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Welcome to how epidemics and project based at the University of Oxford.

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My name is Erica Charters.

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And in these videos I'll be discussing with experts how they research disease as well as their investigations into how epidemics.

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And today, I'm here with Sukhi Chigwedere, who's an associate professor of African politics here at the University of Oxford.

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So, Samukai, you first trained as a Medick, you completed all of your medical training, I believe,

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in the U.K. You also worked as a fellow in public health and then you worked in a range of countries

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to further your medical clinical training before you then switched to the social sciences.

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You did a doctorate in international development and now you're a professor of African politics.

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So why did you make the switch into how you study disease?

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So, Eric, I think the easiest way for me to answer that question is to tell you a story.

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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.

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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.

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When I arrived in the rural hospital, clinical facilities were very rudimentary.

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There was an outpatient ward, an emergency room, basic operating theatre and an HIV and TB service.

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And yet, with only a handful of doctors present this clinic, this hospital was serving an entire region.

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I saw over the four weeks that I was there clinical conditions that in my UK training,

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I was told we would never come across because medicine had advanced so much that we would no

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longer see people with cryptococcal meningitis or pregnant women and full blown eclampsia.

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And yet that with those were the very sorts of conditions I was encountering in South Africa.

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The entire experience was overshadowed by the devastating HIV AIDS pandemic unfolding in the country at that time.

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Now, I had had no training whatsoever in the social sciences or the humanities and

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was desperately reaching for modes of interpreting what I was seeing before me.

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I thought that my clinical toolkit might tell me what drugs to prescribe or how to suture a wound,

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but wouldn't necessarily explain why the rural hospital experience was so much

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more dramatic than the one I encountered later when I moved to the urban setting.

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And I remember very vividly reading an article by a South African journalist about the social components of HIV AIDS in South Africa.

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And I'll share a quote with that piece for you,

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because it stayed with me ever since he wrote Shelvey abating fiction that disasters don't discriminate,

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that they flatten everything in their path with the democratic disregard plague zero in on the dispossessed,

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on those forced to build their lives in the paths of danger. And so I think from that moment,

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I began to think about the wider context in which disease occurs and how a combination of population level factors, certainly,

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but also more profoundly, how politics, how history,

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how culture and how social conditions come to be and indeed come to shape both disease and responses to it.

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And so after several years of clinical medicine and in public health,

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I decided that it was time for me to step into the social sciences initially with a master's in African studies,

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learning about history, politics and anthropology,

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and then later on specialising in a doctoral programme that looked much more squarely at politics in Zimbabwe.

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That's really interesting as an approach to understanding disease,

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and it sounds as if you've basically studied a wide range of diseases and especially of health crises and particularly in Africa.

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But I think the disease that you've studied most extensively is cholera.

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And really the epidemic that you studied most extensively is the two thousand eight cholera outbreak in Zimbabwe,

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which form the basis of your book, The Political Life of an Epidemic.

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So I wonder if you can tell us a little bit about cholera, but also about this particular epidemic.

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Part of the inspiration for my study of cholera in Zimbabwe came from reading the history of my and my relation book,

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whose book, Africa in a Time of Cholera, is a history of pandemics from about 1817 to the present.

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And in this work,

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Archambeau takes Africa as a vantage point to narrate the longer history of cholera and its ever changing relationship to currents and politics,

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geography and public health. Hesterberg points out that there have been seven major pandemics of cholera,

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but the first six from eighteen seventeen to nineteen forty seven were truly global events,

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whereas the seventh pandemic from 1947 onwards has largely been an African phenomenon.

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How do we explain this for Aschenbach? The answer lies in a combination of ecological catastrophe and war and conflict on the continent.

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So this is kind of amply demonstrated by the devastating outbreak that occurred in eastern DRC in 1994 after the Rwandan genocide,

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when a mass of people left the country and arrived in refugee camps in this part of Central Africa with very,

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very poor sanitary facilities, very poor housing and disease spread,

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infecting about seventy seven thousand people with cholera causing about twelve thousand deaths.

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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,

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in part because Zimbabwe's 20 cholera outbreak is associated with neither open

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war or conflict on the one hand or with environmental catastrophe on the other.

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And I argue that Zimbabwe's cholera outbreak makes clear what's true of all disastrous epidemics,

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which is from their origins to resolution's epidemics, are to a greater or lesser extent a social and political calculus.

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So to kind of flesh this out a bit more with respect to the Zimbabwe case,

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the cholera outbreak began in August of 2008 in the impoverished high density townships that circumvent Harare metropolitan area.

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The epidemic then quickly spread into urban and rural areas before crossing the country's borders into South Africa, Botswana, Zambia and Mozambique.

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Over a 10 month period, cholera would go on to infect nearly one hundred thousand people claim over 4000 lives

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and at the peak of the epidemic could have an exceptionally high case fatality rate.

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And so this the Zimbabwe 2008 outbreak has gone down in history as the most extensive in recorded African history.

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Now, at face value, we might explain the outbreak by the cross contamination of the capital city's water delivery and sewage systems.

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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,

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economic and historical factors that explain what caused the water systems to fail in the first place.

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That delineates the social and spatial spread of the outbreak,

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and that account for the fragmented and inadequate response of Zimbabwe's national health

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system to my book then set out to to see cholera not only as a public health crisis,

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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.

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So then how because I think an interesting question for someone who's doing research

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is how you conduct research to show this and what kind of sources do you use?

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Because in the book you often talk about stories and the collection and the process of storytelling,

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but you also talk about storytelling itself as a political act.

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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.

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Why did this outbreak occur? What were the responses to it?

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And what is its afterlife in civic institutions and political life in Zimbabwe?

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And to do this, I was very ecumenical in the range of sources I gathered.

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I collate everything from the minutes of meetings,

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postdoc evaluations from development agencies and humanitarian groups that had been responsive to the cholera outbreak.

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I went into the archives and looked at the histories of city planning and therefore the determinants

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of housing and water services that shaped the city and how those have changed over time.

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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,

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trying to excavate from them their sense of memory and how they've come to narrate

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and to explain the cholera outbreak within contemporary Zimbabwean history.

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And something that I saw across this range of sources was that whether there were very technical or very conversational,

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there were interpretive prisms constantly at work that give an account of how

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structural inequality comes to exist within a city and why disease occurs.

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And very often official accounts that either try to neutralise an outbreak or

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blame it on an exogenous factor are contradicted by the accounts that lay people

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hold who interpret an outbreak through the prism of a government that has neglected

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them at a time of need and allowed them to suffer from a preventable disease.

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And in that sense, storytelling is a political act because it is a mode of holding, of holding power to account.

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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.

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And so I was really interested in tracing the competing logics across these different

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sources and thinking constantly about what kinds of political logics are at play.

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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

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can tell us different reasons for why they think something happened and what is or who is responsible for an epidemic and for crisis.

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And I wonder this notion the politics of epidemics are the political life, what this means to talk about the politics of epidemics.

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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,

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say, a public health worker or historian or an epidemiologist?

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Yeah, that's a fantastic question.

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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,

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the pattern of its unfolding, its social impact, official and communal responses to it and its aftermath and civic and public life.

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And I think doing that exercise entails, in a sense, a degree of intellectual judgement.

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It entails us making some determination of how far in history do we have to go back

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to identify the factors that may have contributed to the making of a given outbreak.

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And I tried to challenge some of the immediate logics that perhaps might exist in public health and public health on the epistemological model.

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And therefore the methodological model is to try to establish a relationship between exposures and

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outcomes and really to try to draw a fine causal line between how one variable leads to another.

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I think taking a more interdisciplinary approach allows us to think not only

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about the immediate making of an epidemic and as a kind of biosocial phenomenon,

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but trying to think about the historical and political factors. For instance, the design of a city, the patterns of inequality,

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why some people are kind of structurally denied access to clean water and other people are not.

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And how all of those things interplay and how governments and populations make sense of their environment and therefore,

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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.

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And then to give one other example that I think illustrates this is even in responding to the outbreak,

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we're kind of confronted with the question of how we responding only to immediate clinical need,

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which is to say, you know, pumping fluids into the desiccated veins of cholera patients.

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We think about the prevention of onward transmission and making sure people can clean water supplies that they have.

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Or are we thinking about a structural rewriting of the hydraulic infrastructure that serves communities?

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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.

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So responses themselves have both the public health and a political dimension that I tried to illustrate.

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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.

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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,

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but actually to think about it as a kind of patterning that long term context.

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So when we use your framing this notion of the political life or the politics of epidemics,

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how did this epidemic end or how should we understand that the ending of epidemics?

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Yeah, so a pattern started to emerge for me as I was doing my field research with each interview I did,

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each document I looked at, there were these competing explanations for the nature of the outbreak.

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And so what I found was that cholera was itself implicated in multiple crises that were happening in Zimbabwe.

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At the same time, coming to grips with that was just overwhelming for any one agency to do.

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And so in the exigent circumstances of 2008 and 2009,

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there was a kind of bottom line agreement that everybody could agree on, which is that we need to save lives.

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And so despite all of the complexity that I talked about,

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this ended up becoming the guiding principle of how consensus was forged, let's say, between the Ministry of Health,

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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.

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But what happens when that becomes the approach is that as the epidemic curve begins to diminish and

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there's a recognisable pattern amongst epidemiologists that the rate of diseases are coming down,

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many of these institutions. Organisations withdraw their funding and leave the country as one of my informants puts it was one,

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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,

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the maintenance of the water system, the political disenfranchisement of the urban poor, don't go anywhere.

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They continue to persist as a result of that.

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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.

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But we've also continued to see the same sense of political disgruntlement from those who

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are most sharply affected by the diseases and therefore an ever diminishing sense of trust,

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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

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powerful shift in how how the Zimbabwean body politic kind of cohere together.

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And instead we see a much more fragmented picture. So in a manner of speaking, the cholera outbreak has never really ended.

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That's really fascinating and I love how this different approach, this kind of disciplinary or methodological approach,

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the way that you understand disease and define the disease and how you define a problem can also then,

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of course, change how you define the end, where you find the ending.

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Thank you very much for joining us and thank you all for joining us.

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I hope that you'll watch some of the other videos and the interviews with other project experts.