American Medical and Intellectual Reaction to African Health Issues, 1850-1960: From Racialism to Cross-Cultural Medicine

During recent decades, social scientists, particularly anthropologists, sociologists and medical historians, have looked increasingly at how social and cultural factors inform a society\u27s medical community and vice-versa. As Roger Cooter recently stated, ... medicine is a social phenomenon capable of being properly studied only when treated as a part of its social, political, economic and cultural totality. [1] In America, a steady flow of medical sociologists -- most notably Henry E. Sigerist in the 1940s, Talcott Parsons in the 1950s, David Mechanic in the 1960s and 1970s, and Vern and Bonnie Bullough in the 1980s -- contributed numerous empirical studies that revealed that the development of American medicine was shaped moreso by its social and cultural context than clinical discoveries.[2] These studies have demonstrated conclusively that the American health profession\u27s approaches to disease (etiology and therapy), the institutional structure of medical research and care, and public health care policy all have been deeply influenced by socioeconomic and cultural factors specific to historical epochs of evolving American society

No. 60: Linking Migration, Food Security and Development

Two issues have recently risen to the top of the international development agenda: (a) Food Security; and (b) Migration and Development. Each has its own global agency champions, international gatherings, national line ministries and body of research. Global and regional discussions about the relationship between migration and development cover a broad range of policy issues including remittance flows, the brain drain, the role of diasporas and return migration. Strikingly absent from these discussions is any systematic discussion of the relationship between population migration and food security. If the global migration and development debate sidelines food security, the current international food security agenda has a similar disregard for migration. The primary focus of the agenda is food insecurity and undernutrition and how enhanced agricultural production by small farmers can resolve these endemic problems. There is a tendency to ignore the reality that migration is a critical food security strategy for rural households up and down the African continent. If migration is a neglected aspect of discussions about rural food insecurity, it is almost totally absent from considerations of the causes and impact of food security amongst urban populations. In practice, therefore, there is a massive institutional and substantive disconnect between these two development agendas. Current conceptualisations of the food security crisis in Africa provide an inadequate basis for working at the interface between migration and food security. First, there is the assumption that food security is primarily a rural problem that will be resolved through technical innovation amongst smallholders (in the guise of a new Green Revolution). What seems to be forgotten in this romantic view of the African rural household is that its food security is not simply, or even mainly, a function of what it does or does not produce itself. Up and down the continent rural households purchase some or most of their food and they do so with cash that they receive from household members who have migrated to earn income in other places within the country and across borders. The evidence for Southern Africa is that these rural households do not invest remittances in agriculture but in basic necessities, including food purchase. Rural food security, in other words, may be improved but will not be resolved by current approaches to food insecurity. A second assumption is that food security in urban areas is about promoting urban agriculture. The obsession with urban agriculture may be well-intentioned but it derives from misplaced idea that increased food production is the key to urban food security. The primary determinant of food insecurity in African cities is not production shortfalls but the lack of access to food and that means the absence of a regular and reliable income with which to purchase it. Even within the poorest areas of the city, access varies considerably from household to household with wage employment, other income generating activity, the size and structure of the household, the educational level of the household members, access to social grants and being embedded in social networks. There are some recent signs of recognition of the reality that migration and remittances play an important role in the food security strategies of rural households. A recent issue of the journal Food Policy, for example, suggests that “the sending of a migrant means the loss or reduced presence of one or more members of the household. On the consumption side this clearly means fewer mouths to feed and to support in other ways. On the production side, migration means the loss of labor and, in fact, the negative consequences of migration on nutrition are likely to come through this labor loss.” The major positive impact of migration is the remittances sent home by the migrant which can have direct and indirect effects on production and consumption. This is an important issue, but so is the relationship between migration and the food security of the urban household. Food security needs to be “mainstreamed” into the migration and development agenda and migration needs to be “mainstreamed” into the food security agenda. Without such an effort, both agendas will proceed in ignorance of the other to the detriment of both. The result will be a singular failure to understand, and manage, the crucial reciprocal relationship between migration and food security. This report sets out to promote a conversation between the food security and migration agendas in the African context in the light of what we know and what we need to know about their connections. This report focuses primarily on the connections in an urban context. Four main issues are singled out for attention: (a) the relationship between internal migration and urban food security; (b) the relationship between international migration and urban food security; (c) the difference in food security between migrant and non-migrant urban households; and (d) the role of rural-urban food transfers in urban food security. The simplest way to examine the relationship between cross-border migration and food security is to ascertain (a) how international migrants address their own food and nutrition needs in the destination country and (b) what happens to the income that they earn while away from home. The two questions are related to one another for the amount of money available to send home is to some degree contingent on the food-related expenditures of the migrant in the destination country. Migrants rarely live alone and their income may often have to support members of “makeshift” households (not all of whose members can find work) as well as second households. Migration within and to the Southern African region has changed dramatically in recent decades. All of the evidence suggests that the region is undergoing a rapid urban transition through internal migration and natural population increase. There has also been significant growth in temporary cross-border movement within the region. The implications of the region’s new mobility regime for food security in general (and urban food security in particular) need much further exploration and analysis. SAMP has conducted major household surveys in several SADC countries which provide valuable information on food expenditures in migrant-sending households. The 2005 Migration and Remittances Survey (MARS) interviewed 4,276 households with international migrants. Cash remittances were the most important source of income in all countries with 74% of all migrant-sending households receiving remittances (with as many as 95% in Lesotho and 83% in Zimbabwe). In-country wage employment was a source of income for 40% of households followed by remittances in kind (37%). Remittances in-kind are particularly important in Zimbabwe and Mozambique. At the other end of the spectrum, only 8% of households receive income from the sale of agricultural produce and only 5% receive social grants. The vast majority of households (93%) purchase food and groceries with their income. No other expenditure category comes close although a significant minority of households pay for cooking fuel, transportation, clothing, utilities, education and medical expenses. A mere 15% spend income on agricultural inputs (mainly in Swaziland). The proportion of households spending remittances on food was over 80%. Average household expenditures on food were R288 per month which is much greater than the amounts spent on other common categories such as transportation, education and medical expenses. The average monthly expenditure of remittances on food was R150 per month. In other words, remittances provided over 50% of average household income spent on food. Without remittances the amount being spent on food would drop precipitously. Remittances are therefore a critical component of food security for migrant-sending households. The SAMP study found that 28% of households spend more than 60% of their income on food. Even with remittances, only 17% said that they had always or almost always had enough food in the previous year. Cash remittances are not the only way in which migration contributes to household security as many migrants also send food back home as part of their in-kind remittance “package.” Further proof of the importance of migration to household food security and other basic needs is provided in the types of goods that migrants send home. There was little evidence of luxury goods being sent. Instead, clothing (received by 41% of households) and food (received by 29%) were the items most frequently brought or sent. In the case of Mozambique, 60% of households received food and in Zimbabwe, 45%. The next question is whether migrants are more food insecure than longer term residents of the poorer areas of Southern African cities. AFSUN conducted a survey in 11 SADC countries in 9 countries in 2008 which helps to answer this question. Because access to income is a critical determinant of food security in urban areas, it is important to know if non-migrant households are more or less likely to access regular and reliable sources of income, both formal and informal. Across the sample as a whole, unemployment rates were high with nearly half of both migrant and non-migrant households receiving no income from regular wage work. This suggests that migrants do not find it harder to obtain wage employment than permanent residents in the city. Migrant households do find it easier to derive income from casual work while non-migrant households were more involved in running informal and formal businesses (20% versus 14%). Very few households in either category earn any income from the sale of home-grown agricultural produce. The similarities in the access of migrant and non-migrant households to the labour market and to various income-generating activities suggests that they might have similar income levels and, in turn, levels of food security. In fact, there was one distinct difference in the income profile of migrant and non-migrant households. About a third of the households in each group fell into the lowest income tercile. However, 36% of nonmigrant households were in the upper income tercile, compared to only 29% of migrant households. The situation was reversed with the middle income tercile. In other words, migrant status is not a completely reliable predictor of whether a household will be income poor. However, nonmigrant households are likely to have a better chance of having better incomes, primarily because some are able to access better-paying jobs. The Household Food Insecurity Scale (HFIAS) measures household access to food on a 0 (most secure) to 27 (most insecure) point scale. In terms of the relationship between the HFIAS and migration, migrant households had a mean score of 10.5 and non-migrant households a score of 8.9. This suggests that non-migrant households have a better chance of being food secure than migrant households. The Household Food Insecurity Access Prevalence (HFIAP) Indicator. found that only 16% of migrant households were “food secure” compared with 26% of non-migrant households. Although levels of food insecurity are disturbingly high for both types of household, migrant households stand a greater chance of being food insecure. Another question is whether there are any differences between migrant and non-migrant households in where they obtain their food in the city. Migrant households were more likely than non-migrant households to patronise supermarkets. The opposite was true with regard to the informal food economy. This may have to do with the fact that nonmigrant households would be more familiar with alternative food sources compared with recent in-migrants, in particular, who would be more likely to know about and recognise supermarket outlets. A second difference is the extent to which households rely on other households for food, either through sharing meals or food transfers. This was more common among migrant than non-migrant households, suggesting the existence of stronger social networks amongst migrants. Thirdly, non-migrant households were more likely to grown some of their own food than migrant households. The majority of poor households in Southern African cities either consist entirely of migrants or a mix of migrants and non-migrants. Rapid urbanization, increased circulation and growing cross-border migration have all meant that the number of migrants and migrant households in the city has grown exponentially. This is likely to continue for several more decades as urbanization continues. We cannot simply assume that all poor urban households are alike. While levels of food insecurity are unacceptably high amongst all of them, migrant households do have a greater chance of being food insecure with all of its attendant health and nutritional problems. This fact needs to be recognised by policy-makers and acted upon

A Labor Market Approach to the Crisis of Health Care Professionals in Africa

This paper adopts a labor market economics perspective to understanding the crisis of healthcare professionals in Africa. Five challenges resulting from this crisis are identified: a production challenge, an underutilization challenge, a distributional challenge, a performance challenge, and a financing challenge. Differences between the labor market approach and others used in the health field are noted. We conclude that more empirical data, a full labor market analysis, and the use of social benefit-cost criteria are all needed before policy recommendations to address any of these challenges can be confidently offered

Divided Diasporas: Southern Africans in Canada

The protracted economic and political crisis in Zimbabwe led directly to a major increase in mixed migration flows to South Africa. Migrants were drawn from every sector of society, all education and skill levels, equal numbers of both sexes, and all ages (including unaccompanied child migration). Many migrants claimed asylum in South Africa which gave them the right to work while they waited for a refugee hearing. Many others were arrested and deported back to Zimbabwe. Migrants who were unable to find employment in the formal economy turned to employment and self-employment in the informal economy. These migrant entrepreneurs used personal savings to establish small and micro enterprises in many urban areas. The businesses focused on retail trading, manufacturing and services and contributed to the South African economy in various ways, including providing employment for South Africans. Nationwide xenophobic violence in 2008 targeted all migrants, irrespective of origin and legal status. From 2008 onwards, violent attacks on migrant-owned informal businesses began to escalate. This culminated in a second round of nationwide xenophobic violence in early 2015 when migrant-owned businesses were targeted by mobs. Migrants send essential remittances to family in Zimbabwe and return migration is not a viable or long-term response until Zimbabwe’s economic crisis is resolved. As a result, informal migrant entrepreneurs have adapted to hostile business conditions by adopting a range of strategies to avoid and protect themselves and their businesses from xenophobia. Against this backdrop, this report first discusses the nature of the crisis in Zimbabwe and its connections with large-scale out-migration, particularly to South Africa. The South African response to crisis-driven migration is reviewed showing how the government shifted from a predominantly coercive and control-oriented policy towards a more realistic assessment of the need to accommodate migrants through an immigration amnesty and the right to work in the formal and informal sector. One of the major challenges facing migrants and all stakeholders in South Africa is xenophobic violence. Nationwide attacks on migrants and refugees in 2008 and 2015 have been interspersed with ongoing lower-level episodes of violence. These attacks have increasingly targeted migrants and refugees, including many Zimbabweans, seeking to make a living in the country’s urban informal economy. The research for this report focused on the business activities and responses to xenophobic violence of Zimbabweans in the informal economy. Amongst the key findings were the following: Between 20-30% of Zimbabwean migrants in South African cities are involved in the informal economy and the importance of informal sector employment to Zimbabweans has increased over time. Zimbabweans operating enterprises in the informal economy are predominantly young (50- 75% under the age of 35) and male (60-70%). Nearly two-thirds of the migrant entrepreneurs arrived in South Africa in the peak years of the Zimbabwean crisis between 2000 and 2010 (42%). Another 32% migrated after 2010. Less than 2% migrated to South Africa before the end of apartheid. Economic hardship, unemployment and political persecution are the main push drivers of migration to South Africa. Pull drivers include the assistance of relatives already in South Africa and the prospect of employment. The majority of the Zimbabwean migrant enterprises are in the retail, trade and wholesale sector, followed by services and manufacturing. Around three-quarters of the migrants relied on their personal savings to start their businesses and many worked in the formal economy first. Business expansion has occurred despite the prime obligation of the entrepreneurs to support family still in Zimbabwe. Instead of reinvesting all of the business profits into further expansion, a portion is therefore diverted into remittance channels. Over one-third remit funds at least once per month and only 12% never send remittances. A significant number of the entrepreneurs had been victims of or knew other who had been victims of crime such as looting and robbery, xenophobic abuse and police misconduct abuse. The report then presents the results of in-depth interviews with Zimbabwean business-owners who had experienced xenophobic violence in 2008 and 2015 or at other times. The narratives of the migrants provide insights into the unpredictable nature of the violence, their vulnerability to attack, the loss of business goods and property during mob violence and the need to restart from scratch, and the various strategies that they adopt to reduce risk. These strategies include operating in safer areas (not feasible for all), avoiding areas where corrupt police tend to operate, paying for protection and flight when xenophobic violence erupts. Return to Zimbabwe is not considered a viable option because of the economic conditions there. The interviews also provide insights into the migrants’ perceptions of government and stakeholder responses to the xenophobic violence. Almost without exception, the migrants felt that neither government (the Zimbabwean or South African) had done anything to protect or assist them during and after the violence. This perception of inaction also extended to international and non-governmental organisations. The migrants were particularly harsh in their comments about the police who were widely seen as either conniving in the violence or uninterested in protecting migrants. The perceptions of the migrants that nothing is done may simply be a function of who was interviewed and does not necessarily reflect the actual reality. The report therefore evaluates the response of the South African government to the ongoing crisis of xenophobia and concludes that some actions – such as sending in the army – are taken during episodes of nationwide violence but that ongoing daily and weekly attacks are generally ignored. There is a strong official line that these attacks are not motivated by xenophobia and. Indeed, that xenophobia does not even exist. This is clearly contradicted by the migrants who view the attacks as motivated by xenophobia. A second element of the official response is that the migrants are partially to blame for what happens to them as their business success builds resentment amongst South Africans. Government has yet to acknowledge that migrant-owned informal enterprises make a valuable contribution to the economy of the country, including through job creation for South Africans. The primary response to the violence of 2015 was the launching of a military-style Operation Fiela which was justified as a crime-fighting initiative but appears to have targeted migrant enterprises. The final sections of the report examine the responses and programmes of various non-governmental and international organisations to the crisis of xenophobia. During large-scale xenophobic violence there is considerable mobilisation of anti-xenophobia civil society organisations to offer protection and protest. Their effectiveness and impact tends to dissipate when the violence is more scattered and random. The South African Human Rights Commission (SAHRC) has played a major role in the past in holding government to account and articulating extensive recommendations for remedial action, most of which have not been taken up and many of which are still highly relevant. International organisations have tended to target integration and education programming at the community level but there has only been one systematic evaluation (of the UNHCR’s response) which was highly critical of the organisation. These organisations and other governments are considerably hamstrung by xenophobia denialism at the highest level because it means that government will avoid the kinds of partnership that are urgently needed to address this endemic crisis

The extent of community and public support available to families caring for orphans in Malawi.

There are an estimated 15 million AIDS orphans worldwide. Families play an important role in safeguarding orphans, but they may be increasingly compromised by the HIV/AIDS epidemic. The international aid community has recognized the need to help families continue caring for orphaned children by strengthening their safety nets. Before we build new structures, however, we need to know the extent to which community and public safety nets already provide support to families with orphans. To address this gap, we analyzed nationally representative data from 27,495 children in the 2004-2005 Malawi Integrated Household Survey. We found that communities commonly assisted orphan households through private transfers; organized responses to the orphan crisis were far less frequent. Friends and relatives provided assistance to over 75% of orphan households through private gifts, but the value of such support was relatively low. Over 40% of orphans lived in a community with support groups for the chronically ill and approximately a third of these communities provided services specifically for orphans and other vulnerable children. Public programs, which form a final safety net for vulnerable households, were more widespread. Free/subsidized agricultural inputs and food were the most commonly used public safety nets by children's households in the past year (44 and 13%, respectively), and households with orphans were more likely to be beneficiaries. Malawi is poised to drastically expand safety nets to orphans and their families, and these findings provide an important foundation for this process

Human resources needs for universal access to antiretroviral therapy in South Africa: a time and motion study

<p>Background - Although access to life-saving treatment for patients infected with HIV in South Africa has improved substantially since 2004, treating all eligible patients (universal access) remains elusive. As the prices of antiretroviral drugs have dropped over the past years, availability of human resources may now be the most important barrier to achieving universal access to HIV treatment in Africa. We quantify the number of HIV health workers (HHWs) required to be added to the current HIV workforce to achieve universal access to HIV treatment in South Africa, under different eligibility criteria.</p> <p>Methods - We performed a time and motion study in three HIV clinics in a rural, primary care-based HIV treatment program in KwaZulu-Natal, South Africa, to estimate the average time per patient visit for doctors, nurses, and counselors. We estimated the additional number of HHWs needed to achieve universal access to HIV treatment within one year.</p> <p>Results - For universal access to HIV treatment for all patients with a CD4 cell count of ≤350 cells/μl, an additional 2,200 nurses, 3,800 counselors, and 300 doctors would be required, at additional annual salary cost of 929 million South African rand (ZAR), equivalent to US$141 million. For universal treatment (‘treatment as prevention’), an additional 6,000 nurses, 11,000 counselors, and 800 doctors would be required, at an additional annual salary cost of ZAR 2.6 billion (US$ 400 million).</p> <p>Conclusions - Universal access to HIV treatment for patients with a CD4 cell count of ≤350 cells/μl in South Africa may be affordable, but the number of HHWs available for HIV treatment will need to be substantially increased. Treatment as prevention strategies will require considerable additional financial and human resources commitments.</p&gt

Modeling solutions to Tanzania's physician workforce challenge.

BACKGROUND:There is a great need for physicians in Tanzania. In 2012, there were approximately 0.31 physicians per 10,000 individuals nationwide, with a lower ratio in the rural areas, where the majority of the population resides. In response, universities across Tanzania have greatly increased the enrollment of medical students. Yet evidence suggests high attrition of medical graduates to other professions and emigration from rural areas where they are most needed. OBJECTIVE:To estimate the future number of physicians practicing in Tanzania and the potential impact of interventions to improve retention, we built a model that tracks medical students from enrollment through clinical practice, from 1990 to 2025. DESIGN:We designed a Markov process with 92 potential states capturing the movement of 25,000 medical students and physicians from medical training through employment. Work possibilities included clinical practice (divided into rural or urban, public or private), non-clinical work, and emigration. We populated and calibrated the model using a national 2005/2006 physician mapping survey, as well as graduation records, graduate tracking surveys, and other available data. RESULTS:The model projects massive losses to clinical practice between 2016 and 2025, especially in rural areas. Approximately 56% of all medical school students enrolled between 2011 and 2020 will not be practicing medicine in Tanzania in 2025. Even with these losses, the model forecasts an increase in the physician-to-population ratio to 1.4 per 10,000 by 2025. Increasing the absorption of recent graduates into the public sector and/or developing a rural training track would ameliorate physician attrition in the most underserved areas. CONCLUSIONS:Tanzania is making significant investments in the training of physicians. Without linking these doctors to employment and ensuring their retention, the majority of this investment in medical education will be jeopardized

Debating medicalization of Female Genital Mutilation/Cutting (FGM/C) : learning from (policy) experiences across countries

Background: Although Female Genital Mutilation/Cutting (FGM/C) is internationally considered a harmful practice, it is increasingly being medicalized allegedly to reduce its negative health effects, and is thus suggested as a harm reduction strategy in response to these perceived health risks. In many countries where FGM/C is traditionally practiced, the prevalence rates of medicalization are increasing, and in countries of migration, such as the United Kingdom, the United States of America or Sweden, court cases or the repeated issuing of statements in favor of presumed minimal forms of FGM/C to replace more invasive forms, has raised the debate between the medical harm reduction arguments and the human rights approach. Main body: The purpose of this paper is to discuss the arguments associated with the medicalization of FGM/C, a trend that could undermine the achievement of Sustainable Development Goal 5.3. The paper uses four country case studies, Egypt, Indonesia, Kenya and UK, to discuss the reasons for engaging in medicalized forms of FGM/C, or not, and explores the ongoing public discourse in those countries concerning harm reduction versus human rights, and the contradiction between medical ethics, national criminal justice systems and international conventions. The discussion is structured around four key hotly contested ethical dilemmas. Firstly, that the WHO definition of medicalized FGM/C is too narrow allowing medicalized FGM to be justified by many healthcare professionals as a form of harm reduction which contradicts the medical oath of do no harm. Secondly, that medicalized FGM/C is a human rights abuse with lifelong consequences, no matter who performs it. Thirdly, that health care professionals who perform medicalized FGM/C are sustaining cultural norms that they themselves support and are also gaining financially. Fourthly, the contradiction between protecting traditional cultural rights in legal constitutions versus human rights legislation, which criminalizes FGM/C. Conclusion: More research needs to be done in order to understand the complexities that are facilitating the medicalization of FGM/C as well as how policy strategies can be strengthened to have a greater de-medicalization impact. Tackling medicalization of FGM/C will accelerate the achievement of the Sustainable Development Goal of ending FGM by 2030