Welcome to how epidemics and project based at the University of Oxford.
My name is Erica Charters.
And in these videos I'll be discussing with experts how they research disease as well as their investigations into how epidemics.
And today, I'm here with Sukhi Chigwedere, who's an associate professor of African politics here at the University of Oxford.
So, Samukai, you first trained as a Medick, you completed all of your medical training, I believe,
in the U.K. You also worked as a fellow in public health and then you worked in a range of countries
to further your medical clinical training before you then switched to the social sciences.
You did a doctorate in international development and now you're a professor of African politics.
So why did you make the switch into how you study disease?
So, Eric, I think the easiest way for me to answer that question is to tell you a story.
In 2008, I was a fourth year medical student at Newcastle University and I elected to take a two month clinical placement that summer in South Africa.
Half of the time, I would spend in a rural hospital in the Transkei and the other half of the time I would spend in an urban hospital in Durban.
When I arrived in the rural hospital, clinical facilities were very rudimentary.
There was an outpatient ward, an emergency room, basic operating theatre and an HIV and TB service.
And yet, with only a handful of doctors present this clinic, this hospital was serving an entire region.
I saw over the four weeks that I was there clinical conditions that in my UK training,
I was told we would never come across because medicine had advanced so much that we would no
longer see people with cryptococcal meningitis or pregnant women and full blown eclampsia.
And yet that with those were the very sorts of conditions I was encountering in South Africa.
The entire experience was overshadowed by the devastating HIV AIDS pandemic unfolding in the country at that time.
Now, I had had no training whatsoever in the social sciences or the humanities and
was desperately reaching for modes of interpreting what I was seeing before me.
I thought that my clinical toolkit might tell me what drugs to prescribe or how to suture a wound,
but wouldn't necessarily explain why the rural hospital experience was so much
more dramatic than the one I encountered later when I moved to the urban setting.
And I remember very vividly reading an article by a South African journalist about the social components of HIV AIDS in South Africa.
And I'll share a quote with that piece for you,
because it stayed with me ever since he wrote Shelvey abating fiction that disasters don't discriminate,
that they flatten everything in their path with the democratic disregard plague zero in on the dispossessed,
on those forced to build their lives in the paths of danger. And so I think from that moment,
I began to think about the wider context in which disease occurs and how a combination of population level factors, certainly,
but also more profoundly, how politics, how history,
how culture and how social conditions come to be and indeed come to shape both disease and responses to it.
And so after several years of clinical medicine and in public health,
I decided that it was time for me to step into the social sciences initially with a master's in African studies,
learning about history, politics and anthropology,
and then later on specialising in a doctoral programme that looked much more squarely at politics in Zimbabwe.
That's really interesting as an approach to understanding disease,
and it sounds as if you've basically studied a wide range of diseases and especially of health crises and particularly in Africa.
But I think the disease that you've studied most extensively is cholera.
And really the epidemic that you studied most extensively is the two thousand eight cholera outbreak in Zimbabwe,
which form the basis of your book, The Political Life of an Epidemic.
So I wonder if you can tell us a little bit about cholera, but also about this particular epidemic.
Part of the inspiration for my study of cholera in Zimbabwe came from reading the history of my and my relation book,
whose book, Africa in a Time of Cholera, is a history of pandemics from about 1817 to the present.
And in this work,
Archambeau takes Africa as a vantage point to narrate the longer history of cholera and its ever changing relationship to currents and politics,
geography and public health. Hesterberg points out that there have been seven major pandemics of cholera,
but the first six from eighteen seventeen to nineteen forty seven were truly global events,
whereas the seventh pandemic from 1947 onwards has largely been an African phenomenon.
How do we explain this for Aschenbach? The answer lies in a combination of ecological catastrophe and war and conflict on the continent.
So this is kind of amply demonstrated by the devastating outbreak that occurred in eastern DRC in 1994 after the Rwandan genocide,
when a mass of people left the country and arrived in refugee camps in this part of Central Africa with very,
very poor sanitary facilities, very poor housing and disease spread,
infecting about seventy seven thousand people with cholera causing about twelve thousand deaths.
Now, what's interesting to me is that Zimbabwe's cholera outbreak bucks this trend and poses a challenge to the BBC's core thesis,
in part because Zimbabwe's 20 cholera outbreak is associated with neither open
war or conflict on the one hand or with environmental catastrophe on the other.
And I argue that Zimbabwe's cholera outbreak makes clear what's true of all disastrous epidemics,
which is from their origins to resolution's epidemics, are to a greater or lesser extent a social and political calculus.
So to kind of flesh this out a bit more with respect to the Zimbabwe case,
the cholera outbreak began in August of 2008 in the impoverished high density townships that circumvent Harare metropolitan area.
The epidemic then quickly spread into urban and rural areas before crossing the country's borders into South Africa, Botswana, Zambia and Mozambique.
Over a 10 month period, cholera would go on to infect nearly one hundred thousand people claim over 4000 lives
and at the peak of the epidemic could have an exceptionally high case fatality rate.
And so this the Zimbabwe 2008 outbreak has gone down in history as the most extensive in recorded African history.
Now, at face value, we might explain the outbreak by the cross contamination of the capital city's water delivery and sewage systems.
But such a reading, which was very popular in the press at the time when this occurred, belies the kind of complex interaction of political,
economic and historical factors that explain what caused the water systems to fail in the first place.
That delineates the social and spatial spread of the outbreak,
and that account for the fragmented and inadequate response of Zimbabwe's national health
system to my book then set out to to see cholera not only as a public health crisis,
but to situated within the larger frame of the political and economic crisis that had gripped Zimbabwe in the 10 years prior to 1990 to 2008.
So then how because I think an interesting question for someone who's doing research
is how you conduct research to show this and what kind of sources do you use?
Because in the book you often talk about stories and the collection and the process of storytelling,
but you also talk about storytelling itself as a political act.
So what kind of what kind of evidence did you use in your research? Yes, the book set out to answer kind of three big questions.
Why did this outbreak occur? What were the responses to it?
And what is its afterlife in civic institutions and political life in Zimbabwe?
And to do this, I was very ecumenical in the range of sources I gathered.
I collate everything from the minutes of meetings,
postdoc evaluations from development agencies and humanitarian groups that had been responsive to the cholera outbreak.
I went into the archives and looked at the histories of city planning and therefore the determinants
of housing and water services that shaped the city and how those have changed over time.
I looked at press coverage and the kind of accounts that were given of the cholera outbreak, and then I just spent a lot of time talking to people,
trying to excavate from them their sense of memory and how they've come to narrate
and to explain the cholera outbreak within contemporary Zimbabwean history.
And something that I saw across this range of sources was that whether there were very technical or very conversational,
there were interpretive prisms constantly at work that give an account of how
structural inequality comes to exist within a city and why disease occurs.
And very often official accounts that either try to neutralise an outbreak or
blame it on an exogenous factor are contradicted by the accounts that lay people
hold who interpret an outbreak through the prism of a government that has neglected
them at a time of need and allowed them to suffer from a preventable disease.
And in that sense, storytelling is a political act because it is a mode of holding, of holding power to account.
And it's a mode of saying that the lives that we live are fundamentally and structurally conditioned by the political system of which we are apart.
And so I was really interested in tracing the competing logics across these different
sources and thinking constantly about what kinds of political logics are at play.
It's a it's a very interesting point and a recognition that we can get in some ways conflicting and competing accounts and that our sources
can tell us different reasons for why they think something happened and what is or who is responsible for an epidemic and for crisis.
And I wonder this notion the politics of epidemics are the political life, what this means to talk about the politics of epidemics.
I wonder if you can just explain a little bit more and maybe to explain to us what the how that approach might be different to,
say, a public health worker or historian or an epidemiologist?
Yeah, that's a fantastic question.
I think that so when I what I say the political life of an epidemic, what I have in mind is tracing the origins of an epidemic,
the pattern of its unfolding, its social impact, official and communal responses to it and its aftermath and civic and public life.
And I think doing that exercise entails, in a sense, a degree of intellectual judgement.
It entails us making some determination of how far in history do we have to go back
to identify the factors that may have contributed to the making of a given outbreak.
And I tried to challenge some of the immediate logics that perhaps might exist in public health and public health on the epistemological model.
And therefore the methodological model is to try to establish a relationship between exposures and
outcomes and really to try to draw a fine causal line between how one variable leads to another.
I think taking a more interdisciplinary approach allows us to think not only
about the immediate making of an epidemic and as a kind of biosocial phenomenon,
but trying to think about the historical and political factors. For instance, the design of a city, the patterns of inequality,
why some people are kind of structurally denied access to clean water and other people are not.
And how all of those things interplay and how governments and populations make sense of their environment and therefore,
when disaster strikes, how they then seek to explain it. And I think that's part of the political life of an epidemic within the frame of its origins.
And then to give one other example that I think illustrates this is even in responding to the outbreak,
we're kind of confronted with the question of how we responding only to immediate clinical need,
which is to say, you know, pumping fluids into the desiccated veins of cholera patients.
We think about the prevention of onward transmission and making sure people can clean water supplies that they have.
Or are we thinking about a structural rewriting of the hydraulic infrastructure that serves communities?
Or indeed, are we think about holding a government to account for failing to respond to an outbreak when it was politically obliged to do so.
So responses themselves have both the public health and a political dimension that I tried to illustrate.
And I thought I was very convinced by your kind of reframing why we can think about the immediacy of a kind of isolated crisis or outbreak.
And I think you're really encouraging us to step back and think more broadly about the infrastructure and to not think about this as one event,
but actually to think about it as a kind of patterning that long term context.
So when we use your framing this notion of the political life or the politics of epidemics,
how did this epidemic end or how should we understand that the ending of epidemics?
Yeah, so a pattern started to emerge for me as I was doing my field research with each interview I did,
each document I looked at, there were these competing explanations for the nature of the outbreak.
And so what I found was that cholera was itself implicated in multiple crises that were happening in Zimbabwe.
At the same time, coming to grips with that was just overwhelming for any one agency to do.
And so in the exigent circumstances of 2008 and 2009,
there was a kind of bottom line agreement that everybody could agree on, which is that we need to save lives.
And so despite all of the complexity that I talked about,
this ended up becoming the guiding principle of how consensus was forged, let's say, between the Ministry of Health,
UNICEF, medicines, so Frontier, the show and so on, to go out into those communities and just to save lives and to worry about the rest later.
But what happens when that becomes the approach is that as the epidemic curve begins to diminish and
there's a recognisable pattern amongst epidemiologists that the rate of diseases are coming down,
many of these institutions. Organisations withdraw their funding and leave the country as one of my informants puts it was one,
it was like, thank God that's over and we can all go home. And yet all of the structural factors that I've talked about, the topography of the city,
the maintenance of the water system, the political disenfranchisement of the urban poor, don't go anywhere.
They continue to persist as a result of that.
What we've seen since 2008 and 2009 is a recurrence of cholera outbreaks, but also typhoid outbreaks and other diarrhoeal disease outbreaks, one hand.
But we've also continued to see the same sense of political disgruntlement from those who
are most sharply affected by the diseases and therefore an ever diminishing sense of trust,
a violation of the social contract between the state and its citizenry. So one of the legacies of the cholera outbreak is that it kind of signifies a
powerful shift in how how the Zimbabwean body politic kind of cohere together.
And instead we see a much more fragmented picture. So in a manner of speaking, the cholera outbreak has never really ended.
That's really fascinating and I love how this different approach, this kind of disciplinary or methodological approach,
the way that you understand disease and define the disease and how you define a problem can also then,
of course, change how you define the end, where you find the ending.
Thank you very much for joining us and thank you all for joining us.
I hope that you'll watch some of the other videos and the interviews with other project experts.