Articulate

Undergraduate Research Applied to International Development

Volume II Issue II Fall 2009

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ar•ti•cu•late / -v., (of an idea or feeling) to express or state clearly.

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 educate motivate activate

Articulate: Undergraduate Research Applied to International Development

is an undergraduate scholarly journal that publishes academic papers
and writings online and in-print on issues concerning international
development and health care in Africa.
Articulate is a sub-division and publication of the non-profit SCOUT
BANANA, which seeks to educate, motivate, and activate the
public about the health care crisis in Africa. This journal will act as
a forum for students to contribute to, as well as make, the debates in
international development. We believe undergraduate students are a
vital, untapped force to bring fresh ideas, perspectives, and concepts
into the development dialogue. Our goal is to spark, share, and spread
knowledge for the sake of innovative change now.
SCOUT BANANA Mission: To combine efforts to save lives. We
seek to build a domestic and international movement dedicated
to fundamental social change in which global health is everyone’s
responsibility and every individual’s human right.
Articulate operates under a Creative Commons (CC) “Attribution –
Noncommercial – No derivative” license. Anyone is free to make use
of all materials found in this issue, as long as such use complies with the
terms of the license. More detailed information can be found at
http://creativecommons.org/licenses/by-nc-nd/3.0/.

issn 1943-6742
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 Articulate
Undergraduate Research Applied to International Development

Volume II Issue II Fall 2009

Editor-in-Chief
Jonars Spielberg
Michigan State University
jonars.s@scoutbanana.org

Editorial Board
Cory Connolly Stacie Dodgson
Michigan State University Michigan State University
Alejandro Lara-Briseno Sophia Mosher
UC-Berkeley Michigan State University

Faculty Advisors
John Metzler, Outreach Director Mary Anne Walker, Director
Michigan State University Michigan State University
metzler@msu.edu mawalker@msu.edu

Peer Reviewers
Alexandra Ghaly Emily Lawler
Michigan State University Michigan State University
Bethany Young Nada Zhody
UC-Berkeley Michigan State University

Designer
Brandon Bourdganis
Michigan State University
brandon.b@scoutbanana.org

The opinions expressed within this journal are exlusively those of the individual authors and do not represent the
views of the editorial board, SCOUT BANANA, or any of the organization’s chapters, advisors, or affiliates.

Current and past issues of Articulate can be accessed at http://scoutbanana.org/articulate.

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 Letter From the Editor
Dear Readers,
With generous support from the Michigan State University African Studies Center, James
Madison College, editors, and peer reviewers, it gives me great pleasure to offer you this
second issue of the second volume of Articulate: Undergraduate Research Applied to
International Development.
The world is in the midst of monumental change. America inaugurated its first African-
American president, the European Union ratified the Lisbon Treaty and selected its first
permanent president, and Iranian citizens challenged the outcome of their presidential
election, demonstrating in the streets and calling for full-fledged democracy. All of these
events were deemed dubious at best, and impossible by many. That they did happen
challenges our conception of what is possible. Similarly, the articles in this issue challenge us
to see old problems in new and different ways, giving us license us to expand the borders of
what is “realistic” or “feasible.”
Dara Carroll examines the challenging task of treating mental illness in Uganda, and urges
health care providers and informal caretakers to provide more supportive social environments.
Brian Beachler evaluates the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and the
United States President’s Emergency Plan for AIDS Relief (PEPFAR), using the key concern
of equity as his reference point for comparison. Geoffrey Levin lays bare the consequences
of cumbersome intellectual property rights, as enshrined in the Trade-Related Aspects of
Intellectual Property Rights (TRIPS) agreement, to critical health needs in Africa. Pedro
Marcelino describes the current renegotiation and evolution of identity in Cape Verde, a
dynamic process informed by post-colonialism, geography, immigration, and globalization.
This issue also includes two personal essays. Sarah Lynn-Andrews Losinski relates an intensely
personal, enlightening, and perhaps sobering account of her five-month stay in Durban, South
Africa that captures the bewildering experience of working abroad. The issue ends with an
essay by Gracie Vivian, who takes an incisive, inquisitive look into her work as a medical
volunteer and the work of the entire development industry.
During his inaugural visit to Africa as president, Barack Obama delivered a speech to the
Ghanaian Parliament on July 11, 2009. In his speech – which covered issues of democracy,
opportunity, health, and conflict resolution – he appealed to a sense of mutual responsibility
and respect, and directed his comments specifically to young people. “I see Africa as a
fundamental part of our interconnected world, as partners with America on behalf of the future
we want for all of our children…It will be the young people brimming with talent and energy
and hope who can claim the future that so many in previous generations never realized.” The
authors in this issue are exemplary examples of such young people who are claiming that
future with a sense of purpose. They realize that the twenty-first century will be shaped by
what happens not only in the U.S. or Europe, but also by what will happen in Africa.
I urge you to read the following pages with care and attention. Not only have the authors
combined intelligence and insight with dedication and passion, they have also produced well-
crafted and timely pieces. Their work is impressive, and I am confident that their analyses and
conclusions will have lasting resonance.

Sincerely,
Jonars Spielberg
Michigan State University
December 2009

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 Africa Map of Contents

Uganda
Carroll

Cape Verde
Marcelino

Rwanda
Vivian

South Africa
Levin
Losinski

Sub-Saharan Africa
Beachler

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 Table of Contents
Foreword 1
Jonathan Choti, Ph.D. Candidate

Scholarly Articles
The Core Resource 5
The Role of Informal Caretakers of the Mentally Ill in Uganda
Dara Carroll

Equity in HIV/AIDS Funding 29

A Comparison of the Global Fund and PEPFAR
Brian Beachler

Making TRIPS Work 45

A South African Case Study
Geoffrey Levin

Postcolonial Identity, Transition, and Challenges

to National Identity in Cape Verde 53
Pedro Marcelino

Young People in the Field

Nkosi sikelel’ iAfrika 75

Sarah Lynn-Andrews Losinski

A Different Dimension of Development 81

Holding the Mirror up to Oneself
Gracie Vivian

Call for Papers 87

Style Sheet 89

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 Foreword
In the international arena, the past few months have been extremely eventful. The culmination
of all of this activity has been the United Nations Climate Change Conference, commonly
known as the Copenhagen Summit, held from December 7-18, 2009. To some, the Summit
was a failure; to others, its outcome was half a loaf, judged better than having nothing at all.
The outcome of the Conference, the Copenhagen Accord, drafted by the USA, South Africa,
Brazil and China, was recognized but not agreed upon, and is not legally binding. A key
debate emerging within and around the summit was the relationship between developed and
developing nations, and the responsibilities of each group. On the one hand, many claimed
that those of the Global South were using the summit as a forum in which to make demands
that the world help improve their standards of living. On the other hand, representatives of
developing nations, especially those from Africa, felt that developed nations were not making
the necessary concessions or demonstrating enough leadership.
These two positions illustrate the fact that Africa’s role in world affairs cannot be ignored.
For instance, in the climate change realm, Africa will be the continent hardest hit by adverse
impacts, with implications for health care and larger development aims; and although Africa is
still vexed with many problems, the potential for growth and improvement is vast. The future
of the continent will ultimately rest with the actions of its citizens, but that future will also be
shaped by people and events outside of Africa.
Now than ever before, the citizens of the world have come to realize that we live in a global
village in which we share our misfortunes and opportunities alike. The Copenhagen Summit
bears testimony to this fact. It is this realization that is also the driving force behind the
articles in this issue. By highlighting the development and health care situation in Africa,
and incorporating a keen understanding of historical antecedents, the authors are in essence
training their spotlight on an eyesore in our own village.
One may argue that these young writers are out to accomplish an academic task. So be it
– that too is a feat! An academic enterprise it may be, but these articles also make a variety
of notable contributions. They will remain a monument of the individual authors’ efforts in
making a difference in the world. Indeed, the point of writing about an issue is to help draw
others’ attention to the issue at hand. Historians have done their part in tracing the events
of slave trade, World War I and II, colonization and liberation efforts, et cetera. In Volume
II Issue II, determined young scholars have elucidated the nature, trend, extent and effects
of the numerous situations in Africa, a continent broken by civil wars, dictatorial regimes,
poverty, disease (notably HIV/AIDS and Malaria), high levels of illiteracy, and environmental
degradation. The authors in this issue see all of this, what is, but also see before and beyond it,
to what was and should be, and how they are crucial for action in the present.
The Swahili believe that mwenye shibe hamjui mwenye njaa, a proverb that means “he whose
stomach is full never thinks about the hungry.” This issue of Articulate embodies a different
philosophy. Its authors may be from the “developed,” “first world,” but still their hearts have
space for those ailing elsewhere. I applaud their effort.

Jonathan Choti
Ph.D. candidate, Linguistics
Michigan State University

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Scholarly Articles

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 The Core Resource
The Role of Informal Caretakers for the Mentally Ill in Uganda
Dara Carroll
Northwestern University

Abstract
Recent studies have highlighted the significant role of culture in mental health, mental illness, and mental
illness treatment. The aim of this paper is to identify the cultural determinants of mental illness treatment
in Uganda. Specifically, I examine the role of family members in the recovery process for individuals with
serious mental illness. In Uganda, family members and close friends often assume the role of caretaker
for a mentally ill person. Family members are typically the first to recognize that the individual is ill, take
him or her for treatment, and monitor or administer treatment during and after hospitalization. Recently,
there have also been attempts to use family members to fight the stigma of mental illness. Although
social support is often heralded as a positive force in the African context, I argue that this assumption be
examined critically. Unfortunately, family members and informal caregivers sometimes neglect or even
aggravate mentally ill patients. This often occurs because of social stigma, a misunderstanding of mental
health, or increased economic stress. Mental health professionals and mental health service providers must
find ways to assist caretakers to create a more supportive home environment for people suffering from
serious mental illness.

Introduction
In 2001, the Ministers of the World Health Organization (WHO) published
Mental Health: A Call for Action, in which they expressed their commitment “to put
mental health right at the core of the global health and development.” They found that
“four of the ten leading causes of disability worldwide [were] neuropsychiatric disorders,
accounting for 30.8% of total disability and 12.3% of the total burden of disease,” with
these figures expected to rise.1 Mental health, however, is inextricably linked with culture
and society. Culture plays a significant role in how people conceptualize mental health,
normality, and healing.2 For this reason, mental health treatment is most effective when
it is informed by knowledge and understanding of the socio-cultural factors influencing
the patient. For this reason, WHO’s 2001 world health report called for further
research into the cultural context of mental health, especially in developing countries. In
particular, there was an “urgent need” for research on “factors likely to enhance uptake
and utilization of effective interventions.”3
One important socio-cultural factor in the treatment of the mentally ill is the family
structure. It has been shown that social ties, such as the family, can both help and hinder
recovery from mental illness. Time-consuming and demanding social relationships are
correlated with mental illness. This is one explanation for higher rates of mental illness
in women. Social support networks, on the other hand, can decrease the likelihood of

1 WHO, Mental Health: a Call for Action by World Health Ministers, World Health Organization:
54th World Health Assembly, World Health Organization (2001), 4.
2 Laurence J. Kirmayer, “Cultural Variations in the Response to Psychiatric Disorders and Emotional Dis-
tress,” Social Science Medicine 29 (1989): 327-331.
3 WHO, “Chapter 4: Mental Health Policy and Service Provision,” WHO, 1-2.

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mental illness and help with a speedy recovery.4 Although a support network may exist
naturally within a family, it has also been found that family resources in the treatment
of the mentally ill are often underused. Professional mental health practitioners can
overlook the useful information that family members could provide, and take for granted
the effectiveness of a well-informed family member acting as a caretaker.5
These studies, however, were all conducted in Western societies, where the nuclear
family is the most common family structure. Ugandan families are much more likely to
consist of large, extended networks. There may be grandparents, uncles, aunts, nieces,
and nephews all in one home. Even when not living together, the concept of the family
extends beyond the physical household, unlike in the US or Europe.6
Previous mental health research has produced three major findings. First, mental
illness is a serious health consideration. Second, culture plays an important role with
respect to mental health and finding effective mental health treatments. Finally, it has
been shown that family structure and behavior affects treatment outcomes of patients
in Western countries. What has not been rigorously researched is whether family has a
strong influence on treatment outcomes in Uganda. It seems likely that families do play
an important role in the healing process, based on the fact that culture is known to be a
strong mediator of mental health in Uganda, and that it is common for families to play
such a role in other countries.
For this reason, further research is needed to determine how families in Uganda are
affecting the treatment of mentally ill relatives. Such a study has yet to be conducted.
This study was designed to begin to fill this gap in the literature on culture and mental
health in Uganda. In doing so, it also addresses the research areas that the WHO has
highlighted as essential to improving and disseminating effective mental health services
to all. This study draws from over 90 semi-structured, open-ended interviews conducted
with mental health professionals, mental health NGO workers, and informal caretakers
of individuals with mental illness. Additionally, over 30 home visits with families dealing
with mental illness and several site visits to mental health units and hospitals throughout
Uganda were also conducted. Participants were divided into three groups: Group 1
– mental health professionals; Group 2 – mental health NGO workers; and Group 3 –
informal caretakers (family or friends) of persons with mental illness.

Global Trends in Mental Health

Mental health has recently been recognized as a priority for global and public health
intervention. The WHO has stated that “nearly 450 million people suffer from mental
and behavioral disorders” and that “mental health problems represent five of the ten

4 Ichiro Kawachi and Lisa F. Berkman, “Social Ties and Mental Health,” Journal of Urban Health 78
(2001): 458-460.
5 B. Friesen, and N. Korolof, “Family-Centered Services: Implications for Mental Health Administration
and Research,” Journal of Mental Health Administration 17 (1990): 13-16.
6 Jerome Del Pino and Gordon L. Anderson, eds., “Uganda,” Worldwide State of the Family (New York:
Paragon House, 1995), 206-207.

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leading causes of disability.”7 Depression is projected to be the second leading cause of
disability by 2020. It is also clear that, in many areas of the world, this challenge is not
being met. A recent WHO study has revealed that:

• Over 40% of countries do not have an explicit mental health policy.

• Over 30% of countries do not have a mental health program.
• More than 25% of countries do not have access to basic psychiatric
medication at the primary care level.
• 70% of the world’s population have access to less than one psychiatrist per
100,000 people.8

In addition to few resources, many countries are also failing to effectively use the
resources they have for mental health service provision. For this reason, WHO has
made an urgent call for research on the effectiveness of mental health interventions and
policies in low-resource settings, as well as research on “factors likely to enhance uptake
and utilization of effective interventions.”9 One such factor may be family members and
informal caretakers.
Community mental health programs are one way that the world has confronted
mental health in resource-poor settings. These programs seek to utilize existing
infrastructure and human resources to deliver mental health care efficiently and at a
grass-roots level. One new strategy for such programs is to train non-medical workers to
diagnose and treat common mental disorders. The largest current project implementing
this strategy runs out of Goa, India. Designed by Dr. Vikram Patel, over 2,000 patients
(as of March 2008) have been treated in this program. As Dr. Patel explains, in caring for
the mentally ill, “the core resource is humans.”10 So far the project has received positive
feedback from users, but there is an ongoing randomized clinical trial to determine the
effectiveness of the project.11 This project is an example of one way that local resources
can be used effectively. One local resource that has not been seriously studied is the
people living with and caring for mentally ill patients.
The methods used in the Goa project are promising in that they use culturally
relevant models and treatments of mental illness. It has been shown that cultural models
play a significant role in the definition and interpretation of illness. This may occur in
a number of ways, including socially learned symptomatology and culturally mediated
somatization.12 The convergence of anthropology and psychiatry to study how culture

7 WHO, Mental Health Policy Project; Policy and Service Guidance Package (World Health Organization,
2001), 8.
8 Elialilia Okello, “Cultural explanatory models of depression in Uganda,” Thesis for doctoral degree (Kam-
pala: Makerere University and Karolinska Intitutet, 2006), 3.
9 WHO, “Chapter 4: Mental Health Policy and Service Provision,” 1-2.
10 David Kohn, “Psychotherapy for All: an Experiment,” New York Times, March 11, 2008, US edition, p.
2.
11 Ibid., 1-3.
12 Kirmayer 1989, 327-331

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influences mental health and illness is being termed “the new cross-cultural psychiatry.”13
This type of research would be useful in understanding one of cross-cultural
psychiatry’s biggest surprises. In 1976, the WHO conducted a study on schizophrenia
treatment outcomes in developed and developing countries. Despite significant
advantages in terms of resources and training for the developed countries, treatment
outcomes in developing countries were much better. There was so much skepticism
about these results that another study followed, which confirmed the original results.
It has been posited that because the extended family network is a stronger social force
in developing countries, mentally ill individuals are getting more social support.14 This
theory, however, has never been subjected to empirical analysis, and must be studied
country-by-country or cultural setting-by-cultural setting.
There is yet another reason to consider culture. As science delves further into the
mechanics of the human brain, psychiatry and psychology are increasingly equated to
neurological processes and therefore illnesses are treated with biomedical interventions.
To date, however, “social, psychotherapeutic, and educational interventions are still the
only known forms of prevention.”15 There is no immunization for mental illness, so it is
to society that we must turn in order to prevent and treat individuals from mental illness.

The African Context

In 2001, the WHO conducted a self-reporting study on countries’ resources to
address mental health. Of the African countries that responded, less than half had a
mental health policy.16,17 In most African countries, the psychiatrist to patient ratio is
1:2 million, with most of the psychiatrists and even lower-level mental health workers
concentrated around the wealth and infrastructure of urban centers. Common mental
disorders (CMD)18 are, however, among the most frequent disorders of persons seeking
primary health care in Africa.
It has also been demonstrated that there are certain commonalities in explanatory
models of mental illness within Sub-Saharan Africa. Namely, many believe the mind to
be distinct from the body and to be housed in the head as well as the heart or elsewhere
in the torso. Often, mental illness is explained as a spiritual disruption or dysfunction.
“Madness,” or psychotic disorders, are often defined by presenting behavioral and or
somatic symptoms.19 This information indicates that Western medical measurements
of mental illness are not especially useful in Africa because they do not focus on the

13 Arthur M. Kleinman, “Depression, Somatization and the ‘New Cross-Cultural Psychiatry,” Social
Science and Medicine 11 (1977): 3; Vikram Patel, “Explanatory Models of Mental Illness in Sub-Saharan
Africa,” Social Science Medicine 40 (1995): 1292.
14 Byron J. Good, “Studying Mental Illness in Context: Local, Global, or Universal?” Ethos 25 (1997): 234.
15 Ibid., 230-231
16 It is predicted that the actual number of countries with a mental health policy in Africa is lower.
17 WHO, “Chapter 4: Mental Health Policy and Service Provision,” 1-2.
18 Defined as “disorders which are commonly encountered in the community and whose occurrence signals
a break down in the normal functioning.”
19 Patel 1995, 1291-1298.

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symptoms that are be reported. Instead, studies should include cultural contextualization
to determine what different populations consider to be mental illness so that the correct
symptomatology can be incorporated into applicable measurements and diagnostic tools.

Mental Health in Uganda

While Uganda’s mental health care system is somewhat developed relative to other
African countries, it still suffers from serious resource shortages. In 2006, the WHO
categorized Uganda as “research constrained” when it came to mental health, because the
country lacked sufficient infrastructure and personnel.20 As of 2006, Uganda had only
approximately 25 trained psychiatrists, 18 of which were working in Kampala.21 Due to
the lack of knowledge about mental illnesses, individuals with depression are three times
more likely to seek formal health care because depression is not a recognized illness;
therefore, individuals go untreated.22 If depression were recognized earlier and the correct
treatment were given, it could lower health care costs.23
The WHO specifies four major challenges to the mental health of populations:
poverty, urbanization, natural disasters, and war and conflict.24 Unfortunately, Uganda
currently experiences three of these four challenges. Poverty and urbanization exist on a
wide scale. Violence and war have long been a part of life in Uganda, creating traumatized
populations. As a result of civil wars and the ongoing wars in the surrounding East
African countries, refugees and internally displaced persons (IDPs) pose another
significant challenge.
It has been estimated that 26% of the population of Uganda lives in chronic poverty.
Chronic poverty is defined as a family or individual that is trapped in “severe” and
“multidimensional poverty” for a long period of time, often being transmitted across
generations.25 Mental illness and poverty create a cycle: Just as poverty can lead to
mental illness, mental illness can impoverish an individual because it may cause disability
or discrimination that prevents him or her from working. Similarly, poverty makes
treatment less readily available. Rural poverty, in turn, forces people into urban centers
to find work. Between 2000 and 2005, the urban population growth rate in Uganda was
4.2%; in 2007, 13% of the population was living in an urban area. “The population of
Kampala has steadily grown in the last three decades, faster than the pace at which urban
services and housing are provided.”26
It has been posited that urbanization has had deleterious effects on the close-

20 WHO, Working Together for Health: The 2006 World Health Report (World Health Organization:
Geneva, 2006).
21 Okello 2006, 11-12.
22 Figure determined after controlling for medical co-morbidity.
23 Okello 2006, 3.
24 WHO, Mental Health: a Call for Action by World Health Ministers 2001, 4.
25 “Does Chronic Poverty Matter in Uganda?” 2006: 1-2.
26 Shuaib Lwasa, “Urban Expansion Processes of Kampala in Uganda: Perspectives on contrasts with cities
of developed countries,” PERN Cyberseminar on Urban Spatial Expansion. http://www.populationenvi-
ronmentresearch.org/papers/Lwasa_contribution.pdf.

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knit extended family that is common throughout Africa and in Uganda in particular.
The theory suggests that urbanization has 1) removed the social pressure to maintain
family bonds, and 2) put new and increased economic strain on families. This is in
comparison to the formerly strong bonds between extended family members, which
created a psychosocial support network. Recently this assumption has been called into
question based on evidence that large families can also cause psychological stress.27 What
remains clear, however, is that urbanization has disrupted family dynamics in Africa.
Furthermore, functional families (of any size or shape) are known to help minimize the
effects and/or risk factors of mental illness. Although a recent study found that family
structure was not a risk factor for depression in Uganda, it discovered that family-related
negative life events were. The depressed participants in this study were much less likely
to have regular incomes and more likely to be separated from their spouses, a condition
more common in an urban setting.28
One community is particularly at risk to the social and psychological dangers of
urban centers. Street children, or children that do not have homes and are living in
slum areas, are numerous in Kampala. In a recent study has examined the lives of street
children in Kampala, the most common reason that children left home was because of
abuse or neglect from parents or other caregivers in the home. Other common reasons
included looking for work, the break-up of the family due to separation or divorce, and
parental death.29 As mentioned above, these types of events are significant risk factors for
the development of mental illness.
Street children are also subject to a wide range of traumatic events. Among the
participants of the aforementioned study, 80% reported physical harassment from the
police and general public, 50% reported not having shelter, and 28% reported going
hungry regularly. Although the girls were the only ones to report sexual harassment,
the figures are staggering. Eighty-four percent of the girls reported being sexually
abused, and 43% reported being raped, while 11% of them turned to prostitution for
survival. Other common survival tactics included stealing (100% reported stealing) and
substance abuse (27%). The most common reasons given for abusing substances such
as alcohol, marijuana, and fuel, were to numb feelings or go to sleep. Due to the many
negative life events to which street children are exposed, they often experience some
degree of psychological and emotional damage, especially relating to abandonment
and insecurity.30 It has been shown that, in Uganda, successful rehabilitation and
reintegration of street children involves an extremely supportive social environment,

27 Good 1997, 236.

28 Wilson Muhwezi et al., “Life events and depression in the context of the changing African family; the
case of Uganda,” World Cultural Psychiatry Research Review 10 (2007): 12-18.
29 Seggane Musisi, “Chapter 10: The Life and Causes of Street Children in Kampala, Uganda,” 195-208,
in Poverty, AIDS, and Street Children in East Africa, Joe Lugalla and Colleta Kibassa, eds (Lewiston, New
York: The Edwin Mallen Press, 1992), 197.
30 Lorraine Young, “The place of street children in Kampala, Uganda: marginalization, resistance and accep-
tance in the urban environment,” Environment and Planning D: Society and Space 21:5 (2002): 607-612.

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most importantly in the home and family unit.31
Trauma also exists in Uganda as a result of war and torture. It is widely accepted that
torture can lead to a variety of mental health complications; in fact, this is often the goal
of the perpetrators of torture. A study of patient records at the Kampala-based African
Centre for Treatment and Rehabilitation of Torture Victims showed that the most
common forms of torture were kicking and beating, witnessing the torture of family
members or other victims, and rape. The prevalence of mental illness in these patients
was significantly higher than in the general population: 75.4% were diagnosed with
Post-Traumatic Stress Disorder (PTSD),32 32% with somatoform disorders, 28% with
depression, and 17% with anxiety disorders.33
There are also a number of civil conflicts, both resolved and ongoing, that have been
disrupting mental health prevention and treatment in Uganda. It is estimated that, in
populations affected by armed conflict, at least 10% will develop mental health problems
and an additional 10% will have trouble functioning as a result of trauma. Mental health
problems due to trauma emerge most prevalently immediately following the incident.
Studies of populations that had recently experienced trauma showed depression rates of
40-80%. The war experienced in Uganda can be characterized as “low intensity warfare”
or conflicts that target civilian populations. The goal in such wars is often to destroy,
terrorize and demoralize a population to stop or prevent resistance, which is exactly
what happened.34 Among the war-affected Ugandans in the North, prevalence rates
of disorders are high: PTSD at 39.9%, depression at 52%, anxiety disorders at 60%,
somatization disorders at 72.2%, suicidal behavior at 22.7%, and alcohol abuse at 18.2%.
The study that yielded these results also found that the number of traumatic events in
a person’s lifetime is highly related to developing PTSD. Prevalence rates were 23% in
those reporting three or more trauma experiences, and 100% in those reporting twenty-
eight or more trauma experiences.35
Another result of past and current conflicts in Uganda and East Africa is a large
number of refugees and internally displaced persons (IDPs). These populations are
not only exposed to trauma because of conflict, but also experience additional trauma
as a result of being displaced. In the process, many societal constructs and bonds are
destroyed. This type of “cultural discontinuity” is often correlated with depression,
alcoholism, suicide, and violence.36 These psychological stressors exist in Uganda refugee

31 Christopher Wakiraza, “Chapter Twelve: Reintegration of Street Children: A Critical Look at Sustain-
able Success,” in Poverty, AIDS, and Street Children in East Africa, Joe Lugalla and Colleta Kibassa, eds.
(Lewiston, New York: The Edwin Mallen Press, 1992): 223-233.
32 The most common forms of PTSD were chronic (67% of patients in the study) and complex (9% of
patients in the study).
33 Seggane Musisi, Eugene Kinyanda, Helen Liebling, and R. Mayengo-Kiziri, “Post-traumatic torture
disorders in Uganda: A three-year retrospective study of patient records at a specialized torture treatment
centre in Kampala, Uganda,” Torture 10 (2000): 81-87.
34 Seggane Musisi, “Mass trauma and mental health in Africa,” African Health Sciences 4 (2004): 80.
35 Frank Njenga, Anna Nguithi, Rachel Kang’ethe, “War and mental disorders in Africa,” World Psychiatry
5 (2006): 38-39.
36 Laurence Kirmayer, J., G.M. Brass, and C.L. Tait, “The mental health of Aboriginal people: transforma-

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and IDP camps. Among refugees at a camp in the West Nile region,37 31.6% of the males
and 40.1% of the females were diagnosed with PTSD.38 Another study found that over
25% of refugee children were severely psychologically disturbed. Among these children,
a supportive family was found to be the most effective factor form at preventing mental
illness.39 At a camp in Gulu District, high rates of mental illness existed, with 6% of
respondents reporting homicidal thoughts.40 This points to the cyclic nature of violence
and psychological trauma. It has been found that in Uganda, mass trauma can create a
tendency to solve all conflicts militarily, even interpersonal ones.41
Previously, Western researchers claimed that PTSD and other trauma-related mental
disorders did not exist in Africa. It was soon uncovered by researchers native to African
countries that the former studies had yielded inaccurate results because the studies
were designed for Western societies and with Western biases. More comprehensive and
culturally sensitive research has shown that in traumatized populations there is a core
set of mental health symptoms that manifest themselves differently in varying cultural
situations. These are now referred to as “post-traumatic culture bound syndromes.”
In Africa, dissociation and possession syndromes are most common.42 In Northern
Uganda, group interpersonal psychotherapy was an effective intervention for depressed
adolescents, partially because the measurements and treatment took locally described
syndromes into account.43
When interventions do not provide for cultural considerations, treatment and
diagnosis are less effective. In fact, it may even cause additional stress to the patient.
For example, Western models of treatment that are based on the modern concept of
science and the individual – as opposed to tradition, religion, and community – can
put unwanted pressure on the individual to accept Western conceptual models.44
Additionally, in Uganda, it is clear that mentally ill individuals respond better to
treatment when the caregiver is somebody who understands the cultural meaning behind
his or her illness.45 This has demonstrated through studies that investigate the work of
traditional healers, but it is also possible that family members could be utilized in the

tions of identity and community,” Canadian Journal of Psychiatry 45 (2000): 607-608.

37 The majority of the refuges were from Sudan.
38 Frank Njenga et al. 2006, 38.
39 Mina Fazel and Alan Stein, “The mental health of refugee children,” Arch Dis Child 87 (2002): 367-368.
40 Eugene Kinyanda and Seggane Musisi, “War traumatization and its psychological consequences on
women of Gulu District,” Review of Women’s Studies: 102-122.
41 Musisi 2004, 81.
42 Ibid., 80-82; 94.
43 Paul Bolton et al., “Interventions for Depressive Symptoms Among Adolescent Survivors of War and
Displacement in Northern Uganda; A Randomized Controlled Study,” Journal of the American Medical
Association 298 (2007): 519-521.
44 Patrick Bracken, Patrick, Joan E. Giller, and Derek Summerfield, “Rethinking Mental Health Work with
Survivors of Wartime Violence and Refugees,” Journal of Refugee Studies 10 (1997): 431-442.
45 Seggane Musisi and Sudarmono, “Traditional Healing in Conflict/Post-Conflict Societies,” 107; Elialilia
Okello, Solvig Ekblad, and Stella Neema, “Beliefs and practices of traditional healers regarding non-psychot-
ic depression: Implications for the health policy in Uganda,” (Submitted 2006): 15.

12
capacity of providing socially and culturally meaningful treatment.

Mental Health Service Users in Uganda

For present study, the first step was to ascertain who in Uganda was coming to study
sites, namely the Mulago National Referral Hospital’s S.B. Bosa Mental Health Unit
and the Butabika National Referral Hospital. Both institutions see more male patients,
with a 2-3:1 ratio of men to women, depending on the time. This is due to the fact that
men are more likely than women to become violent, which is the most common reason
for the hospitalization of the mentally ill in Uganda. As one participant put it, “quietly
depressed women are ignored.” Most patients are roughly between the ages of twenty
and forty. This is because most of the illnesses manifest during this age bracket. The
most common diagnoses are bi-polar disorder, schizophrenia, depression, and epilepsy46.
Because Mulago and Butabika are both national referral hospitals, and because mental
health services are not usually sought out except in extreme cases, the patients there are
often very severely ill.
Because only those individual with the most severe cases of illness are brought
to Mulago and Butabika, treatment almost always involves psychopharmacological
interventions. Few patients are able to see psychologists because they are a scarce
commodity and are not readily available, and the severe psychotic disorders do not
necessarily lend themselves to psychotherapy. A patient presenting depression or an
affective disorder usually stays at Butabika for two to three weeks, while a patient with
a substance abuse problem stays for about one month, and a patient with schizophrenia
or other psychosis stays for one or two months. These figures are similar at Mulago,
although the stays are generally a bit shorter.
There are several reasons for short admission periods. First, as mentioned, many
patients brought to these clinics are severely ill, so they respond quickly to drug therapy.
Second, hospitalization at Mulago can be a burden to family members because an
attendant is required. Thus, a member of the family is removed from economic and social
activity for the hospitalization period. Additionally, there is some evidence to show
that hospitalizations for mental health should be as short as possible to avoid “social
breakdown syndrome.” This occurs when a mentally ill individual is removed from his or
her social environment and social role for an extended period of time, and can be just as
detrimental as the original illness.47
Outpatients can be seen for a period of anywhere from a few months to several years,
depending on the severity of the illness. The frequency of visits also depends on the
disorder, but follow-ups generally take place weekly, bi-weekly, monthly, or bi-monthly.

Informal Caretakers for the Mentally Ill in the Ugandan Setting

A number of factors make family members and friends of the mentally ill an
important group to study. First, there is the problem of human capacity. There are simply

46 Although not considered a mental illness in the West, epilepsy is dealt with in mental health units be-
cause of the frequency of behavioral symptoms and the neurological basis.
47 Good 1997, 236.

13
not enough mental health professionals to deal with the average burden of mental health,
let alone the additional challenges in Uganda resulting from poverty, urbanization,
torture, war, and displacement. Therefore, it is necessary to look for support beyond and
outside of the professional sphere. Furthermore, the beliefs and attitudes of a society
toward mental illness have a considerable effect on the way the community interacts
with and responds to mentally ill individuals. These interactions both directly and
indirectly influence the illness and treatment outcome.48 It is possible that this influence
is even stronger among family members, but such a hypothesis has yet to be tested and
studied. Finally, it has been shown that caregivers who are familiar to the patient are
more effective.49 There often exists a large gap between patients and doctors, who often
come from a higher socioeconomic class and are viewed as “bosses.” For example, one
attendant at Mulago reported that the patient would not accept food, medication, or
assistance from basawo (Luganda for doctors) because they were frightening. Despite
knowing that patients benefit more from care given by someone with whom he or she
feels comfortable, it has not been determined to what degree family members and friends
are filling this role in Uganda, or if there is any way to improve the utilization of informal
caregivers.
Results of this study indicate that the people close to mentally ill individuals fill
the role of caregiver in numerous ways. It is most often somebody living with or near a
mentally ill person who recognizes the illness. With the exception of cases that require
police involvement, relatives almost always bring the patient to the hospital or clinic.
All except for two of the nineteen caretakers interviewed were family members. Female
relatives visit more frequently than their male counterparts. Only one of the fourteen
interviewed attendants at Mulago was male, and none of the five family members that
were interviewed from the Schizophrenia Fellowship (SF) were male. Men only became
involved if the patient was extremely violent or physically unmanageable. There are
several explanations for why women are more involved in taking care of the mentally ill.
First, there is a strong cultural expectation that women fill the care-giving role, while men
financially support the family. Since men are also more likely to be supporting the family,
there is also an economic component in charging women with the time-consuming
caretaker role.
After the patient has gone to the hospital, informal caretakers are essential for
providing three types of support. They often ensure that the patient’s basic needs are met.
While at Mulago Hospital, attendants help with everything from feeding, to washing
clothes, to bathing and hygiene. Many attendants also make sure that the patients are
eating properly and that any special dietary needs are met. After discharge, it is usually a
family member who takes over the responsibility for ensuring the physical well being of
the patient. This includes protecting them from harm and harassment, whether it be self-
inflicted or at the hands of others. In Uganda, it is also common for mentally ill persons
to wander, so it is the caregiver’s job to ensure that they do not become lost.

48 Ibid., 233.
49 Musisi and Sudarmono, 99-100.

14
 Doctors and nurses also use caregivers to assist in treatment. Even when patients
are still at Mulago, the attendants monitor and give medication. Occasionally, it is
necessary for family members to find and purchase medications that are not available
at the hospital. After discharge, mental health workers depend completely on informal
caregivers. They are the ones who remind and encourage the patient to continue taking
medication properly, and are considered responsible for ensuring that the patient attends
his or her follow-up appointments.
Finally, informal caregivers can provide crucial emotional and social support. In
Uganda, this type of assistance takes two forms. The first, and possibly most effective,
is listening. Many caretakers reported that they help the patient by listening to them.
Several also said that they “counsel” patients, or offer them advice on how to face certain
challenges, including stress. Secondly, sometimes the caretakers, without intention,
help the patient psychologically. One psychiatrist reported that his patients’ treatment
outcomes were better when the family was treating the patient like a “normal” human
being, or similarly to the way they were treated before the illness. For example, patients
whose families were able to keep them involved in the work at home were very successful.
Families or caretakers who encourage individuals to become as independent as possible
by pushing them to take care of themselves and find work increase the likelihood of a
quicker and more complete recovery.
Children, in particular, are in need of informal caregivers, and it is best if the family
is the source. Children respond strongly to negative life events associated with family
members, particularly parents. In fact, it is the most significant risk factor for deliberate
self-harm (DSH), which is not only possibly fatal, but also is itself a risk factor for
suicide.50 Children are also more likely to be psychologically traumatized if the parents
are also traumatized. 51 Although negative experiences related to family are the most
damaging in children, family is also the saving grace. A strong, functional family is
cited in a Ugandan training manual for health workers as the number one protective
factor against psychological trauma. For this reason, family members and caregivers of
mentally ill children are given special attention. The aforementioned manual mentions in
several places the importance of counseling and psycho-educating parents. In particular,
it is important for parents to recognize that the child is ill, despite the fact that this
realization may be upsetting. For this reason, Butabika children’s ward conducts group
sessions for family members. These group sessions involve some psychoeducation and
then ample time for the family members to ask questions and talk among themselves.
In this way it also functions as an informal support group or group therapy. The family
members also undergo their own form of counseling, to help them deal with having a
mentally ill child and prepare them to care for the child.
Unfortunately, the effect that family members and friends have on the mentally ill

50 Eugene Kinyanda, H. Hjelmeland, and Seggane Musisi, “Negative Life Events Associated With Deliber-
ate Self-Harm in an African Population in Uganda,” Crisis 26 (2005): 4-11.
51 Eugene Kinyanda, Sheila Ndyanabangi, Ruth Ochieng, and Juliet Were Oguttu, eds., Management of
Medical and Psychological Effects of War Trauma; Training Manual for Operational Level Health Workers
(Kampala: Isis WICCE), 88.

15
is not always positive. First of all, they do not always exhibit ideal help seeking-behavior
on the behalf of the patient. As previously discussed, it is only patients displaying severe
behavioral symptoms that are recognized as ill. In the absence of recognizably “mad” or
disturbing behavior, an individual is not considered ill, and therefore not brought to the
hospital.
Even when patients are brought to the hospital or clinic, it is often as a last resort.
Traditional healers and churches are preferred over hospitals and clinics for a variety of
reasons. When a community or family recognizes a mental illness, or “madness” as it is
commonly referred to, the consensus is usually that it is caused by something other than
psychological or psychiatric factors. There are a variety of cultural explanations, from
a curse from a neighbor to a neglected ancestor. In this case, a traditional or spiritual
healer is sought. Some also believe that the problem stems from a spiritual deficiency or
problem from within a Christian religion, in which case the family turns to the church
for healing. One Group 3 participant was still convinced that the patient’s problem was a
result of being bewitched by a female neighbor, and that God was the only answer to the
problem. Furthermore, traditional healers and churches are more available. As mentioned
before, mental health workers are few and far between. If the family or community is far
from a well-known mental health center like Butabika, they may decide that it would
be too expensive to travel the far distance to the health center. Traditional healers and
churches, on the other hand, are plentiful. Families may also face social pressure from the
community to seek out cultural or spiritual assistance first, even if they are questioning
the effectiveness of these measures.
Another reason to avoid the mental health unit or hospital is stigma. Community
members who do not understand mental illness have been observed harassing and
abusing mentally ill persons, including taunting, beating, demoralizing, name calling,
and ignoring in order to dehumanize. When faced with stigmatizing behavior, patients
often internalize the stigma, which translates into self-hatred and low self-esteem, both
of which have very detrimental effects on recovery and improvement. Also, in order to
avoid such abuses, mentally ill persons may withdraw from social situations, perpetuating
the poor social functioning that often accompanies mental illness. To protect himself or
herself from community abuse, a mentally ill person may try to hide his or her illness for
as long as possible, in anticipation of stigmatization.
Mental illness is not only stigmatizing for the individual, but also for the whole
family. To avoid judgment, families might try to hide the patient instead of seeking
treatment. Butabika, in particular, is well known as a mental health hospital, and
therefore does not appeal to families who are uncomfortable with public knowledge that
such an illness exists in their family. Unfortunately, fewer people know about the mental
health services offered at alternate institutions, such as Mulago or other health centers.
Most attendants and family members who were part of the study were referred from
another ward of the hospital, usually the emergency ward. In Jinja, the Schizophrenia
Fellowship is working to spread the word that there is treatment for mental illness.
Most of the members are relatives to and caretakers of mentally ill persons. Of the ones
interviewed, they had all heard about mental health services offered at Bugembe Health

16
Center IV from somebody who was already a member of the organization. This kind
of grass roots information dissemination was found to be very effective in this setting.
Finally, families or caretakers may simply be in denial about the illness. It can be upsetting
to acknowledge that somebody is seriously ill, especially if the family or caretakers is
blaming themselves or the ill individual. As a result of lack of knowledge, fear of stigma,
and denial, most mentally ill persons do not receive formal care until he or she has been
ill for some time and the illness has become severe.
The ways in which family members can negatively impact treatment outcomes go
beyond missing out on formal services. They can actually reverse some of the progress
made by treatment. Stigma does not only come from the community. Caretakers are
often observed using the term mulalu, or “mad person,” when addressing or referring to
the patient. Even more common and less obvious is the tendency for the family or other
people living with the patient to marginalize him or her. They quietly remove the patient
from daily activities, refuse to eat with them, discount what he or she says, expect little or
no productive activity from the person, and so on. Some parents go so far as to remove
children from school unnecessarily. If the patient becomes upset at any point, it is often
attributed to the illness, despite the fact that anger and sadness are common emotions.
While it is true that mental illness can cause disability, most people in treatment can
function quite well in his or her previous role. When they are denied the chance to
function in these roles, the result is withdrawal and self-stigmatization.
Sometimes families or caretakers give up on the patient and recovery. Instead of
taking them for help, they will bring them to hospitals to get rid of them. Some even
go so far as to beg psychiatrists to admit them, when the chosen course of intervention
was outpatient treatment. One doctor had observed families that brought in a
patient repeatedly, hoping that a different doctor would admit the patient. If they are
unsuccessful at “dumping” the patient at the hospital, the family may force the person
out of the home or pretend not to know the patient. In other cases, the patient is tied
up, tied to a tree, or locked in a room to remove them from the family and society.
Frustration on the part of the caretakers can also lead to what is called “high expressed
emotions,” which is essentially a lack of patience or understanding leading to visible anger
with the patient. Even physical abuse is fairly common, especially toward patients who
are aggressive as a result of their illness.
All of this behavior has negative impacts on treatment and is known to aggravate
mental illnesses in most patients. At the very least, these behaviors inhibit recovery. If a
patient is being told or shown through marginalization that they are not able to function
in society, it can become a self-fulfilling prophecy. Several mental health professionals
had observed that the above actions consistently cause relapses or “episodes.” One
member of the Schizophrenia Fellowship, herself a former patient, explained that when
community members stigmatize or harass her, her natural response is to get upset or
angry. Stress caused by hurtful and abusive behavior made it more difficult for her to
overcome her illness.
At this point, the prescribed intervention for damaging family or caretakers is
family therapy or counseling. It would also be useful to counsel communities in which

17
mentally ill persons are living. The community mental health program based at Butabika
has attempted to do some of this, but faces resource restraints that prevent them from
doing the necessary follow-up. Another protective factor is the patient’s ability to
care for himself or herself. Those that are able to provide for their own basic needs
are better at overcoming community stigma and familial abuse. Because women are
more often involved in activities like cooking, cleaning, etc., a female patient is more
likely to function well in the absence of a supportive network of friends and/or family.
Additionally, psychoeducation and sensitization are extremely effective methods for
preventing harmful practices in the care of the mentally ill.

Challenges for and to Informal Caretakers

The most common difficulty in caring for a mentally ill person mentioned by the
caretakers interviewed was financial challenges. It is expensive to transport the individual
and caretaker or caretakers – who often accompany patients to the hospital the first
time and for follow-ups – to the hospital. The best solution is decentralization of mental
health services, which the government is currently working on. There is also a community
mental health program being run through Butabika. The program, which is “rather
amorphous” according to one psychiatrist, runs four outreach clinics and handles some
cases that require special attention to the discharge and reintegration process. Although
it is only reaching communitieswithin a ten-kilometer radius of Butabika, it is having a
positive. For example, women are more plentiful at the outreach clinics, which means
that in some areas, it is not only the violent male patients that are getting treatment.
The outreach workers are also more likely to examine the family and social environment
of the patient. Even when the patient is going to an outreach clinic, however, it may
require a considerable amount of time and money to reach. The program itself also lacks
the funds and resources to do the home visits and follow-ups on reintegration that are
necessary in many cases. For patients whose home is far away, “reintegration” may involve
putting them on public transport to return home by themselves, because there are not
enough funds to send a counselor or nurse with them.
Another financial hurdle is medication. The majority of the Group 3 respondents
specifically requested or suggested that drug availability be improved, and prices
lowered. Mental health treatment is now part of the Basic Health Care Package
(BHCP), which means that it should be free at government health centers, including
psychopharmacological treatments. While most necessary medication can be found
at Mulago and Butabika, the supply is inconsistent. Patients may come in for follow-
up and the medication that they were taking successfully is not in stock. The patient
is then forced to take a chance on whatever drugs are available, or locate and pay for
the effective one. At smaller hospitals and health centers, the problem is even more
pronounced. Additionally, psychiatrists do not always consider the patient’s or family’s
economic situation when prescribing medications. In an attempt to give the patient
the best prognosis, a doctor may prescribe the medication that he or she knows is most
effective, but is not on the list of drugs provided by the government. When the family
cannot afford to buy the medications, however, they cannot help no matter how much

18
better they are. Families are reluctant to admit to doctors or authority figures that they
cannot afford the medication, and so they may keep quiet and leave the patient without
necessary drugs.
The patients themselves can also be an economic strain to families and caretakers.
In all Mental Health Units (MHUs) excluding Butabika, attendants are required for
admission. This means that the caretaker is removed from economic activity for the
period of hospitalization. Once at home, it is often still necessary for someone to forego
work in order to care for the patient. Wandering is an extremely common symptom of
mental illness in Uganda, meaning careful observation of the patient is often necessary. In
some cases, someone is needed to vigilantly watch the patient for signs of relapse, which
can distract from work or chores. A relapse may also result in property destruction, such
as the mother of a patient whose family is without bedding because the patient destroyed
the family’s bedding. Finally, patients often become financially dependent on family
members, at least for a period of time, which leaves the caretaker with an additional
dependent, one who would otherwise be living independently or supporting himself or
herself. In cases where the patient is a mother, the family (usually the patient’s mother)
steps in to care for the children, translating to even more dependents and work for the
caretaker.
Caring for a mentally ill person can cause emotional and psychological stress. Most
caretakers are somebody very close to the patient. Seeing a close friend or relative in
serious distress often leads to distress. In particular, it can be very upsetting for parents or
older family members to see the patient’s chances at success in school and work diminish.
As one psychiatrist explained, it is hard for family members to accept the fact that the
patient “is not going to become the person that they thought they were.” Furthermore,
the mental illness can put strain on and damage the relationship between the two people.
In some cases, family members (particularly mothers) blame themselves for the illness.
Similarly, the community may blame the caretakers. Communities also stigmatize the
family or people living with mentally ill persons. Many Ugandans, for example, consider
epilepsy contagious, and so people will stop visiting the home or family members of an
epileptic.
Unfortunately, the mental health system is not equipped to address the
psychological needs of family members and caretakers, although attempts to do so have
begun. The previously mentioned group sessions for parents of children with a mental
illness may be offering some solace to family members. Family therapy is also used fairly
often when the patient is a child. In addition, the community mental health program
seeks to ensure a healthy social environment for patients by counseling family members
when necessary. The financial problems of the community mental health program still
apply to these attempts, however, and therefore they are not extensive. In general, the
formalized mental health system is not addressing the needs of informal caretakers.
It is organizations that provide mental health services that are currently most
successful in the role of caring for the caregivers. Hope After Rape (HAR) provides
both individual and group counseling to family members of victims of sexual abuse. It
is considered a necessary step because the distress caused by having a family member

19
who is a victim, and a family member who is mentally ill as a result, can make it difficult
for family members to care properly for victims. The Transcultural Psychosocial
Organization (TPO) also makes stabilizing the family and social environment a priority,
through group counseling and community awareness.
Support groups are an extremely valuable method of assisting caretakers. BasicNeeds
Uganda (BN) has helped organize several caretakers groups. Not only do these groups
offer support to each other, some have formed drug banks. Drug banks are groups
of caretakers in which each member contributes some money so that the group can
buy expensive drugs in bulk, thereby saving each member money. The Schizophrenia
Fellowship (SF) has formed similar groups. SF is a membership organization based in
Masaka and Jinja. The Jinja group is based at Bugembe HCIV, and is run by the health
center’s PCO. Most members are parents or relatives caring for someone with mental
illness. All of the respondents who were members from SF reported that they were
having a difficult time caring for their family member, and that they were unhappy for
some time. They also all responded that – since joining the group – while they still face
difficulties, they are much happier. They described the group as “a place to laugh and feel
relieved,” a place they feel “embraced,” “at peace,” and “a lot of joy.”
Ignorance and misunderstanding is a dilemma for both caretakers and mental health
care workers. The general public has a very different conception of mental illness than
formally trained professionals. First, mental health professionals have sometimes found
it difficult to explain to family members and patients that mental illness is, in most cases,
a chronic disorder. There are certain cultural expectations of doctors in Uganda. Namely,
people expect medication in the form of pills or an injection. They expect the medication
to work quickly, and that once the symptoms are no longer visible the disorder is cured,
making the drugs unnecessary. As a result, drug therapy is often terminated much too
early: indeed, in some cases it is needed for the duration of the patient’s life. It is easier
for the patient to accept that he or she must take medication permanently because they
are able to observe what happens to them without medication. In the case of Butabika
patients, they are also interacting with mental health professionals on a daily basis,
and can see other patients that are there because they have relapsed. Once they are in
the home, however, the patient is subject to pressure from the caretaker or family. It
can be difficult for families to accept that the patient is not cured because of cultural
preconceptions and because it is upsetting news that is often difficult to process. When
the caretaker is encouraging a patient to discontinue medication, the patient often
acquiesces. Thus, if caretakers were made to accept the long-term nature of mental illness,
it would reduce the quantity of patients that relapse. There is, however, a Catch-22. It has
been shown that societies that conceptualize mental illnesses as curable as opposed to
permanent have better treatment outcomes.52 More research is needed to determine how
best to inform patients and caretakers about medication options.
As mentioned earlier, violence is the symptom most likely to prompt hospitalization.
This fits into a general tendency for people to recognize and identify behavioral

52 Good 1997, 233.

20
symptoms over emotional ones.53 The Group 3 participants were asked about how they
knew the patient was ill, and what happened when the patient became ill. Besides violent
or uncontrollable behavior, the most common responses were “over-talking,” “over-
walking,” and disrupted speech. When asked about the cause of the illness, the Group
3 participants also had a very consistent view: The fact that the patients were in the
hospital was an indicator that most of the caretakers had accepted that it is not caused
by cultural or spiritual factors. Only one attendant cited the cause as being “bewitched.”
Instead, the explanation usually begins with environmental factors, like too much work
or stress. The patient is unable to deal with the circumstances, and the result is “too many
thoughts” or “over-thinking.” In summary, the vast majority of the Group 3 participants
had the following conception of mental illness:

Environmental stress → Cognitive disruption → Behavioral symptoms

(too much stress or work) (“too many thoughts”) (violence, “over-talking”)

While most of the Group 3 participants were sympathetic to the patients, this
sample is biased toward this result because the caretakers have taken the time to seek
treatment and participate in treatment. There are, however, some families that will
actually blame the patient for the illness. As shown above, biological or organic causes
do not factor into the common conception of mental illness, which is also confirmed by
the observations of Group 1 and 2 participants, and Dr. Elialilia Okello’s work on the
cultural construction of depression in Uganda.54 It becomes the responsibility of the
mental health workers and community sensitization programs to explain that the patient
is not at fault. In order to remove blame, Ugandan psychiatrists have found it useful
to explain the organic causes of mental illness. Although medical terms are not always
easily or effectively translated from English to local languages, there are certain semantic
constructions that have proven useful. One experienced psychiatrist explains mental
illness as a result of “imbalances” in the “fluids” in the brain. Other phrases that have
proven useful are “the illness disturbed the brain,” the illness is “in the blood,” or “runs in
families.” It is important that mental health workers take the time to translate and explain
mental illness in terms that are not only easy to understand, but are also culturally
significant to patients, families, and communities.

The Importance of Psychoeducation

Psychoeducation has been found to be the most effective method of improving
informal caretaking practices and fighting stigma, and has the added benefit of being
inexpensive. Psychoeducation, as it exists in Uganda, essentially consists of revealing the
nature and causes of mental illness and the forms of treatment for mental illness. The
primary sphere of influence is the mental health worker to the patient and caretaker. As
discussed earlier, many problems result from misunderstandings and misconceptions on
the part of caregivers. Most, if not all, psychiatrists attempt to perform some degree of

53 Okello 2006, 1-43.

54 Ibid.

21
psychoeducation during consultations, but for some reason it often does not get through
to caretakers. The attendants that were Group 3 participants were quick to praise the
staff at Mulago. However, none of the respondents who were asked the following three
questions could answer all of them:55

a. What do the doctors tell you about your family member’s illness?
b. What do the doctors tell you about why your family member is ill?
c. What do the doctors tell you about your family member’s treatment?

Over half were able to answer the third question by saying that the patient was on
medication, or that the patient was to take drugs regularly. Others, however, said
“nothing” or “not yet.” These were also the most common responses for the first and
second questions. None of the respondents had been informed of the biological nature of
mental illness, and only two reported having been given any information about the cause
of the illness. Before these questions were introduced, the interviewees were still being
asked if he or she knew what caused the illness. Again, none mentioned biological causes.
These findings make it clear that more psychoeducation is needed for caretakers
at MHUs. Psychiatrists, however, are facing serious challenges. They are forced to see
many patients and often do not have the time to explain details and causes. Many are
also forced to work at private clinics because of low pay. Some report that they only
explain the details and causes of the illness if the patient or caretaker asks, or if it is
necessary because the caretaker is blaming or stigmatizing the patient. It is possible that
there is an additional justification for withholding the organic nature of mental illness.
Many caretakers reported that because the illness was caused by stress, they made sure
to help the patient avoid stress. Many of the illnesses seen in Uganda are brought on or
exacerbated by environmental circumstances, so this practice is extremely helpful. More
research is needed to determine exactly what should be included in psychoeducation,
and if explaining biological origins of mental illness is always necessary. What is not
in question is that caretakers should be advised on how to care for the patient, that the
patient is not to blame, and that it is extremely detrimental to stigmatize or marginalize
the patient.
Psychoeducation is also an effective solution for stigma in the community. The
Ministry of Health has taken some steps in this direction by promoting public awareness
on the radio and in posters. The community mental health program is also helping
by working in communities and outreach centers. BasicNeeds Uganda, Hope After
Rape, and the Trans-cultural Psychosocial Organization- Uganda are all involved in
community education programs like health talks or awareness promotion session. These
methods have been found effective. A new approach – more like an old approach with
a new appreciation – is also yielding impressive results. Family members of the mentally
ill are uniquely positioned within society to promote awareness and fight stigma. The
community is less likely to discount what they are saying because they are not ill, as

55 Eight of the fourteen attendants were asked these three questions; the other six were interviewed before
the questions were included.

22
opposed to patients themselves. Caretakers have also been exposed to psych-education
through the mental health system and different organizations. In addition, they can
offer compelling testimonies to make the community understand important messages,
for example, that the mentally ill should not be blamed for their illness. Perhaps most
importantly, they have a strong motivation to end stigma. SF in Jinja has had considerable
success in using family members to educate communities.
Their grassroots approach is ideal for communities which cannot be easily convinced
by a poster or meeting. The members themselves are proof of the success. A few of the
members are simply concerned citizens, who were recruited by caretakers. They report
that they are involved even though they are not related to a mentally ill individual
because they recognize mental illness as the community’s responsibility, and because they
know mental illness could happen to anybody. There is an increasing awareness among
mental health professionals and organizations that family members are ideal contact
points for community psychoeducation. With encouragement and assistance from the
mental health system and organizations caretakers could be at the forefront of fighting
stigma and raising awareness from mental health issues.

Conclusion
In order to maximize the potential of informal caregivers in the treatment of
mental illness, they are in need of several types of support. First, the government
must to ensure that medications are available, free, and in supply. Mental health care
workers and organizations should be lobbying the government for the medications, as
well as providing valuable psychoeducation. They should also encourage and promote
networking among caretakers. Caretakers can then form groups to support each other
psychologically and financially. Finally, if all of the aforementioned parties work together
to increase community awareness and understanding of mental illness, then harmful
stigma can be avoided, and caretakers will gain more outside support.
In order for caregivers to receive the necessary support, several things must occur.
First, decentralization is essential to ensure that the mental health needs of the country
are being met. The government’s current method of decentralization is incorporating
mental health into primary health care, which is exactly what is needed. There are,
however, several limitations to the practical execution of this plan. For one, there is
little to no coordination between district hospitals and health centers, district level
governments, and community-based organizations. Furthermore, little effort has been
made to ensure that the district level MHUs are fully functional. There is little district
funding (only federal), and staffing is inadequate. At the local government level, there
is almost no planning or implementation because there is no guidance from the district
or national level. Record keeping at all levels is insufficient, making it difficult to assess
community needs and to lobby for services and resources. Finally, NGO coverage for
mental health concerns is low. The NGOs that are in existence operate in small areas of
Uganda, leaving most districts without services.56

56 BasicNeeds Uganda, Basic Needs Uganda Baseline Study 2004-2005; The Situation of Mental Health in
Kamwokya, Masaka, Hoima, and Masindi (Kampala: BasicNeeds Uganda, 2006).

23
 While these issues are being addressed, continued research is required to assess
the effectiveness of new measures. In particular, findings from this study indicate that
there is a need for research that can determine which methods of psychoeducation are
most effective in what settings, and what information should be included or excluded.
In addition, there is effective work being done on incorporating traditional healers into
mental health care. These studies could lead to important changes and improvements in
the way mental health services are delivered in Uganda.57
Until infrastructure and resources for mental health service delivery are greatly
improved, psychoeducation is an inexpensive and effective intervention. If caretakers
and family members of the mentally ill are properly and thoroughly informed about
mental illness, they can be much more successful in the caretaking role, even to the
point of alleviating some of the burden of the mental health system. Additionally, armed
with complete and accurate information, they can serve as a powerful tool in their
communities for increased education and awareness.

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28
 Equity in HIV/AIDS Funding
A Comparison of the Global Fund and PEPFAR
Brian Beachler
Pennsylvania State University

Abstract
The emergence of the Global Fund to Fight AIDS, Tuberculosis and Malaria and the United States
President’s Emergency Plan for AIDS Relief (PEPFAR) greatly increased funding for HIV/AIDS. With this
influx of aid, it became imperative that all available resources be used equitably. This paper compares the
HIV/AIDS programs established through the Global Fund and PEPFAR based upon Margaret Whitehead’s
theory of health care equity. After providing a brief history of the epidemic and detailing the current
realities of the epidemic, this piece details both funding mechanisms. This paper argues that the Global
Fund provides more equitable assistance. Whitehead’s model requires the following three principles for
equity in health care: equitable health care must provide equal access to care for equal need; equal
utilization for equal need; and equal quality of care for all. By providing fewer restrictions on funding,
allotting a greater amount of assistance to a larger number of people, and including more local community
members in the assistance process, the Global Fund offers more equitable aid than PEPFAR. Certainly both
funding mechanisms have their respective advantages and disadvantages. However, considering Margaret
Whitehead’s theory of health care equity, this paper argues that the Global Fund provides more equitable
assistance.

Introduction
The emergence of HIV/AIDS is arguably the worst and most pressing modern
public health crisis. The global epidemic affected over 33 million in 2007 according to
UNAIDS estimates.1 Since 1983, when researchers first isolated the retrovirus later to be
named the human immunodeficiency virus (HIV), more than 25 million have died from
complications, and over 65 million have been infected.2 In 2007, it was projected that 2.5
million people were infected with HIV, and over 2 million people died.3
Concerned donors throughout the world have responded to the widespread crisis.
Within the past five years the international community, spearheaded by the United
Nations , has responded to HIV/AIDS and the other modern plagues - tuberculosis and
malaria with the Global Fund to Fight AIDS, Tuberculosis and Malaria. The United
States government under President George W. Bush felt similar concerns and funded the
United States President’s Emergency Plan for AIDS Relief (PEPFAR), another initiative
to halt the spread of and treat HIV/AIDS throughout the world. Both the Global Fund
and PEPFAR have spent billions of dollars attempting to combat HIV/AIDS.
Critics have analyzed the progress of both programs on many levels, but little to no
work has assessed the programs within an equity framework. This paper will compare
the equity of both funding initiatives. First, a basic background in HIV/AIDS and both

1 S. Barton-Knott, “Revised HIV Estimates,” UNAIDS: Joint United Nations Programme on HIV/AIDS,
http://data.unaids.org/pub/EPISlides/2007/071118_epi_revisions_factsheet_en.pdf.
2 M. Merson, “The HIV-AIDS Pandemic at 25 – The Global Response,” The New England Journal of Medi-
cine 354 (June 8, 2006): 2414-2417.
3 UNAIDS, AIDS epidemic update: December 2007 (Geneva: World Health Organization, 2007).

29
programs will summarize the necessary historical perspective. This will be followed by a
discussion on the structure of equity in foreign aid as provided by Margaret Whitehead’s
theory of health care equity. Once the framework for equity in foreign aid is established,
an analysis on which program provides more equitable treatment will follow.
HIV/AIDS at one time was a relatively obscure infection, only thought to affect
gay men, Haitian immigrants, and drug abusers. In 1981, researchers first identified
a new disease causing immune deficiency in young homosexual men in the states of
California and New York. Scientists slowly uncovered more about the disease during
the 1980s. At the same time, an enormous stigma prevented wide-spread education or
acceptance of the up-and-coming epidemic throughout the world. In the late 1980s and
1990s the undiscriminating nature of the virus became apparent as the disease spread
outside of stigmatized groups to notable celebrities and millions of others across the
world. Fortunately, scientists made major medical advances during the mid-to-late 1990s
concerning prevention and treatment of HIV/AIDS, which included the effectiveness
of Azido-Thymidine (AZT) and antiretroviral (ARV) treatments. AZT and ARV
treatments respectively decreased the spread of the infection from mother to child and
suppressed the progression of the disease. As a result of these scientific breakthroughs,
the incidence in many developed nations is now declining or stagnant, and HIV-positive
patients often live for many years if they receive proper treatment.
Despite the miraculous breakthroughs concerning new medication available to quell
the epidemic, millions of people throughout the world do not receive treatment for the
disease.4 Unfortunately, two-thirds of HIV/AIDS cases occur in Sub-Saharan Africa
where many health systems cannot support adequate prevention or treatment.5 In 2001,
the international community began to realize the necessity of creating an independent
funding body for HIV/AIDS. In that same year, then United Nations Secretary-General
Kofi Annan called for the need of a funding body that would help quell the modern
plagues of tuberculosis (TB), malaria, and HIV/AIDS. He argued that it was imperative
to increase funding in prevention and treatment of these diseases, as well as support local
health systems.6 After widespread support from the United Nations and African leaders,
and with funding from G8 countries, the Global Fund was founded in 2002 as a unique
private-public funding mechanism for countries burdened by HIV/AIDS, malaria, and
TB.
The Global Fund’s core objectives are to provide increased resources to prevent
and treat malaria, TB, and HIV/AIDS. The independent organization prides itself
on involving participation from wide-ranging entities including political activists,
government officials, the affected community, and the private sector in the decision-

4 The Kaiser Family Foundation, “U.S. Global Health Policy,” Global Health Facts.org, http://www.global-
healthfacts.org/topic.jsp.
5 UNAIDS, UNAIDS 2008 report on the global AIDS epidemic (Geneva: World Health Organization,
2008).
6 Kofi Annan, “Secretary-Gereral Proposes Global Fund for Fight Against HIV/AIDS and other Infec-
tious Diseases at African Leaders Summit,” United Nations Press Release, http://www.un.org/News/Press/
docs/2001/SGSM7779R1.doc.htm.

30
making process.7 Weary of the intensely political bilateral agreements between nations,
the Global Fund desires to present humanitarian aid that is effective rather than
politically symbolic. The Global Fund is unique in that it does not implement its own
programs; rather, the Global Fund provides grants to governments, community groups,
and non-governmental organizations (NGOs).
The United States government and the international community had similar
concerns regarding the HIV/AIDS epidemic. A diverse group, ranging from liberal
HIV/AIDS and foreign development activists to conservative religious leaders, joined
forces with the Bush administration to appropriate a serious commitment to combat
HIV/AIDS in Africa. The support of the Bush administration and republican senators
Bill Frist and Jesse Helms proved crucial in building a bipartisan alliance for the passage
of major legislation.8 In his 2003 State of the Union Address, President Bush announced
a $15 billion proposal for HIV/AIDS prevention and treatment. PEPFAR has proved to
be the largest humanitarian program by one country.
PEPFAR and the Global Fund have been extremely effective at combating HIV/
AIDS throughout the world. According to a 2009 study, PEPFAR prevented 1.1 million
deaths through ARV treatment.9 The Global Fund has demonstrated similar success.
By 2004 it had provided 2 million people with ARV treatment and supported over 1.7
million AIDS orphans.10 Because of the mutual success, it is important to note that one
program is not inherently better than the other. Both funding mechanisms have made
a difference in countless lives, and it is not the objective of this paper to belittle either
intitiatve’s accomplishments. Rather, the equity of the aid allocation will be analyzed.
Subsequent analysis will demonstrate that, when evaluating the funding mechanisms
using Margaret Whitehead’s theory of health care equity, the Global Fund provides more
equitable funding.

Literature Review
The number of people living with HIV/AIDS has risen from approximately 3
million people in 1990 to the current estimate in 2007 of 33 million people. The
epidemic’s rate of growth has decreased considerably, but there are still an increasing
number of people living with HIV/AIDS. Despite the estimate that two million people
died from HIV/AIDS in 2007, there are an increasing number of individuals living
with HIV, as infections outpace deaths. Figure 1 summarizes the growth of the epidemic
within the last fifteen years and it demonstrates that, although global prevalence is
stagnate, the number of people with HIV/AIDS has continued to increase.

7 R. Brugha et al., “The Global Fund: managing great expectations,” The Lancet 364.9428 (3 July-9 July
2004): 95-100.
8 J. Dietrich, “The politics of PEPFAR: The president’s emergency plan for AIDS relief,” Ethics & Interna-
tional Affairs 21.3 (Fall 2007): 277-292.
9 S. Dinan, “Bush AIDS fight saved 1.1M, study says,” The Washington Times, April 7, 2009, Section A01,
U.S. Edition.
10 J. Guiver, “The Global Fund to Fight AIDS, Tuberculosis and Malaria,”Avert, http://www.avert.org/
global-fund.htm.

31
Despite treatment and prevention efforts, the HIV/AIDS epidemic continues to infect
and kill millions of people every year.11 After getting past the pure magnitude of the
epidemic, it is imperative to recognize the geographic disparities that exist. Figure 2 lists
prevalence, incidence, and mortality rates by geographical region. The severity of the
epidemic within Sub–Saharan Africa is evident through the data within Figure 2.
Not surprisingly, future projections of the epidemic estimate that the disease will
most severely affect Sub-Saharan Africa. More specifically, countries within Southern
Africa face the largest burden by HIV/AIDS. Of all nations throughout the world and
Africa, Southern African nations such as Botswana, Namibia, Swaziland, South Africa,
Lesotho, and Zimbabwe all have the highest prevalence rates. Figure 3 displays the
prevalence of HIV/AIDS among adults by country throughout Africa.

Figure 1. Estimated Number of People Living with HIV

Source: UNAIDS 2008 Report on the Global AIDS Epidemic

Figure 2. Regional HIV and AIDS statistics and Features, 2007

Source: UNAIDS 2008 Report on the Global AIDS Epidemic

11 UNAIDS 2008.

32
 Figure 3. 2007 HIV Prevalence in Africa by Country

Source: Joint UN Programme on HIV/AIDS

Review of PEPFAR and the Global Fund

PEPFAR has evolved over time. In 2008, Congress reauthorized and expanded
PEPFAR by appropriating 48 billion dollars for HIV/AIDS, Malaria, and TB.12 Over
a five-year span, PEPFAR will allot 39 billion dollars for HIV/AIDS prevention and
treatment. Between 2003 and 2008, before the legislation was reauthorized, PEPFAR
had several stipulations for receiving aid. Legislation required 55% of the money to
fund treatment for individuals, 10% to orphans or vulnerable children, 15% to palliative
care, and 20% to go toward prevention, of which one third must be spent on abstinence
programs.13 In addition to these requirements, PEPFAR provides assistance to over 100
countries, but the main funding goes to 15 focus nations, which are: Botswana, Côte
d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda,
South Africa, Tanzania, Uganda, Vietnam and Zambia.14

12 N. Bristol, “US Senate passes new PEPFAR Bill,” The Lancet 372.9635 (26 July-1 August 2008): 277-
278.
13 A. Kanabus, “The U.S. President’s Emergency Plan for AIDS Relief,” Avert, http://www.avert.org/pep-
far.htm.
14 N. Oomman, “Following the Funding for HIV/AIDS: A Comparative Analysis of the Funding Practices
of PEPFAR, The Global Fund and World Bank MAP in Mozambique, Uganda and Zambia,” Center for
Global Development, http://www.cgdev.org/content/publications/detail/14569.

33
 The Global Fund model has a unique structure in the manner that it allocates aid.
Each nation that desires funding must establish a Country Coordination Mechanism
(CCM), which is a group made up of individuals ranging from activists to government
officials from the recipient nation.15 The CCM must submit country-specific grant
proposals to the Technical Review Panel, an international non-partisan expert committee
that determines which grants proposals to fund. Once approved, the Principal Recipient
receives the grant, and an independent agency known as the Local Fund Agent (LAF)
assesses the implementation of the funding. The LAF observes and report on the
progress, usage, and effectiveness of the grant.16 After two years, the LAF will make a
recommendation to renew, modify, or discontinue the program. This comprehensive
model allows for the Global Fund to obtain an independent review of the effectiveness of
the aid.
In addition to providing the necessary medicines and prevention material, the
Global Fund also believes in improving infrastructure in order to combat the epidemic
using a horizontal approach. Horizontal funding promotes the development of health
systems whereas vertical funding focuses solely on disease specific initiatives.17 By funding
horizontally, the Global Fund does not only provide aid for ARVs and condoms, but
funding will improve medical facilities and develop an infrastructure that can effectively
utilize the monetary support. Horizontal funding considers the training of nurses and
the construction of facilities in rural areas as equally essential to providing funding for
ARV therapy in combating HIV/AIDS.

Equity Framework
In order to properly evaluate equity in foreign aid, Dr. Margaret Whitehead’s
theories on equity in health will be used to compare PEPFAR and the Global Fund.
Whitehead argues that in order for differences to be considered inequities, the
differences must not only be unnessecary and avoidable, but also unfair and unjust.18 The
judgement of something to be considered unfair is not a concrete yes or no response, but
involves providing context for the judgment. Discerning inequities requires context. In
evaluating equity one must consider the broad societal forces and a comparable situation
that is not inequitable. Therefore, in order to properly evaluate equity, there must be
a standard of what equity is. Whitehead summarizes by adding, “Equity is therefore
concerned with creating equal opportunities for health and with bringing health
differentials down to the lowest level possible.”19 Once societal forces that contribute
to inequities are nonexistent and citizens are presented with fair choices and chances of
how to live their lives, equity is attained. Whitehead continues to elaborate on equity in

15 Brugha et al. 2004.

16 Ibid.
17 V. Roy, “Horizontal, vertical, or diagonal?” GlobeMed, http://www.globemed.org/blog/posts/horizon-
tal-vertical-or-diagonal/.
18 G. Allenye, “Principles and basic concepts of equity and health,” Re Pan American Health Organization,
http://www.paho.org/english/hdp/hdd/pahowho.pdf.
19 Whitehead 1999.

34
health by providing three principles necessary for equity in health care: equitable health
care must provide equal access to care for equal need, equal utilization for equal need,
and equal quality of care for all.20
Allocating equal resources for equal need is defined as horizontal equity. Whitehead
argues that frequent barriers should not prevent equitable care. Common barriers
include discrimination of health care by sex, income, race, age, and religion. It is also
essential to ensure citizens have equal access to care. In order to ensure equity, equal
opportunity to care must exist even through larger systemic barriers such as geographical
location and the inadequate infrastructure of certain regions.
Adapting Whitehead’s equity framework to foreign aid requires some modifications.
The basic principles remain. Equitable aid distribution must be just and fair. Instead of
focusing on providing equitable opportunities, the goal in equitable aid is to provide
equitable resources based upon need. Following the ideology of horizontal equity
outlined by Whitehead, equal resources should be allocated when there is equal need.
For example, equitable aid would provide two communities with identical HIV infection
rates equal resources regardless of geographic, social, or political barriers.
The second aspect of Whitehead’s theory on equity in health care, equal utilization
for equal need, should also be considered as a principle for equity in foreign aid.
Whitehead argues that even if unequal utilization of resources based upon demographic
variables occurs, the scenario itself is not inherently inequitable.21 On the contrary,
researchers should investigate the explanations of why utilization rates vary among
different groups. If the differences result from free choice, then the situation is not
inequitable. However, if the utilization differences result from economic, social, or
political barriers, the circumstance may likely be inequitable.22 Considering foreign aid,
allocation functions as representative comparison to utilization. Nations have historically
allocated unequal amounts of foreign aid, and it remains a problem today. When nations
are differentially allocated aid, the difference is not inherently inequitable. Rather,
the differences must be understood. If nations do not have the capacity to effectively
administer ARV treatment to hundreds of thousands of citizens, less funding should be
allotted. However, if reduced or no aid is provided because of political explanations, the
funding is inequitable. Foreign aid funding should not be politically motivated; it should
be an equitable process that has humanitarian considerations.
Whitehead’s last consideration of equity in health care is equal quality of care for
all. She argues that citizens should not receive inferior treatment based upon social,
economic, or political reasons.23 The same concept applies directly to foreign assistance.
All recipients of the assistance should attain similar quality from the results. No recipient
should receive second-rate supplies while another benefits fully from the aid.
Expanding on the notion of horizontal equity in foreign aid, not only should equal

20 M. Whitehead, “The concepts and principles of equity and health,” Health Promotion International 6.3
(1991): 217-228.
21 Whitehead 1991.
22 Ibid.
23 Ibid.

35
resources be provided for equal need, but certain nations or groups of people should not
be excluded. Foreign aid has almost always had additional political motivations rather
than being solely humanitarian in nature. Citizens should not suffer the consequences of
not receiving foreign aid because of conflicting political ideologies between the donor
and recipient nation. For example, a communist nation refusing to give foreign aid to a
capitalist nation, based purely on the conflicting economic systems, would be considered
inequitable.
In addition to her theory on equity, Whitehead provides principles to pursue
in order to create equitable policies. These include: improving living and working
conditions, enabling people to live healthier lifestyles, involving the public in the policy-
making process, making equity decisions based upon research, and intervening on the
international level.24 Improving living and working conditions, involving the public
and policy-making process, and intervening on the international level all have direct
implications to foreign aid. The concepts are not intrinsic within the theory of equity,
but the fulfillment of these policies can create equitable health care systems. Both
PEPFAR and the Global Fund have policies that attempt to meet the concerns of Dr.
Whitehead.

Discussion
When considering Margaret Whitehead’s theory of equity, the Global Fund provides
more equitable aid than PEPFAR. PEPFAR and the Global Fund have their distinct
advantages and weaknesses, but employing Whitehead’s equity framework, I conclude
that the Global Fund provides more equitable treatment. Both funding mechanisms
require reform in order to incorporate community, governmental, corporate, and
international involvement. Moreover, the Global Fund has fewer funding restrictions,
which allows a greater number of nations and groups receive aid. Additionally, the Global
Fund allocates funds in a more horizontal manner, which facilitates improvements for
health systems. These critiques should not quiet the successes of PEPFAR, including the
millions of people who have received life-saving ARV treatment.25 However, because of
the manner in which both funding initiatives are structured, the Global Fund provides
more equitable treatment.
Both initiatives need to involve local communities in the policy-making process.
Although the structure of the Global Fund allows for more community involvement in
the allocation of grants, early results have shown limited integration of the community.26
In a study by Brugha et al., CCMs were dominated by the government in most cases,
which hindered public involvement. Margaret Whitehead stressed establishing
community involvement in the policy-making process in order to create equity. In
the grant-making process for the Global Fund, the CCM ideally engages individuals
who represent various institutions such as the government, business, and the affected

24 Ibid.
25 Dinan 2009.
26 Brugha et al. 2004.

36
community of the recipient nation. As noted earlier, the CCM is responsible for writing
grants to be reviewed, so if community leaders take part in the CCM, they have an
integral role of policy-making.
Within PEPFAR there is a smaller role for community members of the recipient
nation in the policy-making process. Most funding decisions come from the Office
of the U.S. Global AIDS Coordinator (OGAC) in Washington.27 Country specific
management of PEPFAR is run by United States staff employed by USAID, CDC,
Department of Defense, the Department of Labor, the Peace Corps, and the US Embassy
within the recipient nation.28 The United States staff collaborates with the host country
government to implement a country operational plan every year, but community
members of the recipient country are not directly involved with the planning. Neither
initiative has an excellent background at involving the locals of the recipient nation. The
Global Fund has a framework that can incorporate community members, while PEPFAR
should alter its structure to engage locals of the recipient nation in policy decisions.
From 2003 to 2008 PEPFAR legislation restricted care from certain groups of
people, which was inherently inequitable. Whitehead’s theory of health care equity states
that equal access, utilization, and quality of care should be attained by all individuals.29
The original PEPFAR legislation from 2003 to 2008 prevented funding to any foreign
nongovernmental organizations that provide any abortion services. Known as the
“Mexico City” policy, this broad family planning restriction limited the distribution
of condoms and educational materials under a mandate that crippled multiple family
planning NGOs.30 In early 2009, the Obama administration reversed the Mexico City
policy and now these family planning agencies have access to PEPFAR funds.31 This
is an indication that government policies can change over time when new leadership
is in place. Another restriction before the Obama administration took office was a
moratorium on funding toward needle exchange programs. Needle exchange programs
have been proven effective to reduce the incidence of HIV/AIDS among drug users.32
A restriction that has been ingrained within PEPFAR since 2003 has been requiring
recipients of aid to sign a pledge opposing prostitution and sex trafficking.33 Opponents
of this policy argue that such a clause prevents confronting one of the most vulnerable
and dangerous groups for acquiring and spreading the disease. This restriction alienates
sex workers, as interventions cannot reach this high-risk group. In 2005 Brazil rejected
40 million dollars in aid from PEPFAR citing that accepting the pledge of opposition

27 Oomman 2007.
28 Kanabus 2007.
29 Whitehead 1991.
30 Bristol 2008.
31 M. Sessions, “Overview of the president’s emergency plan for AIDS relief (PEPFAR),” HIV/AIDS
Monitor, Center for Global Development, http://www.cgdev.org/section/initiatives/_active/hivmonitor/
funding/pepfar_overview#1.
32 Bristol 2008.
33 Kanabus 2009.

37
would endanger sex workers and their clients from acquiring necessary protection.34
The mentioned restrictions limit the reach of PEPFAR. These politically motivated
limitations reflect the opinions of the politicians who passed the legislation. The
restrictions may have been necessary in order to pass legislation, but the restrictions
create inequities for the recipients.
The Global Fund does not restrict aid in the manner that PEPFAR does. Within
the structure of the Global Fund, the grant proposal process allows any CCM to apply
for funding. The technical review panel decides to whom the Global Fund will allocate
funding. This process may slow the disbursement of funding, but it does not inherently
restrict funding to certain groups.35
In addition to the noted restrictions on aid from PEPFAR, focusing the vast
majority of aid on 15 “focus nations” excludes millions of people who also require HIV/
AIDS treatment. Ninety-two percent of the funding for PEPFAR goes to the 15 focus
nations.36 This funding benefits millions in the selected countries, but the PEPFAR aid
rarely reaches people outside the 15 focus countries. As of 2009, the Global Fund has
provided over 10 million dollars to over 73 nations.37 Up until 2008 PEPFAR funded
approximately 4 billion dollars to HIV/AIDS, giving over 10 million or more to only 23
nations.38 Table 1 summarizes the amount of funding distributed by PEPFAR and the
Global Fund to 23 nations sorted by the amount of funds each country has received.
As displayed in Table 1, PEPFAR provides an extraordinary amount of funding to
a few nations, while the Global Fund provides a smaller amount of funding to a greater
number of nations. HIV/AIDS treatment and prevention does not reach every citizen in
either program, but the Global Fund method of disbursing aid is more equitable because
it promotes access to a more diverse group of people as more nations are served. Having
CCMs write grants allows funding to be distributed to a larger number of nations. Table
1 demonstrates that both initiatives have donated large sums of money to countries with
great need.
Surprisingly, not all Southern African nations with the highest HIV prevalence in
the world receive the most aid. Four Southern African nations appear in the top ten of
disbursements for both initiatives, but nations with high HIV/AIDS infection rates such
as Zimbabwe, Lesotho, and Botswana do not appear in the top ten of either list. Unstable
governments, relatively small populations, and many other factors help explain the
disparity between HIV prevalence and funding. When evaluating equity by examining
the amount of funding, it is important to understand the entire set of circumstances
before classifying a situation as unfair or unjust.

34 Ibid.
35 Guiver 2009.
36 The Global Fund, “Funding Decisions - Grant Portfolio,” The Global Fund to Fight AIDS Tuberculosis
and Malaria, http://www.theglobalfund.org/en/fundingdecisions/.
37 The Kaiser Family Foundation 2008.
38 Ibid.

38
Table 1. Total Aid Donated Directed toward HIV/AIDS: PEPFAR vs Global Fund
PEPFAR Global Fund
Rank Country Amount Rank Country Amount
Global $3,999,535,858 Global $4,516,112,464
1 South Africa $590,897,685 1 Ethiopia $404,268,659
Tanzania (United
2 Kenya $534,794,604 2 $243,312,051
Rep. of)
3 Nigeria $447,635,679 3 India $220,117,696
4 Ethiopia $354,539,354 4 Malawi $189,174,001
Tanzania
5 $313,415,559 5 Zambia $179,560,187
(United Rep. of)
6 Uganda $283,635,476 6 Russian Federation $179,415,268
7 Zambia $269,246,552 7 China $172,270,427
8 Mozambique $228,624,654 8 South Africa $152,810,440
9 Rwanda $123,468,840 9 Thailand $134,565,001
10 Cote d’Ivoire $120,537,903 10 Ukraine $128,135,782
11 Namibia $108,864,477 11 Rwanda $124,930,156
12 Haiti $100,646,286 12 Haiti $104,263,455
Congo (Dem.
13 Botswana $93,159,747 13 $97,551,814
Republic of)
14 Viet Nam $88,855,000 14 Nigeria $91,278,915
15 India $29,829,900 15 Mozambique $88,274,817
16 Zimbabwe $26,366,350 16 Cambodia $79,233,084
17 Malawi $23,862,300 17 Namibia $78,484,360
18 Guyana $23,799,308 18 Kenya $75,614,063
19 Cambodia $17,898,750 19 Uganda $72,522,979
Congo (Dem.
20 $15,413,330 20 Swaziland $67,202,255
Republic of)
21 Lesotho $13,127,910 21 Cameroon $64,321,294
22 Swaziland $12,731,960 22 Ghana $63,389,207
Russian
23 $12,000,000 23 Sudan $51,656,484
Federation
Source: The Henry J. Kaiser Family Foundation

The Global Fund allocates aid in a more horizontal approach than PEPFAR.
Whitehead argued that in order to establish health equity working and living conditions
should be improved along with promoting healthy lifestyles. Horizontal funding is
more likely to promote healthy lifestyles and improve working conditions than vertical
funding. Therefore, by promoting horizontal funding, the Global Fund also promotes
equity in aid allocation.
Although PEPFAR and the Global Fund are both vertical funding initiatives
designed to combat HIV/AIDS, they also serve as mechanisms for health system
development. Before 2008, the main focus of PEPFAR was to focus on disease

39
specific interventions such as prevention and treatment of HIV/AIDS. However,
with the reauthorization of PEPFAR in 2008, the legislation plans to train over
140,000 health care workers throughout the recipient nations.39 The addition of this
goal by American politicians displays a new dedication to horizontal funding and
health system development. In 2009, 42% of aid through the Global Fund went to
horizontal commitments that included infrastructure, administration, human resources,
and training.40 As is evident from the large sum, the Global Fund champions the
development of health systems. Both initiatives demonstrate a commitment to horizontal
funding, but the Global Fund has displayed it as a higher priority.

Conclusion
When using Whitehead’s theory of equity, the Global Fund provides more equitable
aid than PEPFAR. However, both initiatives need to improve community involvement
in the policy-making process in order to establish equitable policies. The Global Fund
already has the necessary framework to engage a local perspective, but in some cases it
needs to be used more effectively. A CCM should not be dominated by the government,
and it should include a community perspective in order to follow the principles provided
by Whitehead. PEPFAR should broaden the in-country staff outside of US officials
to embrace a local perspective within the policy-making process. Until community
members of the recipient nation partake in policy discussions, PEPFAR will fall short of
adhering to the principal of community involvement as outlined by Whitehead.
The Global Fund has fewer restrictions and necessary conditions for donor
recipients. Whitehead encouraged access to all when detailing the ideals of health equity.
The Global Fund grant review and proposal process does not limit applicants in any way,
and more nations and a wider range of groups have received funding because of these
policies. PEPFAR has several politically motivated guidelines and limitations on whom
and under what conditions a group will receive funding. These restrictions limit access
to treatment and prevention to many, which by Whitehead’s theory is inequitable. In
addition, the Global Fund allocates funds in a more horizontal manner than PEPFAR,
which facilitates improvements for health systems. Improving health systems has
implications for developing primary care and living conditions.
From this information, it is evident that the Global Fund provides more equitable
aid than PEPFAR when considering Whitehead’s theory of health care equity. This
conclusion should not be misconstrued to argue that the Global Fund is better than
PEPFAR. Moreover, the claims presented within this paper only represent the equity
framework provided by Whitehead; other theories of equity could argue that PEPFAR is
more equitable than the Global Fund.
Future investigations should evaluate the evolution of both initiatives over time. The
United States Congress drastically changed many aspects of PEPFAR in a five year span
from its first authorization in 2003 to its reauthorization in 2008. As time progresses, the
Global Fund and PEPFAR will both adapt. By comparing these initiatives with equity

39 Bristol 2008.
40 The Global Fund 2009.

40
in mind, an individual can construct a fair and just system for aid allocation. The relative
strengths and weaknesses of both funding mechanisms should be considered to improve
both projects. It is important to remember that both funding mechanisms have the same
goal in mind. As the Global Fund and PEPFAR continue to age, hopefully they will
develop a more equitable approach to aid allocation, while promoting a more equitable
world through the reduction of HIV/AIDS.

References

Allenye, G. “Principles and basic concepts of equity and health.” Re Pan American
Health Organization. http://www.paho.org/english/hdp/hdd/pahowho.pdf
(Accessed May 2, 2009).
Annan, K. “Secretary-Gereral Proposes Global Fund for Fight Against HIV/AIDS and
other Infectious Diseases at African Leaders Summit.” United Nations Press Release.
http://www.un.org/News/Press/docs/2001/SGSM7779R1.doc.htm (Accessed May
2, 2009).
Barton-Knott, S. “Revised HIV Estimates.” UNAIDS: Joint United Nations Programme
on HIV/AIDS. http://data.unaids.org/pub/EPISlides/2007/071118_epi_
revisions_factsheet_en.pdf (Accessed May 2, 2009).
Bristol, N. “US Senate passes new PEPFAR Bill.” The Lancet 372.9635 (26 July-1 August
2008): 277-278.
Brugha, R., M. Donoghue, M. Starling, P. Ndubani, and F. Ssengooba. “The Global
Fund: managing great expectations.” The Lancet 364.9428 (3 July-9 July 2004): 95-
100.
Dietrich, J. “The politics of PEPFAR: The president’s emergency plan for AIDS relief.”
Ethics & International Affairs 21.3 (Fall 2007): 277-292.
Dinan, S. “Bush AIDS fight saved 1.1M, study says.” The Washington Times, April 7,
2009, Section A01, U.S. Edition.
Global Fund, The. “Funding Decisions - Grant Portfolio.” The Global Fund to
Fight AIDS Tuberculosis and Malaria. http://www.theglobalfund.org/en/
fundingdecisions/ (Accessed May 2, 2009).
Guiver, J. “The Global Fund to Fight AIDS, Tuberculosis and Malaria.” Avert.
http://www.avert.org/global-fund.htm (Accessed May 3, 2009).
Kaiser Family Foundation, The. “U.S. Global Health Policy.” Global Health Facts.
http://www.globalhealthfacts.org/topic.jsp (Accessed May 2, 2009).
Kanabus, A. “The U.S. President’s Emergency Plan for AIDS Relief.” Avert. http://www.
avert.org/pepfar.htm (Accessed May 2, 2009).
Merson, M. “The HIV-AIDS Pandemic at 25 – The Global Response.” The New England
Journal of Medicine 354 ( June 8, 2006): 2414-2417.

41
Oomman, N. “Following the Funding for HIV/AIDS: A Comparative Analysis of
the Funding Practices of PEPFAR, The Global Fund and World Bank MAP in
Mozambique, Uganda and Zambia.” Center for Global Development. http://www.
cgdev.org/content/publications/detail/14569 (Accessed May 2, 2009).
Roy, V. “Horizontal, vertical, or diagonal?” GlobeMed. http://www.globemed.org/blog/
posts/horizontal-vertical-or-diagonal/ (Accessed May 3, 2009).
Sessions, M. “Overview of the president’s emergency plan for AIDS relief (PEPFAR).”
HIV/AIDS Monitor. Center for Global Development. http://www.cgdev.org/
section/initiatives/_active/hivmonitor/funding/pepfar_overview#1 (Accessed May
2, 2009).
UNAIDS. AIDS epidemic update: December 2007. Geneva: World Health
Organization, 2007.
UNAIDS. UNAIDS 2008 report on the global AIDS epidemic (Annex 1). Geneva:
World Health Organization, 2008.
Whitehead, M. “The concepts and principles of equity and health.” Health Promotion
International, 6.3 (1991): 217-228.

42
43
44
 Making TRIPS Work
A South African Case Study
Geoffrey Levin
Michigan State University
Abstract
Advances in modern medical technology have saved millions of lives in the developed world, but have
created a new moral quandary with which scholars, leaders, and businessmen must now grapple. While
manufacturing pills and other remedies may be inexpensive, research and development requires millions of
dollars of investment. Who should ultimately pay the research costs, especially considering the suffering of
the sick and impoverished in places like Africa? In line with contemporary views on intellectual property,
many believe that the company that owns the rights to a new treatment should be able to defend its patent
rights all over the world, allowing pharmaceutical companies to charge incredibly high amounts to sick
and desperate people. After the United Nations added the Trade-Related Aspect Intellectual Property
Rights, or TRIPS, provision to the WTO, WTO member countries were forced to protect the intellectual
property rights of foreign corporations. This created a humanitarian crisis in places like South Africa,
where HIV victims could not afford legal HIV drugs and were denied access to cheap generic alternatives.
This case study sheds light on the larger issue of intellectual property rights and Africa’s lack of access to
medical treatments that are considered basic and inexpensive in the developed world.

Introduction: Is TRIPS Tripping Up The Progress of Developing Countries?

Each day, AIDS kills nearly 5,500 people around the world. Another 2.7 million
people are infected with HIV, the precursor to AIDS, each year.1 The majority of
these victims live on the African continent in some degree of poverty. The AIDS crisis
is one of the most pressing problems facing the world today, yet few would imagine
that the AIDS crisis is an important case study for world intellectual property law,
stimulating a worldwide debate. TRIPS, the World Trade Organization’s (WTO)
provision on intellectual property, led to protests across the globe, most notably in
South Africa, a G20 nation with a 25% HIV infection rate.2 Despite their emerging-
market status, millions of South African HIV victims were simply unable to afford the
inflated prices charged by the American drug companies that held the patents to life-
saving antiretroviral drugs. In light of the public health crisis, South Africa took action
by breaking the TRIPS provision and importing a cheap Indian generic HIV drug,
triggering a worldwide debate and a confrontation with the U.S. pharmaceutical industry.
Clearly, exceptions for public health crises had to be made, and the Doha Declaration,
which amended TRIPS, created such exceptions. Overall, however, more must be done
to prevent unnecessary deaths resulting from inadequacies in international intellectual
property law.
As long as patents have existed, the idea of intellectual property rights has been
heavily contested. While the merits of patent laws are still debated within academic
settings, it is generally accepted among developed countries that intellectual property
laws are necessary to provide incentive for innovation. These developed countries

1 Avert, “Worldwide HIV and AIDS Statistics,” Avert: HIV and AIDS, http://www.avert.org/worldstats.
htm.
2 Ibid.

45
inserted intellectual property laws into the General Agreement on Tariffs and Trade
(GATT) and later the WTO. The agreement was on the Trade-Related Aspects of
Intellectual Property Rights, or TRIPS, and includes rules requiring countries to enforce
international trademarks, copyrights, and patents. Many advocates for developing
countries criticize TRIPS on various grounds. Some claim that such restrictions keep
nations from developing by forcing increased dependence on the developed world. Most
controversially, TRIPS institutionalized the idea that “…imports of the patented product
or products made by the patented process constitute working the patent.”3 This provision
makes it more difficult for many people to buy the goods or medicines they need, as it
effectively raises the price, therefore further hindering economic development in the
Third World by sucking up its income.

Give the People What They Need!

Most of the time, developing countries give in to TRIPS’ demands, as they fear that
the United States will impose painful unilateral retaliatory trade sanctions if they do
not enforce patent laws. An example of an agreement conceptually similar to TRIPS
was the 1998 “Africa Growth and Recovery Act”, which was promoted as a way to
help African countries’ governments and economies by “tying economic benefits to
economic reforms.”4 However, it was essentially a tariff reduction act that forced African
governments to protect American intellectual property rights and implement market-
friendly reforms; any country that did not comply would face economic repercussions,
thus inspiring Congressman Jessie Jackson Jr. to label it the “African Recolonization
Act.”5 But in the case of HIV antiretroviral drug cocktails, at least one country was
willing to take its chances. In the 1990s, an American pharmaceutical company created
an HIV antiviral cocktail that prevented HIV from turning into lethal AIDS. While
a year’s worth of the patented product cost about $15,000, a generic brand made in
India, which had no such patent restrictions, sold for $200 a year.6 As nearly 25% of its
population was HIV-positive, South Africa declared it was in a state of emergency and
imported the affordable Indian alternative.7 The American pharmaceutical companies
sued, but those advocating for developing countries fought back, claiming that it was
highly immoral to prohibit sick people from buying the only type of life-saving drug they
could afford.
The resulting lawsuit caught the attention of the world, but not the type of
attention that the pharmaceutical companies wanted. Their actions and their lawsuit
was condemned and criticized by many in the international community; even many
TRIPS advocates were too ashamed by the companies’ gross display of greed and

3 David N. Balaam and Veseth, Michael, Introduction to International Political Economy, 3rd ed., (Upper
Saddle River, NJ: Pearson Prentice Hall, 2005), 231.
4 William K. Tabb, The Immoral Elephant: Globalization and the Search for Social Justice, 1st ed., (New
York City: Monthly Review Press, 2001), 1530.
5 Ibid., 154.
6 Balaam and Veseth 2005, 233.
7 Avert 2009.

46
callousness to stand up for them. The incident caused a great deal of embarrassment for
the pharmaceutical corporations, so much so that they not only dropped the suit, but
also worked out a deal with South Africa and other developing nations to sell them the
drugs at a greatly reduced price.8 Of course, even this deal worked out to the US drug
companies’ advantage, as they still were able to hold onto the African market and sold
their medicines for slightly more than the Indian companies did, while also decreasing
the incentive for South Africa to work to develop its own pharmaceutical industry.9
However, many continue to fight against international patent laws under the same
banner, arguing that preventing people around the world from getting the products they
need at wholesale prices is patently unethical.

The Doha Declaration: An International Solution or a Global Band-Aid?

In response to the uproar over the South African incident, the developing world
began a major push to amend TRIPS. The resulting amendment, called the Doha
Declaration, was adopted in November 2001. It stated in unequivocal terms that:

The TRIPS Agreement does not and should not prevent Members from
taking measures to protect public health…we reaffirm the right of WTO
Member to use…the provisions in the TRIPS Agreement, which provide
flexibility for this purpose…Each Member has the right to grant compulsory
licenses…(and) to determine what constitutes a national emergency.10

Essentially, the Declaration permitted all WTO members to grant compulsory licenses
whenever they deemed it was necessary to combat an epidemic or national emergency. A
compulsory license is a license that a government may grant to one of its own companies
to allow that company to manufacture a patented product and thus break the patent
rights of the inventing corporation without its permission. In addition, the Declaration
allows “WTO Members with insufficient or no manufacturing capabilities in the
pharmaceutical sector” to work with the WTO to find an expeditious solution, such as
importing cheap generic drugs from non-TRIPS signatories like India.11

What About the Big Picture?

Even if pharmaceutical companies were simply greedy, there is far more to their
argument in general than in that specific incident. The merits of TRIPS are easiest to see
by envisioning a world in which international pharmaceutical patents did not exist. There
likely would be no HIV drug cocktails, as wealthy investors would refuse to invest the
massive sums of money required to research for the cure because they would know that

8 The Economist, “The right to good ideas; How patents help the poor,” The Economist 359.8227 (June 23,
2001): 27-30. 
9 Balaam and Veseth 2005, 235.
10 WTO, “Obligations and Exceptions Under TRIPS,” World Trade Organization, http://www.wto.org/
english/tratop_e/trips_e/factsheet_pharm02_e.htm.
11 Ibid.

47
the pharmaceutical company would not be able to recoup those expenses if people could
legally purchase cheap generic alternatives. For example, US drug companies estimate
that they lose almost $500 billion in sales because India, a non-TRIPS nation, allows its
companies to make unlicensed generic drugs. Not only does this hurt the companies’
profit margins, it means that this is $500 million that these companies cannot use for
further HIV drug research.12 Additionally, people often forget that patentees must
“provide a detailed description of their invention.”13 Often times, other companies use
this public information to innovate even further. Without patent laws, companies would
keep their innovations secret to cut out competitors, yet in the process they would also
prevent other companies from adding onto their current innovation.

Stiglitz and Intellectual Property Law: Better Management Needed

According to economist Joseph Stiglitz, “Intellectual property does not really belong
in a trade agreement.”14 Yet the United States has continually pushed for more and more
intellectual property protections in their trade agreements, despite the protests of other
countries. For example, Stiglitz cites the 2004 protests in Rabat and Paris where people
“took to the streets to protest a proposed new trade agreement between the United States
and Morocco that they feared would ban Moroccan companies from manufacturing
AIDS drugs.”15 This said, it is surprising how hard the United States pushed for the
controversial TRIPS provision in the WTO. The US has continued to go out of its way
to protect the economic intellectual property interests of its corporations, insisting that
all countries accept its conditions. Stiglitz says explicitly that the TRIPS provision should
not exist, and questions how much it had done to increase innovation in comparison
with the inefficiencies and high costs it engendered.
That being said, Stiglitz does offer solutions to make international intellectual
property laws fairer and more efficient, again stressing that like globalization itself,
IPRs are not inherently bad; they are just being mismanaged. He acknowledges that
innovation is important, but questions how much TRIPS actually adds to innovation,
explaining how “poorly designed intellectual property regimes not only reduce access
to medicine, but also lead to a less efficient economy, and may even slow the pace of
innovation.”16 He advocates not for the abolition of international intellectual property
rights, but rather for a better and more balanced intellectual property system. He starts
by pointing out the differences between normal property laws and intellectual property
laws. Property rights “provide incentives to take care of your property and put it to
best use, but these rights are not unfettered; uses which impede economic efficiency
or infringe upon the well being of others” are restricted. There are no such restrictions

12 The Economist 2001.

13 Paulo Bifani, “International Stakes of Biotechnology and Patent Wars,” Agriculture and Human Values
Spring (1993): 47-59.
14 Joseph Stiglitz, Making Globalization Work, 2nd ed., (New York City: W.W. Norton & Company, Inc.,
2007), 116.
15 Ibid., 104.
16 Ibid., 106.

48
on intellectual property rights, which could potentially allow for monopolies and
conspiracies that harm others and impede economic growth.17 Patent holders effectively
receive temporary monopolies on their products, and often use the patents and the
resulting profits to quash any potential competitors, thus stifling innovation, much like
Microsoft once did when it marginalized Netscape and RealNetworks.18

Fixing a Broken and Unbalanced System

Due to such abuses, Stiglitz and others make the case for additional changes that
would make intellectual property rights fairer on a global scale. First, patent rights
should be made narrower to ensure maximum innovation. For example, at the turn of
the century, when someone tried to patent all four-wheeled motorized vehicles, Henry
Ford and other innovators challenged the patent, which they saw as being too broad. If
Ford had not had won and the patent not been narrowed, Ford and other innovators
would have been shut out of the industry and the nation would have suffered. After all,
it was Ford who came up with the idea of creating a mass-produced “people’s car,” and it
was this revolutionary concept that fundamentally altered American culture.19
Secondly, the patent license duration, which is currently twenty years for most
products, should be shortened in light of the increasingly fast pace in which our society
innovates. Innovating companies would still be able to reap the benefits of a patent, but
shaving a few years off of the license could greatly benefit society by spreading innovation
and cutting prices.
Thirdly, those applying for patents must be forced to prove that they themselves
invented the product. There are numerous cases of people who have made millions by
patenting things that they did not invent, ranging from free software to indigenous
plants and treatments.
Fourthly, some industries should consider not patenting at all. Societies without
patents, such as 19th century Switzerland and the Netherlands, had innovation without
intellectual property protection; today, there is a growing movement within the software
industry toward free-base innovation, in which people freely work off each others’
innovations, creating gradual improvements. Linux and Mozilla Firefox have been highly
successful at this, and many say that their software is better than what Microsoft has
to offer because it has been less subject to security breaches than Microsoft’s Internet
Explorer; however, many fear that Linux may hit a hidden patent while free-basing,
which could force it to pay millions of dollars in fines and threaten its very existence.20
Stiglitz also sees a greater role for the government in encouraging innovation. Not
only does he encourage the government to fund more research and ask for more of a say
in what happens to the results of that research, he wants to take things a step further.
If the point of IPR is to ensure that corporations recoup their research costs and are
rewarded with a decent profit, then perhaps there is a more efficient and humane way

17 Ibid., 107.
18 Ibid., 109.
19 Ibid.
20 Ibid., 110.

49
of doing that. The government could offer a certain amount of money, say $2 billion, to
any company that creates a drug to combat some of the world’s most dangerous diseases,
such as AIDS. Upon creating the AIDS drug, the company would receive the $2 billion
without receiving any additional intellectual property rights, thus allowing that company
and any other able company to manufacture the drug at generic prices, thus forcing
the companies to compete to figure out the least expensive way of manufacturing that
drug. Yes, that $2 billion would be taxpayer money, but if the disease is harming society
that much, then the whole society should pay for it. After all, the alternative would be
only having each sick person pay an equal part of that $2 billion when buying expensive
patented drugs, no matter how rich or poor the person is.

Conclusion: Tough Questions, Complicated Solutions

If every HIV victim had to pay high prices for their treatment, the pharmaceutical
companies could spend more for research and development and find the actual cure for
AIDS even faster. However, millions in developing countries may die waiting. On the
other hand, if there were no international patents and HIV treatment only cost $200 a
year, it would be difficult to raise funds for future AIDS advances because there would be
neither income nor investors. Perhaps it is possible to have it both ways, and the WTO
has already taken steps in the right direction after the South African crisis. The Doha
Declaration made many important changes to TRIPS, allowing countries with public
health crises to either issue compulsory licenses domestically or import cheap generics
from abroad, but it did not go far enough. By implementing the intellectual property
reforms listed earlier, ranging from narrowing patent definitions to offering government
monetary rewards, the United States and the WTO could even the playing field and
create an IPR system that is both more humane and more efficient.

References

Avert. “Worldwide HIV and AIDS Statistics.” Avert: HIV and AIDS. http://www.avert.
org/worldstats.htm (Accessed March 17, 2009).
Balaam, David N., and Veseth, Michael. Introduction to International Political Economy,
3rd ed. Upper Saddle River, NJ: Pearson Prentice Hall, 2005.
Bifani, Paulo. “International Stakes of Biotechnology and Patent Wars.” Agriculture and
Human Values Spring (1993): 47-59.
Economist, The. “The right to good ideas; How patents help the poor.” The Economist
359.8227 ( June 23, 2001): 27-30. 
Stiglitz, Joseph. Making Globalization Work, 2nd ed. New York City: W.W. Norton &
Company, Inc., 2007.
Tabb, William K. The Immoral Elephant: Globalization and the Search for Social Justice,
1st ed. New York City: Monthly Review Press, 2001.
WTO. “Obligations and Exceptions Under TRIPS.” World Trade Organization. http://
www.wto.org/english/tratop_e/trips_e/factsheet_pharm02_e.htm (Accessed May 2,
2009).
50
51
52
 Postnational Identity, Transition, and
Challeneges to Tradition in Cape Verde
Pedro Marcelino
University of Wales Aberystwyth (undergraduate)
York University (current)

Abstract
Cape Verde is an island-nation located 500 km west of Dakar, Senegal. Although it does not possess
any economically relevant natural resources, it has achieved reasonable development through good
governance, democracy, sound economic policies and efficient management of foreign aid. The country
is still learning to manage its newly found affluence and the attendant growing pains. For the first time
since the onset of colonization Cape Verde is a net receiver of immigrants: mainland Africans, Chinese
entrepreneurs and European paradise-seekers. This has fueled social tensions partly motivated by
economic concerns but diguised by a perceived challenge to the homogeneity of the islands. Although at
base an economic issue, these tensions often inform public discourses of loss of identity and the dilution of
“capeverdeanness,” the very essence of what Cape Verdeans believe makes them “different” or “unique.”
Through a postcolonial lens, this article explores an exciting new period in the country’s history. Core
values are being questioned and renegotiated while Cape Verde and its citizens attempt to adapt to its new
demography and to the demands of a globalized world.

The author wishes to acknowledge the helpful comments and advice on sources provided by Dr. Rita
Abrahamsen (University of Ottawa), Dr. Jørgen Carling (Peace Research Institute of Oslo), Luzia Oca
González (University of Trás-os-Montes, Portugal), and Martina Giuffrè (La Sapienza University, Rome),
among others – particularly in Cape Verde.

The Roots of Cape Verde

The story is all but original: a small, independent island-nation develops a successful
economy based on political stability, mature democracy, sound financial management,
universal education and health care, and a strong sense of national identity. In the African
context, Cape Verde joins textbook cases such as the Seychelles and Mauritius. In spite
of limited reliable and comprehensive statistical information, it is usually accepted that
with a national population of 500,000 at least an equal number of first, second, and third
generation Cape Verdeans live overseas. By some accounts, this number may be closer to
one million, actually exceeding the population in the islands.1
It is generally agreed that the islands were uninhabited when first discovered by the
Portuguese around 1456. Some historians do concede to the presence of ancient signs of
human life, possibly from short, seasonal stays by groups from mainland Africa, but they
agree that there were no permanent settlers before Portuguese settlement.2
Cape Verdeans ironically refer to the creation of their own territory as a “joke of

1 There are large Cape Verdean communities in Boston, Lisbon, Rotterdam and Paris; significant numbers
in Rome, Madrid, São Tomé and Dakar; and smaller or residual communities in Luxembourg, Libreville,
Luanda, Bissau, Banjul, Toronto, Rio and Buenos Aires, as well as in other former Portuguese colonies and
territories.
2 J. Thornton, “Monumenta Missionaria Africana, edited by António Brásio” (book review), The Inter-
national Journal of African Historical Studies 20.1 (1987): 31.

53
God.”3 According to the legend, God created the world in six days, and while preparing
for the Sabbath He shook His hands to cleanse them of dry clay. This dirt fell in ten
clumps in the Atlantic Ocean, roughly 450 km west of the Cap Vert, in today’s Senegal.
God, tired of much sculpting and distributing of riches throughout the week, thought
nothing more of it. Surely, in such a vast world no one would bother inhabiting the dirt
from His hands. But God was wrong. The Portuguese sent their lower nobility, their
peasants, their merchants, their criminals, their priests and their amanuenses; they then
brought in slaves from the western coasts of Africa. Isolated and protected from the
enforcement of all but the starkest social norms most of the time, it was not long before
the islands’ new inhabitants were – as in other insular colonies – allowing sexuality to
dictate the future ethnic composition of the country.
By the early 1600s, the roots of what could be understood as the Cape Verdean
nation were set. The falsehood of the country’s name, with its promise of lush forests
and fertile soils when it in fact lacks natural resources, is a perennial reminder of its
quasi-abandonment by the colonizer for most of the last five centuries. The climate and
isolation help explain the “democratization of poverty,”4 and partially justify a perceived
racial homogeneity in a society in which everyone , “live[s] with the daily normality of
no one ever noticing the next man’s skin colour.”Almeida 5
Cape Verdeans realized early that migration was not only a necessity but a fate, from
16th century slaves and slave traders to 19th century deckhands in New England whalers
and today’s economic migrants. It became such a staple of Cape Verde’s daily life that one
will seldom find an islander who does not have a direct relative overseas.6 Jason DeParle7
dubbed the archipelago “the Galapagos of migrations,” a place where every phenomenon
of migration can be studied within a relatively small territory, while Góis8 speaks of a
Cape Verdean “transnation,” an inchoate nation-state that exists beyond its territorial
borders, echoing what Paasi conceptualized as the reconstruction of border
based on the social as well as the spatial.9 To those who stayed, severe draughts taught

3 The name Cape Verde refers to the closest point in the African mainland, translatable as “green cape.”.
Green, admittedly, is not a very common adjective to describe the country’s barren landscape.
4 In an archipelago routinely plagued by hunger, disease and piracy and where the ability to leave was limited
by economic conditions (and at times by law), it is unsurprising that many white settlers found themselves
struggling to make ends meet. On occasion, particularly during severe food crises, slaves were freed and left
to fend for themselves by slaveowners that could not cope.
5 G. Almeida, Cabo Verde: Viagem Pela História das Ilhas, (Mindelo: Ilhéu Editora, 2004), 20. My
translation. In the original: “a gente tem que ter estado noutras paragens do mundo e depois aqui entre nós,
convivendo com a diária normalidade de ninguém reparar na cor de pele do outro.”
6 J. Carling, “Return and reluctance in transnational ties under pressure,” Paper presented at the
workshop The dream and reality of coming home: The imaginations, policies, practices and experiences
of return migration, Institute of Anthropology, University of Copenhagen, May 8-10, 2002; J. Carling,
“The human dynamics of migrant transnationalism,” Ethnic and Racial Studies, No vol. (2008): 1-26.
7 J. DeParle, “Border crossings: In a world on the move, a tiny land strains to cope,” The New York
Times (New York), June 24, 2007 (online edition).
8 P. Góis, “Low Intensity Transnationalism: the Cape Verdean case,” Stichproben – Vienna Journal of
African Studies 8.5 (2005): 255-276.
9 A. Paasi, “The re-construction of borders: A combination of the social and the spatial,” Alexander

54
them how to plant with minimal irrigation, and recurrent famines taught survival by
chewing on little stones like goats. The only perennial, fixed reality for Cape Verdeans has
always been constant change, an adaptation and renegotiation of identity based on how
transient relationships are in a society where someone close is always coming or going.
“Capeverdeanness,” as identity goes, can hardly be construed as more “unique” than other
“unique” identities elsewhere. Yet, the historical and geographical particularities of the
land provide substantial evidence to argue otherwise.
Until recently, the country’s perception of its homogeneity was considerably static,
although this premise already encapsulates strong internal contradictions. While
geographically African, Cape Verdeans do not necessarily think of themselves as such.
The country is not located in Europe, although sections of its society identify closely
with European societies. While 97% of the population can be identified as black or
mixed race, patent (and perhaps convenient) race blindness means this is not always
acknowledged. Thus, the arrival of large numbers of migrants from mainland Africa
complicates the equation.
In 1991, sixteen years after independence, Cape Verde became the first sub-Saharan
African country to hold free, multi-party elections. Carlos Veiga, the new majority
prime minister from the MpD party,10 pushed through a series of democratizing bills.
He reformed the economy to enhance a business-friendly environment that welcomed
foreign investment and singled out tourism and education as sustainable sources of
development. Nearly two decades later the result of his neo-liberal agenda is a country
widely considered one of the most democratic in Africa with one of the continent’s most
stable economies.11
Although these political and economic changes have been beneficial, they have
also alienated the socialist drive of the early years of independence under the PAIGC/
PAICV.12 As in other liberal democracies, the gap between rich and poor is nowadays
more visible both in the streets and in the statistics, with worrying unemployment
levels reflecting the inability for large sectors of the population to benefit from growing
national affluence .13
Cape Verde is, nonetheless, well off by African standards.14 Consequently, in
addition to momentous economic restructuring, the country has to cope with an
increasing flow of economic migrants: Chinese entrepreneurs whose shops have

von Humboldt lecture, University of Nijmegen, The Netherlands (9 November), 2000.

10 Movimento para a Democracia (Movement for Democracy).
11 The Economist, Country Profile 2005: Cape Verde, London: The Economist Intelligence Unit,
2005.
12 Amílcar Cabral’s African Party for the Independence of Guinea-Bissau and Cape Verde (PAIGC), re-
placed after the 1980 breakaway by the African Party for the Independence of Cape Verde (PAICV).
13 B. Baker, “Cape Verde: The most democratic nation in Africa?” Journal of Modern African Studies
44.4 (2006): 507.
14 Cape Verde ranks 6th in the latest latest Human Development Report (UNDP, 2009). Its GDP per
capita of $3,800 per year is surpassed only by a handful of other African states. However, its unemployment
rate is currently 21%, while 30% of the population continue to live under the poverty line (CIA, 2009).

55
appeared in every town; and black West Africans in search of jobs in Sal, Boavista,
Praia and São Vicente, and sometimes in search of a platform to the Canary Islands, the
continental European Union or the United States. Baker15 admits the growing racism
and xenophobia aimed at mainland Africans as a notorious exception to Cape Verde’s
ethnic harmony. I argue that this latent racism could in fact have been embedded in the
country’s belief system before this change in the social fabric occurred. This antipathy is
mostly limited to black Africans, and has been so for a very long time.
It is this ongoing renegotiation of identities and material expectations that will be
the focus of this article’s main argument. The initial question from which I depart is: To
what extent do the current migratory cycles influence and challenge the Cape Verdean
identities that were already in place as a result of historical migrations? As in the past,
with the democratization of poverty that resulted in a partial levelling of social and
racial strata, the reactions against the other suggest that identity is not entirely dislocated
from economic struggles. I hope to demonstrate that, although Cape Verdean identity is
inherently bound by very weighty historical and geographical factors, it is not stable per
se, nor is it immune to reappraisal.
This article first examines selected ideas on identity and subsequently tests their
relevance and application to the Cape Verdean case, specifically with the intent of
understanding how these concepts connect to Cape Verde’s history, geography and
economic experiences. An overview of the democratic transition of the 1990s and
ensuing economic development follows, introducing the last elements that are necessary
for a discussion of the effects of Cape Verde’s newest migration patterns. This builds
up the case that none of the core elements of “capeverdeanness”16 are challenged by the
intake of migrants. However, the latest economic developments – driven in large part
by globalization – shift the historical and geographic parameters that traditionally had
primacy in discussions of national identity.

Location, Location, Location: From Hybridity to “Hybridism”

There is a fundamental problem with using the word “postcolonial” to describe
Cape Verde. Certainly, the country is post-colonial in the historical sense that it was
once a colony and has now gained independence. However, branding it as postcolonial
without qualification may obfuscate its uniqueness among former colonial territories:
no human being inhabited Cape Verde permanently before Europeans colonists (and
African slaves) arrived.
Cape Verde is part of the crescent-shaped Macaronesia mountain ridge that connects
the archipelago to the Canaries, Madeira and the Azores. As such, the islands are
certainly not in Europe, although they are geologically connected to places construed as
European. They are also not part of the African landmass, despite the incidental closeness
and genetic make-up of the population that makes them also “African.” What this

15 Baker 2006.
16 By this I understand, in this context, a “nuclear” perceived identity that most Cape Verdeans – regardless
of their island or country of origin – see as intrinsic to their being. This evidently clashes with the notion that
identity is, stritu sensu, fluid.

56
geographical feature neatly illustrates is the liminal position of Cape Verde, which has
important identity implications. Cape Verde’s geography, its genius locus, is an essential
feature to its identity and claims to uniqueness.
Although some of the early settlers were adventurers, most traveled to Cape Verde
due to extreme poverty in the homeland, political banishment, or criminal offenses.17
The forcefulness of this migration is a common trait of the slave experience. Once in the
islands, power relations quickly reverted to the simple premise of European supremacy.
This power relationship is seen by key postcolonial thinkers as fitting numerous dualities,
including the dichotomy between the colonizer and the colonized,18 domination and
resistance,19 master and slave,20 civilization and barbarism,21 and the rapist and the
raped.22 These oppositions entail the application of power on the colonizer’s part,
particularly through forms of violent subjugation that can only occur when the settler
actively engages in the act of forceful domination of body and mind.23 This is not to
say, however, that cultural and physical domination happens unilaterally, or without
resistance. Subjugation presupposes an acceptance of one’s fate that – at the level of the
individual slave – was often not true. To reduce colonization to domination without
resistance is misleading.
Cape Verde is a rare case study among former colonies in that its colonization did
not impose upon pre-existing social constructions. Instead, the imbalanced power
relations typical in other colonies were transferred only when both European settlers and
African slaves arrived. Although it is clear that the country today bears many trademarks
of a former colony, and although the reality of Cape Verde’s colonization can be best
explained within a postcolonial context (at least in an aesthetical and representational
sense), it is questionable if it should be called “postcolonial.”
The ambiguity arising from the domination binomials described is particularly
relevant for the analysis of the postcolonial character of Cape Verdean identity. Here we
find a myth that qualifies the islanders’ conception of themselves as not quite African and
yet part of a history that intrinsically links them to the past of African slaves. But here
things get confusing. The process of defining identities through uniqueness or difference
is true for identities everywhere.24 Cape Verde’s ocean-lined space, nonetheless, makes
for a particularly interesting case. A number of aspects later construed as fundamental

17 R. Lobban and Halter, M. Historical Dictionary of the Republic of Cape Verde, 2nd edition
(Metuchen and London: The Scarecrow Press, 1988).
18 A. Memmi, The Colonizer and the Colonized (Boston: Beacon Press, 1967).
19 E.W. Said, “Resistance, Opposition and Representation,” in Bill Ashcroft et al., The Post-Colonial
Studies Reader, 2nd ed. (New York and Oxford: Routledge, 2006), 95-98.
20 H. Bhabha, The Location of Culture, (London: Routledge, 2006), 37.
21 F. Fanon, The Wretched of the Earth (London: Penguin, 1990).
22 A. Loomba, Colonialism/Postcolonialism: The New Critical Idiom (London: Routledge, 1998),
69-71.
23 A. Mbembe, On the Postcolony (Berkeley: University of California Press, 2001), 25-26.
24 A. Arpadurai, “Disjunction and Difference,” in Bill Ashcroft et al., The Post-Colonial Studies Reader,
2nd ed. (New York and Oxford: Routledge, 2006), 469-476.

57
to Cape Verde’s “imagined community” are intimately linked to the Cape Verdeans’
existence and experience in these islands off the African coast, marked by specific
historical developments and by an aggressive climate. Violent colonization marked each
and every slave ever brought to Cape Verde. Their status upon landing was that of the
“colonized,” despite the fact that they had been removed from their homelands. The
majority of slaves were sold and taken elsewhere.25 For those bought locally, a second
colonization in a proxy location occurred. What might be termed “displaced colonial
violence” thus took place in a geographic location to which both colonizer and colonized
were alien.
In this context, the limited geography of the islands not only functioned as a
melting pot of identities from across Africa, but it also created a colony that was unique.
Specifically, it planted the seeds for an identity partly bound to its African heritage,
but that also developed its own hybrid identity over time. As an isolated yet connected
space, Cape Verde’s geographical position facilitated, tested and renegotiated a process
of hybridization that is perhaps less obvious in larger colonies, with native populations of
their own and less punishing climatologic conditions.
Early accounts report that slaves already born in Cape Verde, some of whom were
educated and multilingual, had a higher market value. Because of this, many became
cultural brokers between the new arrivals and their masters.26 Within a couple of
generations some descendants of these slaves were free men and women. There are two
key reasons for the relatively quick transition from slave to freedman. First, the difficulty
some slave owners had in providing for their slaves in a country that was already affected
by periodic droughts and subsequent food shortages aggravated by its isolation. And
Secondly, the development of forced and voluntary personal and intimate relations
between mostly male colonizers and the mostly female colonized27 often times resulted
in the children of born in these circumstances being granted benefits or eventually freed.
This is a point to which I will return later. Fastforwarding a hundred years, mixed race
people that can by now be called Cape Verdeans are found all over the river deltas of
the west coast of Africa, living with locals, acting as tangomaus and lançados,28 and as
middlemen to slavers from Cape Verde or elsewhere in Whydah, Mina, Gorée, Cacheu or
the Bissagos Islands.
In practical terms this meant that Cape Verdeans had themselves become colonizers
along the African coast. Back in the islands, newly arrived slaves often dealt only with

25 Primarily to Brazil, Jamaica, Cuba and other Caribbean islands, North America and Europe (Eltis et al.,
1999).
26 See C.R. Boxer, Race Relations in the Portuguese Colonial Empire, 1415-1825 (London: Oxford
University Press, 1963); C.R. Boxer, The Portuguese Seaborne Empire, 1415-1825 (London: Hutchin-
son, 1969).
27 Boxer 1969, 305-314.
28 Lançados, literally “thrown,” were mixed race middlemen in the African coast, whereas tangomaus, liter-
ally “tattooed,” who had a similar role, typically lived further inland with locals, and overtime blended into
their social structures. The term was fairly pejorative and often implied lack of allegiance and trustworthiness,
possibly due to their “excessive” identification with mainland Africans, be it culturally or genetically (Lobban
and Halter, 1988: 67, 108).

58
mixed-race freedmen, themselves descendants of slaves, who were now part of the
economic structure that had once victimized their ancestors. From the perspective of new
slaves, some of whom were captured and handled by Cape Verdean men only, they were
undoubtedly the colonizer.29 The ambivalence of the Cape Verdean position continued
well throughout the 20th century. The Estado Novo regime in Portugal developed an
indigenat policy30 that considered 95% of Cape Verdeans automatically assimilados, or
assimilated – that is to say, through mimicry, almost Portuguese, but not quite31 – and
sent many of them to other colonies as administrators and clerks.
This type of ambivalence is intimately connected to the notion of hybridity, as
Bhabha suggests.32 Cape Verde soon became a conduit for Portugal in the tropics, a space
where “anything goes,” as many early accounts testify. Boxer suggests that

[t]he frequent arrival of so many dissolute degredados [expelled convicts],

rogues, vagabonds and sturdy beggars, exiled from Portugal…inevitably
aggravated an already difficult social situation. The prevalence of slave-
prostitution and of other obstacles in the way of a sound family-life, such as the
double standard of chastity between husbands and wives, all make for a great
deal of casual miscegenation between white men and coloured women.33

This process of casual miscegenation, of course, hosted violence, oppression and the
subjugation of female slaves to the white masters. The duality of the colonial relationship
existed in Cape Verde as in other colonies, but was perhaps distorted by the fact that
colonizer and colonized were equally restricted to a limited territory. In 1627 Santiago
Island was described as a “dungheap” and its mostly mixed race inhabitants were referred
to as “vicious and immoral.”34 Fêo Rodrigues suggests that

the use of sexuality to explain the formation of Creole identities were not
fabrications of a distant metropole to be exported, consumed and contested in
the colonies. Rather, such tropes often found inspiration and co-authorship in
the social practices of the colonies. …Creole populations were in a privileged
position to co-author and to transform colonial ideologies, often subverting its
outcomes into a political project of their own.35

29 These middlemen were not always fair skinned, not always subjugated, and not always men: Bibiana Vaz,
for example, was a female rebel of Cape Verdean descent who ran a short-lived independent African “repub-
lic” based in Cacheu (Guinea), developing a powerful commercial slave trade ring that included several large
ships over many years.
30 Indigenismo.
31 The remaining 5% mostly lived in Santiago. These statistics contrasted greatly with those from other colo-
nies.
32 Bhabha 2006.
33 Boxer 1969, 314.
34 Lobban and Halter 1988, 14.
35 I.P.B. Fêo Rodrigues, “Islands o Sexuality: Theories and Histories of Creolization in Cape Verde,” The
International Journal of African Historical Studies 36.1 (2003, Special Issue: Colonial Encounters between

59
 This was the case in Cape Verde, where, over the centuries, isolation and
permissiveness blurred the fault lines between white and black, colonizer and colonized,
so that by the early 20th century Cape Verdean identity was fairly solidified, as is reflected
in the contemporary literature of the time.
Between the initial settlement and the 20th century, a diversity of identities were
established on different islands, all of them transitional, but all of them overlapping
with a set of characteristics that would soon be called “capeverdeanness.” For instance,
“[t]he island of Santiago became a kind of mainland. Other islands were only “as ilhas,”
whereas Santiago was Cape Verde, the centre of a narrow world.”36 The differentiation
between the islands remains to this day. Yet, Cape Verdeans are quick to assert that
these are minor differences, and that being Cape Verdean is in essence the same on
every island. An approximate conscious or unconscious definition of what constitutes
capeverdeanness can be summed up as thus: learning how to cope with departure and
perennial sôdade,37 with abandonment, and with the sea as a prison and a horizon of
possibilities; appreciating the heritage of famine, slavery and colonial violence and
indifference; acknowledging the comings and goings of those who make up the diaspora,
and consequent transient nature of local society; and, especially, experiencing the
recurring droughts and feeling gratitude for the rare rainfall. Notably, every aspect of
Cape Verdean identity formation strongly reflects the very geography from which it
emerged and in which it was shaped.
These elements were deliberately grandfathered into Cape Verdean collective
memory as illustrated by the example of the Claridade modernist movement of the
1930s.38 The writers, poets and musicians who codified capeverdeanness did little
more than draw from existing feelings and realities, bringing them into the realm
of national consciousness. These authors invoked an “imagined community” of
Cape Verde by representing it in novels, morna songs and increasingly provocative
articles that repeatedly focused on Cape Verdean themes like poverty, hunger and
subsequent migrations. Courageous writing about “inequality, injustice and legalized
preconceptions”39 eventually turned into physical escalation in 1934 as Nhô Ambrósio
led a revolt in Mindelo in response to the dire conditions of unemployment, extreme
poverty and hunger provoked by the port’s decline. This moment is reminiscent of the
frequent slave revolts of the early settlement.

Africa and Portugal): 84.

36 A. Llyal, Black and white make brown: an account of a journey in Portuguese Guinea and the Cape
Verde Islands – two of the least known territories in the world (London and Toronto: William Heine-
mann, 1938), 236.
37 From the untranslatable Portuguese “saudade,” meaning something close to feeling for someone’s ab-
sence.
38 The movement was roughly initiated by former seminar students from São Nicolau, then by Brava and
Fogo intellectuals. Claridade’s intellectual production – and the bohemian lifestyle often attached to it –
would reach its maximum exponent in the city of Mindelo, the archipelago’s largest port and also the location
of its high school at the time.
39 T. Virgínio, “Letras caboverdianas do pós-independência.” Luso-Brazilian Review 33.2 (Special
Issue: Luso-African Literatures, 1996): 85.

60
 Claridosos40 – as members of the Claridade movement were known – ambiguously
praised the “Portuguese values” of the islanders, while simultaneously asserting their
difference, and increasingly voicing a desire for political autonomy. The Claridade
movement assumes particular importance because it acts as a disseminator of an idea of
“capeverdeanness.” Despite high literacy rates, many texts, particularly poems in Creole,
circulated widely in the form of morna songs. Some of these are still part of the lore of
contemporary Cape Verdeans around the world.
It is worth noting that the language used in most of Claridade’s original cultural
productions was erudite Portuguese rather than Cape Verdean Creole. On a linguistic
level, however, Portuguese was unable to convey the diversity of Cape Verde’s realities.
Although Creole had taken hold centuries before as the hegemonic language in the
islands, its role remained purely private and unwritten, whereas Portuguese was reserved
for most public occasions.41 Creole’s colourfulness, musicality, wit and flexibility
are hardly translatable into the harsher, more rigid Portuguese linguistic structures.
Portuguese became a foreign language that most Cape Verdeans do speak, but that they
in turn colonized with borrowings from their mother tongue, Brazilian Portuguese and
other languages. The ambivalence of Creole, a characteristic shared with many aspects of
Cape Verdean identity, exposes hybridity at a linguistic level.
Cape Verde’s hybridity, then, is as much cultural and social as it is genetic, intimately
linked and produced partly as a result of the archipelago’s geographical location and
partly as a result of its past. This third space encompasses the post-colonial experience of
Cape Verde and testifies to an ideology of difference, an “-ism” that is characterized by
the insistence on the islands’ crossover role as the cultural and genetic bridge between
Europe and Africa, which both resists and asserts multiple understandings of identity.
This, I suggest, might be termed hybridism, or an ideology of hybridity evident in what
has been discussed so far, and easily observed in popular attitudes to this day.
In light of this, it seems foolish to presume that the islands of Cape Verde are either
a part of Europe or Africa. Instead, it seems more fitting to argue that Cape Verde should
be considered, as Baker states authoritatively, “neither and both.”42 Rego speaks of a
people “of Africa, but not African, just as it is also of Portugal, but hardly Portuguese
[emphasis added].”43 Baltasar Lopes, one of the earliest claridosos, argues that “those
who held dichotomous theories based on a priori conceptions of Africa and Europe as
mutually exclusive were destined to misunderstand societies like Cape Verde.”44
The violent nature of the colonizer/colonized dichotomy earmarked by postcolonial
studies as pivotal to identity formation in the post-colony is present in Cape Verde. Its

40 “The Enlightened.”
41 M. Veiga, Diskrison Strutural di Lingua KabuVerdeanu (Cidade da Praia: Institutu KabuVerdeanu di
Livru, 1982), 16-17.
42 Baker 2006, 506.
43 M. Rego, “Cape Verdean Tongues: Understanding Competing Discourses of ‘Nation’ at Home and
Abroad,” Conference on Cape Verdean Migration and Diaspora, Centro de Estudos de Antropologia
Socia (Lisbon, 6-8 February 2005), 2.
44 Quoted in Fêo Rodrigues 2003, 88.

61
representation through mimicry as proposed by Homi Bhabha fits the postcolonial
model, resulting in an inter-island national identity that Benedict Anderson would surely
call an imagined community. However, the liminality and dislocated colonization that
characterized Cape Verdean history prompts some caution before definitively labelling it
as simply “postcolonial.”

Challenges to the Self-Conception of an Emerging “Middle-Income Nation”

In The Fortunate Isles,45 Basil Davidson urges for a degree of reservation in
understanding the first attempts at literary, if not always political, autonomy of Cape
Verde in the 1930s. Davidson notes that the intellectual movement seems to “appear
to have believed in no kind of ‘African alternative’ to the paternity of Portugal.”46
Unexpectedly, the image of early claridosos today is one of unreserved support for Cape
Verdean uniqueness and the need for independence. I would argue that this in itself
is a revisionist perspective of history that has made its way into the representations
of national mythology. The claridosos have thus become the “founding fathers” of
the nation, despite the fact that many of them seemed more interested in a kind of
independence that did not sever ties with Portugal.
In the independence struggles of the 1960s and 1970s, Cape Verde gained
“new fathers.” Davidson gives an account of the very real possibility that, after a
long ideological union with Guinea-Bissau, Cape Verde would remain an adjacent
autonomous region of Portugal, in the image of Madeira or the Azores.47 The political
maneuvering conducted behind the scenes eventually bestowed Cape Verde with its
full political independence, although the country willingly remained united with
Guinea-Bissau until 1981. In Cape Verde, where communism was not deeply rooted,
many suspected not only that the party had Soviet aspirations, but also that it did not
serve the people’s interests to remain associated with Guinea, “a ‘savage land’ better
kept at arm’s length.”48 According to Patrick Chabal, “socialism did not sit easily with
a people long accustomed to roam the world, seek employment abroad, freely use their
earnings and invest their savings.”49 Amílcar Cabral, the Cape Verdean leader of the
Guinean resistance, had managed to draw the world’s attention to the independence
struggle, particularly after his inspired speech to the fourth Commission of the United
Nations General Assembly on October 16, 1972, on “Questions of Territories Under
Portuguese Administration.” He also managed to lead the islands into a political union
with Guinea. It is no surprise, then, that most modern Cape Verdean politicians see
themselves as heirs of the Cabralian tradition of socialist government; that is, from the
people and for the people. The 1980 military coup in Guinea that ousted Luís Cabral,
Amílcar’s half-brother, ushered in the end of union, but did not prevent the emergence

45 B. Davidson, The Fortunate Isles – A Study in African Tradition (New Jersey: African World Press,
1989).
46 Davidson 1989, 51.
47 Ibid.,109-126.
48 Ibid., 112.
49 Quoted in Baker 2006, 494.

62
of a political class imbued with the prestige of being “former combatants” with the
“Guinean brothers.” This identification with mainland Africans does not necessarily
meet the expectations of many islanders. Cape Verdeans involved in anti-colonial
struggles on the mainland, where they were seen as “almost white,” were themselves
the object of suspicion, with locals fearing they would take over the space left empty by
the colonizers.50 Once again, the insular factor of differentiation becomes evident and
troublesome.
In 1975 Pedro Pires, a former military commander of socialist extraction, assumed
the post of prime minister – an office he held for sixteen years. In the interim, the
Cape Verdean government established fairly stable structures that reduced corruption.
Universal food security and education programs, including widespread adult education,
re-forestation and water retention projects were initiated during this period. Well-
managed poverty reduction schemes attracted donors from Europe, Cuba and the
United States, among others, in what was often noted as an exemplary use of direct
foreign aid resources.51 By the mid-1980s, the African Party for the Independence of
Cape Verde (PAICV) had started to liberalize the economy and ease its political control
of the country, in what Baker calls “in practice…a more pragmatic and social democratic”
government “than its socialist ideological claims might have suggested.”52 Gradually,
and despite its interest in development, PAICV moved toward Claude Aké’s argument
on the democratization of disempowerment, a shift away from mainstream conceptions
of development for Africa.53 This much is suggested by the perseverance of an ex-
revolutionary elite clinging to power, by the trivializing of democracy, and the political
alienation of the population, particularly those outside Praia. Cahen describes what he
saw in 1989 as a “miscegenated government and a black people.”54
In fairness, PAICV was not a totalitarian party. The 1990 pacto de regime (regime
pact) and consequent constitutional amendment that paved the way for a multi-party
republic partially emerged from within the party itself. In 1991, despite Pedro Pires’
claims that Cape Verdeans were not ready for democracy, the newly formed MpD forced
an election that resulted in Carlos Veiga’s appointment to the office of prime minister.
The MpD went on to win all the elections until 2001. Meyns explains that

[d]rawing on intellectual traditions of debate within their society and aware of

the vulnerability of their country, they have developed a nonviolent political
culture that has shaped the process of democratic transition.55

50 Fêo Rodrigues 2003, 94.

51 P. Meyns, “Cape Verde: An African Exception,” Journal of Democracy 13.3 (2002): 157.
52 Baker 2006, 494.
53 C. Aké, “The democratisation of disempowerment in Africa,” in J. Hipper, ed., The Democratisation of
Disempowerment (London: Pluto Press, 1995), 70-89.
54 M. Cahen, “Review: La fortune changeante des Iles du Cap-Vert,” The International Journal of African
Historical Studies 25.1 (1992):135.
55 Meyns 2002, 164.

63
 After one decade of full democracy, characterized by fast-paced neo-liberal reforms,
Cape Verde was developing steadily and coherently. However, the fairly well-educated
political body still had strong aspirations for autonomy and choice, aspirations which
had arguably existed over the last five centuries. From the mid-90s onwards, Cape
Verde shared the lead of African democracy charts with São Tomé, South Africa and
Mauritius,56 perhaps as a result of all these years of political dissatisfaction and aspirations
for greater autonomy and choice.
The close relationship between economic development and democracy is a
compelling aspect of Cape Verde’s recent history. A Cape Verdean diplomat affirms that
the “democratic system is now in the minds of Cape Verdeans; it was long their ideal.”57
Baker adds that they “support that political system, even if not unconditionally.”58 This,
he says,

is more than an electoral democracy. …It is a serious democracy and for that
reason alone a rarity in Africa. Its roots go deeper than the constitution, and
shape political and social practice. And among the elite democracy is not simply
a device to attract donors, but appears to be a deep-rooted commitment.59

In 2001 and 2006, the legislative and presidential elections proved that a peaceful
democratic transition had, by then, become firmly rooted. Baker describes a clean
process, although he fails to identify possible flaws. One of these possible imperfections
include the fact that media diversity is limited, with all major newspapers heavily
indebted to one party or the other. Allegations of electoral fraud in 2001 and 2006
suggest that the 17-year old Cape Verdean democracy has not yet fully matured. There
are also signs of an increasing impatience toward the more conservative diaspora. On
both occasions, the MpD leader Carlos Veiga won the elections at home, only to be
sidestepped by the over-represented and overwhelmingly pro-PAICV diaspora vote,
more faithful to the ideal of a PAICV-led Cape Verde, and largely unacquainted with
alternative political projects in the islands.
The peaceful development of a democratic regime has so far been eased by a
growing service-based economy. However, development has been mostly felt in the
more urbanized islands of Sal, Santiago and São Vicente. The International Fund for
Agricultural Development identified rural poverty as a source of potential problems
in the future.60 Although the standard of living has dramatically improved since 1991,
urban and rural poverty are now more visible than before, perhaps following the global
trend toward neo-liberalism. Chinese manufactures have inundated the streets of most
cities and towns, making consumer goods more accessible to underprivileged people, but

56 Baker 2006, 494.

57 Quoted in Baker 2006, 508.
58 Ibid., 508.
59 Ibid., 509.
60 International Fund for Agricultural Development, “Oeuvrer pour que les ruraux pauvres se libèrent de la
pauvreté au Cap-Vert,” IFAD, http://www.ifad.org.

64
also seriously damaging the incipient Cape Verdean industrial sector.61
Tourism, on the other hand, brings an increasing number of visitors every year.
Multinational travel companies control much of the tourist flow, which means the
amount of profits re-invested in the country is limited. Furthermore, visitors put an
enormous stress on the available transport and telecommunications infrastructures
fundamental to daily life in the archipelago, and greatly contribute to rising inflation
levels and swelling property values. Additionally, the World Bank now ranks Cape Verde
as a middle-income country. This apparently positive step has actually meant that many
donors have withdrawn from Cape Verde because they prefer to work with and in poorer
countries. The Cape Verdean Foreign Office noted with irony that “[m]ore than a reward
for good behaviour, what is called for here is that a country not be penalized for its
good performance in the area of development.”62 The pressures of decreasing foreign aid
and remittances worsen the conditions imposed by neo-liberal reforms in a vulnerable
population.63

It’s an African Island-Nation’s Economic Aspirations, Stupid!

In a geographically isolated territory so heavily dependent on foreign aid and
its network of transnational citizens,64 small economic changes can easily have great
significance. The closing of factories or rising inflation not met by salary top-ups are two
examples. Baker shows concern over the “danger that a permanent underclass may be
forming, and that the benefits of a nation homogenous in race may be lost to a nation
divided by class.”65 He continues on this worrying note:

One economic expert…noted that: “the economic expectations of the people

are far beyond our economic power.” Their widespread travel and their contacts
with emigrants makes them well aware of the standard of living of those in the
West. Their educational levels have given them high expectations in terms of
employment. Consequently, the government is under considerable pressure to
provide or face the wrath of its frustrated body of citizens.66

After sixteen years of socialist government, the centre-right MpD has often accused
its predecessor of fostering a “foreign aid syndrome” in Cape Verde. The MpD has
attempted to correct this syndrome by implementing market-based policies, privatizing
many of the national companies and welcoming foreign investment. However, these
strategies seemed unlikely to answer to the limitations of an island-nation with no

61 C. Alden et al., eds., China Returns to Africa: A Rising Power and a Continent Embrace (London: Hurst
& Company, in press); H.O. Haugen and J. Carling, “On the edge of the Chinese diaspora: The surge of
baihuo business in an African city,” Ethnic and Racial Studies 28.4 (2005): 639-662.
62 Baker 2006, 508.
63 Economist 2005.
64 Ibid., 14.
65 Baker 2006, 507.
66 Ibid.

65
natural resources other than access to a large Atlantic exclusive economic zone, which
it lacks the means to patrol. The reduced size of the economy and the economy’s high
dependency on fuel imports and expensive transportation of people and goods results in
a very high cost of living, and a lack of commercial competitiveness. In response to social
decline, voters elected the PAICV in 2001, slowing down some of the neo-liberal reforms
and restoring the balance between economic and social development.67 This, in turn, gave
the economy more time to adjust to the new challenges.
Despite these developments and in contrast to the neighbouring Economic
Community of West African States (ECOWAS) on continental Africa, Cape Verde
continues to maintain a privileged position. Its tourism industry, for example, is
attracting more foreign investments every year, particularly in transport and hospitality
infrastructures.68 This encouraging growth has awakened the old debate of association
with Europe, which has now materialized into a privileged partnership with the EU and
a close relationship with NATO.
One consequence of this recent development is the agreement of alternate assistance
in patrolling the territorial waters by the Portuguese and Spanish navies. This happens
in the context of fighting illegal immigration to the EU, since Cape Verdean waters have
become a major thoroughfare for boat people attempting to reach the Canary Islands
and continental Europe from mainland Africa. A second consequence is the increasing
distancing from ECOWAS, notably during the MpD governments. On more than one
occasion, the national debates considered opting out of the ECOWAS open borders
agreement, which contributed to the maintenance of heavy limits to Cape Verdeans
travelling to the EU. The ease with which Cape Verdeans moved across borders up to
the late 20th century has been drastically changed by strict immigration policies in most
of their countries of destination, particularly the US and the EU, especially following
9/11.69
Meanwhile, the flow of ECOWAS migrants – both documented and undocumented
– has increased and so has their visibility in Cape Verde’s urban landscape. In places
where Cape Verdeans have a darker complexion, such as Santiago, migrants for a while
went unnoticed, except in their use of African languages.70 Things have changed. In
urbanized islands such as Santiago, São Vicente and Sal (the latter three with lighter-
skinned populations) they now represent a visible minority that causes some discomfort.
The national press has picked up on the rising tension, and routinely reports on crimes
committed by African migrants, or on shipwrecked boats attempting to reach the Cape
Verdean coast, vessels overloaded with cadavers found adrift in territorial waters and
the odd abandoned yacht in a desert beach, hinting at the possibility that some Africans

67 Meyns 2002, 164.

68 Economist 2005, 22.
69 Haugen and Carling 2005.
70 There have been reports of the Public Order Police singling out and harassing citizens of Nigeria. In March
2005, after a Guinean immigrant was murdered, hundreds of West Africans marched in the streets of the capi-
tal, attempting to invade the Government Palace. There is still some potential for racially motivated violence
(Baker 2006, 503).

66
are arriving illegally. With immigration being a growing concern for Cape Verdeans,
television reports of the “invasion” of African migrants in the Canaries, Malta or Italy go
a long way to reinforce a mild sense of panic.
Although the “race card” is not often openly used against these migrants, there
are indicators to suggest identity politics plays a role in explaining discrimination.71
With growing concerns about economic hardship and the global economic crisis
slowly impacting local economies, the obvious vulnerability and limited nature of Cape
Verde’s resources attract extra attention to migration issues. The recent focus on ethnic
labelling, at least on the surface, finds no real parallel in Cape Verdean history. It is
possible that this had been latent within Cape Verdean society all along, as an identity
within an identity: “We” are Cape Verdeans because “we” are fair-skinned. It can be
argued that the badíu vs. sampadjudo equation exemplifies this, opposing Santiago’s
dark-skinned population to the rest of the country’s lighter complexion. Although no
one questions Santiago’s “capeverdeanness,” its difference is often stated, even when skin
color is not mentioned. The fact that usually only people from Santiago are called badiú
probably owes as much to the historic situation of the island as the nucleus of Cape
Verde as it does to the fact that it is its only “black” island. Whilst slow miscegenation
happened throughout the centuries elsewhere, Santiago was a deposit of slaves well into
the eighteenth century. Thus, more than spite for its cultural, economic, and political
macrocephaly within the Cape Verdean context, this differentiation could denote an
idiosyncrasy in Cape Verde’s alleged color blindness. The imagined community of Cape
Verde may be able to override some internal difference, but may be unable to extend
tolerance to the racial sphere.
Further, the limited resistance to recent Chinese migrants and other new residents
from Europe might be indicative of the extent to which race is playing a real role. These
are groups with either a higher educational level or investment potential. In the larger
urban areas, Chinese migrants have set up businesses, creating a very distinct merchant
class and challenging established economic networks. Europeans are purchasing property
in most islands and opening small and large businesses. The fact that the economic
clout of both groups competes with that of traditional elites seems to be of little
importance. Cape Verdeans have grown familiar with endogenous and exogenous shifting
circumstances. New settlers integrate what Arpadurai called ethnoscape, “a landscape
of persons who constitute the shifting world in which we live: tourists, immigrants,
refugees, exiles [and] guest workers.”72

Final Notes: Could it be the West Within?

While it is still true that Cape Verdean identity is rooted in the islands’ geography,

71 I heard several people in Mindelo refer that “those mandjakos” should go back to their countries, an all-
encompassing expression in clear reference to the West African ethnic group (although it is unlikely that more
than a few migrants belong to this group). In Mindelo’s Carnival, one of the most popular costumes is the
“mandjako.” Young men with their semi-naked bodies painted with black shoe wax brandish makeshift spears,
jump and grunt around the streets, scaring children, in a clear construction as ‘the African’ as savage.
72 Arpadurai 2006, 469.

67
history and diasporic dynamics, there are new economic factors at play that propose a
shift toward something else, perhaps even the racialization of specific groups. Under the
pretence of a threat to “capeverdeanness,” African migrants are being singled out in this
process, in what seems to be identity politics operating at its most perverse. While in the
past they were accepted in limited numbers, they are now pointed out as scapegoats for
some of the economic problems Cape Verde is facing, and perhaps even of Cape Verde’s
problematic sense of self. If some of the elements of “capeverdeanness” listed earlier are
rehearsed again, it is difficult to see how they could in any way challenge this process.
The antagonistic reaction toward African migrants is not exclusive to Cape Verde, but
is exclusive within Cape Verde. They are construed as a combination of disenfranchised,
low-skilled, low-paid workers that dispute the few available jobs and contribute little
if anything to the economy, particularly in a time of crisis. Ironically, they are also
the only newcomers whose complexion suggests a sense of connection to the place
capeverdeanness has negated for the better part of the country’s history: Africa.
Naturally, every identity depends on the assertion of its own difference to others. In
Cape Verde, identity politics appears to have translated into an ideology of difference. It
could be argued that the colonizer is imbued in the Cape Verdean identity, a condition
postcolonial theory explains as the West “inside” the (former) colony. Renewed
economic challenges prompt the question of what will happen to the newest members of
the national ethnoscape. Will they eventually blend in with the Cape Verdean fabric, or
are they the precursors to an emerging identitarian alternative? This factor, if anything,
makes the case study more compelling for further study. It is clear that identity is
inherently transitional, constantly negotiated, fundamentally construed, and composed
by a multiplicity of concomitant and conflicting identities. In Cape Verde, as the country
grows, so might challenges to racial harmony and economic equity.

Pedro wrote this piece for his undergraduate dissertation in 2008 at the University of Wales
Aberystwyth, where he received a BScEcon in Interational Politics and the Third World.
Currently, he is attending York University in Toronto, Canada, where he is pursuing a MA
in Development Studies and continues to reserach the same topic.

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71
72
Young People in the Field

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74
 Nkosi sikelel’ iAfrika
Sarah Lynn-Andrews Losinski
Michigan State University
Health Studies and Gender History

I have to admit, I had very distinct expectations of Africa. Expansive sunsets over
an untamed savannah landscape, with lions and tribal people roaming around in animal
skins and ebony masks, that occasional elephant, maybe some poachers with white hats
and handlebar mustaches, wild drumming and dancing and beautifully patterned native
garments. And after enduring thirty-six hours of air travel, I was not disappointed. It
was well past midnight when I took my first step off the plane and onto African soil. It
smelled so different from home, yet oddly what one would expect when traveling to this
mysterious continent: a lingering scent in the air almost identical to the “Safari” section
of a zoo. A dense humidity enveloped me and immediately transformed the stray blond
wisps of hair around my face into tight curls. Ah. Africa.
There are thirteen us of in total; thirteen American college students who packed
their bags for a semester and headed into the unknown with great expectations. All of
us were quiet as we drove through the city that first night on the way to our flats. The
windows were down in the huge passenger van and the warm air was so novel after
leaving the snow drifts of midwinter back home. As we passed through the heart of
Durban, the city that was to become our home for the next five months, the standard
noise of traffic and people sounded just like the cacophony you would experience in
downtown Chicago. The smell of the air transformed from stereotypical Africa to
the familiarity of a traditional city. As we pulled up to our apartment building, the
neighborhood looked just like classic suburbia in the States, with quaint housing
complexes and trees shading the seemingly quiet street. There was an increased amount
of security and barbed wire that I had expected to be found in a Durban neighborhood,
but I had felt disappointed that night; disappointed at how normal and, well, boring the
entire scene seemed to be. I came to Africa to experience something different, something
exciting…perhaps something almost primal.
My roommate has been working a couple days each week this semester in an
elementary school here. One day a few months ago, we were sitting outside on campus
after she had just gotten back from the school. Over only a couple of months, she had
learned quite a bit about the problems facing local schools. According to statistics given
to her by the principle, less than one percent will graduate high school and a typical
class will have fifty students in one room, all speaking different languages than that of
the provided educational material or even the teacher. Particularly distressing, though,
she was told that out of the three hundred elementary-aged girls, nearly all of them have
already been raped multiple times and are now likely HIV-positive.
A South African friend that we met the first week of school was enjoying lunch
along with us. He nodded his head and agreed with my roommate’s musings. “Yeah, my
mother’s a teacher and she can tell you too. It’s the same story in every school across the

75
country.”
I passionately shoved my fork into my curry rice. “You’re kidding me!” I gasped.
“They should alert the authorities! Some kind of action needs to be taken!”
He looked at me kindly like I was a small, ignorant child and sadly chuckled. “The
authorities? Corrupt. The police, the ones that are supposed to serve justice and ensure
safety? The worst of criminals. The government, the ones that are supposed to protect
and guide us? Self-serving and immoral.”
“There has to be something that can be done, someone who can help.” And then, half
to myself, I questioned, “Someone who wants to help?”
He then gave me a look that hinted a little less patience with my Western ignorance
than a few minutes previous. “TIA sissy.” This Is Africa.
So much has changed since my first ridiculous notions of South Africa. Back home,
we tend to call challenges in our lives “learning experiences.” I have a hard time finding
that introspection right now while I am still here, but maybe in the future I’ll look back
and agree; that this semester was indeed a great “learning experience” while for everyone
else in this country, it was simply another five months of “real life.” If I make it home
again…
The streets become deserted after dark here. And silent. At 5:00 every night,
something eerie settles over the entire city. You can’t leave the house to walk down the
street under any circumstances. Crime in this country is out of control. Some say it
has gotten worse since the end of apartheid…others say the crime has always been this
awful but that now it is also affecting the white community, thus the sudden publicized
increase in concern. To make matters worse, the South African infrastructure is not
constructed to fulfill the current energy demand, and so initiates rolling blackouts that
cut off all power for varying blocks of time. Much of the security set up in the city, such
as electric gates and doors, then becomes disengaged during the blackouts...even street
lamps and traffic lights extinguish.
One day, my soccer coach offered to give me and a friend a lift home from practice.
We gave him directions along the way, but he surprised us when he came to a complete
stop about six blocks from our apartment. We were even more shocked when he then
refused to drive us through the neighborhood because of its reputation for hijackings.
He spoke a truth; our “quaint, quiet little neighborhood” was not as safe as my first
impressions assumed it to be. But I was irate; I understood that he was concerned for his
personal well-being, but I was angry that he was then willing to put our personal safety at
an even greater risk. Without thanking him, we got out of the car and slammed the door.
He nervously gunned the car in the opposite direction. Putting on a false air of courage,
we walked quickly all the way back to our flat, gripping our bottles of pepper spray and
recently-purchased tasers. We were lucky.
And luck is all there really ever is to survival here. Crimes in Durban are random and
lethal. They stem out of anger more than want or need for valuables: violence is almost
always involved as an outlet for this hatred. This overarching hatred can almost be tasted
in the air here; a vile hatred between blacks and whites, of course, but even more so
between men and women, between young and old, white Afrikaaners and white English,

76
Xhosa people and Shona people, Christian followers and Traditional followers. I have to
wonder, who actually benefits from all this animosity?
Others we know were not so lucky. Every day, it is something. Bheka’s car was
blown up…someone broke into our backyard last night…Jackie is in the hospital again
from severe beatings…Mbali’s mother was just shot to death in one of the nearby shanty
towns…two new babies came into the orphanage today; both have genital herpes…
Maddy was almost kidnapped on her walk home today; luckily there was another
woman around to warn her…did you hear that woman screaming outside our window
last night?…Phil has been mugged for the third time this semester…apparently Nathan’s
friend Sipho was just beat to hell by the cops…
Every day, we come home and debrief amongst ourselves, an attempt at self-therapy,
though I’m not really so sure of its effectiveness. Every day, I can physically feel the
incredible toll that this stress takes on my mind and body. I live in paranoia and constant
fear. And more distressing than the fear is my acceptance of it.
On Thursdays, I volunteer for the day at an HIV/AIDS hospice clinic over in
Pinetown, a poor suburb of the city. The center holds over a hundred men and women
with advanced AIDS. Some come to the clinic for hope and help, some come to die. The
entire building has a desperate, starched feeling to it and it smells like a horrible mixture
of decay and powerful hand sanitizer. Like all non-profits in South Africa, the Dream
Centre is chronically understaffed, under-funded and over-crowded.
At random, I always just pick a room, take a deep breath, and enter. “Sawubona!”
Hello.
The woman slowly turned away from the window and smiled at me. “Sawubona
ngani?” Hello, how are you?
“Ngisaphila ngiyabonga. NguDrew.” Fine, thank you. My name is Drew.
“NguMzwandile.”
I grabbed a chair and pulled up to Mzwandile’s bed, which was a downgraded
version of a standard summer-camp cot. We always have to switch over to English, as
my repertoire of isiZulu comes to an end fairly quickly. As I expected, her English was
only slightly better than my Zulu. I asked her the translation of her name. The family has
increased. This is the attitude I have often enough seen Africa bestow on a beautiful new
child brought into the world. One more mouth to feed.
But the family had now decreased. Mzwandile has been disowned by her family for
a disease that another cruelly bestowed on her. Her story was no different than the other
woman I had spent that past few months visiting. Young, four children, no education,
no job, and always the intense hatred for the male sex. Out of respect, I asked her if
she was married, knowing very well the answer I would receive, as I had from so many
others before. Lobola. Of course not. Lobola is the age-old Zulu tradition that one has
to pay for their wife with the gift of eleven cows. Essentially, no one can afford eleven
cows and, thus, no one gets married. And then conversation always ceases because, really,
where can we go from here? Her leisure interests? Nonexistent. Stories of her life and her
family? She doesn’t want to bring up the pain that conversation would evoke and I can’t
bring myself to ask her to. My life? My experiences? My hopes and dreams? Unrelatable,

77
unrealistic and irrelevant to the life that she lives. And so we sat there; just sat there,
holding hands, staring out the window in silence. Sometimes, in other situations, I would
read to patients or paint their nails or brush their hair but, most often, I just sat there
with them.
An hour passed. The reverie was then broken by a new occupant entering the
humid, semi-sterile room. The woman was beautiful…or, rather, had the shadows of a
once gorgeous face. Obviously in her young twenties with charcoal skin and high cheek
bones, she only weighed about 70 pounds. She was carried in by a nurse to her bed and
continued coughing from the tuberculosis that inevitably spreads to everyone in the
center. And just when I began to worry if her tired body could even muster the energy to
take another breath, the woman started violently vomiting up blood.
The time for me to return back to my flat always eventually comes. Just before I
walked out of the room, I turned back to leave Mzwandile with a smile and she half
returned one. Then with incredible labor, she lifted her hand and hoarsely mumbled, “Ah
sissy, nkosi sikelel’ iAfrika.”
I looked down at the tiled floor as a complete sadness washed over my entire being. I
lifted my eyes to meet hers once again and replied, “Yebo” half-heartedly. God save Africa.
If only it were that easy.
In all this time I find I now have since we are forced to spend our evenings indoors,
I often simply stare out my window. Sometimes I think of nothing at all, allowing my
thoughts to rest and my mind to relax. If my thoughts were of my own choosing, this
emptiness is what I think I would prefer; it’s so much easier. But as it is, my mind usually
races to debrief the day, compartmentalize, explain, organize, rationalize it. Sometime
last week, I was back at my window, listening to music leaking from my computer. I
couldn’t help but note the irony as John Lennon’s “Imagine All the People” started to
play. Nevertheless, I allowed the mellow lyrics to relax me while I gazed into the thick
night. But I did not actually see the darkness, the sparse garden below my window, the
castle of barbed wire and imposing security that surrounded our flat. My mind was
instead traveling back home, enjoying a quiet evening meal with my family. It was all I
could do to blot out the events of the past couple days: the mugging I witnessed early
that afternoon, the recent drugging of a friend, the political tension of Zimbabwe ready
to spill over into northern South Africa.
Suddenly, a series of sharp shots interrupted my thoughts and broke my trance.
The shots had seemed closer than they usually did, but this was the life that I was slowly
becoming callused to and I quickly returned to my daydreaming. No more than ten
minutes later, when the incident was all but erased completely from my recollection,
my housemate Maddy walked into the room sullenly. She relayed that the shooting had
been right outside our flat’s entry gate. On the sidewalk in front of our apartment, the
man lay immobile, shot six times. Reportedly, he had attempted to hijack our neighbor’s
car and the security guard caught him. As blood ran freely into the gutters of our street,
people passing by simply turned their heads and continued on their way. The body was
eventually hauled away by a couple of beat cops, no questions or motives asked. They say
that the African earth is tainted from of all the blood shed over the past two hundred

78
years or so. The soil here is actually red in color; it’s the strangest thing…
I am supposed to be traveling in Botswana right now, but South Africa is in a recent
uproar. Xenophobic attacks have spread across the country, already forcing 25,000
people to flee. The papers blame the violence on high unemployment rates and citizens
becoming territorial about job opportunities going to migrants, but rumors around here
hint that the fighting was actually instigated directly by the government as a conspiracy
to take some heat away from their recent failings. I am a bit disappointed in the timing
of the uprising, especially since we’ve already purchased the tickets, but the bus would’ve
taken us into the heart of Johannesburg, where forty-three people have already been
tortured and murdered. It is probably a good thing we didn’t go, as the US Embassy
just today put the country on crisis alert. I was worried about Ashe, a friend I had made
through school; she fled here from Zimbabwe with her family a number of years ago to
escape the political violence of South Africa’s northern neighbor. I finally got a hold of
her a couple of hours ago and she reported that she and her family were all safe, much to
my relief, but that her best friend had been murdered. Forced to drink diesel fuel. African
against African. But what is the human motivation behind this? How can one do such a
thing? Why would one do such a thing?
I guess that is what I’ll fall asleep thinking about tonight, but here is the honest
truth: it doesn’t bother me as much anymore. I still enjoy a good, fresh mango from
the woman down the street. I still laugh at a bawdy joke that my housemate entertains
us with. I still scowl at the new zit that is taking over my chin. And this absence of
sentiment bothers me…sort of. But not even that fear is felt with much intensity; feelings
have been numbed as emotional survival has kicked in.
I strive each and every day of my life so that I may continuously evolve to be a
“better” person, but I can feel myself slipping in another direction; not towards vice, but
rather into a third direction, a trance of reality. I am now caught up in the realities of the
larger world. I can no longer choose ignorance, though along with this decision comes
a certain amount of misery. From my experiences these past few of months, I have lost
unquestionable trust for people. I have lost unwavering faith. I have lost any sense of pity.
Whether these personal transformations are a positive or negative change in one’s self, I
do not know. I’ve always wanted to believe that people are inherently good, but I’ve come
to realize that people are just people; they are too complex to be labeled with terms as
simple as “good” and “evil.”
But amongst it all, I still observe and feel a sense of hope for this country and
continent, and ultimately, the world; hope for the present and hope for the future. The
human race has survived and will continue to survive. As human beings, we are strong
and it is our nature to survive. But there has to be more to life than mere survival, like
purpose and compassion and happiness. How can all this violence really be conducive to
individual survival? And if it is not, when will Africa learn so? Is there hope for humanity
in a region like this? Can we find it in one another? Or can God really be the only one to
save this place?
iAfrika.

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80
 A Different Dimension of Development
Holding the Mirror up to Oneself
Gracie Vivian
University of Western Australia
MBBS, BA in Philosophy

When I was eleven, I drew a picture of what I wanted to be when I grew up. I dressed
myself in a white coat, placed a stethoscope around my neck, and printed “traveling
doctor” underneath the image. I was going to help the poor and the needy, like those
African kids I had seen on TV with swollen bellies and crusted eyes. My purpose was
admirable and it filled me with exuberance and pride.
This attitude went unchanged for seven years until I traveled to Calcutta and Nepal
as a medical student volunteer. The experience uprooted much I had previously accepted
as truth and marked the beginning of an evolving shift in the way I view the world and
myself in it.
Whilst navigating the grimy back streets of Calcutta to one of Mother Teresa’s
orphanages, I came across a man sitting on the roadside with his leg outstretched before
him, a soiled bandage over his foot. He beckoned me over and removed the bandage,
revealing the grossly swollen remnants of a foot covered in maggots. I gasped in shock
and revulsion and rushed to the orphanage to inform a nun. She told me that he could
not be accepted there and then hurried away. I sat on the step seething with anger and
indignation. These nuns who preach compassion and social service are such hypocrites,
shifting the responsibility of a dying man to someone else! Why won’t she help me help him?
On her return she told me to take the man to another one of the homes and slipped
something in my hand with a gentle smile. I drew a small crowd as I ushered the man into
a taxi with a grave look on my face. Once settled in the vehicle I checked the contents of
my hand: money to pay the driver and a note to the nun in charge, “We found baby Jesus
here on the street. Please take care of him.” A wave of shame for my self-righteousness
came over me.
Meanwhile, the man began to sing and dance in his seat, clapping his hands and
shaking his head in delight whilst the maggots squirmed in his foot. Again I was caught
off guard. This man was suffering; he was not supposed to behave like this! He should be
downcast and depressed…not happy! My ideas about what suffering should entail and of
my own self-importance and pride were subjected to much reflection in time to come.
Soon I felt overwhelmed by the multitude of other “issues” that sprang from this first
flirtation with “development” and perplexed by the vague uneasiness they gave me.

Suffering
How should I deal with other people’s suffering and how much responsibility
should I take for it? How does this affect my own personal experiences of suffering? My
attitude toward suffering oscillated from pitying sentimentality to a sensationalized,
morbid sort of intrigue, to grim stoicism. At times I normalized it so that the suffering I
81
encountered no longer demanded my attention or provoked a response. At other times
I wanted to escape its relentless and unyielding nature and cocoon myself within the
comforts of ignorance and the relatively trivial distractions of life back home. However,
I was simultaneously reviled by this attitude and found the Global North’s excess and
materialism abhorrent, refusing to pay four dollars for a coffee because, didn’t you know?
Four dollars could feed a whole family in India! I couldn’t fathom how such extreme
dichotomies of wealth and poverty, suffering and joy, privilege and disadvantage could
exist in the world side by side. In light of this, happiness began to feel like an indulgence,
like, as Gill Courtemanche once wrote, “…a kind of sin. How can we be happy when the
earth is falling apart before our eyes and humans are turning into demons?”1

Power
I soon became aware of the inequities that tipped the balance of power between the
development workers and those we helped. Some obvious factors included education
and wealth. But a more insidious aspect was the very way we identified ourselves as
the subjects, the helpers or saviors, and the others as objects, the beneficiaries of our
benevolence. This made us powerful and superior while constructing “them” as powerless,
inferior and dependent.2 Carter describes this simply but accurately: “Some folks liked to
just continually give because it made them feel uppity, and better than the feller they was
giving to.”3 Slowly, this perception of superiority made me increasingly uneasy. I realized
that it reeked of a sinister arrogance that lurked covertly within some individuals, in the
development industry as a whole, and, most disturbingly, sometimes in me, too.

Self-Image
At the start, it was easy to revel in my own goodness and pat my own back for being
a good person doing good deeds. I thought I could change people’s lives by pouring forth
my limitless compassion. But I wasn’t and I didn’t. Sometimes I didn’t want to clean the
patient who soiled her pants for the nth time, so I looked the other way. Sometimes I
took a different route home so I wouldn’t cross paths with a certain beggar who would
undoubtedly pour out her troubles to me and ask for money. Instead of expressing
appreciation, a child I “helped” once pulled my hair and spat at me. But I was helping
him; he was supposed to be grateful!
I slowly began to see myself for what I was: a clichéd, bleeding heart youth. I was
loftily idealistic and passionately outraged at the injustices of the world, but also ignorant
and arrogant. My expertise consisted of half-baked ideas about the way I thought the
world should be, but I had no experience or skills with which to transform my dreams to
reality. Martel describes this realization of the impotence and conceit of youth well: “I

1 Gil Courtemanche, A Sunday at the Pool in Kigali, trans. Patricia Claxton (Toronto: A.A. Knopf Canada,
2003).
2 “When you fix, you assume something is broken. When you help, you see the person as weak. But when
you serve, you see the person as intrinsically whole. You create a relationship in which both parties gain”, says
Dr. Stan Goldberg. Source: Goldberg, S. (2004) Fixing? Helping? Serving?, San Francisco Call (reprinted
from Power of Purpose Awards), November 23, 2004.
3 Forrest Carter, The Education of Little Tree (Albuquerque: University of New Mexico Press, 1990).

82
felt like a piece of plastic to her worn leather… new, shiny, stupid… my youthfulness came
out in too many words, too many opinions, too many emotions.”4

Motivations
On deeper reflection of my motivations for going on the trip, I found myself
surprised. It wasn’t just that I wanted “to help people,” but I also wanted to travel
somewhere thrilling and exciting for the summer, to alleviate my own sense of guilt for
my privileged life, to feel good about myself. I kept going back for the deep friendships,
drawn by the intimacy of community life. Others were compelled for different reasons
(many of which were “running from” rather than “striving toward”). Some development
workers internalized guilt to such an extent their work became a self-punishing act
of martyrdom, devoid of joy. Others exhibited great compassion and generosity as
development workers, but harbored bitterness against their estranged families and drifted
restlessly about the world, incapable of settling in one place. It seemed that escapism was
their main motivation. I asked myself: which is the greater challenge, loving those closest
to me at home or loving complete strangers in an exotic country?

Ego
I soon discovered that my volunteer experience was intimately intertwined with
my ego. It was reflected in the way other volunteers and myself shared our experiences;
collecting and embellishing stories, competing to see whose were most entertaining,
the pride and ownership we had about “volunteering,” about “India,” about the “Third
World.” The way we preached to our loved ones back home from our moral pedestal
about the injustices of the “real” world with a pained angst, revealing the fact we now
carried a burdensome secret knowledge about the world that they could not understand
because they hadn’t experienced “it” yet. And so forth.

Going Home
Maskalyk writes, “People who do this type of work talk about the rupture we feel on
our return, an irreconcilable invisible distance between us and others. We talk about how
difficult it is to assimilate, to assume routine.”5 When I went home I felt like I didn’t fit
in and that no one understood me or my experiences. This made me lonely at times. But
if fitting in and being understood meant succumbing to the superficial, bubble-wrapped
world of the people around me, then I would heroically go my own way in dignified
solitude. From this, a strange paradoxical pride grew as I isolated myself further. I became
quite scathing and condemnatory of our Western society, quietly condemning others for
their shallowness and material greed. I talked about how despite all their suffering, the
poor were truly happy, and how we, with all our wealth, were so unhappy and ungrateful.
I thought I was acting as their advocate, only realizing much later that instead, such
sentiments misrepresented and sensationalized their suffering in a grossly oversimplistic
manner, doing both them and myself a disservice.

4 Yann Martel, Self (Toronto: Vintage Canada, 1997).

5 James Maskalyk, Six Months in Sudan (New York: Canongate, 2009).

83
The System
What is “development” and where did it come from? After sixty years of
development, why haven’t things improved? I began to suspect the term “development”
was a euphemism for Westernization or neo-colonialism. Seeing tribal people in
remote villages wearing Madonna shirts and listening to J.Lo was deeply disturbing
and suggested to me that the development of economies is inextricably linked with
the process of eroding other cultures and transforming them into our own. It made me
question the industry in which I had become a part of, to ask if we’re deluding ourselves
to the possibility that development work actually subscribes to the righteous imposition
of colonialist ideologies we’re supposed to despise. Scroggins describes this well: “Dozens
of… university graduates still set off for Africa each year with what might be described as
a modern version of that (colonialist) urge, an ambition to ‘develop’ Africa that arouses
much the same pleasurable hopes and feelings as did earlier pledges to service Kipling’s
‘lesser breeds without the law.’”6

Larger Questions
What is the meaning of life? What is the meaning of my life? What is truth? Why
does evil exist? How does this challenge my concept of God?
The most valuable outcome of “helping” the Global South was helping myself.
It held up a mirror that reflected my hidden ugliness back to me, a simultaneously
distressing and freeing revelation. This unexpected introspection is echoed with precision
by Fothergill: “My first impressions of Sudan were rather blurred and uncertain; I was
so much more interested in myself than I was in my surroundings.”7 But rather than
being “bad,” the preliminary self-obsession that comes from doing development work
in the Global South is necessary; it subdues after the initial shock and paves the way
for a potentially more selfless and giving service. Slowly the despair at discovering one’s
ugliness transforms fixed answers, narrow mindedness, and pride into fluid questions,
open mindedness, and greater humility, guiding a new way of relating to the world. Put
in another way, we need to realize how plastic we are in order to let that plasticity melt
away and, in time, form leather.
The lessons I’ve learned hold true for me only at this very point in time and they
are neither exhaustive nor unequivocal truths. They include the following: The line
between right and wrong, acceptable and unacceptable, is hazy. There are rarely blacks
and whites, just many shades of grey that can surprisingly coexist harmoniously. The old
middle path seems to unfailingly pull through most of the time. Those lacking insight
are just as dangerous as the excessively over-analytical. Self-justification for failing to
take responsibility and self-depreciation for an honest mistake are equally detrimental.
Unbridled cynicism and disproportionate naiveté are both dangerous traps. It’s essential
to balance the striving for my self-improvement with a lighthearted kindness and an
acceptance of my own ugliness. Rather than rejecting my privileged life in the Global

6 Deborah Scroggins, Emma’s War (New York: Pantheon Books, 2002) makes reference to Rudyard Ki-
pling’s The White Man’s Burden.
7 Edward Fothergill, Five Years in the Sudan (New York: D. Appleton, 1911).

84
North, I should embrace it, letting the lessons I’ve learned in the Global South spill into,
saturate, and transform it. What I do at home is just as important as what I do overseas;
small dreams of treating family and friends well and living simply and ethically are just as
helpful as (if not more helpful than) grandiose dreams of saving humanity. Humans are
astounding beings with seemingly infinite capacities for resilience, meaning-making, and
joy. Philosophy and development studies are valuable ways to arm oneself with the tools
necessary to address the “issues” that may arise when working in the Global South.
Years later, when I went to East Africa to do my medical elective and to travel, I was
confronted with the same array of troublesome issues. In Rwanda I visited a number
of genocide memorials. One housed the preserved bodies of some of the thousands
of victims that were slaughtered there, their contorted faces frozen. The guide who
showed us around was soft-spoken with an impassive face and deeply furrowed brow.
He carried a large ring of keys, robotically opening and locking each door in succession
like a formidable prison guard. Whilst he had fled to neighboring Burundi during the
genocide, his entire family was killed at this place. I wondered what it must be like for
him to take foreigners, who didn’t understand his suffering, through that place day
after day – what he thought of our deliberate, awkward solemnity; our silent, pained
expressions; our measured, heavy plods that reflected the numbness in our heads. My
mind recoiled at the immensity of the suffering. I wondered, what should I think? How
should I think it?
But I paused and quelled the inundation of internal comments and questions, and
instead tried to be present with every other faculty other than my mind. It helped me to
not intellectualize the ghost of the other man’s suffering or to turn it into being about
me, and it destroyed the delusion that I was there to help this man. Having had the values
of rationality and purpose-driven action so strongly instilled in me, letting go of my
need to immediately “fix it,” to “do something,” to “work it out” was, and still is, difficult.
But sometimes all you can do is just be present, and that’s enough. Reflecting on this
experience, I realized that all that time devoted to addressing the myriad, challenging
development questions with “the brain dance” allowed me to move beyond the cerebral
and approach suffering on a deeper level.
This was a valuable lesson. Undoubtedly, my next encounter with the development
industry and that mirror it inevitably holds up will bring me more lessons such as these.

85
86
 Call for Papers
SCOUT BANANA, in conjunction with Michigan State University’s African
Studies Center and Office of International Development, invites you to submit a
manuscript to Volume III, Issue I of Articulate: Undergraduate Research Applied to
International Development.
Articulate is an undergraduate journal that publishes academic papers and
writings on international development and health care in Africa. It is a forum for
students to contribute to, as well as initiate, debates in international development.
Undergraduates remain a vital, untapped force for new ideas and perspectives. Our
goal is to spark, share, and spread knowledge to create innovative change now.
Primary criteria for inclusion in the journal are quality of research, relevance, and
originality. All manuscripts must have been written as an undergraduate student.
For scholarly articles, we ask for submissions of roughly 15-20 pages double-spaced,
citations formatted according to the Chicago Manual of Style, and an abstract of 200
words. We also ask that the author’s name, major, college, and university appear on a
separate cover sheet, with no reference to the author within the manuscript.
Potential topics include, but are not limited to:
• The effectiveness of foreign aid, microfinance, and social enterprise in Africa
• Intersections of gender, religion, ethnicity, and sexuality in African development
• Consequences of globalization, especially financial and trade integration
• Historical analyses and case studies of health care programs in Africa
• Politics of water and medicine in Africa
• The role of African youth in development programs and projects
• Effects of conflict and forced migration on health care and development
Articulate is also seeking brief reflective essays on your experiences in Africa, as well
as reviews on literature relevant to Africa, development, and health care.
Reflective essays are 2-3 single-spaced pages and can take a variety of creative forms.
They should explore development work from the perspective of a young person
(under 30) from the Global North entering the Global South. Was it how you
thought it would be? What did you like and/or dislike about it? What do you wish
you had known when you were just “studying,” as opposed to working, in Africa on
health-related issues? Other themes may be considered with consultation from the
Editor-in-Chief.
Literature reviews are 2-3 single-spaced pages and are meant to keep Aritculate’s
readers abreast of current works and on-going debates pertinent to development,
Africa, and health care. Reviews must provide a careful, thoughtful analysis and
critique of a work’s main themes, objectives, arguments, and conclusions. They
should include at least three titled sub-sections: an introduction that includes a
synopsis of the work; an analysis that considers what, if any, assumptions underlie
the author’s thinking and, if evidence is cited, how well it supports the work’s main
objective; and a conclusion that summates your analysis and states the overall merits
and/or shortcomings of the work.
Manuscripts will be accepted until Monday, January 18, 2010, with an intended
publication date during May 2010. For submissions, please contact the Editor-in-
Chief at articulate@scoutbanana.org. For more information, check out
http://scoutbanana.org/articulate.
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88
 Articulate Style Sheet
Documentation Guidelines

Articulate adheres to the Chicago Manual of Style’s humanities, or note-bibliography,

format system. All citations and references of a submission to the journal must align with
the guidelines outlined here. For more detailed information, please refer to the most recent
edition of the manual.

References
This page should appear at the end of the paper, but before any figures and appendixes,
and should be arranged in alphabetical order according to the authors’ last names. All
entries with no author should be placed before those with authors, and should be arranged
alphabetically according to the title of the work (keep in mind that an organization can act as
an author).

In the examples that follow below, the first entry shows the format of the first note
as it should appear in the text proper. These should be placed in footnotes, and ordered
sequentially by number. After the first note entry for a work, all subsequent references to
that work should be formatted as “Author’s last name, page number.” If you have referenced
several works from the same author, include the title in secondary notes, as in, “Author’s last
name, title of work, page number.” If no author is given, include the title and page number.
If there is no page number (e.g., a website), simply include the title of the reference. The
second entry shows the format of the note as it should appear in the references page. Note
that each line after the first is indented. Also note that there is no use of italics or underlining:
book titles are left as regular, plain text, while everything else – sections of books, websites,
articles, papers, presentations, etc. – are placed within quotation marks.

Book
One author
1. Ferdinand Oyono, Houseboy (London: Heinemann, 1980), 27.

Ake, Claude. Democracy and Development in Africa. Washington, D.C.: Brookings

Institution, 1996.

Two authors
2. Toyin Falola and Matthew Heaton, Health Knowledge and Belief Systems in Africa
(Durham, N.C.: Carolina Academic Press, 2008), 94-97.

Feierman, Steven and John Janzen. The Social basis of health and healing in Africa.
Berkeley: University of California Press, 1992.

Three or more authors

3. Edward O. Laumann et al., The Social Organization of Sexuality: Sexual Practices in
the United States (Chicago: University of Chicago Press, 1994), 262.

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 Laumann, Edward O., John H. Gagnon, Robert T. Michael, and Stuart Michaels.
The Social Organization of Sexuality: Sexual Practices in the United States.
Chicago: University of Chicago Press, 1994.

Chapter or other part of a book

4. Gustavo Esteva, “‘Development,” in The Development Dictionary: A Guide to
Knowledge as Power, ed. Wolfgang Sachs (London: Zed Books, 1992), 6-25.

Hoogvelt, Ankie. “Globalization, Imperialism and Exclusion: The Case of Sub-

Saharan Africa.” In Africa in Crisis, edited by Tunde Zack-Williams, Diane Frost,
and Alex Thomson, 15-28. London: Pluto Press, 2002.

Preface, foreword, introduction, or similar part of a book

5. Nancy Birdsall, introduction to Reinventing Aid, ed. William Easterly (Cambridge, MA:
MIT Press, 2008), xi–x.

Keim, Curtis. Preface to Mistaking Africa: Curiosities and Inventions of the

American Mind, by Curtis Keim, xi–xii. Boulder, CO: Westview Press, 2009.

Journal article

6. Sally Matthews, “Post-development Theory and the Question of Alternatives: A View

from Africa,” Third World Quarterly 25.2 (April 2004): 373-384.

Cohen, Michael A., Maria Figueroa Küpçü, and Parag Khanna. “The New
Colonialists.” Foreign Policy 167 (July-August 2008): 74-76.

Popular magazine article

7. Russ Hoyle, “A Continent Gone Wrong,” Time Magazine, January 16, 1984, 26.

Sachs, Jeffrey. “A Deadline on Malaria.” Scientific American, July 29, 2008.

Newspaper article

Newspaper articles may be cited in running text (“As William Niederkorn noted in a New
York Times article on June 20, 2002, . . . ”) instead of in a note, and they are commonly
omitted from a works cited as well. The following examples show the more formal versions
of the citations.

8. Mangoa Mosota, “Report: Recession will affect HIV plans,” The East African
Standard, July 9, 2009, Health section, Kenya edition.

Timberg, Craig. “How AIDS in Africa was Overstated; Reliance on Data From
Urban Prenatal Clinics Skewed Early Projections.” Washington Post, April 6, 2006,
section A, Final edition.

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Book or Movie review

9. William Easterly, “The Big Push Déjà vu,” review of The End of Poverty: Economic
Possibilities for our Time, by Jeffrey Sachs, Journal of Economic Literature 76.1 (February
2005), 1-22.

Seitz, Matt Zoller. “Healing Cultural Wounds.” Review of A Walk to Beautiful,

directed by Mary Olive Smith and Amy Bucher. New York Times Movie Review,
February 8, 2008.

Thesis or dissertation

10. Nic Cheeseman, “The Rise and Fall of Civil Authoritarianism in Africa: Patronage,
Participation in Political Parties in Kenya and Zambia” (Ph.D. diss., Oxford University,
2008), 31-37.

Almeida, Edgar F. “Was the Colonial Policy of Ethnic Self-Rule Responsible for
the Divided Polity in Uganda?” MA thesis, University of Western Ontario, 2000.

Paper presented at a meeting or conference

11. C. Everett Koop, “Health policy working group briefing: the Surgeon General’s report
on AIDS” (presented in Washington D.C., September 24, 1986).

Sen, Amartya. “Health in Development.” Keynote address presented to the

Fifty-fifth World Health Assembly, Geneva, Switzerland, May 18, 1999.

Website or Blog

Web sites may be cited in running text (“On its Web site, the Evanston Public Library Board
of Trustees states . . .”) instead of in a note, and they are commonly omitted from a works
cited as well. The following examples show the more formal versions of the citations.

12. Hans Rosling, “Hans Rosling on HIV: New facts and stunning data visuals,” TED,
http://www.ted.com/talks/hans_rosling_the_truth_about_hiv.html.

Stiglitz, Joseph. “Making Globalization Work.” Project Syndicate.

http://www.project-syndicate.org/commentary/stiglitz74 (Accessed July 27, 2009).

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Articulate is supported generously by:

African Studies Center

Michigan State University

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