Seven lessons from Africa

Use of language—I was born in Kenya but left, aged 12, for an English public school. When I returned 30 years later my colleagues gave me an eloquent personal lesson in the assumptions held by colonialists. My Swahili, though rusty, was passable, but my conversations provoked incredulity. Do you realise, my colleagues said, that you still speak the “come here,” “do this” instructive Swahili of the colonial era? Whereas I believe I learnt my lesson, the language widely used by powerful nations when speaking of Africa is equally patronising and dismissive.

The truth about primary care—Several colleagues formed an association to offer practical health related help to anticolonial revolutionaries. We worked particularly closely with Frelimo (the Mozambique Liberation Front), who graciously accepted the basic health kits we sent. However, we all realised that what was important to health was mobilising people to till fields, dig wells, teach children, emancipate women, and help distribute vaccines. Seeds and agricultural equipment are better for health than bandages. The fruits of this approach were clear: when Frelimo gained power they initiated a mass vaccination campaign that reached the entire population. Yet Western governments still haven't got this message. Despite excellent work by some individuals and primary care trusts in the United Kingdom, primary health care is still mainly seen as happening after the first contact with a health professional. We can only hope that our imminent public health white paper will learn from Africa. Health and wellbeing are a product of environmental, social, and economic determinants, not just genetics, individual behaviour, and a well functioning health service.

Drama and health—Salt and sugar solutions have had a big effect on mortality from diarrhoea. Getting the message across is difficult. How do we reach thousands of poor people whose understanding of their body and its functions is rudimentary? Play acting, with motivated local people playing all the parts, is a powerful communication tool. I saw a drama on dehydration that was systematically used in Zimbabwe in the early 1980s with impressive effect. Africa can teach us that we need to pay proper regard to different approaches to communication.

Research and health—The West is belatedly recognising that much health research has little relevance to the world's most unhealthy people. Communities know what their problems are but rarely suggest an area of research. While I was in Harare we asked the people of the Chinamora district what they wanted us to research. They produced a list of topics, mostly relating to the effect on health of poverty, lack of access to education, and the like. They were perplexed that we weren't able to help research these fundamental problems but delighted when we said that one problem they identified, goitre, was within our capacity. With their help we managed to survey entire villages and schools, taking blood and urine samples from those with goitre and matched controls. Calling ourselves the Chinamora research group we published our results in the Lancet, but such publications are rare, despite much grassroots investigation. Such small scale stuff can illustrate wider truths, but African voices have little influence in directing or getting resources for research.

Macroeconomics and health—The debt crisis in Africa has hindered development since the early 1980s. Colleagues from all over Africa were clear that the International Monetary Fund's structural adjustment policies were a disaster for health. They accurately predicted that fewer children would go to school and that unemployment, poverty, malnutrition, and mortality among the under 5s would increase. A few voices in the West relayed their anxieties; but not until the problems were devastating did the world take much notice. African influence in the corridors of power was and is negligible. We do not yet listen and learn from the people who suffer, even though they may have better solutions than we do.

Resilience and health—Despite the circumstances in which people have to live in Africa, the reality of life in many villages is one of joy, communal endeavour and sharing, delight in children, and much laughter, dancing, and song. When African communities are able to work out their own solutions—whether to the aftermath of genocide or to securing food supplies—resilience translates into effective action. Only by supporting rather than directing these initiatives will we help the transformation that Africa is quite capable of once rid of colonialist attitudes and debt, along with many other of our pernicious influences.

Role of health professionals in rich countries—As long as the present global order perpetuates the grave imbalance in access to social, economic, and environmental goods, my colleagues in Africa don't think we will learn any lessons and are pessimistic for Africans' health and wellbeing. For me the most important lesson is that we must understand and tackle the major global forces undermining the health of people not just in Africa but around the world. Let all health professionals come together and insist that public policy be directed to improving all the determinants of health, and let's start by cancelling the debt and controlling the arms trade. That will be true learning.