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Product Details
| ISBN-13: | 9780822372196 |
|---|---|
| Publisher: | Duke University Press |
| Publication date: | 12/21/2017 |
| Series: | Critical Global Health: Evidence, Efficacy, Ethnography |
| Sold by: | Barnes & Noble |
| Format: | eBook |
| Pages: | 256 |
| File size: | 6 MB |
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CHAPTER 1
Governing Multiplicities
Morrumbala Town, the capital of Morrumbala District in Zambézia Province, stretches for a couple of kilometers along a main road. Entering along the unpaved thoroughfare that connects to the north-south highway, the road passes a cotton-processing plant, an expansive industrial warehouse, and a small market. As it approaches the town, the road becomes busier and is soon lined with stalls, shops, and markets. The town's commercial center is situated around a crowded intersection, where chapas wait for passengers and dry goods stores sell clothes, agricultural supplies, bicycles, and food. To the left, the road drops steeply downhill past the old municipal market, housed in a colonial-era tile building, before descending to a small creek. It then crosses a bridge and rises again to the administrative part of town. At the top of the hill is a secondary school, newly built with European funds. The old boarding school that serves as a hostel for students from more rural parts of the district hovers close by, as does the community radio station. Behind these, the offices of the municipality are clustered together with the bulky Catholic cathedral, the police station, the Social Services (MMAS) office, and the district hospital, renovated with funds from a variety of NGOs and set around a breezy courtyard. Situated even higher up a small hill, the white wedding-cake home of the district administrator looks down on the activity below.
The offices of the Global Children's Fund (GCF) are here too, in a dusty compound between the municipal administration and the hospital. A large international NGO headquartered in Europe, GCF has been present in Morrumbala since the early 1980s. Ringed with a five-foot cement wall and accessible through a creaky metal gate, during the time of my research, the offices occupied two permanent structures and a trailer. The rest of the compound was filled with a small cement guest house, an outhouse, a garage, and a large warehouse, all set around a large, partially paved courtyard. To the side of the main trailer, a small verandah covered in green plastic sheeting had been constructed to provide shade for a set of wooden benches and worn plastic chairs.
It was here on the verandah that GCF community activists, or health workers, met each month with their supervisor, Violeta. Focusing on support for patients with chronic diseases and their families, the program was part of a national pilot program to formally incorporate "child- friendly" health policies into Ministry of Health spaces. The volunteers were residents of the seventeen neighborhoods in which the program operated, and they were trained to identify and care for patients with chronic illness, to distribute public health goods (such as water purification solution), conduct health awareness campaigns, and accompany GCF-enrolled patients to the hospital. Though GCF did not pay them for their efforts, the volunteers received small and intermittent subsidies and were given the material tools of their work: a T-shirt, a pair of canvas sneakers, a backpack, notebooks, pens, and a bicycle. In the absence of a salary, these benefits motivated many of the activists and were also a significant point of tension between the volunteers and the program organizers.
Benefits were also a point of tension between local health authorities and the volunteers who frequently accompanied patients to the hospital (as GCF policies encouraged them to do). Frequently, volunteers arrived at the hospital only to be told that the patient would need to pay for the consultation, tests, or prescriptions. As one volunteer put it, "We end up paying out of our own pockets, even though we don't have any money either. Because otherwise we are just wasting our time sitting there [at the hospital] for nothing. And then how can we make someone go home without medicine when they are ill, when we have told them to go there? In this way we are losing money." To these complaints, Violeta replied that the volunteers were not supposed to pay for patients. If the patients are unable to pay, she regularly repeated, they should be referred to the local authorities to apply for a Statement of Poverty, with which they can have their hospital fees waived. The complexities of accessing such a statement, or the fact that many hospital "fees" were actually informal payments, went unaddressed in Violeta's reply. Herself hamstrung by GCF policies, Violeta could do little in response to the volunteers' frustration.
How did GCF staff, volunteers, and patients negotiate the resources and practices of care that GCF made available in Morrumbala? How did distinctions between "local authorities" and "community actors" work to shape the forms of care and governance that GCF enacted in these encounters? What kinds of claims are possible in this context? This chapter introduces one NGO, the Global Children's Fund, as it worked to enhance access to health care in Morrumbala by directing patients to the hospital, extending community health programs, providing food support to the chronically ill, and expanding programs supporting children in the district. I focus on how entanglement with and distinctions from state programs and practices came to be a focus of many GCF activities and a central point of contestation among the volunteers who enacted GCF programs and the community members to whom these programs were directed.
When I began my research, I expected that the proliferation of nongovernmental projects to expand access to medical care would lead me away from public institutions and from salient political categories of "rights" and "claims." I imagined that, as nongovernmental projects defined and intervened in medical and social problems in new ways, humanitarian categories would override public health projects and social services. Yet, following GCF staff and volunteers, I soon found that NGO practices and public institutions were entangled in surprising ways; the story of humanitarian aid in Morrumbala was a political story, too. Attending to these entanglements, I aim to show how humanitarian and public forms of government come to be at work, together but unequally, in projects of making community health. As NGO staff like Violeta worked within entangled fields of governmental practices, time and the future became key means through which they worked to delimit care and to disentangle nongovernmental practices from imagined public futures. As a result, temporality was a key means by which inequality and exclusion were built into everyday NGO practices.
Being attentive to how public policies, actors, and institutions are entangled with — or inseparable from — GCF practices and to how humanitarian categories come to be built into public practices offers two important insights. It alerts us, first, to how political claims and practices are made through humanitarian words, concepts, and practices in ways that may narrow as well as extend opportunities for care. This is what I refer to as a politics of multiplicity, rooted in unequal, inextricable, and frequently obscured relations between public and nongovernmental institutions, actors and concepts. Such multiplicity, I suggest, emerges from the long history of nongovernmental intervention in Morrumbala District. Second, keeping the public in our peripheral vision as we trace the political life of global health also helps make clear how efforts to help "the most vulnerable" may fail to assist some of those in need — may sometimes, in fact, fail the neediest — as claims to public and nongovernmental services alike come to depend on singular processes of humanitarian recognition.
Locating Volunteers
One sunny May morning, about three dozen people, most wearing bright red GCF T-shirts, pulled up wooden benches and chairs in a semicircle in the yard outside the office. After welcoming the volunteers, Violeta asked who would like to begin. One of the volunteers raised her hand and said, "I told you about the problem we were having with the son of Pascua [one of the patients], that he had left home. So, we went to the house and talked with the grandmother, and with Pascua and her daughters, and we talked with him. He has already returned home to his mother's house." Violeta nodded in approval. Another volunteer raised his hand and complained that new volunteers had not yet received their "kits"— the backpack with basic medical supplies, a pair of sneakers, and a bicycle. A third voice chimed in, commenting that the bicycles in their neighborhood had been in need of repairs for many months. To these complaints, Violeta responded wearily that another program officer, Edilson, was in charge of kits and transportation. There was a routine quality to these comments; they had all been discussed many times before. As more volunteers trickled in and joined the group, chairs and benches were shifted around to make room for the latecomers and to avoid the swarms of ants that streamed out of the dry, cracked earth, climbing up chairs and benches, pouring over toes and ankles, sometimes biting and leaving large, stinging welts. Our location in the yard seemed to match the volunteers' sense that they were marginal to the organization, and it contributed to the frustration with which volunteers sometimes voiced their complaints.
Volunteers were primarily tasked with conducting visits at the homes of community residents who had been enrolled in GCF's community health and home-based care projects. These were most often patients who had been diagnosed with HIV/AIDS or other chronic diseases, and a typical visit was expected to last between fifteen and thirty minutes. In practice, since the enrolled patients were sometimes relative strangers and sometimes close friends, the content, tone, and style of visits varied; some visits entailed little more than a brief chat while others involved lengthy conversations on a wide range of topics. On arriving at a patient's home, volunteers and I would generally greet the patient and any family members. Chairs and stools might be organized or a woven reed mat spread on the ground so that we could sit nestled against the shady wall of the house. When patients were very ill, we might sit indoors, at their bedside, but for the most part, we chatted outside with patients and their families, inquiring about the patients' health and perhaps asking for medication bottles to see whether or not they were properly taking their pills.
Although GCF policies emphasized medical interventions, in practice most volunteer visits combined gentle surveillance (asking about the patient's health, for instance) with companionship and practical advice. Often, it was not only the patient who was the object of encouragement and surveillance. Family members and others were also pushed to take on appropriate roles as caregivers, and suggestions that patients might be excluded or marginalized within the household were cause for concern. Despite rules concerning medical confidentiality, it was not uncommon for volunteers to enlist the help of patients' relatives in caring for patients or performing other kinds of work. This work ranged from the medical to the practical. For instance, in one case, hospital staff asked a volunteer to visit a particular patient to find out why he had not been coming for his tuberculosis treatment lately. At his house, we found only his sister, who was hanging washing out to dry. "We are here for your brother," one of the volunteers announced, "we're here from the tuberculosis program to find out why he hasn't gone to the hospital. Tell him to come to my house when he returns." In another instance, at the house of a woman who had lost the use of her legs, volunteers organized the children to clean up a mess of dirty dishes and leftovers that were piled haphazardly in the yard. In addition, volunteers were expected to inquire after and help resolve any difficulties that might interfere with treatment or contribute to illness, including providing referrals to other public or nongovernmental services that offered additional support. In practice, volunteers most frequently referred patients to family members, suggested that they pray or ask church groups for help, and encouraged efforts at independence. Finally, volunteers used the social connections they developed through their work to help others. For instance, the adult daughter of a terminally ill patient asked volunteers to help her find good domestic help to look after her mother while she was away. Volunteers drew on their knowledge of other neighbors in need of work to help arrange a suitable person. In a context of weak social services and narrowly defined nongovernmental interventions, volunteers served as a social "para-infrastructure" (Biehl 2013) through which practices of care, medical goods, and institutional referrals were distributed.
As these examples show, volunteer work entailed a familiarity with not only basic medical practices but also familial, institutional, and neighborhood relations through which patients were identified and resources located. This mastery was particularly salient when volunteers were charged with generating "local knowledge." Community participants were important, I was told by program staff, because the volunteers "live in the community, so they know who is the most vulnerable. To us, each house may look the same, but they know what is happening inside the house." Yet even as community participants persisted in observing and recording health information about their neighbors, identifying and singling out the vulnerable, they often complained that their observations went unheeded.
Principal Cases
During one of GCF's monthly meetings, Pastor Tomás, one of the most outspoken and dedicated GCF volunteers, raised his hand and spoke to this question of recognition. To the issues already raised by his colleagues, Pastor Tomás added: "There is another thing too. We see things in the field, we report these things, and we are not heard." Pastor Tomás gave the example of a patient who had recently died. The patient's wife, Paula, was visually impaired and, now a widow, had been left alone with two small children. "These are principal cases for GCF," Tomás said, raising his voice:
This man already died. He had TB associated with HIV and his wife is blind. The children are small, they are eight and ten years old, and they are already trying to do something to help the family — to carry bricks and sell plastic bags in the market, but this means they are missing school. I asked if they could become beneficiaries of the cesta básica, but [the provincial GCF supervisor] said that they can't. But this man already lost his life because he had medicine but he didn't have anything to eat. No one gave him anything to eat, just medication only. He died the week before last. The kids and the wife are bad. And this woman will die too if we don't give her a hand!
As Pastor Tomás described this "case," he was careful to emphasize the variety of ways in which Paula might qualify for GCF programs: her deceased husband's HIV status, the risk to the children's education, and their status as paternal orphans. In doing so, he argued for providing a cesta básica — a food basket composed of beans, sugar, flour, and salt, as well as soap and chlorine solution to purify drinking water.
Like many similar programs, GCF food baskets were initially designed to support HIV patients in the early stages of treatment and followed national guidelines on the composition and distribution of food baskets. In early 2007, food support policies had been expanded to cover patients with a broad range of "chronic illnesses," including but not limited to HIV. In keeping with national guidelines, GCF had adopted the language of "chronic illness," a category elaborated not only by the Ministry of Health but also by the National Social Welfare Institute, or INAS. In practice, however, GCF's food program was housed under the organization's HIV/AIDS project and AIDS patients were the most common beneficiaries of food support. This reflected both the comparatively ample funding available for HIV/AIDS programs, relative to GCF's other initiatives, and a broader practice of emphasizing discrete illness categories in organizing interventions and projects.
As a result of these organizational priorities, Violeta's next question for Tomás was obvious: had Paula already been tested for HIV? She had not, and did not want to be. This was not necessarily grounds for excluding her from GCF assistance; not infrequently, Violeta and her colleagues included disabled, visually impaired, or chronically ill residents in GCF programs. Sometimes, these cases were considered exceptional and the circumstances that motivated them were clear; a child with spina bifida, for instance, was included in the program after one of the GCF drivers, who had been named as the child's godfather, had advocated on her behalf. Many others, however, were unremarkable, including the almost twenty elderly patients whose GCF enrollment cards listed only "cataracts." Elderly and impoverished, these patients could perhaps be more easily seen as suited to the broad mission of supporting vulnerable community members with chronic conditions. It was often assumed in such "borderline" cases that patients were sharing food they received with the staff and volunteers who enrolled them.
(Continues…)
Excerpted from "Medicine in the Meantime"
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Table of Contents
Acknowledgments viiIntroduction. Care and the Work of History 1
1. Governing Multiplicities 29
2. Making Communities of Care 57
3. Afterlives: Food, Time, and History 88
4. Nourishing Relations 112
5. The Work of Health in the Public Sector 142
6. Paperwork: Capacities of Data and Care 167
Afterword. Critique and Caring Futures 192
Notes 199
Works Cited 217
Index 237
What People are Saying About This
"With meticulous sympathy and an eye for detail, Ramah McKay examines new entanglements of humanitarian sentiment and public institutions in Mozambique. Medicine in the Meantime reveals how care refracts through a prism of varied perspectives, ranging from nostalgic former refugees to harried professional counselors. Anyone who wants to understand what global health looks like in experience—beyond abstract metrics of lives and numbers—should read this book."
"Medicine in the Meantime is a major contribution to critical studies of global health. With its careful tracing of the work of care and the politics of multiplicity, it stands as a milestone in scholarship on health care in contemporary Africa. Ramah McKay elegantly combines powerful, close-up descriptions of the dilemmas and concerns of care workers on the ground with broader theoretical discussions of the entanglements of transnational and national health services."