which everyone , “live[s] with the daily normality of no one ever noticing the next man’s skin colour.”Almeida 5

Cape Verdeans realized early that migration was not only a necessity but a fate, from 16th century slaves and slave traders to 19th century deckhands in New England whalers and today’s economic migrants. It became such a staple of Cape Verde’s daily life that one will seldom find an islander who does not have a direct relative overseas.6 Jason DeParle7 dubbed the archipelago “the Galapagos of migrations,” a place where every phenomenon of migration can be studied within a relatively small territory, while Góis8 speaks of a Cape Verdean “transnation,” an inchoate nation-state that exists beyond its territorial borders, echoing what Paasi conceptualized as the reconstruction of border based on the social as well as the spatial.9 To those who stayed, severe draughts taught

3 The name Cape Verde refers to the closest point in the African mainland, translatable as “green cape.”. Green, admittedly, is not a very common adjective to describe the country’s barren landscape.4 In an archipelago routinely plagued by hunger, disease and piracy and where the ability to leave was limited by economic conditions (and at times by law), it is unsurprising that many white settlers found themselves struggling to make ends meet. On occasion, particularly during severe food crises, slaves were freed and left to fend for themselves by slaveowners that could not cope.5 G. Almeida, Cabo Verde: Viagem Pela História das Ilhas, (Mindelo: Ilhéu Editora, 2004), 20. My translation. In the original: “a gente tem que ter estado noutras paragens do mundo e depois aqui entre nós, convivendo com a diária normalidade de ninguém reparar na cor de pele do outro.”6 J. Carling, “Return and reluctance in transnational ties under pressure,” Paper presented at the workshop The dream and reality of coming home: The imaginations, policies, practices and experiences of return migration, Institute of Anthropology, University of Copenhagen, May 8-10, 2002; J. Carling, “The human dynamics of migrant transnationalism,” Ethnic and Racial Studies, No vol. (2008): 1-26.7 J. DeParle, “Border crossings: In a world on the move, a tiny land strains to cope,” The New York Times (New York), June 24, 2007 (online edition).8 P. Góis, “Low Intensity Transnationalism: the Cape Verdean case,” Stichproben – Vienna Journal of African Studies 8.5 (2005): 255-276.9 A. Paasi, “The re-construction of borders: A combination of the social and the spatial,” Alexander

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them how to plant with minimal irrigation, and recurrent famines taught survival by chewing on little stones like goats. The only perennial, fixed reality for Cape Verdeans has always been constant change, an adaptation and renegotiation of identity based on how transient relationships are in a society where someone close is always coming or going. “Capeverdeanness,” as identity goes, can hardly be construed as more “unique” than other “unique” identities elsewhere. Yet, the historical and geographical particularities of the land provide substantial evidence to argue otherwise.

Until recently, the country’s perception of its homogeneity was considerably static, although this premise already encapsulates strong internal contradictions. While geographically African, Cape Verdeans do not necessarily think of themselves as such. The country is not located in Europe, although sections of its society identify closely with European societies. While 97% of the population can be identified as black or mixed race, patent (and perhaps convenient) race blindness means this is not always acknowledged. Thus, the arrival of large numbers of migrants from mainland Africa complicates the equation.

In 1991, sixteen years after independence, Cape Verde became the first sub-Saharan African country to hold free, multi-party elections. Carlos Veiga, the new majority prime minister from the MpD party,10 pushed through a series of democratizing bills. He reformed the economy to enhance a business-friendly environment that welcomed foreign investment and singled out tourism and education as sustainable sources of development. Nearly two decades later the result of his neo-liberal agenda is a country widely considered one of the most democratic in Africa with one of the continent’s most stable economies.11

Although these political and economic changes have been beneficial, they have also alienated the socialist drive of the early years of independence under the PAIGC/PAICV.12 As in other liberal democracies, the gap between rich and poor is nowadays more visible both in the streets and in the statistics, with worrying unemployment levels reflecting the inability for large sectors of the population to benefit from growing national affluence .13

Cape Verde is, nonetheless, well off by African standards.14 Consequently, in addition to momentous economic restructuring, the country has to cope with an increasing flow of economic migrants: Chinese entrepreneurs whose shops have

von Humboldt lecture, University of Nijmegen, The Netherlands (9 November), 2000.10 Movimento para a Democracia (Movement for Democracy).11 The Economist, Country Profile 2005: Cape Verde, London: The Economist Intelligence Unit, 2005.12 Amílcar Cabral’s African Party for the Independence of Guinea-Bissau and Cape Verde (PAIGC), re-placed after the 1980 breakaway by the African Party for the Independence of Cape Verde (PAICV). 13 B. Baker, “Cape Verde: The most democratic nation in Africa?” Journal of Modern African Studies 44.4 (2006): 507.14 Cape Verde ranks 6th in the latest latest Human Development Report (UNDP, 2009). Its GDP per capita of $3,800 per year is surpassed only by a handful of other African states. However, its unemployment rate is currently 21%, while 30% of the population continue to live under the poverty line (CIA, 2009).

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appeared in every town; and black West Africans in search of jobs in Sal, Boavista, Praia and São Vicente, and sometimes in search of a platform to the Canary Islands, the continental European Union or the United States. Baker15 admits the growing racism and xenophobia aimed at mainland Africans as a notorious exception to Cape Verde’s ethnic harmony. I argue that this latent racism could in fact have been embedded in the country’s belief system before this change in the social fabric occurred. This antipathy is mostly limited to black Africans, and has been so for a very long time.

It is this ongoing renegotiation of identities and material expectations that will be the focus of this article’s main argument. The initial question from which I depart is: To what extent do the current migratory cycles influence and challenge the Cape Verdean identities that were already in place as a result of historical migrations? As in the past, with the democratization of poverty that resulted in a partial levelling of social and racial strata, the reactions against the other suggest that identity is not entirely dislocated from economic struggles. I hope to demonstrate that, although Cape Verdean identity is inherently bound by very weighty historical and geographical factors, it is not stable per se, nor is it immune to reappraisal.

This article first examines selected ideas on identity and subsequently tests their relevance and application to the Cape Verdean case, specifically with the intent of understanding how these concepts connect to Cape Verde’s history, geography and economic experiences. An overview of the democratic transition of the 1990s and ensuing economic development follows, introducing the last elements that are necessary for a discussion of the effects of Cape Verde’s newest migration patterns. This builds up the case that none of the core elements of “capeverdeanness”16 are challenged by the intake of migrants. However, the latest economic developments – driven in large part by globalization – shift the historical and geographic parameters that traditionally had primacy in discussions of national identity.

locAtion, locAtion, locAtion: from hyBridity to “hyBridism”There is a fundamental problem with using the word “postcolonial” to describe

Cape Verde. Certainly, the country is post-colonial in the historical sense that it was once a colony and has now gained independence. However, branding it as postcolonial without qualification may obfuscate its uniqueness among former colonial territories: no human being inhabited Cape Verde permanently before Europeans colonists (and African slaves) arrived.

Cape Verde is part of the crescent-shaped Macaronesia mountain ridge that connects the archipelago to the Canaries, Madeira and the Azores. As such, the islands are certainly not in Europe, although they are geologically connected to places construed as European. They are also not part of the African landmass, despite the incidental closeness and genetic make-up of the population that makes them also “African.” What this

15 Baker 2006.16 By this I understand, in this context, a “nuclear” perceived identity that most Cape Verdeans – regardless of their island or country of origin – see as intrinsic to their being. This evidently clashes with the notion that identity is, stritu sensu, fluid.

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geographical feature neatly illustrates is the liminal position of Cape Verde, which has important identity implications. Cape Verde’s geography, its genius locus, is an essential feature to its identity and claims to uniqueness.

Although some of the early settlers were adventurers, most traveled to Cape Verde due to extreme poverty in the homeland, political banishment, or criminal offenses.17 The forcefulness of this migration is a common trait of the slave experience. Once in the islands, power relations quickly reverted to the simple premise of European supremacy. This power relationship is seen by key postcolonial thinkers as fitting numerous dualities, including the dichotomy between the colonizer and the colonized,18 domination and resistance,19 master and slave,20 civilization and barbarism,21 and the rapist and the raped.22 These oppositions entail the application of power on the colonizer’s part, particularly through forms of violent subjugation that can only occur when the settler actively engages in the act of forceful domination of body and mind.23 This is not to say, however, that cultural and physical domination happens unilaterally, or without resistance. Subjugation presupposes an acceptance of one’s fate that – at the level of the individual slave – was often not true. To reduce colonization to domination without resistance is misleading.

Cape Verde is a rare case study among former colonies in that its colonization did not impose upon pre-existing social constructions. Instead, the imbalanced power relations typical in other colonies were transferred only when both European settlers and African slaves arrived. Although it is clear that the country today bears many trademarks of a former colony, and although the reality of Cape Verde’s colonization can be best explained within a postcolonial context (at least in an aesthetical and representational sense), it is questionable if it should be called “postcolonial.”

The ambiguity arising from the domination binomials described is particularly relevant for the analysis of the postcolonial character of Cape Verdean identity. Here we find a myth that qualifies the islanders’ conception of themselves as not quite African and yet part of a history that intrinsically links them to the past of African slaves. But here things get confusing. The process of defining identities through uniqueness or difference is true for identities everywhere.24 Cape Verde’s ocean-lined space, nonetheless, makes for a particularly interesting case. A number of aspects later construed as fundamental

17 R. Lobban and Halter, M. Historical Dictionary of the Republic of Cape Verde, 2nd edition (Metuchen and London: The Scarecrow Press, 1988). 18 A. Memmi, The Colonizer and the Colonized (Boston: Beacon Press, 1967).19 E.W. Said, “Resistance, Opposition and Representation,” in Bill Ashcroft et al., The Post-Colonial Studies Reader, 2nd ed. (New York and Oxford: Routledge, 2006), 95-98.20 H. Bhabha, The Location of Culture, (London: Routledge, 2006), 37.21 F. Fanon, The Wretched of the Earth (London: Penguin, 1990).22 A. Loomba, Colonialism/Postcolonialism: The New Critical Idiom (London: Routledge, 1998), 69-71.23 A. Mbembe, On the Postcolony (Berkeley: University of California Press, 2001), 25-26.24 A. Arpadurai, “Disjunction and Difference,” in Bill Ashcroft et al., The Post-Colonial Studies Reader, 2nd ed. (New York and Oxford: Routledge, 2006), 469-476.

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to Cape Verde’s “imagined community” are intimately linked to the Cape Verdeans’ existence and experience in these islands off the African coast, marked by specific historical developments and by an aggressive climate. Violent colonization marked each and every slave ever brought to Cape Verde. Their status upon landing was that of the “colonized,” despite the fact that they had been removed from their homelands. The majority of slaves were sold and taken elsewhere.25 For those bought locally, a second colonization in a proxy location occurred. What might be termed “displaced colonial violence” thus took place in a geographic location to which both colonizer and colonized were alien.

In this context, the limited geography of the islands not only functioned as a melting pot of identities from across Africa, but it also created a colony that was unique. Specifically, it planted the seeds for an identity partly bound to its African heritage, but that also developed its own hybrid identity over time. As an isolated yet connected space, Cape Verde’s geographical position facilitated, tested and renegotiated a process of hybridization that is perhaps less obvious in larger colonies, with native populations of their own and less punishing climatologic conditions.

Early accounts report that slaves already born in Cape Verde, some of whom were educated and multilingual, had a higher market value. Because of this, many became cultural brokers between the new arrivals and their masters.26 Within a couple of generations some descendants of these slaves were free men and women. There are two key reasons for the relatively quick transition from slave to freedman. First, the difficulty some slave owners had in providing for their slaves in a country that was already affected by periodic droughts and subsequent food shortages aggravated by its isolation. And Secondly, the development of forced and voluntary personal and intimate relations between mostly male colonizers and the mostly female colonized27 often times resulted in the children of born in these circumstances being granted benefits or eventually freed. This is a point to which I will return later. Fastforwarding a hundred years, mixed race people that can by now be called Cape Verdeans are found all over the river deltas of the west coast of Africa, living with locals, acting as tangomaus and lançados,28 and as middlemen to slavers from Cape Verde or elsewhere in Whydah, Mina, Gorée, Cacheu or the Bissagos Islands.

In practical terms this meant that Cape Verdeans had themselves become colonizers along the African coast. Back in the islands, newly arrived slaves often dealt only with

25 Primarily to Brazil, Jamaica, Cuba and other Caribbean islands, North America and Europe (Eltis et al., 1999).26 See C.R. Boxer, Race Relations in the Portuguese Colonial Empire, 1415-1825 (London: Oxford University Press, 1963); C.R. Boxer, The Portuguese Seaborne Empire, 1415-1825 (London: Hutchin-son, 1969). 27 Boxer 1969, 305-314.

28 Lançados, literally “thrown,” were mixed race middlemen in the African coast, whereas tangomaus, liter-ally “tattooed,” who had a similar role, typically lived further inland with locals, and overtime blended into their social structures. The term was fairly pejorative and often implied lack of allegiance and trustworthiness, possibly due to their “excessive” identification with mainland Africans, be it culturally or genetically (Lobban and Halter, 1988: 67, 108).

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mixed-race freedmen, themselves descendants of slaves, who were now part of the economic structure that had once victimized their ancestors. From the perspective of new slaves, some of whom were captured and handled by Cape Verdean men only, they were undoubtedly the colonizer.29 The ambivalence of the Cape Verdean position continued well throughout the 20th century. The Estado Novo regime in Portugal developed an indigenat policy30 that considered 95% of Cape Verdeans automatically assimilados, or assimilated – that is to say, through mimicry, almost Portuguese, but not quite31 – and sent many of them to other colonies as administrators and clerks.

This type of ambivalence is intimately connected to the notion of hybridity, as Bhabha suggests.32 Cape Verde soon became a conduit for Portugal in the tropics, a space where “anything goes,” as many early accounts testify. Boxer suggests that

[t]he frequent arrival of so many dissolute degredados [expelled convicts], rogues, vagabonds and sturdy beggars, exiled from Portugal…inevitably aggravated an already difficult social situation. The prevalence of slave-prostitution and of other obstacles in the way of a sound family-life, such as the double standard of chastity between husbands and wives, all make for a great deal of casual miscegenation between white men and coloured women.33

This process of casual miscegenation, of course, hosted violence, oppression and the subjugation of female slaves to the white masters. The duality of the colonial relationship existed in Cape Verde as in other colonies, but was perhaps distorted by the fact that colonizer and colonized were equally restricted to a limited territory. In 1627 Santiago Island was described as a “dungheap” and its mostly mixed race inhabitants were referred to as “vicious and immoral.”34 Fêo Rodrigues suggests that

the use of sexuality to explain the formation of Creole identities were not fabrications of a distant metropole to be exported, consumed and contested in the colonies. Rather, such tropes often found inspiration and co-authorship in the social practices of the colonies. …Creole populations were in a privileged position to co-author and to transform colonial ideologies, often subverting its outcomes into a political project of their own.35

29 These middlemen were not always fair skinned, not always subjugated, and not always men: Bibiana Vaz, for example, was a female rebel of Cape Verdean descent who ran a short-lived independent African “repub-lic” based in Cacheu (Guinea), developing a powerful commercial slave trade ring that included several large ships over many years.30 Indigenismo.31 The remaining 5% mostly lived in Santiago. These statistics contrasted greatly with those from other colo-nies.32 Bhabha 2006.33 Boxer 1969, 314.34 Lobban and Halter 1988, 14.35 I.P.B. Fêo Rodrigues, “Islands o Sexuality: Theories and Histories of Creolization in Cape Verde,” The International Journal of African Historical Studies 36.1 (2003, Special Issue: Colonial Encounters between

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This was the case in Cape Verde, where, over the centuries, isolation and permissiveness blurred the fault lines between white and black, colonizer and colonized, so that by the early 20th century Cape Verdean identity was fairly solidified, as is reflected in the contemporary literature of the time.

Between the initial settlement and the 20th century, a diversity of identities were established on different islands, all of them transitional, but all of them overlapping with a set of characteristics that would soon be called “capeverdeanness.” For instance, “[t]he island of Santiago became a kind of mainland. Other islands were only “as ilhas,” whereas Santiago was Cape Verde, the centre of a narrow world.”36 The differentiation between the islands remains to this day. Yet, Cape Verdeans are quick to assert that these are minor differences, and that being Cape Verdean is in essence the same on every island. An approximate conscious or unconscious definition of what constitutes capeverdeanness can be summed up as thus: learning how to cope with departure and perennial sôdade,37 with abandonment, and with the sea as a prison and a horizon of possibilities; appreciating the heritage of famine, slavery and colonial violence and indifference; acknowledging the comings and goings of those who make up the diaspora, and consequent transient nature of local society; and, especially, experiencing the recurring droughts and feeling gratitude for the rare rainfall. Notably, every aspect of Cape Verdean identity formation strongly reflects the very geography from which it emerged and in which it was shaped.

These elements were deliberately grandfathered into Cape Verdean collective memory as illustrated by the example of the Claridade modernist movement of the 1930s.38 The writers, poets and musicians who codified capeverdeanness did little more than draw from existing feelings and realities, bringing them into the realm of national consciousness. These authors invoked an “imagined community” of Cape Verde by representing it in novels, morna songs and increasingly provocative articles that repeatedly focused on Cape Verdean themes like poverty, hunger and subsequent migrations. Courageous writing about “inequality, injustice and legalized preconceptions”39 eventually turned into physical escalation in 1934 as Nhô Ambrósio led a revolt in Mindelo in response to the dire conditions of unemployment, extreme poverty and hunger provoked by the port’s decline. This moment is reminiscent of the frequent slave revolts of the early settlement.

Africa and Portugal): 84.36 A. Llyal, Black and white make brown: an account of a journey in Portuguese Guinea and the Cape Verde Islands – two of the least known territories in the world (London and Toronto: William Heine-mann, 1938), 236.37 From the untranslatable Portuguese “saudade,” meaning something close to feeling for someone’s ab-sence.38 The movement was roughly initiated by former seminar students from São Nicolau, then by Brava and Fogo intellectuals. Claridade’s intellectual production – and the bohemian lifestyle often attached to it – would reach its maximum exponent in the city of Mindelo, the archipelago’s largest port and also the location of its high school at the time. 39 T. Virgínio, “Letras caboverdianas do pós-independência.” Luso-Brazilian Review 33.2 (Special Issue: Luso-African Literatures, 1996): 85.

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Claridosos40 – as members of the Claridade movement were known – ambiguously praised the “Portuguese values” of the islanders, while simultaneously asserting their difference, and increasingly voicing a desire for political autonomy. The Claridade movement assumes particular importance because it acts as a disseminator of an idea of “capeverdeanness.” Despite high literacy rates, many texts, particularly poems in Creole, circulated widely in the form of morna songs. Some of these are still part of the lore of contemporary Cape Verdeans around the world.

It is worth noting that the language used in most of Claridade’s original cultural productions was erudite Portuguese rather than Cape Verdean Creole. On a linguistic level, however, Portuguese was unable to convey the diversity of Cape Verde’s realities. Although Creole had taken hold centuries before as the hegemonic language in the islands, its role remained purely private and unwritten, whereas Portuguese was reserved for most public occasions.41 Creole’s colourfulness, musicality, wit and flexibility are hardly translatable into the harsher, more rigid Portuguese linguistic structures. Portuguese became a foreign language that most Cape Verdeans do speak, but that they in turn colonized with borrowings from their mother tongue, Brazilian Portuguese and other languages. The ambivalence of Creole, a characteristic shared with many aspects of Cape Verdean identity, exposes hybridity at a linguistic level.

Cape Verde’s hybridity, then, is as much cultural and social as it is genetic, intimately linked and produced partly as a result of the archipelago’s geographical location and partly as a result of its past. This third space encompasses the post-colonial experience of Cape Verde and testifies to an ideology of difference, an “-ism” that is characterized by the insistence on the islands’ crossover role as the cultural and genetic bridge between Europe and Africa, which both resists and asserts multiple understandings of identity. This, I suggest, might be termed hybridism, or an ideology of hybridity evident in what has been discussed so far, and easily observed in popular attitudes to this day.

In light of this, it seems foolish to presume that the islands of Cape Verde are either a part of Europe or Africa. Instead, it seems more fitting to argue that Cape Verde should be considered, as Baker states authoritatively, “neither and both.”42 Rego speaks of a people “of Africa, but not African, just as it is also of Portugal, but hardly Portuguese [emphasis added].”43 Baltasar Lopes, one of the earliest claridosos, argues that “those who held dichotomous theories based on a priori conceptions of Africa and Europe as mutually exclusive were destined to misunderstand societies like Cape Verde.”44

The violent nature of the colonizer/colonized dichotomy earmarked by postcolonial studies as pivotal to identity formation in the post-colony is present in Cape Verde. Its

40 “The Enlightened.”41 M. Veiga, Diskrison Strutural di Lingua KabuVerdeanu (Cidade da Praia: Institutu KabuVerdeanu di Livru, 1982), 16-17.42 Baker 2006, 506.43 M. Rego, “Cape Verdean Tongues: Understanding Competing Discourses of ‘Nation’ at Home and Abroad,” Conference on Cape Verdean Migration and Diaspora, Centro de Estudos de Antropologia Socia (Lisbon, 6-8 February 2005), 2.44 Quoted in Fêo Rodrigues 2003, 88.

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representation through mimicry as proposed by Homi Bhabha fits the postcolonial model, resulting in an inter-island national identity that Benedict Anderson would surely call an imagined community. However, the liminality and dislocated colonization that characterized Cape Verdean history prompts some caution before definitively labelling it as simply “postcolonial.”

chAllenges to the self-concePtion of An emerging “middle-income nAtion”In The Fortunate Isles,45 Basil Davidson urges for a degree of reservation in

understanding the first attempts at literary, if not always political, autonomy of Cape Verde in the 1930s. Davidson notes that the intellectual movement seems to “appear to have believed in no kind of ‘African alternative’ to the paternity of Portugal.”46 Unexpectedly, the image of early claridosos today is one of unreserved support for Cape Verdean uniqueness and the need for independence. I would argue that this in itself is a revisionist perspective of history that has made its way into the representations of national mythology. The claridosos have thus become the “founding fathers” of the nation, despite the fact that many of them seemed more interested in a kind of independence that did not sever ties with Portugal.

In the independence struggles of the 1960s and 1970s, Cape Verde gained “new fathers.” Davidson gives an account of the very real possibility that, after a long ideological union with Guinea-Bissau, Cape Verde would remain an adjacent autonomous region of Portugal, in the image of Madeira or the Azores.47 The political maneuvering conducted behind the scenes eventually bestowed Cape Verde with its full political independence, although the country willingly remained united with Guinea-Bissau until 1981. In Cape Verde, where communism was not deeply rooted, many suspected not only that the party had Soviet aspirations, but also that it did not serve the people’s interests to remain associated with Guinea, “a ‘savage land’ better kept at arm’s length.”48 According to Patrick Chabal, “socialism did not sit easily with a people long accustomed to roam the world, seek employment abroad, freely use their earnings and invest their savings.”49 Amílcar Cabral, the Cape Verdean leader of the Guinean resistance, had managed to draw the world’s attention to the independence struggle, particularly after his inspired speech to the fourth Commission of the United Nations General Assembly on October 16, 1972, on “Questions of Territories Under Portuguese Administration.” He also managed to lead the islands into a political union with Guinea. It is no surprise, then, that most modern Cape Verdean politicians see themselves as heirs of the Cabralian tradition of socialist government; that is, from the people and for the people. The 1980 military coup in Guinea that ousted Luís Cabral, Amílcar’s half-brother, ushered in the end of union, but did not prevent the emergence

45 B. Davidson, The Fortunate Isles – A Study in African Tradition (New Jersey: African World Press, 1989).46 Davidson 1989, 51.47 Ibid.,109-126.48 Ibid., 112.49 Quoted in Baker 2006, 494.

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of a political class imbued with the prestige of being “former combatants” with the “Guinean brothers.” This identification with mainland Africans does not necessarily meet the expectations of many islanders. Cape Verdeans involved in anti-colonial struggles on the mainland, where they were seen as “almost white,” were themselves the object of suspicion, with locals fearing they would take over the space left empty by the colonizers.50 Once again, the insular factor of differentiation becomes evident and troublesome.

In 1975 Pedro Pires, a former military commander of socialist extraction, assumed the post of prime minister – an office he held for sixteen years. In the interim, the Cape Verdean government established fairly stable structures that reduced corruption. Universal food security and education programs, including widespread adult education, re-forestation and water retention projects were initiated during this period. Well-managed poverty reduction schemes attracted donors from Europe, Cuba and the United States, among others, in what was often noted as an exemplary use of direct foreign aid resources.51 By the mid-1980s, the African Party for the Independence of Cape Verde (PAICV) had started to liberalize the economy and ease its political control of the country, in what Baker calls “in practice…a more pragmatic and social democratic” government “than its socialist ideological claims might have suggested.”52 Gradually, and despite its interest in development, PAICV moved toward Claude Aké’s argument on the democratization of disempowerment, a shift away from mainstream conceptions of development for Africa.53 This much is suggested by the perseverance of an ex-revolutionary elite clinging to power, by the trivializing of democracy, and the political alienation of the population, particularly those outside Praia. Cahen describes what he saw in 1989 as a “miscegenated government and a black people.”54

In fairness, PAICV was not a totalitarian party. The 1990 pacto de regime (regime pact) and consequent constitutional amendment that paved the way for a multi-party republic partially emerged from within the party itself. In 1991, despite Pedro Pires’ claims that Cape Verdeans were not ready for democracy, the newly formed MpD forced an election that resulted in Carlos Veiga’s appointment to the office of prime minister. The MpD went on to win all the elections until 2001. Meyns explains that

[d]rawing on intellectual traditions of debate within their society and aware of the vulnerability of their country, they have developed a nonviolent political culture that has shaped the process of democratic transition.55

50 Fêo Rodrigues 2003, 94.51 P. Meyns, “Cape Verde: An African Exception,” Journal of Democracy 13.3 (2002): 157.52 Baker 2006, 494.53 C. Aké, “The democratisation of disempowerment in Africa,” in J. Hipper, ed., The Democratisation of Disempowerment (London: Pluto Press, 1995), 70-89. 54 M. Cahen, “Review: La fortune changeante des Iles du Cap-Vert,” The International Journal of African Historical Studies 25.1 (1992):135.55 Meyns 2002, 164.

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After one decade of full democracy, characterized by fast-paced neo-liberal reforms, Cape Verde was developing steadily and coherently. However, the fairly well-educated political body still had strong aspirations for autonomy and choice, aspirations which had arguably existed over the last five centuries. From the mid-90s onwards, Cape Verde shared the lead of African democracy charts with São Tomé, South Africa and Mauritius,56 perhaps as a result of all these years of political dissatisfaction and aspirations for greater autonomy and choice.

The close relationship between economic development and democracy is a compelling aspect of Cape Verde’s recent history. A Cape Verdean diplomat affirms that the “democratic system is now in the minds of Cape Verdeans; it was long their ideal.”57 Baker adds that they “support that political system, even if not unconditionally.”58 This, he says,

is more than an electoral democracy. …It is a serious democracy and for that reason alone a rarity in Africa. Its roots go deeper than the constitution, and shape political and social practice. And among the elite democracy is not simply a device to attract donors, but appears to be a deep-rooted commitment.59

In 2001 and 2006, the legislative and presidential elections proved that a peaceful democratic transition had, by then, become firmly rooted. Baker describes a clean process, although he fails to identify possible flaws. One of these possible imperfections include the fact that media diversity is limited, with all major newspapers heavily indebted to one party or the other. Allegations of electoral fraud in 2001 and 2006 suggest that the 17-year old Cape Verdean democracy has not yet fully matured. There are also signs of an increasing impatience toward the more conservative diaspora. On both occasions, the MpD leader Carlos Veiga won the elections at home, only to be sidestepped by the over-represented and overwhelmingly pro-PAICV diaspora vote, more faithful to the ideal of a PAICV-led Cape Verde, and largely unacquainted with alternative political projects in the islands.

The peaceful development of a democratic regime has so far been eased by a growing service-based economy. However, development has been mostly felt in the more urbanized islands of Sal, Santiago and São Vicente. The International Fund for Agricultural Development identified rural poverty as a source of potential problems in the future.60 Although the standard of living has dramatically improved since 1991, urban and rural poverty are now more visible than before, perhaps following the global trend toward neo-liberalism. Chinese manufactures have inundated the streets of most cities and towns, making consumer goods more accessible to underprivileged people, but

56 Baker 2006, 494.57 Quoted in Baker 2006, 508.58 Ibid., 508.59 Ibid., 509.60 International Fund for Agricultural Development, “Oeuvrer pour que les ruraux pauvres se libèrent de la pauvreté au Cap-Vert,” IFAD, http://www.ifad.org.

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also seriously damaging the incipient Cape Verdean industrial sector.61 Tourism, on the other hand, brings an increasing number of visitors every year.

Multinational travel companies control much of the tourist flow, which means the amount of profits re-invested in the country is limited. Furthermore, visitors put an enormous stress on the available transport and telecommunications infrastructures fundamental to daily life in the archipelago, and greatly contribute to rising inflation levels and swelling property values. Additionally, the World Bank now ranks Cape Verde as a middle-income country. This apparently positive step has actually meant that many donors have withdrawn from Cape Verde because they prefer to work with and in poorer countries. The Cape Verdean Foreign Office noted with irony that “[m]ore than a reward for good behaviour, what is called for here is that a country not be penalized for its good performance in the area of development.”62 The pressures of decreasing foreign aid and remittances worsen the conditions imposed by neo-liberal reforms in a vulnerable population.63

it’s An AfricAn islAnd-nAtion’s economic AsPirAtions, stuPid!In a geographically isolated territory so heavily dependent on foreign aid and

its network of transnational citizens,64 small economic changes can easily have great significance. The closing of factories or rising inflation not met by salary top-ups are two examples. Baker shows concern over the “danger that a permanent underclass may be forming, and that the benefits of a nation homogenous in race may be lost to a nation divided by class.”65 He continues on this worrying note:

One economic expert…noted that: “the economic expectations of the people are far beyond our economic power.” Their widespread travel and their contacts with emigrants makes them well aware of the standard of living of those in the West. Their educational levels have given them high expectations in terms of employment. Consequently, the government is under considerable pressure to provide or face the wrath of its frustrated body of citizens.66

After sixteen years of socialist government, the centre-right MpD has often accused its predecessor of fostering a “foreign aid syndrome” in Cape Verde. The MpD has attempted to correct this syndrome by implementing market-based policies, privatizing many of the national companies and welcoming foreign investment. However, these strategies seemed unlikely to answer to the limitations of an island-nation with no

61 C. Alden et al., eds., China Returns to Africa: A Rising Power and a Continent Embrace (London: Hurst & Company, in press); H.O. Haugen and J. Carling, “On the edge of the Chinese diaspora: The surge of baihuo business in an African city,” Ethnic and Racial Studies 28.4 (2005): 639-662.62 Baker 2006, 508.63 Economist 2005.64 Ibid., 14.65 Baker 2006, 507.66 Ibid.

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natural resources other than access to a large Atlantic exclusive economic zone, which it lacks the means to patrol. The reduced size of the economy and the economy’s high dependency on fuel imports and expensive transportation of people and goods results in a very high cost of living, and a lack of commercial competitiveness. In response to social decline, voters elected the PAICV in 2001, slowing down some of the neo-liberal reforms and restoring the balance between economic and social development.67 This, in turn, gave the economy more time to adjust to the new challenges.

Despite these developments and in contrast to the neighbouring Economic Community of West African States (ECOWAS) on continental Africa, Cape Verde continues to maintain a privileged position. Its tourism industry, for example, is attracting more foreign investments every year, particularly in transport and hospitality infrastructures.68 This encouraging growth has awakened the old debate of association with Europe, which has now materialized into a privileged partnership with the EU and a close relationship with NATO.

One consequence of this recent development is the agreement of alternate assistance in patrolling the territorial waters by the Portuguese and Spanish navies. This happens in the context of fighting illegal immigration to the EU, since Cape Verdean waters have become a major thoroughfare for boat people attempting to reach the Canary Islands and continental Europe from mainland Africa. A second consequence is the increasing distancing from ECOWAS, notably during the MpD governments. On more than one occasion, the national debates considered opting out of the ECOWAS open borders agreement, which contributed to the maintenance of heavy limits to Cape Verdeans travelling to the EU. The ease with which Cape Verdeans moved across borders up to the late 20th century has been drastically changed by strict immigration policies in most of their countries of destination, particularly the US and the EU, especially following 9/11.69

Meanwhile, the flow of ECOWAS migrants – both documented and undocumented – has increased and so has their visibility in Cape Verde’s urban landscape. In places where Cape Verdeans have a darker complexion, such as Santiago, migrants for a while went unnoticed, except in their use of African languages.70 Things have changed. In urbanized islands such as Santiago, São Vicente and Sal (the latter three with lighter-skinned populations) they now represent a visible minority that causes some discomfort. The national press has picked up on the rising tension, and routinely reports on crimes committed by African migrants, or on shipwrecked boats attempting to reach the Cape Verdean coast, vessels overloaded with cadavers found adrift in territorial waters and the odd abandoned yacht in a desert beach, hinting at the possibility that some Africans

67 Meyns 2002, 164.68 Economist 2005, 22.69 Haugen and Carling 2005.70 There have been reports of the Public Order Police singling out and harassing citizens of Nigeria. In March 2005, after a Guinean immigrant was murdered, hundreds of West Africans marched in the streets of the capi-tal, attempting to invade the Government Palace. There is still some potential for racially motivated violence (Baker 2006, 503).

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are arriving illegally. With immigration being a growing concern for Cape Verdeans, television reports of the “invasion” of African migrants in the Canaries, Malta or Italy go a long way to reinforce a mild sense of panic.

Although the “race card” is not often openly used against these migrants, there are indicators to suggest identity politics plays a role in explaining discrimination.71 With growing concerns about economic hardship and the global economic crisis slowly impacting local economies, the obvious vulnerability and limited nature of Cape Verde’s resources attract extra attention to migration issues. The recent focus on ethnic labelling, at least on the surface, finds no real parallel in Cape Verdean history. It is possible that this had been latent within Cape Verdean society all along, as an identity within an identity: “We” are Cape Verdeans because “we” are fair-skinned. It can be argued that the badíu vs. sampadjudo equation exemplifies this, opposing Santiago’s dark-skinned population to the rest of the country’s lighter complexion. Although no one questions Santiago’s “capeverdeanness,” its difference is often stated, even when skin color is not mentioned. The fact that usually only people from Santiago are called badiú probably owes as much to the historic situation of the island as the nucleus of Cape Verde as it does to the fact that it is its only “black” island. Whilst slow miscegenation happened throughout the centuries elsewhere, Santiago was a deposit of slaves well into the eighteenth century. Thus, more than spite for its cultural, economic, and political macrocephaly within the Cape Verdean context, this differentiation could denote an idiosyncrasy in Cape Verde’s alleged color blindness. The imagined community of Cape Verde may be able to override some internal difference, but may be unable to extend tolerance to the racial sphere.

Further, the limited resistance to recent Chinese migrants and other new residents from Europe might be indicative of the extent to which race is playing a real role. These are groups with either a higher educational level or investment potential. In the larger urban areas, Chinese migrants have set up businesses, creating a very distinct merchant class and challenging established economic networks. Europeans are purchasing property in most islands and opening small and large businesses. The fact that the economic clout of both groups competes with that of traditional elites seems to be of little importance. Cape Verdeans have grown familiar with endogenous and exogenous shifting circumstances. New settlers integrate what Arpadurai called ethnoscape, “a landscape of persons who constitute the shifting world in which we live: tourists, immigrants, refugees, exiles [and] guest workers.”72

finAl notes: could it Be the west within?While it is still true that Cape Verdean identity is rooted in the islands’ geography,

71 I heard several people in Mindelo refer that “those mandjakos” should go back to their countries, an all-encompassing expression in clear reference to the West African ethnic group (although it is unlikely that more than a few migrants belong to this group). In Mindelo’s Carnival, one of the most popular costumes is the “mandjako.” Young men with their semi-naked bodies painted with black shoe wax brandish makeshift spears, jump and grunt around the streets, scaring children, in a clear construction as ‘the African’ as savage. 72 Arpadurai 2006, 469.

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history and diasporic dynamics, there are new economic factors at play that propose a shift toward something else, perhaps even the racialization of specific groups. Under the pretence of a threat to “capeverdeanness,” African migrants are being singled out in this process, in what seems to be identity politics operating at its most perverse. While in the past they were accepted in limited numbers, they are now pointed out as scapegoats for some of the economic problems Cape Verde is facing, and perhaps even of Cape Verde’s problematic sense of self. If some of the elements of “capeverdeanness” listed earlier are rehearsed again, it is difficult to see how they could in any way challenge this process. The antagonistic reaction toward African migrants is not exclusive to Cape Verde, but is exclusive within Cape Verde. They are construed as a combination of disenfranchised, low-skilled, low-paid workers that dispute the few available jobs and contribute little if anything to the economy, particularly in a time of crisis. Ironically, they are also the only newcomers whose complexion suggests a sense of connection to the place capeverdeanness has negated for the better part of the country’s history: Africa.

Naturally, every identity depends on the assertion of its own difference to others. In Cape Verde, identity politics appears to have translated into an ideology of difference. It could be argued that the colonizer is imbued in the Cape Verdean identity, a condition postcolonial theory explains as the West “inside” the (former) colony. Renewed economic challenges prompt the question of what will happen to the newest members of the national ethnoscape. Will they eventually blend in with the Cape Verdean fabric, or are they the precursors to an emerging identitarian alternative? This factor, if anything, makes the case study more compelling for further study. It is clear that identity is inherently transitional, constantly negotiated, fundamentally construed, and composed by a multiplicity of concomitant and conflicting identities. In Cape Verde, as the country grows, so might challenges to racial harmony and economic equity.

Pedro wrote this piece for his undergraduate dissertation in 2008 at the University of Wales Aberystwyth, where he received a BScEcon in Interational Politics and the Third World.

Currently, he is attending York University in Toronto, Canada, where he is pursuing a MA in Development Studies and continues to reserach the same topic.

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Nkosi sikelel’ iAfrikaSarah Lynn-Andrews Losinski

Michigan State UniversityHealth Studies and Gender History

I have to admit, I had very distinct expectations of Africa. Expansive sunsets over an untamed savannah landscape, with lions and tribal people roaming around in animal skins and ebony masks, that occasional elephant, maybe some poachers with white hats and handlebar mustaches, wild drumming and dancing and beautifully patterned native garments. And after enduring thirty-six hours of air travel, I was not disappointed. It was well past midnight when I took my first step off the plane and onto African soil. It smelled so different from home, yet oddly what one would expect when traveling to this mysterious continent: a lingering scent in the air almost identical to the “Safari” section of a zoo. A dense humidity enveloped me and immediately transformed the stray blond wisps of hair around my face into tight curls. Ah. Africa.

There are thirteen us of in total; thirteen American college students who packed their bags for a semester and headed into the unknown with great expectations. All of us were quiet as we drove through the city that first night on the way to our flats. The windows were down in the huge passenger van and the warm air was so novel after leaving the snow drifts of midwinter back home. As we passed through the heart of Durban, the city that was to become our home for the next five months, the standard noise of traffic and people sounded just like the cacophony you would experience in downtown Chicago. The smell of the air transformed from stereotypical Africa to the familiarity of a traditional city. As we pulled up to our apartment building, the neighborhood looked just like classic suburbia in the States, with quaint housing complexes and trees shading the seemingly quiet street. There was an increased amount of security and barbed wire that I had expected to be found in a Durban neighborhood, but I had felt disappointed that night; disappointed at how normal and, well, boring the entire scene seemed to be. I came to Africa to experience something different, something exciting…perhaps something almost primal.

My roommate has been working a couple days each week this semester in an elementary school here. One day a few months ago, we were sitting outside on campus after she had just gotten back from the school. Over only a couple of months, she had learned quite a bit about the problems facing local schools. According to statistics given to her by the principle, less than one percent will graduate high school and a typical class will have fifty students in one room, all speaking different languages than that of the provided educational material or even the teacher. Particularly distressing, though, she was told that out of the three hundred elementary-aged girls, nearly all of them have already been raped multiple times and are now likely HIV-positive.

A South African friend that we met the first week of school was enjoying lunch along with us. He nodded his head and agreed with my roommate’s musings. “Yeah, my mother’s a teacher and she can tell you too. It’s the same story in every school across the

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country.”I passionately shoved my fork into my curry rice. “You’re kidding me!” I gasped.

“They should alert the authorities! Some kind of action needs to be taken!”He looked at me kindly like I was a small, ignorant child and sadly chuckled. “The

authorities? Corrupt. The police, the ones that are supposed to serve justice and ensure safety? The worst of criminals. The government, the ones that are supposed to protect and guide us? Self-serving and immoral.”

“There has to be something that can be done, someone who can help.” And then, half to myself, I questioned, “Someone who wants to help?”

He then gave me a look that hinted a little less patience with my Western ignorance than a few minutes previous. “TIA sissy.” This Is Africa.

So much has changed since my first ridiculous notions of South Africa. Back home, we tend to call challenges in our lives “learning experiences.” I have a hard time finding that introspection right now while I am still here, but maybe in the future I’ll look back and agree; that this semester was indeed a great “learning experience” while for everyone else in this country, it was simply another five months of “real life.” If I make it home again…

The streets become deserted after dark here. And silent. At 5:00 every night, something eerie settles over the entire city. You can’t leave the house to walk down the street under any circumstances. Crime in this country is out of control. Some say it has gotten worse since the end of apartheid…others say the crime has always been this awful but that now it is also affecting the white community, thus the sudden publicized increase in concern. To make matters worse, the South African infrastructure is not constructed to fulfill the current energy demand, and so initiates rolling blackouts that cut off all power for varying blocks of time. Much of the security set up in the city, such as electric gates and doors, then becomes disengaged during the blackouts...even street lamps and traffic lights extinguish.

One day, my soccer coach offered to give me and a friend a lift home from practice. We gave him directions along the way, but he surprised us when he came to a complete stop about six blocks from our apartment. We were even more shocked when he then refused to drive us through the neighborhood because of its reputation for hijackings. He spoke a truth; our “quaint, quiet little neighborhood” was not as safe as my first impressions assumed it to be. But I was irate; I understood that he was concerned for his personal well-being, but I was angry that he was then willing to put our personal safety at an even greater risk. Without thanking him, we got out of the car and slammed the door. He nervously gunned the car in the opposite direction. Putting on a false air of courage, we walked quickly all the way back to our flat, gripping our bottles of pepper spray and recently-purchased tasers. We were lucky.

And luck is all there really ever is to survival here. Crimes in Durban are random and lethal. They stem out of anger more than want or need for valuables: violence is almost always involved as an outlet for this hatred. This overarching hatred can almost be tasted in the air here; a vile hatred between blacks and whites, of course, but even more so between men and women, between young and old, white Afrikaaners and white English,

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Xhosa people and Shona people, Christian followers and Traditional followers. I have to wonder, who actually benefits from all this animosity?

Others we know were not so lucky. Every day, it is something. Bheka’s car was blown up…someone broke into our backyard last night…Jackie is in the hospital again from severe beatings…Mbali’s mother was just shot to death in one of the nearby shanty towns…two new babies came into the orphanage today; both have genital herpes…Maddy was almost kidnapped on her walk home today; luckily there was another woman around to warn her…did you hear that woman screaming outside our window last night?…Phil has been mugged for the third time this semester…apparently Nathan’s friend Sipho was just beat to hell by the cops…

Every day, we come home and debrief amongst ourselves, an attempt at self-therapy, though I’m not really so sure of its effectiveness. Every day, I can physically feel the incredible toll that this stress takes on my mind and body. I live in paranoia and constant fear. And more distressing than the fear is my acceptance of it.

On Thursdays, I volunteer for the day at an HIV/AIDS hospice clinic over in Pinetown, a poor suburb of the city. The center holds over a hundred men and women with advanced AIDS. Some come to the clinic for hope and help, some come to die. The entire building has a desperate, starched feeling to it and it smells like a horrible mixture of decay and powerful hand sanitizer. Like all non-profits in South Africa, the Dream Centre is chronically understaffed, under-funded and over-crowded.

At random, I always just pick a room, take a deep breath, and enter. “Sawubona!” Hello.

The woman slowly turned away from the window and smiled at me. “Sawubona ngani?” Hello, how are you?

“Ngisaphila ngiyabonga. NguDrew.” Fine, thank you. My name is Drew. “NguMzwandile.” I grabbed a chair and pulled up to Mzwandile’s bed, which was a downgraded

version of a standard summer-camp cot. We always have to switch over to English, as my repertoire of isiZulu comes to an end fairly quickly. As I expected, her English was only slightly better than my Zulu. I asked her the translation of her name. The family has increased. This is the attitude I have often enough seen Africa bestow on a beautiful new child brought into the world. One more mouth to feed.

But the family had now decreased. Mzwandile has been disowned by her family for a disease that another cruelly bestowed on her. Her story was no different than the other woman I had spent that past few months visiting. Young, four children, no education, no job, and always the intense hatred for the male sex. Out of respect, I asked her if she was married, knowing very well the answer I would receive, as I had from so many others before. Lobola. Of course not. Lobola is the age-old Zulu tradition that one has to pay for their wife with the gift of eleven cows. Essentially, no one can afford eleven cows and, thus, no one gets married. And then conversation always ceases because, really, where can we go from here? Her leisure interests? Nonexistent. Stories of her life and her family? She doesn’t want to bring up the pain that conversation would evoke and I can’t bring myself to ask her to. My life? My experiences? My hopes and dreams? Unrelatable,

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unrealistic and irrelevant to the life that she lives. And so we sat there; just sat there, holding hands, staring out the window in silence. Sometimes, in other situations, I would read to patients or paint their nails or brush their hair but, most often, I just sat there with them.

An hour passed. The reverie was then broken by a new occupant entering the humid, semi-sterile room. The woman was beautiful…or, rather, had the shadows of a once gorgeous face. Obviously in her young twenties with charcoal skin and high cheek bones, she only weighed about 70 pounds. She was carried in by a nurse to her bed and continued coughing from the tuberculosis that inevitably spreads to everyone in the center. And just when I began to worry if her tired body could even muster the energy to take another breath, the woman started violently vomiting up blood.

The time for me to return back to my flat always eventually comes. Just before I walked out of the room, I turned back to leave Mzwandile with a smile and she half returned one. Then with incredible labor, she lifted her hand and hoarsely mumbled, “Ah sissy, nkosi sikelel’ iAfrika.”

I looked down at the tiled floor as a complete sadness washed over my entire being. I lifted my eyes to meet hers once again and replied, “Yebo” half-heartedly. God save Africa. If only it were that easy.

In all this time I find I now have since we are forced to spend our evenings indoors, I often simply stare out my window. Sometimes I think of nothing at all, allowing my thoughts to rest and my mind to relax. If my thoughts were of my own choosing, this emptiness is what I think I would prefer; it’s so much easier. But as it is, my mind usually races to debrief the day, compartmentalize, explain, organize, rationalize it. Sometime last week, I was back at my window, listening to music leaking from my computer. I couldn’t help but note the irony as John Lennon’s “Imagine All the People” started to play. Nevertheless, I allowed the mellow lyrics to relax me while I gazed into the thick night. But I did not actually see the darkness, the sparse garden below my window, the castle of barbed wire and imposing security that surrounded our flat. My mind was instead traveling back home, enjoying a quiet evening meal with my family. It was all I could do to blot out the events of the past couple days: the mugging I witnessed early that afternoon, the recent drugging of a friend, the political tension of Zimbabwe ready to spill over into northern South Africa.

Suddenly, a series of sharp shots interrupted my thoughts and broke my trance. The shots had seemed closer than they usually did, but this was the life that I was slowly becoming callused to and I quickly returned to my daydreaming. No more than ten minutes later, when the incident was all but erased completely from my recollection, my housemate Maddy walked into the room sullenly. She relayed that the shooting had been right outside our flat’s entry gate. On the sidewalk in front of our apartment, the man lay immobile, shot six times. Reportedly, he had attempted to hijack our neighbor’s car and the security guard caught him. As blood ran freely into the gutters of our street, people passing by simply turned their heads and continued on their way. The body was eventually hauled away by a couple of beat cops, no questions or motives asked. They say that the African earth is tainted from of all the blood shed over the past two hundred

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years or so. The soil here is actually red in color; it’s the strangest thing…I am supposed to be traveling in Botswana right now, but South Africa is in a recent

uproar. Xenophobic attacks have spread across the country, already forcing 25,000 people to flee. The papers blame the violence on high unemployment rates and citizens becoming territorial about job opportunities going to migrants, but rumors around here hint that the fighting was actually instigated directly by the government as a conspiracy to take some heat away from their recent failings. I am a bit disappointed in the timing of the uprising, especially since we’ve already purchased the tickets, but the bus would’ve taken us into the heart of Johannesburg, where forty-three people have already been tortured and murdered. It is probably a good thing we didn’t go, as the US Embassy just today put the country on crisis alert. I was worried about Ashe, a friend I had made through school; she fled here from Zimbabwe with her family a number of years ago to escape the political violence of South Africa’s northern neighbor. I finally got a hold of her a couple of hours ago and she reported that she and her family were all safe, much to my relief, but that her best friend had been murdered. Forced to drink diesel fuel. African against African. But what is the human motivation behind this? How can one do such a thing? Why would one do such a thing?

I guess that is what I’ll fall asleep thinking about tonight, but here is the honest truth: it doesn’t bother me as much anymore. I still enjoy a good, fresh mango from the woman down the street. I still laugh at a bawdy joke that my housemate entertains us with. I still scowl at the new zit that is taking over my chin. And this absence of sentiment bothers me…sort of. But not even that fear is felt with much intensity; feelings have been numbed as emotional survival has kicked in.

I strive each and every day of my life so that I may continuously evolve to be a “better” person, but I can feel myself slipping in another direction; not towards vice, but rather into a third direction, a trance of reality. I am now caught up in the realities of the larger world. I can no longer choose ignorance, though along with this decision comes a certain amount of misery. From my experiences these past few of months, I have lost unquestionable trust for people. I have lost unwavering faith. I have lost any sense of pity. Whether these personal transformations are a positive or negative change in one’s self, I do not know. I’ve always wanted to believe that people are inherently good, but I’ve come to realize that people are just people; they are too complex to be labeled with terms as simple as “good” and “evil.”

But amongst it all, I still observe and feel a sense of hope for this country and continent, and ultimately, the world; hope for the present and hope for the future. The human race has survived and will continue to survive. As human beings, we are strong and it is our nature to survive. But there has to be more to life than mere survival, like purpose and compassion and happiness. How can all this violence really be conducive to individual survival? And if it is not, when will Africa learn so? Is there hope for humanity in a region like this? Can we find it in one another? Or can God really be the only one to save this place?

iAfrika.

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A Different Dimension of DevelopmentHolding the Mirror up to Oneself

Gracie VivianUniversity of Western Australia

MBBS, BA in Philosophy

When I was eleven, I drew a picture of what I wanted to be when I grew up. I dressed myself in a white coat, placed a stethoscope around my neck, and printed “traveling doctor” underneath the image. I was going to help the poor and the needy, like those African kids I had seen on TV with swollen bellies and crusted eyes. My purpose was admirable and it filled me with exuberance and pride.

This attitude went unchanged for seven years until I traveled to Calcutta and Nepal as a medical student volunteer. The experience uprooted much I had previously accepted as truth and marked the beginning of an evolving shift in the way I view the world and myself in it.

Whilst navigating the grimy back streets of Calcutta to one of Mother Teresa’s orphanages, I came across a man sitting on the roadside with his leg outstretched before him, a soiled bandage over his foot. He beckoned me over and removed the bandage, revealing the grossly swollen remnants of a foot covered in maggots. I gasped in shock and revulsion and rushed to the orphanage to inform a nun. She told me that he could not be accepted there and then hurried away. I sat on the step seething with anger and indignation. These nuns who preach compassion and social service are such hypocrites, shifting the responsibility of a dying man to someone else! Why won’t she help me help him? On her return she told me to take the man to another one of the homes and slipped something in my hand with a gentle smile. I drew a small crowd as I ushered the man into a taxi with a grave look on my face. Once settled in the vehicle I checked the contents of my hand: money to pay the driver and a note to the nun in charge, “We found baby Jesus here on the street. Please take care of him.” A wave of shame for my self-righteousness came over me.

Meanwhile, the man began to sing and dance in his seat, clapping his hands and shaking his head in delight whilst the maggots squirmed in his foot. Again I was caught off guard. This man was suffering; he was not supposed to behave like this! He should be downcast and depressed…not happy! My ideas about what suffering should entail and of my own self-importance and pride were subjected to much reflection in time to come.

Soon I felt overwhelmed by the multitude of other “issues” that sprang from this first flirtation with “development” and perplexed by the vague uneasiness they gave me.

suffering

How should I deal with other people’s suffering and how much responsibility should I take for it? How does this affect my own personal experiences of suffering? My attitude toward suffering oscillated from pitying sentimentality to a sensationalized, morbid sort of intrigue, to grim stoicism. At times I normalized it so that the suffering I

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encountered no longer demanded my attention or provoked a response. At other times I wanted to escape its relentless and unyielding nature and cocoon myself within the comforts of ignorance and the relatively trivial distractions of life back home. However, I was simultaneously reviled by this attitude and found the Global North’s excess and materialism abhorrent, refusing to pay four dollars for a coffee because, didn’t you know? Four dollars could feed a whole family in India! I couldn’t fathom how such extreme dichotomies of wealth and poverty, suffering and joy, privilege and disadvantage could exist in the world side by side. In light of this, happiness began to feel like an indulgence, like, as Gill Courtemanche once wrote, “…a kind of sin. How can we be happy when the earth is falling apart before our eyes and humans are turning into demons?”1

Power I soon became aware of the inequities that tipped the balance of power between the

development workers and those we helped. Some obvious factors included education and wealth. But a more insidious aspect was the very way we identified ourselves as the subjects, the helpers or saviors, and the others as objects, the beneficiaries of our benevolence. This made us powerful and superior while constructing “them” as powerless, inferior and dependent.2 Carter describes this simply but accurately: “Some folks liked to just continually give because it made them feel uppity, and better than the feller they was giving to.”3 Slowly, this perception of superiority made me increasingly uneasy. I realized that it reeked of a sinister arrogance that lurked covertly within some individuals, in the development industry as a whole, and, most disturbingly, sometimes in me, too.

self-imAge

At the start, it was easy to revel in my own goodness and pat my own back for being a good person doing good deeds. I thought I could change people’s lives by pouring forth my limitless compassion. But I wasn’t and I didn’t. Sometimes I didn’t want to clean the patient who soiled her pants for the nth time, so I looked the other way. Sometimes I took a different route home so I wouldn’t cross paths with a certain beggar who would undoubtedly pour out her troubles to me and ask for money. Instead of expressing appreciation, a child I “helped” once pulled my hair and spat at me. But I was helping him; he was supposed to be grateful!

I slowly began to see myself for what I was: a clichéd, bleeding heart youth. I was loftily idealistic and passionately outraged at the injustices of the world, but also ignorant and arrogant. My expertise consisted of half-baked ideas about the way I thought the world should be, but I had no experience or skills with which to transform my dreams to reality. Martel describes this realization of the impotence and conceit of youth well: “I

1 Gil Courtemanche, A Sunday at the Pool in Kigali, trans. Patricia Claxton (Toronto: A.A. Knopf Canada, 2003). 2 “When you fix, you assume something is broken. When you help, you see the person as weak. But when you serve, you see the person as intrinsically whole. You create a relationship in which both parties gain”, says Dr. Stan Goldberg. Source: Goldberg, S. (2004) Fixing? Helping? Serving?, San Francisco Call (reprinted from Power of Purpose Awards), November 23, 2004. 3 Forrest Carter, The Education of Little Tree (Albuquerque: University of New Mexico Press, 1990).

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felt like a piece of plastic to her worn leather… new, shiny, stupid… my youthfulness came out in too many words, too many opinions, too many emotions.”4

motivAtions

On deeper reflection of my motivations for going on the trip, I found myself surprised. It wasn’t just that I wanted “to help people,” but I also wanted to travel somewhere thrilling and exciting for the summer, to alleviate my own sense of guilt for my privileged life, to feel good about myself. I kept going back for the deep friendships, drawn by the intimacy of community life. Others were compelled for different reasons (many of which were “running from” rather than “striving toward”). Some development workers internalized guilt to such an extent their work became a self-punishing act of martyrdom, devoid of joy. Others exhibited great compassion and generosity as development workers, but harbored bitterness against their estranged families and drifted restlessly about the world, incapable of settling in one place. It seemed that escapism was their main motivation. I asked myself: which is the greater challenge, loving those closest to me at home or loving complete strangers in an exotic country?

ego

I soon discovered that my volunteer experience was intimately intertwined with my ego. It was reflected in the way other volunteers and myself shared our experiences; collecting and embellishing stories, competing to see whose were most entertaining, the pride and ownership we had about “volunteering,” about “India,” about the “Third World.” The way we preached to our loved ones back home from our moral pedestal about the injustices of the “real” world with a pained angst, revealing the fact we now carried a burdensome secret knowledge about the world that they could not understand because they hadn’t experienced “it” yet. And so forth.

going home

Maskalyk writes, “People who do this type of work talk about the rupture we feel on our return, an irreconcilable invisible distance between us and others. We talk about how difficult it is to assimilate, to assume routine.”5 When I went home I felt like I didn’t fit in and that no one understood me or my experiences. This made me lonely at times. But if fitting in and being understood meant succumbing to the superficial, bubble-wrapped world of the people around me, then I would heroically go my own way in dignified solitude. From this, a strange paradoxical pride grew as I isolated myself further. I became quite scathing and condemnatory of our Western society, quietly condemning others for their shallowness and material greed. I talked about how despite all their suffering, the poor were truly happy, and how we, with all our wealth, were so unhappy and ungrateful. I thought I was acting as their advocate, only realizing much later that instead, such sentiments misrepresented and sensationalized their suffering in a grossly oversimplistic manner, doing both them and myself a disservice.

4 Yann Martel, Self (Toronto: Vintage Canada, 1997).5 James Maskalyk, Six Months in Sudan (New York: Canongate, 2009).

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the system

What is “development” and where did it come from? After sixty years of development, why haven’t things improved? I began to suspect the term “development” was a euphemism for Westernization or neo-colonialism. Seeing tribal people in remote villages wearing Madonna shirts and listening to J.Lo was deeply disturbing and suggested to me that the development of economies is inextricably linked with the process of eroding other cultures and transforming them into our own. It made me question the industry in which I had become a part of, to ask if we’re deluding ourselves to the possibility that development work actually subscribes to the righteous imposition of colonialist ideologies we’re supposed to despise. Scroggins describes this well: “Dozens of… university graduates still set off for Africa each year with what might be described as a modern version of that (colonialist) urge, an ambition to ‘develop’ Africa that arouses much the same pleasurable hopes and feelings as did earlier pledges to service Kipling’s ‘lesser breeds without the law.’”6

lArger questions

What is the meaning of life? What is the meaning of my life? What is truth? Why does evil exist? How does this challenge my concept of God?

The most valuable outcome of “helping” the Global South was helping myself. It held up a mirror that reflected my hidden ugliness back to me, a simultaneously distressing and freeing revelation. This unexpected introspection is echoed with precision by Fothergill: “My first impressions of Sudan were rather blurred and uncertain; I was so much more interested in myself than I was in my surroundings.”7 But rather than being “bad,” the preliminary self-obsession that comes from doing development work in the Global South is necessary; it subdues after the initial shock and paves the way for a potentially more selfless and giving service. Slowly the despair at discovering one’s ugliness transforms fixed answers, narrow mindedness, and pride into fluid questions, open mindedness, and greater humility, guiding a new way of relating to the world. Put in another way, we need to realize how plastic we are in order to let that plasticity melt away and, in time, form leather.

The lessons I’ve learned hold true for me only at this very point in time and they are neither exhaustive nor unequivocal truths. They include the following: The line between right and wrong, acceptable and unacceptable, is hazy. There are rarely blacks and whites, just many shades of grey that can surprisingly coexist harmoniously. The old middle path seems to unfailingly pull through most of the time. Those lacking insight are just as dangerous as the excessively over-analytical. Self-justification for failing to take responsibility and self-depreciation for an honest mistake are equally detrimental. Unbridled cynicism and disproportionate naiveté are both dangerous traps. It’s essential to balance the striving for my self-improvement with a lighthearted kindness and an acceptance of my own ugliness. Rather than rejecting my privileged life in the Global

6 Deborah Scroggins, Emma’s War (New York: Pantheon Books, 2002) makes reference to Rudyard Ki-pling’s The White Man’s Burden.7 Edward Fothergill, Five Years in the Sudan (New York: D. Appleton, 1911).

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North, I should embrace it, letting the lessons I’ve learned in the Global South spill into, saturate, and transform it. What I do at home is just as important as what I do overseas; small dreams of treating family and friends well and living simply and ethically are just as helpful as (if not more helpful than) grandiose dreams of saving humanity. Humans are astounding beings with seemingly infinite capacities for resilience, meaning-making, and joy. Philosophy and development studies are valuable ways to arm oneself with the tools necessary to address the “issues” that may arise when working in the Global South.

Years later, when I went to East Africa to do my medical elective and to travel, I was confronted with the same array of troublesome issues. In Rwanda I visited a number of genocide memorials. One housed the preserved bodies of some of the thousands of victims that were slaughtered there, their contorted faces frozen. The guide who showed us around was soft-spoken with an impassive face and deeply furrowed brow. He carried a large ring of keys, robotically opening and locking each door in succession like a formidable prison guard. Whilst he had fled to neighboring Burundi during the genocide, his entire family was killed at this place. I wondered what it must be like for him to take foreigners, who didn’t understand his suffering, through that place day after day – what he thought of our deliberate, awkward solemnity; our silent, pained expressions; our measured, heavy plods that reflected the numbness in our heads. My mind recoiled at the immensity of the suffering. I wondered, what should I think? How should I think it?

But I paused and quelled the inundation of internal comments and questions, and instead tried to be present with every other faculty other than my mind. It helped me to not intellectualize the ghost of the other man’s suffering or to turn it into being about me, and it destroyed the delusion that I was there to help this man. Having had the values of rationality and purpose-driven action so strongly instilled in me, letting go of my need to immediately “fix it,” to “do something,” to “work it out” was, and still is, difficult. But sometimes all you can do is just be present, and that’s enough. Reflecting on this experience, I realized that all that time devoted to addressing the myriad, challenging development questions with “the brain dance” allowed me to move beyond the cerebral and approach suffering on a deeper level.

This was a valuable lesson. Undoubtedly, my next encounter with the development industry and that mirror it inevitably holds up will bring me more lessons such as these.

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Call for Papers

SCOUT BANANA, in conjunction with Michigan State University’s African Studies Center and Office of International Development, invites you to submit a

manuscript to Volume III, Issue I of Articulate: Undergraduate Research Applied to International Development.

Articulate is an undergraduate journal that publishes academic papers and writings on international development and health care in Africa. It is a forum for students to contribute to, as well as initiate, debates in international development. Undergraduates remain a vital, untapped force for new ideas and perspectives. Our goal is to spark, share, and spread knowledge to create innovative change now.

Primary criteria for inclusion in the journal are quality of research, relevance, and originality. All manuscripts must have been written as an undergraduate student. For scholarly articles, we ask for submissions of roughly 15-20 pages double-spaced, citations formatted according to the Chicago Manual of Style, and an abstract of 200 words. We also ask that the author’s name, major, college, and university appear on a separate cover sheet, with no reference to the author within the manuscript. Potential topics include, but are not limited to:

Articulate is also seeking brief reflective essays on your experiences in Africa, as well as reviews on literature relevant to Africa, development, and health care.

Reflective essays are 2-3 single-spaced pages and can take a variety of creative forms. They should explore development work from the perspective of a young person (under 30) from the Global North entering the Global South. Was it how you thought it would be? What did you like and/or dislike about it? What do you wish you had known when you were just “studying,” as opposed to working, in Africa on health-related issues? Other themes may be considered with consultation from the Editor-in-Chief.

Literature reviews are 2-3 single-spaced pages and are meant to keep Aritculate’s readers abreast of current works and on-going debates pertinent to development, Africa, and health care. Reviews must provide a careful, thoughtful analysis and critique of a work’s main themes, objectives, arguments, and conclusions. They should include at least three titled sub-sections: an introduction that includes a synopsis of the work; an analysis that considers what, if any, assumptions underlie the author’s thinking and, if evidence is cited, how well it supports the work’s main objective; and a conclusion that summates your analysis and states the overall merits and/or shortcomings of the work.

Manuscripts will be accepted until Monday, January 18, 2010, with an intended publication date during May 2010. For submissions, please contact the Editor-in-Chief at [email protected]. For more information, check out http://scoutbanana.org/articulate.

• The effectiveness of foreign aid, microfinance, and social enterprise in Africa• Intersections of gender, religion, ethnicity, and sexuality in African development• Consequences of globalization, especially financial and trade integration• Historical analyses and case studies of health care programs in Africa• Politics of water and medicine in Africa• The role of African youth in development programs and projects• Effects of conflict and forced migration on health care and development

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Articulate Style SheetDocumentation Guidelines

Articulate adheres to the Chicago Manual of Style’s humanities, or note-bibliography, format system. All citations and references of a submission to the journal must align with the guidelines outlined here. For more detailed information, please refer to the most recent edition of the manual.

references

This page should appear at the end of the paper, but before any figures and appendixes, and should be arranged in alphabetical order according to the authors’ last names. All entries with no author should be placed before those with authors, and should be arranged alphabetically according to the title of the work (keep in mind that an organization can act as an author).

In the examples that follow below, the first entry shows the format of the first note as it should appear in the text proper. These should be placed in footnotes, and ordered sequentially by number. After the first note entry for a work, all subsequent references to that work should be formatted as “Author’s last name, page number.” If you have referenced several works from the same author, include the title in secondary notes, as in, “Author’s last name, title of work, page number.” If no author is given, include the title and page number. If there is no page number (e.g., a website), simply include the title of the reference. The second entry shows the format of the note as it should appear in the references page. Note that each line after the first is indented. Also note that there is no use of italics or underlining: book titles are left as regular, plain text, while everything else – sections of books, websites, articles, papers, presentations, etc. – are placed within quotation marks.

Book

One author1. Ferdinand Oyono, Houseboy (London: Heinemann, 1980), 27.

Ake, Claude. Democracy and Development in Africa. Washington, D.C.: Brookings Institution, 1996. Two authors2. Toyin Falola and Matthew Heaton, Health Knowledge and Belief Systems in Africa (Durham, N.C.: Carolina Academic Press, 2008), 94-97.

Feierman, Steven and John Janzen. The Social basis of health and healing in Africa. Berkeley: University of California Press, 1992.

Three or more authors3. Edward O. Laumann et al., The Social Organization of Sexuality: Sexual Practices in the United States (Chicago: University of Chicago Press, 1994), 262.

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Laumann, Edward O., John H. Gagnon, Robert T. Michael, and Stuart Michaels. The Social Organization of Sexuality: Sexual Practices in the United States. Chicago: University of Chicago Press, 1994.

Chapter or other part of a book4. Gustavo Esteva, “‘Development,” in The Development Dictionary: A Guide to Knowledge as Power, ed. Wolfgang Sachs (London: Zed Books, 1992), 6-25.

Hoogvelt, Ankie. “Globalization, Imperialism and Exclusion: The Case of Sub- Saharan Africa.” In Africa in Crisis, edited by Tunde Zack-Williams, Diane Frost, and Alex Thomson, 15-28. London: Pluto Press, 2002.

Preface, foreword, introduction, or similar part of a book5. Nancy Birdsall, introduction to Reinventing Aid, ed. William Easterly (Cambridge, MA: MIT Press, 2008), xi–x.

Keim, Curtis. Preface to Mistaking Africa: Curiosities and Inventions of the American Mind, by Curtis Keim, xi–xii. Boulder, CO: Westview Press, 2009.

JournAl Article

6. Sally Matthews, “Post-development Theory and the Question of Alternatives: A View from Africa,” Third World Quarterly 25.2 (April 2004): 373-384.

Cohen, Michael A., Maria Figueroa Küpçü, and Parag Khanna. “The New Colonialists.” Foreign Policy 167 (July-August 2008): 74-76.

PoPulAr mAgAzine Article

7. Russ Hoyle, “A Continent Gone Wrong,” Time Magazine, January 16, 1984, 26.

Sachs, Jeffrey. “A Deadline on Malaria.” Scientific American, July 29, 2008.

newsPAPer Article

Newspaper articles may be cited in running text (“As William Niederkorn noted in a New York Times article on June 20, 2002, . . . ”) instead of in a note, and they are commonly omitted from a works cited as well. The following examples show the more formal versions of the citations.

8. Mangoa Mosota, “Report: Recession will affect HIV plans,” The East African Standard, July 9, 2009, Health section, Kenya edition.

Timberg, Craig. “How AIDS in Africa was Overstated; Reliance on Data From Urban Prenatal Clinics Skewed Early Projections.” Washington Post, April 6, 2006, section A, Final edition.

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Book or movie review

9. William Easterly, “The Big Push Déjà vu,” review of The End of Poverty: Economic Possibilities for our Time, by Jeffrey Sachs, Journal of Economic Literature 76.1 (February 2005), 1-22.

Seitz, Matt Zoller. “Healing Cultural Wounds.” Review of A Walk to Beautiful, directed by Mary Olive Smith and Amy Bucher. New York Times Movie Review, February 8, 2008.

thesis or dissertAtion

10. Nic Cheeseman, “The Rise and Fall of Civil Authoritarianism in Africa: Patronage, Participation in Political Parties in Kenya and Zambia” (Ph.D. diss., Oxford University, 2008), 31-37.

Almeida, Edgar F. “Was the Colonial Policy of Ethnic Self-Rule Responsible for the Divided Polity in Uganda?” MA thesis, University of Western Ontario, 2000.

PAPer Presented At A meeting or conference

11. C. Everett Koop, “Health policy working group briefing: the Surgeon General’s report on AIDS” (presented in Washington D.C., September 24, 1986).

Sen, Amartya. “Health in Development.” Keynote address presented to the Fifty-fifth World Health Assembly, Geneva, Switzerland, May 18, 1999.

weBsite or Blog

Web sites may be cited in running text (“On its Web site, the Evanston Public Library Board of Trustees states . . .”) instead of in a note, and they are commonly omitted from a works cited as well. The following examples show the more formal versions of the citations.

12. Hans Rosling, “Hans Rosling on HIV: New facts and stunning data visuals,” TED, http://www.ted.com/talks/hans_rosling_the_truth_about_hiv.html.

Stiglitz, Joseph. “Making Globalization Work.” Project Syndicate. http://www.project-syndicate.org/commentary/stiglitz74 (Accessed July 27, 2009).

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African Studies CenterMichigan State University

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Documents

Volume II, Issue II, Fall 2009