This summer, President Obama spoke to the citizens of Ghana from their capital, Accra, his first speech in an African country. At the same time I was at a conference in Cape Town, South Africa, sponsored by the African Religious Health Assets Program (ARHAP), an interdisciplinary group of scholars and practitioners in the social sciences, public health, and religious studies, that explores the role of religion in addressing the challenges facing contemporary African cultures.
In one presentation, a speaker referenced the Accra speech, focusing on one sentence in particular: “This is the simple truth of a time when the boundaries between people are overwhelmed by our connections.” This statement was singled out as a powerful exemplar of the kinds of shifts in American foreign policy under Obama regarding the divergent contexts on the African continent.
I hope so. And I have real reason to be hopeful about possibilities that would not have existed with earlier administrations. But this description of connections and boundaries seems to me to be inordinately complex. When the speaker at the conference quoted this line, I immediately thought, “That’s precisely what allowed HIV to spread.” The permeability of boundaries and the proliferation of connections allowed that virus, which had existed in isolated contexts for decades, to break out across national and international borders in the early 1980s. We do indeed live in a time when the boundaries among people are overwhelmed by our connections. Such a time is marked by possibilities and challenges: we need to attend to both.
In saying this, I am not advocating for a nationalistic policing of borders, for efforts to quash connections and reinforce boundaries. And I am not critiquing fields of scholarship and research that help us understand the implicit, intangible, multiple connections that permeate our postmodern moment (in fact, it seems to me that this kind of scholarship has much to teach American efforts in public health, which rely so heavily on positivistic certainties). I am saying, however, that while the connections across boundaries allow resources to flow into new and widely divergent contexts, they also allow large-scale, chaotic, destabilizing challenges to flow into new, widely divergent contexts.
A Case Study: The Village of Namatande
Three days before Obama’s speech, I had spent the day in villages in southern Zambia witnessing ongoing efforts to address hunger, education, and the support for microenterprise. These villages are the perfect example of the kind of destabilization I have just described. Citizens struggle to cope with grinding poverty, hunger, water scarcity, and a complete absence of educational opportunities beyond primary school. These interrelated challenges overwhelm the formalized boundaries of public health, international development, educational theory, microeconomics, religious studies, and social sciences erected in the academy. Just how are these challenges interrelated? The village of Namatande in southern Zambia provides an excellent case study.
The people of Namatande were moved from their land in late May of this year. This land, occupied long beyond the farthest reaches of memory, was home for these women and men—it is no longer. The government moved the village because their land had flooded for the last three rainy seasons, killing villagers and destroying homes and crops. The solution to this annual disaster was to resettle the villagers on a plot of new land about six miles from the Zimbabwe border, midway between the towns of Livingstone and Sesheke. This move, this complete uprooting from their land, has meant that the villagers of Namatande were not ready for the growing season. No seeds were planted on that new land during the rains. No crops have grown during the growing season. In the coming months, the dry land will become parched; there will be no crops for a year.
And there will be no infrastructure to support this village in the meantime. Some of the families in the village have constructed homes by hand, but many are still living in the canvas tents provided to them when they first resettled. The families faced a difficult choice: do they build their homes or do they try to get a few crops out of the ground while some moisture remains? No one knows which choice was the better one.
The primary school in Namatande is a canvas tent donated by UNICEF. There is no medical clinic. The latrines were just finished by the women in the village in the first week of July. I was in Namatande for a few days in early July, less than a week before President Obama’s speech in Accra. I was the guest of people partnering with villagers to provide cornmeal and cabbage and educational supplies and a wheelbarrow to help build the latrines. The villagers were gracious and warm to my friends and me; Zambians always are. But their quiet requests for food or assistance—such direct requests are quite rare—also betrayed the desperation that is beginning to pervade this village of 300 people.
The challenges facing the citizens of Namatande are interconnected. Efforts to grow crops have led to a shortage of viable shelter. Water scarcity (the village has only one pump to provide water for drinking, sanitation, and irrigation) impedes efforts to grow crops. Uncertainty regarding the placement of a pump for the village is hindering the construction of a primary school. The isolated location of the village makes the possibility of a medical clinic unlikely; the nearest clinic will be 12 miles away in the next village, and the distance will only be covered on foot. Limited food affects the health of the citizens of Namatande. The boundaries of singular, isolated challenges are overwhelmed by the connections among those challenges.
HIV and Community
Yet, many public health and development initiatives tend to offer singular, isolated responses to the challenges people face; whether they live in Namatande or New York.
The history of responses to the HIV epidemic reveals this pattern. For over two decades of the epidemic, efforts to care for those infected in the United States were strictly separated from efforts to prevent the spread of the virus; prevention and treatment were seen as two separate dimensions of one viral infection.
In South Africa, the social psychologist Catherine Campbell documented the numerous challenges facing HIV prevention efforts in her book Letting Them Die: Why HIV Prevention Programs Fail. Campbell was part of a well-funded, comprehensive HIV prevention program for a mining town in South Africa with a high HIV rate. Despite exhaustive planning, high levels of funding, evidence-based prevention interventions, and local partnerships with those infected and affected, the program made no difference in the spread of the disease.
Campbell concluded that public health policy focuses on the macro level while public health service delivery focuses on the micro. The distance between these two poles is too vast. She called for public health programs that focus on an intermediary level, which she named the “communal.” Campbell argued for public health responses that could articulate some shared goals for a population (akin to the goals articulated by macro approaches) while allowing flexibility and specificity for local groups (akin to targeted micro approaches). Such responses would need to be situated at the community level. In her work, Campbell did not propose an example of such a model, but some have wondered if religious entities might be just what she describes.
James Cochrane, a professor of religion at the University of Cape Town and one of the founders of ARHAP, spoke to participants at the conference in Cape Town in the days after Obama’s speech in Accra. His presentation focused on the intermediary role that religious organizations could play in addressing the health needs of communities in southern Africa. Cochrane believes that religious entities are uniquely positioned to fill this role that Campbell has described because they are pervasive, dynamic, and multifaceted.
From faith-based Non-Governmental Organizations (NGOs) to local mosques or churches to practitioners of traditional religions, religious structures permeate African society. Public health practitioners and policy-makers need to understand these various religious entities as resources to mobilize to address the health of a community. Furthermore, while some religious entities are slow to respond to changes in a community, others are very dynamic and change their structure and practices rapidly in response to community needs. Finally, religious practice is a hybrid of traditional religion and participation in Christian or Muslim communities: religion structures various dimensions of people’s lives in southern Africa.
Namatande, to come back to our example, may have no permanent structures but it does have a functioning Christian congregation and a traditional healer. Christian relief organizations are providing food, and a Muslim organization has dug the first well for the community. This is not unique to Namatande; in fact, the various church health associations in Africa are outstanding examples of community-level, or intermediary, organizations; they have some degree of central structure and organization so that they can pool disparate resources and provide some administrative and logistical support to programs on the ground; they have member congregations in most communities, both urban and rural. They are large enough to secure funding from large relief organizations, but decentralized so that such resources can flow to far-flung locations. They share common goals, but do not require uniformity in regard to doctrine or practice.
The biggest challenges for religious organizations, however, are addressing sexuality in HIV prevention, reproductive health, family planning, and women’s empowerment. In these contexts, religion has often been a barrier, and efforts to mobilize religion as a positive force for addressing these issues surely need to be strengthened.
President Obama’s words in Accra present us with an opportunity and a challenge. If we want connections to be energized for the purpose of channeling resources from disparate sources to communities in need, then we need to find ways to think and practice beyond the dichotomy of the macro or the micro. Efforts to mobilize religious organizations to stand in the intermediary role at the community level need to be developed, and public health practitioners and policy-makers would do well to partner with religious groups to carry such efforts forward.