By Marissa Mika and Megan Vaughan
In early September we hosted a workshop on Africa and the Epidemiological Imagination at University College London’s Institute of Advanced Studies’ Common Ground. The workshop was sponsored by the Wellcome Trust as part of a Senior Investigator award held by Professor Megan Vaughan on Critical Histories of Chronic Disease in Africa. We wanted to explore how the concept “transition” articulates the complexities of multiple disease burdens facing Africans across the continent. We asked, what does the chronic disease epidemic in Africa look like if we take the local epidemiological context into account? How can we use ethnographic and historical tools to offer nuance “from the South.” How do the concepts of “chronic disease” and “noncommunicable disease” themselves foreclose the possibilities of framing public health as the promotion of wellbeing? This was a chance to examine how historical, epidemiological, political, and economic processes have shaped disease burdens in Africa.
The conversation was truly interdisciplinary, including experts from seven disciplines (Epidemiologists, physicians, historians, public health specialists, anthropologists, demographers, and social theorists) and drawing on case studies from 11 countries (South Africa, Ghana, Malawi, Uganda, Kenya, Botswana, Senegal, Belize, Guatemala, India, and the United Kingdom). Ethnographies revealed intergenerational conflicts, gendered intimacies of care and responsibility, the fragmentation of public and private health offerings, quests for therapy, and a question about stagnation—what happens when things are apparently not changing? The historical papers offered critical insights into the ways in which “transition” can pathologize Africans, render inequality invisible, or detach the histories of chronic disease from much longer stories of economic, political, and demographic change. Epidemiologists, public health practitioners, and physicians offered critical reflections on the uses and limitations of “transition” in a variety of African contexts, as well as the challenges of generating data about disease patterns in the first place.
The conference was organized into six panels and a final roundtable discussion. The first two panels introduced the major theoretical concerns about the utility of transition and the methodological challenges of creating epidemiological knowledge where health data are often thin or unavailable. The panels that followed offered alternative approaches to theorizing the complexities of chronic disease. A summary of the major contributions and take-aways from each panel is below:
- Revisiting Epidemiological Transition Theory
We began by dissecting the utility of epidemiological transition theory for describing changing disease patterns, aging, economies, and political circumstances. Simon Szreter, in a contribution on British epidemiological history, argued that “transition” obscures the important part played by government intervention and public health measures in reducing mortality from infectious disease. Megan Vaughan offered a critique of epidemiological transition theory from the vantage point of the African continent, charting how “diseases of civilization” and modernization theory often obscured fundamental inequalities. Kavita Sivaramakrishnan introduced the idea of “contingent temporalities” as an alternative to linear transition models in discussing the politics of aging in South Asia. David Reubi focused on the history of tobacco use and smoking in Africa to open up conversation about the significance of political economy and the role of major commodities—sugar, alcohol, guns, tobacco, palm oil, rice, maize, gold, diamonds—in shaping the diets, bodies, arteries, injuries, and indeed, epigenetics of populations on the continent.
- Rethinking Epidemiological Methods from Sub-Saharan Africa
The second panel turned to the politics and practicalities of epidemiological knowledge production on the African continent. Shane Doyle presented ongoing research on the changing patterns of maternal mortality and morbidity in eastern Africa. Steven Tollman shared over twenty years of data on the myriad changes in health indicators and population trends collected in Agincourt, South Africa. Tollulah Oni offered a personal reflection on the ways in which chronic disease prevention strategies can foreclose or obscure the possibility for health creation. Olutobi Sanuade deeply contextualized the challenges of chronic disease surveillance in Ghana. As a whole, the panel highlighted the patchiness and problematic nature of much epidemiological data, especially when attempting to identify long-term historical trends
- New Ethnographies of Lifestyle Diseases
The last panel of the day showcased the uses of ethnography in understanding contemporary chronic disease burdens. These papers offered examples of how might we expand and scale Margaret Lock’s idea of local biologies—the synergistic co-production between the biological and the social in shaping the embodied experience of illness and health—to local epidemiologies? Ruth Prince discussed the bodily and material intimacies of living with cancer in Kenya. Branwyn Polykett highlighted the collective, material experiences of eating and consuming food in Dakar at a moment when diabetes and obesity are on the rise. Continuing the focus on food and chronic disease, Ama de-Graft Aikins presented rich, longitudinal work about the complexities of changing diets, food availability, and chronic disease epidemiologies in Accra, Ghana.
- Future directions in non-communicable disease research
This panel showcased emerging research projects on noncommunicable diseases. Kafui Adjaye-Gbewonyo presented work merging quantitative epidemiological data on recent trends in heart disease with life histories of mortality and morbidity in Ghana. Beth Vale is crafting a popular non-fiction book based in the Karoo which situates the chronic disease epidemic in a complex disease ecology fundamentally shaped by alcohol and the stark and racialized inequalities of South Africa. Both of these presentations of new work underscored the necessity of creatively integrating multiple forms of data.
- Local Epidemiologies: The complexities of comorbidities and care
This panel opened up numerous questions about caring for chronic conditions and comorbidities. Using the case study of chronic kidney disease, Catherine Burns explored the dilemmas of public and private care. Jackson Orem’s paper highlighted the synergies between infections and malignancies in eastern Africa, upending easy notions of “noncommunicability.” Amy Moran-Thomas offered a historical and contemporary meditation on the loss of limbs in Belize’s diabetes epidemic and sugar production industry, and introduced the term “paracommunicable” as an alternative to “noncommunicable.” Marissa Mika suggested that thinking with the concept of stress and chronic “dis-ease” might offer a fresh perspective on contemporary South Africa’s quadruple disease burden. This panel highlighted the clinical reality of “multimorbidity” and the close relationships between some infectious and “noncommunicable” conditions. Taken as a whole, this panel suggested that the frame of “noncommunicable” obscured more than it illuminated.
- Temporalities beyond transition: developmental origins, gender, and lifecourse approaches
In this panel, colleagues explored the themes of time, age, and intergenerational inheritances. Emily Yates Doerr discussed conditions of “imperialist food nostalgia” and raised fascinating questions about the weight of history, of violence, and of malnutrition. Using the First 1000 Days as a case study, Michelle Pentecost highlighted the ways in which new understandings in epigenetics and early childhood development are reframing understandings of maternal inheritance. Betsey Brada discussed the politics of intergenerational and gendered struggles around who should care in a southern African context where the HIV/AIDS crisis and epidemics of cancer and heart disease put pressure on aging grandparents and children with HIV. Taken as a whole, this panel explored and also critiqued some of the alternative approaches to theorizing change and continuity across generations and time.
The workshop ended with a roundtable, which consolidated our critique of “transition” as a way to discuss epidemiological change on the African continent. We made significant headway in discussing the work that “transition” actually does as a concept. Megan Vaughan argued that transition can obscure inequality. Amy Moran-Thomas noted that Emily Yates Doerr’s work clearly shows us that “transition” does something to mask the fact that things actually aren’t changing. Transitions, as Catherine Burns noted, are often clumsy progress narratives, but especially in a South African context, the discourse of transition has been critical for opening up the space to articulate what needs to change. Shane Doyle brought up the fact that transition theory is “predictive” and that African history, with its attention to diversity and continental heterogeneity, does not hold for a grand model of transition. And yet, as Steve Tollman argued, most public health experts still find it useful to think in terms of complex transitions. As David Reubi, Tollulah Oni, and others pointed out, epidemiological transition provides a scaffolding for public health research on chronic disease—in this sense functioning as a boundary object; even if it is not stable across field, it can still serve to bring fields together in conversation. The diverse repertoires of “transition” we encountered suggested that many corners of public health are well past linear modeling, and much is being built in its place.
Whether it is a local newspaper in Kampala or Accra or a critical report from the World Health Organization, the explanation for the apparent increase in chronic diseases in Africa is often attributed to wealth and “lifestyle choices,” and an epidemiological transition. And yet, as this workshop explored, in its linear simplicity, its demographic determinism, and its emphasis on distinct categories, the theory of the shift from infectious diseases as the driver of mortality to chronic diseases simply does not hold in the African context, if it ever did entirely for “Western” societies (Mercer 2014). This is a context where cancer and cholera, obesity and malnutrition, hypertension and measles co-exist and interact in complex and synergistic ways (Livingston 2012). These seemingly contradictory disease burdens in bodies and populations similarly upend the notion that diseases of affluence are restricted to the growing African middle class. Hypertension and diabetes strike the poor in Africa as elsewhere. Complex interactions between environments, pathogens, and histories blur the boundary between infectious and noninfectious diseases (Mendenhall 2017, Moran Thomas 2012, Oni et. al. 2014). The cases of epidemiological continuity and change in Africa we explored invite us to re-imagine and develop multi-disciplinary conversations that connect quantitative epidemiological evidence, ethnographic specificity, and integrate the complexities of the past.
Lock, Margaret. 2008. Encounters with Aging: Mythologies of Menopause in Japan and North America. Berkeley, Calif: University of California Press.
Mendenhall, Emily. 2017. “Syndemics: A New Path for Global Health Research.” The Lancet 389 (10072):889–91.
Mercer, Alex. 2014. Infections, Chronic Disease, and the Epidemiological Transition: A New Perspective. Rochester, NY: Univ. of Rochester Press.
Moran Thomas, Amy. 2012. “Metabola: Chronic Disease and Damaged Life in Belize.” PhD. Diss. Princeton University.
Omran, Abdel R. 2005. “The Epidemiologic Transition: A Theory of the Epidemiology of Population Change.” The Milbank Quarterly 83 (4):731–57.
Oni, Tolu, Nuala McGrath, Rhonda BeLue, Paul Roderick, Stephen Colagiuri, Carl R. May, and Naomi S. Levitt. 2014. “Chronic Diseases and Multi-Morbidity – a Conceptual Modification to the WHO ICCC Model for Countries in Health Transition.” BMC Public Health 14 (June):575.
Marissa Mika is a visiting research fellow at University College London. This year, she is completing her book, Africanizing Oncology, which tells the story of how the Uganda Cancer Institute transformed from a small experimental research facility into the key site of public oncology goods in the Great Lakes region. Mika holds a PhD (2015) in History and Sociology of Science from the University of Pennsylvania and an MHS (2007) in International Health from Johns Hopkins. Since 2002, she has lived for extended periods of time in South Africa, Togo and Uganda. Her research has been supported by a variety of institutions including the Social Science Research Council, the Wenner Gren Foundation and the Wellcome Trust.
Megan Vaughan is Professor of African History and Health at the Institute of Advanced Studies, University College London where she heads a research programme on chronic disease in Africa, funded by the Wellcome Trust: www.chronicdiseaseafrica.org. She has published widely on the history of colonial medicine and psychiatry in Africa, on food and famine, environment, gender and social change in central Africa, and on slavery in the Indian Ocean. She is currently researching ‘metabolic disorder’ and food systems in Malawi and South Africa.