Ethnographies of Uncertainty in Africa

E. Cooper, D. Pratten, E. Cooper, D. Pratten

• Publisher: Palgrave Macmillan
• Year: 2014
• Print ISBN:
  9781137350824
• eBook ISBN:
  9781137350831
• Topic: Social Sciences
• Subtopic: Development Economics
• Index: Social Sciences

This collection explores the productive potential of uncertainty for people living in Africa as well as for scholars of Africa. Eight ethnographic case studies from across the continent examine how uncertainty is used to negotiate insecurity, create and conduct relationships, and act as a source for imagining the future.

Part One

Social Contingencies

Contingency: Interpersonal and Historical Dependencies in HIV Care

Susan Reynolds Whyte and Godfrey Etyang Siu

Introduction

The word ‘uncertainty’ has many relatives, each opening particular analytical possibilities. Within the extended family, we might count: insecurity, indeterminacy, risk, ambiguity, ambivalence, obscurity, opaqueness, invisibility, mystery, confusion, doubtfulness, and scepticism. Some of its cousins seem to admit of positive potential: chance, possibility, subjunctivity, hope. Uncertainty and insecurity are the most prominent members of the family. We can think of uncertainty as a state of mind, and minding, when we are unable to predict the outcome of events or to know with assurance about something that matters to us. Insecurity, the lack of protection from danger, the weakness of arrangements to support us when adversity strikes, gives rise to uncertainty. Dealing with uncertainty is often about trying to make more secure, rather than simply trying to ascertain. And making more secure usually has to do with mobilizing resources in order to exert some degree of control. Both terms are broad and often used rather vaguely, without specifying the focus of uncertainty or the source of insecurity (Whyte 2009).

We propose that another related term, ‘contingency’, might sharpen our analyses of the issues with which scholars grapple. Contingency means dependence on another event or occurrence about which there is some uncertainty…or, we may add, on other people, whose situations and actions cannot be known for sure. It can also mean ‘true only under existing or specified conditions’. So to be contingent is to be related: to people, institutions, happenings, circumstances. In its relationality, contingency also implies time and process: one thing leads to another; events have consequences. Contingency denotes uncertainty about what may or may not occur, but it inflects uncertainty with specificity and invites us to consider connections. We usually say ‘contingent upon…’. Finally, contingency has that quality of possibility that John Dewey (1930) saw in uncertainty. It is not always negative and fearsome. Contingency could imply links to people and developments that offer resources. To be contingent upon persons or happenings that cannot be fully foreseen is to lack control and be subject to uncertainty. But to try to create contingencies in the sense of making connections to possible forces for improving security is to attempt to move an uncertain situation towards greater confidence.

For the first generation of people who benefitted from widespread free access to antiretroviral therapy (ART), uncertainty, insecurity, and contingency played out with fateful clarity. We take our examples from them in order to show the interplay of different kinds of contingency, and the relation of contingency to uncertainty and insecurity. Uncertain about the invisible process of disease in their bodies, not knowing when they would die and lacking the security to sustain themselves and seek treatment, they exemplify what Bledsoe (2002) called the contingency of physical life on social relations.

The spread of HIV disease itself encapsulates contingency in the etymological sense of ‘together with’ – ‘touch’. Transmitted through intimate touching with another person whose history you do not fully know, it gives rise to reflection on chains of consequence and lack of knowledge. Even when they discern danger – as when wives know that their husbands are ‘womanizers’ – people may feel insecure because they cannot control those upon whom they depend and do not have other sources of security at hand.

From late 2005 until mid-2007, a team of four Ugandan and four Danish anthropologists¹ talked to forty-eight people on ART about their life histories, and followed twenty-three of them through home visits over a year and a half. We listened to their accounts of despair, worry, secrecy, doubts, recovery, and attempts to get on with the life that the treatment made possible. We call our study Second Chances, after the common assertion in Uganda that free treatment had given them a second chance to live. But as we discovered, chanciness continued to figure even after their health improved. To simplify greatly, two kinds of contingency – historical and social – were evident in their lives.

Historical contingency draws our attention to the spread of the disease and of the means to deal with it. From the late 1980s, the Ugandan government assiduously promoted awareness of ‘Slim’ (HIV)² and its transmission. A decade later, treatment was available to those who could afford to buy it or those fortunate enough to get onto a research project. Not until around 2005 did the big donor programmes like PEPFAR and the Global Fund³ pour in the resources to make treatment free, first at a variety of dispersed sites and later more consistently at government health units. ART became institutionalized in the treatment programmes which people joined as ‘clients’. While only about 10,000 people were on ART in 2003, there was a tenfold increase by 2007 when we ended our study.

Our interlocutors, like others on treatment programmes in those years, constituted a historical generation in Karl Mannheim’s (1952 [1927]) sense of having a place in history that exposed them to the same formative events. They had shared the common experience of the AIDS epidemic in Uganda. They knew AIDS as an invariably fatal disease that had claimed close family members, often after terrible anguish and prolonged suffering. Many had tried to pay for their own treatment before it became available for free, sacrificing family welfare, and missing their medicine when they had no money (Whyte et al. 2004; Byakika-Tusiime 2005). They had lived through a time when people did not want to go for an HIV test because uncertainty was preferable to confirmation of a fatal disease for which there was no security of treatment.

When ART became widely available, news of its life-saving powers spread rapidly throughout the population. For the HIV-positive people who managed to access treatment, a kind of generational consciousness emerged – an awareness that they differed from their predecessors, for whom there was no Second Chance. Narratives of salvation through the miraculous effect of ART helped to maintain consciousness of their unique historical location. So did the health education talks emphasizing that ‘medicines are your life’ which were a part of their regular clinical visits. Historical contingency was evident as well in the way a few worried about whether their treatment programmes would continue. Yet, at that time there was surprisingly little general discussion of sustainability, donor policy, or the rights of therapeutic citizens.

What preoccupied people were social contingencies, that is, their interdependencies with others. Therapy programmes understand themselves as having agency. They reach out and give treatment. But we were struck by the way our interlocutors themselves spoke as agents who had achieved treatment. And by and large they described their achievement not as an individual accomplishment, but as a series of steps facilitated or impeded by other people. Whether they were talking about how they first went to test ‘in order to know my life’, how they managed to get onto an ART programme, or how they were sustained through times of illness and doubt, they spoke of specific relatives, friends, and acquaintances. That is not to say ‘the family’ or ‘the community’ as policymakers put it, but particular members of their own circle of contacts. This inclination to explain the turnings of life in terms of connections to, or dependence upon, other people may be in part a conventional form of discourse, but it remained strong despite the tendency in biomedical treatment to assign individuals responsibility for their own bodies and therapies.

Researchers have long recognized the social basis of response to illness in Africa. John Janzen’s (1978) notion of the therapy-managing group in lower Zaire emphasized the social rather than individual nature of treatment-seeking. The broader the group, the more different treatments were tried. The vulnerable were not necessarily those who went to traditional healers, but those whose therapy-managing group was so limited that they did not receive any kind of treatment (Feierman 1985: 83; Feierman 1981: 402–3). Having someone connected to biomedical health work within your therapy-managing group is so key that Ugandans regularly ask people going to a health facility: ‘Do you know anyone there?’ The value of what Bourdieu would have called social capital was evident in an epidemiological study in Guinea-Bissau. Among children admitted to the paediatric ward in Bissau’s main hospital, those whose mothers knew a doctor had a risk of dying within thirty days that was 48% less than those whose mothers did not know any physician (Sodemann et al. 2006). In Ugandan English this kind of social capital is referred to as ‘technical know who’.

The recognition of the importance of connectedness can be taken a step further to examine the dimension of uncertainty in interdependence. There is an element of chance in relying on another person to help you. He may be transferred or turn indifferent; she may fall ill or die. Being dependent on persons rather than reliable institutions introduces an element of fragility. It was Caroline Bledsoe, in her book Contingent Lives (2002), who brought into focus the uncertainty of social contingency. In her study of women’s conceptions of fertility and ageing in West Africa, she showed how they thought of the life-course not in terms of chronological ageing, but rather as the outcome of chains of dependency. Contingent developments rather than linear time explain bodily ageing.

…the success with which a woman can prevent or contain future bodily harm depends on her investing broadly and deeply in social relations. Indeed, the word contingency connotes a sense of social ties that underlie all aspects of life, including the physical growth, development, and decline of the body (25).

She shows that vulnerability to others upon whom women depend is invested with uncertainty in that it is difficult to predict or control the agency and circumstances of those others. ‘The fact that one person is proximate to another implies that the acts of one will likely have repercussions for the other. These…may be beneficial… But the repercussions of proximity also can be deleterious’ (Bledsoe 2002: 20).

James was a university student who was articulate about the importance of connections. Godfrey once remarked that he was impressed by the networks James had built among staff at Mulago, the national referral hospital, and James explained: ‘You know, maintaining life is not the responsibility of one person, and those other people who help you maintain it should not be your enemies’. He clearly saw the potentially beneficial aspect of contingency. His domestic situation was based on kinship connections. He was staying with the family of his maternal cousin Tito, together with other relatives, including Tito’s brothers. As Godfrey learned, it was a precarious arrangement since no one in the household had a salary; they were thankful for some support from Tito’s mother-in-law. But there came a time when Tito made it clear that the household could no longer maintain James, especially with his extra feeding needs after starting on ART. James was sickly and had lost weight. His dependence on his cousin was proving a source of uncertainty rather than security. James’s friend Kenneth told Godfrey that Tito was actively discriminating against James; this contingency had become deleterious. It was Kenneth who took the initiative to get another relative to accommodate James.

Social contingencies are always multiple in that you are dependent on several other people, and the sources of uncertainty are correspondingly several. Historical contingencies are not singular either, as we shall see in the story of John below. But even with this multiplicity of contingency, it is still possible to trace sources of uncertainty and thus to reach a more detailed understanding of how beneficial and deleterious possibilities follow on from relationships.

Railway Connections

John was a railwayman living in the Kampala railway housing estate known to anthropologists through Ralph Grillo’s (1973) early research on African trade unions. Like many others, he had discontinued his education for lack of funds, but he was fortunate to get a job with help from his brother and other relatives who worked in Uganda Railways. Starting modestly as a porter, transferred here and there all over the country, he helped support his parents and his brothers and their families, even before he rose to a position of greater responsibility and got a railway house in Kampala. Godfrey visited him eight times, and spoke to him on the phone occasionally, over the time from 2006 to 2007.⁴

John’s account of the doubts and worries of his therapeutic journey was full of both historical and interpersonal contingencies. In 2001, he developed a cough and weakness and feared that he had tuberculosis. He first went to a private clinic in Kampala, where he was referred to the Joint Clinical Research Centre (JCRC), the major AIDS treatment facility in the city, for an HIV test. ‘But being a man from Jinja, I decided not to go to this place because I did not know it and I was alone. I thought of where else to go and I decided to have the test done back in Jinja’. Although he had good railway connections, John’s health contacts were weak. He tested positive in Jinja, but there was no one to help him do anything about it.

A year later, he was at death’s door. He lost weight and appetite, developed a cough, and his stomach swelled up ‘like a person who has been poisoned’. At last his brothers and wife decided to take him to Mulago, the national hospital. But they did not know anyone there and it was a terrible experience, as he told Godfrey:

My brother! The way I was handled there! You cannot believe. Those people rejected me. I was sent away. They saw my health condition and maybe thought, ‘After all this one is dying’. They said, ...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Series Preface
• Acknowledgment
• Contributors
• Ethnographies of Uncertainty in Africa: An Introduction
• Part One – Social Contingencies
• Part Two – Future Visions
• Index